summary: 748.753(c)(2) - Pre-Employment Screening-You must document your diligent efforts to contact the reference, which must include more than one attempt to contact.

raw_content: Two files that were reviewed did not have the documentation that references were contacted.

Correction Narrative: An email was received from the Administrator indicating that they will ensure that they document the references that were contacted and what the responses were and not just the name.


state: TX

facility_name: Kaufman County Children's Emergency Shelter

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

raw_content: All fire extinguishers have not been inspected since November 2022.

Category: Individual Standards Evaluated

Standard Risk Level: Medium

Corrected at Inspection: No

Correction Narrative:
An email was received from the Administrator stating that he has had all the fire extinguishers inspected and waiting for the tags to be put on them. He will send a picture once the tags are on and the certificate of the inspection.

The Administrator sent me pictures of the inspection report for the fire extinguishers. Picture of the updated tags were also sent.  Inspections notification reminder will be put on the calendar.


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

raw_content: The operation did not report to licensing an alleged incident in the required timeframe.

Standard Risk Level: Medium High

Correction Narrative: The Administrator sent an email stating that they understand that even if another entity states they are going to report an incident to the hotline, they will as well. This is to ensure that the incident is reported by the operation.


summary: 748.931(a)(1)(B)(iii) - Annual Training-Every 6 months a caregiver must complete at least 4 hours of training in EBI

raw_content: Two out of two staff files that were read, the caregiver did not have a current EBI training.

Category: Training and Professional Development

Correction Narrative: The Administrator emailed the staff sign in sheet that attended the EBI training. The operation will ensure that all training is current. The training was held on 03/04/22.  This was uploaded onto the SharePoint.


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

raw_content: There were two-bathroom doors that had holes in them, mini blinds in one room were broken, a tile in the restroom was missing and speakers in the boys room was detached from the ceiling.

Category: Physical Site

Standard Risk Level: High

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


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

raw_content:
One of the first aid kits were missing the following:
Cotton balls, Multi-size bandages, gauze pads, thermometer and the antiseptic wipes expired on 1/2022.


summary: 748.505(b)(2) - Minimum qualifications for employees-Record of a TB screening showing the employee is free of contagious TB as provided in 749.1583

raw_content: A staff member that had direct contact with the children did not have a TB test completed.

Category: Personnel


raw_content: There was one vehicle that had a fire extinguisher that was not inspected since 2019.  One vehicle did not have a fire extinguisher.

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


summary: 748.983(a) - First-aid-CPR renewal-Each caregiver must complete any new first-aid training, as required to maintain a current certification

raw_content: One employee's First Aid expired on 6/3/21.

Correction Narrative: An email from the Administrator was received.  He also sent an updated certificate showing that the employee did have First Aid and it was now current.  He stated the trainer that created the certificate forgot to list that training. The Administrator stated he would confirm the certificate closer.


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 member was sending messages to a child in care without consent of the DFPS managing conservator or the operation's approval. The staff member also added the child (n care ) in the staff member's social media profile and they exchanged messages that were not developmentally appropriate for the child.

Correction Narrative: The staff was retrained on the cell phone policy and the minimum standard requirements.


facility_name: Hill Country Youth Ranch Residential Treatment Center

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

raw_content: Direct care staff grabbed and shoved a child in response to the childs behavior; this was an inappropriate response. Additionally, before grabbing the child, the direct care staff did not attempt to de-escalate the situation.

Correction Narrative: The walkthrough of the Doss home was completed with no concerns noted for physical site. The bedrooms observed were clean and well kept for the residents. No staff were present at the time of the walkthrough as the next shift doesn't begin until 2PM at Doss Home. An interview with the RTC supervisor was completed and licensing was informed of staff involved in the investigation were terminated. RTC supervisor disclosed how the Doss Home went through restaffing and 3 staff from other Homes in the operation replaced the staff that were in Doss except for one. One of the new staff members in Doss is the lead and has tenured experience working in RTC settings. The RTC supervisor added moving forward the new Lead in Doss will help in guiding staff on how to handle residents in the Doss Home. Weekly meetings will continue in addressing any issues staff have with residents and reviewing minimum standards.


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: Direct care staff threatened to drop a child to the floor in response to the childs heightened behavior.


summary: 748.2203(c)(1) - Medication Error-Document the time & date of the error

raw_content: Medication log reviewed for one child contained missing dosages and was not recorded as a medication error.

Correction Narrative: Documentation received from RTC Supervisor on 8/5/25 reflects an "Employee Counseling Notice" Form that will be used moving forward. This form will include the reason for counseling, employee's statement, and action to be taken.


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

raw_content: Refrigerator had crumbs and syrup stuck to the bottom of the refrigerator in the drawer area.

Correction Narrative: Email received by operation supervisor with an attached document of the daily checklist staff must complete and sign prior to leaving their shift. This includes: "dishes washed, counters wiped down, swept and put away dishes (NO LEFTOVERS)"


summary: 748.3441(m) - Food Preparation-Food must be thawed in the refrigerator, in cold water in a leak-proof bag, or in the microwave

raw_content: Food was left in the sink to defrost.

Deficiency Narrative: Food was left in the sink to defrost.


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

raw_content: The Service Plan Review of a child in care clearly notes the night staff should conduct checks every 10 minutes, specifically from 10PM until midnight. Night Logs note checks were being completed every 10 minutes until 9PM and every hour after 9PM.

Correction Narrative: An addendum that was inadvertently not sent with the records was sent following the investigations. In the future we will strive to see to it all updates or addendums to Service Plans are scanned in as part of the Service Plans that are provided.


raw_content: Service plan was reviewed, and staff did not follow the supervision plan regarding a child not being left alone and requiring a direct care staff present with the child.  Child was alone without direct care staff in the back of a working vehicle during a work program.

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

Correction Narrative:
On 11/11/2024, 2 staff and 2 residents were interviewed.
One resident disclosed never having participated in the work crew program while the other resident has. Resident who has stated they have not done work program recently due to only having this open during the summer. Resident disclosed in the past 5 to 8 residents participate in the program at a time and there will be either 1 or 2 staff present. Resident disclosed this can be maintenance or direct care staff.
Staff stated moving forward when taking applications for the work crew program they will review the residents service plan and application. Staff stated modifications to supervision will be requested if needed and if approved then the resident may participate in the program.
Staff stated moving forward ratio will have qualified direct care staff in ratio with residents.


raw_content: The Service Plan of a child in care clearly notes the Level of Care as IPTP and night checks should be completed every 10 minutes, specifically from 10PM until midnight. Night Logs note checks were being completed every 10 minutes until 9PM and every hour after 9PM.

Correction Narrative: An email was received by the administrator stating that the supervision requirement of the Service Plans are being reviewed and will be highlighted on the log to ensure checks are being completed at the designated rates and times.


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

raw_content: Licensing observed and photographed broken glass pieces on the ground outside a window at Terry Cabin, which staff indicated had been there for two weeks. The staff cleaned up all broken glass pieces during the inspection.

Correction Narrative: A broken window had been replaced by a contractor who did not clean the broken glass from the site.  In the future maintenance will follow-up after a contractor has completed a task and assure the area is free of garbage and debris.


summary: 748.455(a) - Unauthorized Absence-After a child returns from unauthorized absence, foster parent must conduct debriefing w/child no later than 24 hrs after return

raw_content: A debriefing was not conducted with one of the resident involved within the required time frame.

Correction Narrative: 3 staff interviewed and documentation provided reflects that the new incident report includes the documentation of the debriefing with child upon returning to the operation with details on what the discussion will be about.


summary: 748.303(a)(9)(A) - Serious Incident-Report to CCL within 2 hours of notifying LE the absence of a child developmentally/chronologically 6 to 12 years old.

Correction Narrative:
Reports to licensing was made outside of the required time frame.

On 6/12/24 conducted a physical follow-up. Requested documentation how staff would be notified of the new change in contacting the hotline within 2 hrs. of notifing law enforcement. This will be left pending as of 6/12/24, and notification will be provided at the latest on 7/7/24.


summary: 748.453(a)(2) - Unauthorized Absence  Annual summary log must include time and date absence was discovered

raw_content: A time notation is not present in the unauthorized absence log.

Correction Narrative:
On 6/4/24 the following email was received from administrator: We are currently working with our database to automatically generate the log and working with the glitch that leaves that information off some reports. In the future we will fill that information in manually if the database is not able to report it.

Interview with Administrator and documentation provided showed updated annual summary log to continue reflecting the time the child was discovered and now includes the staff who filled out the form and staff who is supervising that child at the time of absence. Moving forward, extended reach is utilized to fill out incident reports and this will populate in the updated unauthorized summary log.


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

raw_content: 2 children records reviewed showed medical log is missing staff signature after administering medications.

Correction Narrative: Reviewed 12 records and all contained signatures of where medication was dispensed properly.


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

raw_content: Staff interviewed confirmed they informed the children they had to be in line of sight but then went inside the house for a brief period, leaving two children unattended.

Correction Narrative: 3 staff were interviewed and conducted a recent supervision training held on 2/19/24. The following topics were covered, " why it's important, on ranch, off ranch, recreation, in the ranch, prohibited Areas, At chapel, and know your children." Training completion log was collected as well.


raw_content: Video footage confirmed staff did not check on the children at the 10 minute time frame as stated in their service plan.

Correction Narrative:
In response to your findings regarding Investigation #3013946 at Operation #215752, the staff member involved in the incident was terminated prior to our receiving your report for violation of both Minimum Standards and agency policy.  She is not eligible for rehire.
On 8/30/23 an in-person inspection was conducted, and 3 staff members were interviewed. Staff stated that at 9pm they are to record in their log every 10min the time of the check in, the activity the child is performing (mainly sleeping) and sign off. At 10:30pm staff are to conduct hourly checks and record it in the log.


raw_content: Video footage confirmed that staff was not present for long periods of time and child interviews confirmed that staff was not present for long periods of time. Video footage showed two children laying on a couch together for a few minutes without staff redirecting them.

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

Correction Narrative: 3 staff interviewed stated that they keep night logs where they are to sign off every 10 minutes starting at 9 pm, until 10:30 pm where they conduct hourly checks. During these checks staff are to also record what residents are doing.


summary: 748.2901(2)(A) - Triggered Reviews-Review if child is personally restrained 4 times within a 7-day period, unless otherwise ordered or recommended in advance

raw_content: There was at least 5 instances where a triggered review should have been conducted based on having at least 4 or more restraints within a 7-day period.

Correction Narrative:
On 9/8/23 an email was received stating that, "In regard to the child in question, a Triggered Review was completed on 4/14/23 and 6/7/23. We also had a treatment plan meeting on her 8/2/23 (However, she was discharge prior to her triggered review due date of 8/6/23  she discharged 8/4/23. We will be requesting an administrative review."

On 09/15/23 5 staff and 2 children confirmed that restraints have been recently changed to 30 minutes of maximum time.


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

raw_content: Video footage shows staff going into child's room and placing their hands on child in order to immediately throw them on the ground.

Correction Narrative:
On 9/5/23 an email was sent stating that, "In the future, should a staff person flagrantly violate Hill Country Youth Ranch policy and DFPS
Minimum Standards regarding Emergency Behavioral Intervention with no remorse or acknowledgement of wrongdoing or desire to rectify the error through training and development of enhanced skills their employment with Hill Country Youth Ranch will be terminated."

On 9/15/23 3 staff and 3 children interviewed confirmed that when restraining a child there is typically multiple staff present in order to
verify that it was conducted correctly and for appropriate reasons.


summary: 748.2463(1) - Emergency Behavior Intervention-Never used as punishment

raw_content: Video footage confirmed child asked staff for toilet paper while staff was standing a few feet away from the child with toilet paper in their hand.  Staff told the child to go to their room first and child became upset and threw a chair away from anyone as they walked in their room. Staff was then seen going into the room and placing the child in a restraint.

Correction Narrative:
On 9/5/23 an email was sent stating that, "In the future, should a staff person flagrantly violate Hill Country Youth Ranch policy and DFPS.
Minimum Standards regarding Emergency Behavioral Intervention with no remorse or acknowledgement of wrongdoing or desire to rectify the error through training and development of enhanced skills their employment with Hill Country Youth Ranch will be terminated."

On 9/15/23 3 staff and 3 children interviewed confirmed that staff are never to place their hands on the child just because. There has to
be reasonable evidence that the child will hurt themselves, others, or property before placing them in a restraint.


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

raw_content: EBI conducted by staff was not conducted in an emergency situation as seen in the video footage and described by program coordinator, and children.

Correction Narrative:
On 9/5/23 an email was sent stating that, "In the future, should a staff person flagrantly violate Hill Country Youth Ranch policy and DFPS Minimum Standards regarding Emergency Behavioral Intervention with no remorse or acknowledgement of wrongdoing or desire to rectify the error through training and development of enhanced skills their employment with Hill Country Youth Ranch will be terminated."

On 9/15/23 Interviewed 3 staff and 3 children who confirmed that a restraint is only preformed when the child is self-harming, harming others, or destroying property.


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

raw_content:
Video footage shows staff forcing another child to sit and watch restraint with another child. Children interviewed also corroborated with another child sitting in and
watching restraint.

Correction Narrative:
On 9/5/23 an email was sent stating that, "In the future, should a staff person flagrantly violate Hill Country Youth Ranch policy and DFPS.
Minimum Standards regarding Emergency Behavioral Intervention with no remorse or acknowledgement of wrongdoing or desire to rectify the error through training and development of enhanced skills their employment with Hill Country Youth Ranch will be terminated."

On 9/15/23 3 children and 3 staff confirmed that when de-escalating a child, they will remove them from others. If this is not possible then
staff will remove the other children by asking them to go into their rooms as they de-escalate with child in the main area. Children added that staff will allow them to use their coping methods.


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: Video footage shows child being taken to the floor on an unwarranted restraint where there was no emergency situation nor was the child a danger to themself or others.

Correction Narrative:
On 9/5/23 an email was sent stating that, "In the future, should a staff person flagrantly violate Hill Country Youth Ranch policy and DFPS Minimum Standards regarding Emergency Behavioral Intervention with no remorse or acknowledgement of wrongdoing or desire to rectify the error through training and development of enhanced skills their employment with Hill Country Youth Ranch will be terminated."

On 9/15/23 3 staff and 3 children interviewed stated that in order to conduct a proper restraint you are to use all de-escalation techniques.
When all those methods have failed then staff is to notify child that a restraint will be placed if they don't use their coping techniques.


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

raw_content: Restrooms in theTerry cabin smelled of urine and orange mildew was present in the shower.

Correction Narrative: Restrooms in theTerry cabin reviewed and and no mildew was seen.


raw_content: The debriefing was not conducted within 24 hours of the child's return. The debriefing did not include the child's condition or what occurred during the time away.

Standard Number / Description: 748.455(a) - Unauthorized Absence-After a child returns from unauthorized absence, foster parent must conduct debriefing w/child no later than 24 hrs after return

Correction Narrative:
On 6/1/23, the agency emailed the changes to the debriefing report to include all requirements.

On 6/16/23 an inspection follow-up was conducted. 3 staff members and 2 residents were interviewed about what is discussed during the debriefing process. Both staff and residents stated that residents are checked to make sure there are no marks/bruises. It is also discussed that staff will ask residents what occurred during their time away and if child refuses then it is noted in the incident report. Staff make sure to try and have the debriefing within 24 hours.


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

raw_content: 3 out of 4 staff stated that les restrictive interventions could have been used prior to conducting an Emergency Behavior Intervention.


raw_content: 3 out 4 staff interviewed stated that there was no emergency situation present and there could have been other alternatives to de-escalate the situation.

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


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

raw_content: When reviewing actions taken leading up to the restraint and the child's service plan the child was not provided a silent and quite place to calm down.


summary: 748.1539(a) - Immunizations-Each child must meet and continue to meet the applicable immunization requirements

raw_content: 1 out of 4 children did not have an immunization record.

Category: Child Care

Correction Narrative: 4 out of 4 records reviewed showed completed immunization records.


summary: 748.1217(c)(14) - Admission Assessment-Prior to initial service plan, add determination of whether operation can meet child's needs

raw_content: 1 out of 4 child's service plans do not include an accurate assesment of the child's strengths, interests, and personality.

Category: Admission, Service Planning, Discharge

Standard Risk Level: Medium Low

Correction Narrative: 4 out of 4 children records reviewed contained a completed "community/cultural/social strengths and needs" section in the service plan.


summary: 748.1545(a) - Vision and hearing screening-must ensure that each child is screened; must have professional exam if problems are detected

raw_content: 1 out of 4 children has not received their hearing exam.

Correction Narrative: 4 out of 4 children records reviewed showed completed and up to date vsion and hearing exam.


raw_content: In the Meadows Home when reviewing the medication log there was a signature missing on who dispensed the medication.

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

Correction Narrative: 5 out of 5 medication logs reviewed with no concerns found.


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

raw_content: Medication Log for 1 out of 6 children investigated showed that their medication was given at the wrong time and not documented accordingly.

Correction Narrative: Medication Logs reviewed in the Mabee cabin with no concerns.


summary: 748.3001(C)(2) - Sanitation inspection- inspection unavailable must maintain documentation at operation and make available to us

raw_content: Yearly updated documentation showing inspections are unavailable at the operation has not been provided.

Correction Narrative: On 11/22/22 received an email from facility stating in a formal letter from the Judge that there is no one available to come done and do a health inspection in which the facility resides in.


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

raw_content: Found a screw sticking out of the playground side rail, Loose-fill missing in the play ground. Swing must not be attached to a composite structure.

Correction Narrative:
On 9/2/22: The playground area inspected is old and is no longer in use. We have made plans to remove the
structure.

9/9/22: A physical walkthrough was conducted of the facility and photos were taken and uploaded on digital storage to show that the playground has been removed since then and the roof will be taken away on 9/12/22.


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

raw_content: One bed in Meadows was missing the mattress cover.

Corrected at Inspection: Yes


summary: 748.3445(b) - Food Preparation-Must keep furniture, equipment, surfaces & other areas where food is prepared, eaten or stored clean & in good repair

raw_content: Both Meadows and Terry cabin contained broken shelves in the fridge.

Correction Narrative:
On 9/2/22: The refrigerator shelves that were cracked have been removed. Staff will inspect appliances
weekly to ensure they are in working order.

9/9/22: A physical walkthrough was conducted of the facility and photos were taken and uploaded on digital storage to show that fridges were repaired.


raw_content: Staff pushed child and was observed on camera doing so.

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:
The former staff reported his version of the incident to a supervisor immediately. He also reported
the incident to licensing. The former staff was moved to another Assessment Center pending the
results of the investigation. Once HCYR Administrators were able to review the video
surveillance, he was immediately terminated. Supporting staff present during incident was
retrained in Reporting Serious Incidents. Supervisors continue to conduct unannounced visits and
provide support through training and staffing meetings. Program Supervisors randomly monitor
video surveillance weekly. All legal guardians were notified of Minimum Standard citation.


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

raw_content: When a child in care was having a behavior, the caregiver lost control and escalated the situation.

Correction Narrative:
The staff member involved in the incident was terminated after reviewing the video surveillance.
HCYR does not condone punishment of children. All staff receive training in EBI, TBRI, and
other trainings related to working with children who have suffered various trauma. HCYR utilizes
SAMA physical containment techniques only when necessary for the child's safety or safety of
others. Staff found to violate HCYR's EBI Procedures are subject to disciplinary action, up to and
including termination. Another staff member present did not intervene when the situation became
non-therapeutic. The staff person was given a written warning and retrained in Reporting
Suspected Abuse or Neglect. The staff member will also take training courses in SAMA (EBI
Interventions) and Documenting Serious Events.
The Program Supervisor will provide direct support and supervision of the program. Video
surveillance will be randomly reviewed to ensure safety of children and staff compliance. The
Program Supervisor is able to review video surveillance in real time. Program Coordinators will be called when children begin to escalate to assist Direct Care Staff in de-escalating the situation.

08/16/22, inspector completed walk through of operation and addressed all concerns. No physical site concerns noted.


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

raw_content: A child in care was so distraught after the staff member pushed the child into their room and closed the door that the child began banging loudly on the door to her room.

Correction Narrative:
The Program Supervisor meets with his team weekly to provide support and training as needed.
Program Coordinators are available during awake hours to process with children and staff.

08/16/22, inspector completed walk through of operation and addressed all concerns. No physical site concerns noted.


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 staff member pushed a child two times causing the child to fall.

Correction Narrative:
The staff member involved in the incident was terminated after reviewing the video surveillance.
HCYR does not condone punishment of children. All staff receive training in EBI, TBRI, and
trauma related training. HCYR utilizes SAMA physical containment techniques only when
necessary for the child's safety or safety of others. Staff found to violate HCYR's EBI Procedures
are subject to disciplinary action, up to and including termination.

08/16/22, inspector completed walk through of operation and addressed all concerns. No physical site concerns noted.


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

raw_content: Staff member physically put himself directly in front of a child   yelled and threatened the child.  Staff member also yelled at other children who were in their bedrooms to be quiet unless they wanted some of this too.

Correction Narrative:
The staff member involved in the incident was terminated after reviewing the video surveillance.
HCYR does not condone punishment of children. All staff receive training in EBI, TBRI, and
other trainings related to working with children who have suffered various trauma.

08/16/22, inspector completed walk through of operation and addressed all concerns. No physical site concerns noted.


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

raw_content: Staff member told a child in care that if they did not go to their room they would put the child there, then grabbed the child by the arm and escorted the child to the bedroom.

Correction Narrative:
The staff member involved in the incident was terminated after reviewing the video surveillance.
HCYR does not condone punishment of children. All staff receive training in EBI, TBRI, and
other trainings related to working with children who have suffered various trauma. HCYR utilizes
SAMA physical containment techniques only when necessary for the child's safety or safety of
others. Staff found to violate HCYR's EBI Procedures are subject to disciplinary action, up to and including termination.

08/16/22, inspector completed walk through of operation and addressed all concerns. No physical site concerns noted.


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

raw_content: A staff member was present when a child was pushed, yelled at and restrained by another staff member and did nothing to intervene.

Correction Narrative:
A staff member present did not intervene when the situation became non-therapeutic. The staff
person was given a written warning and retrained in Reporting Suspected Abuse or Neglect. The
staff member will also take training courses in SAMA (EBI Interventions) and Documenting
Serious Events.

08/16/22, inspector completed walk through of operation and addressed all concerns. No physical site concerns noted.


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

raw_content: Staff stated they were not sure if child required the Epi pen injection for allergic reaction due to bee sting but administered anyway. Staff stated child was not in distress and was not having trouble breathing. The child was given their inhaler. Staff did not request assistance from supervisor or medical professional. Child in care told staff they needed the Epi pen so staff administered.  Staff then stated they did not inject Epi pen according to instructions because they did not leave in for 10 seconds and immediately removed from child's leg, the staff then saw medication dripping from Epi pen. The staff injected the leg and then immediately took it out.

Correction Narrative: Staff involved completed CPR/First Aid training on 5/12/2021.  Administering an Epi Pen is covered in CPR/First Aid training.  Staff also completed HCYR Medications Policy and Procedure training on 5/3/2022.  Following the incident, staff was retrained on 6/10/2022 on how to administer an Epi Pen.  An Administrator-On-Call (AOC) Calendar is placed at Hosler Assessment Center who are available for emergency situations.  Staff have been reminded to call an AOC in situations that require supervisor guidance.


summary: 748.2003(b)(6) - Administration of prescription medication-ensure a person trained in & authorized to administer prescription medication administers the medication

raw_content: Operation staff stated they were not trained to administer an EPI pen and didn't know how to use.

Correction Narrative: Staff involved completed CPR/First Aid training on 5/12/2021.  Administering an Epi Pen is covered in CPR/First Aid training.  Staff also completed HCYR Medications Policy and Procedure training on 5/3/2022.  Following the incident, staff was retrained on 6/10/2022 on how to administer an Epi Pen.  Staff are trained to read and follow directions on the prescription labels which were located with the Epi Pen.  All staff are trained on how to administer an Epi Pen in CPR/First Aid.  HCYR Medications Policy and Procedure curriculum has been updated to include Epi Pen administration so staff receive refresher training annually.


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

raw_content: Child in care was stung by a bee at approximately 3:30 pm. Face sheet and service plan document child is allergic to bee stings. Later in the evening child stated they were having trouble breathing and started to vomit. Staff stated they did not feel child was having trouble breathing but gave child inhaler and administered Epi pen. Staff stated they did not follow instructions for Epi pen administration because they immediately removed the pen without waiting the required amount of time for medication to be fully injected. After child in care was administered the Epi pen incorrectly the child did not receive immediate follow-up medical care to address allergic reaction and any possible adverse reactions to the Epi pen. According to SIR, when child was eventually taken the emergency room the next morning the child required 2 units of IV fluids to treat dehydration. According to child, they were vomiting all night.

Correction Narrative:
Child was monitored after she reported being sting.  She did not display any symptoms requiring emergency medical attention.  The child was taken to the Emergency Room once staff reported an Epi Pen had been administered.  Child was seen by a medical professional within 24 hours of the reported sting.

08/16/22, inspector completed walk through of operation and addressed all concerns. No physical site concerns 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: It was confirmed that a caregiver was asleep when they were supposed to be supervising children in care.

Correction Narrative: The operation responded with a corrective action plan on 06/24/2022. Operation states that the staff member in question was written up and will be attending additional training to address concerns with supervision. Staff member will also check in hourly while on duty. Assessment staff will also be completing unannounced checks. Program supervisors will monitor and make adjustments as needed.


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

raw_content: One out of six medication records was observed not having an accurate daily count.

Category: Medication

Correction Narrative:
An email was received from Designee stating the following: The medication log noted 20 pills remaining, however, only 19 remained in the blister pack. The medication was given correctly and no medications were missed. Blister #24 was sealed without being filled. HCYR received 29 tablets instead of 30 as noted on the label. This error was not discovered by Medication Coordinator or staff who administered the medication prior to March 14, 2022.
The error was documented in an Incident Report and the count was corrected on the blister pack. The Medication Coordinator will ensure that she verifies all counts on prescriptions received. Receiving staff will also verify counts when they receive medications. All receiving staff will sign for receipt of medications.


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: It is alleged that staff became physically aggressive with a child in care and executed an improper and unwarranted restraint on the child in care which resulted in an injury.

Correction Narrative:
Operation intervened and staff member is no longer at the facility.
Operation will be installing cameras in common areas. They will also be providing additional training on EBI for staff.


summary: 748.1661(b) - Tobacco Products-Adult may not smoke tobacco products, e-cigarettes, or vaporizers in children's living areas/inside any building on premises w/ kids

raw_content: Staff member was providing vapes and smoking with children in care.

Correction Narrative:
An email was received by the operation that they will be putting up cameras in the common areas.
Staff member involved is no longer working at the operation.
Staff and children not allowed to have tobacco products. Anyone violating will be subject to disciplinary actions.


summary: 748.3301(c) - Physical Site-Windows & doors must be in good repair & free of broken glass or hazards

raw_content: Observed 3 door frames broken with nails protruding in children's bedrooms and 1 broken wall panel in a child's bathroom.

Correction Narrative:
Received an email on 3/8/22 from Administrator stating that the doors were repaired the same day as inspection date. Photos were provided. In addition, the bathroom materials have been ordered and will be repaired by a contractor on 3/10/22. The Administrator will provide additional photos when completed.
3/10/22: An email was received from the Administrator containing photos of the wall now repaired.


summary: 748.723(a) - Volunteers and Contractors-if the person performs an employee function, he must meet the same requirements as an employee who performs that function

raw_content: A volunteer did not have all the required trainings to be a caregiver for children and supervised 8 residents with a staff.

Correction Narrative: Standard was reviewed and is in compliance.


summary: 748.1003(a) - Child/caregiver ratio-Caregiver may care for 5 children if any require tx svcs, 8 children if not; children under 5 yrs old count as 2 children

raw_content: There was 1 staff supervising total of 8 children during recreation time and three of the children receive treatment services.


summary: 748.303(a)(9)(A) - Serious Incident-Report to Licensing no later than 6 hours after determining unauthorized absence of a child 13 yrs old or older

raw_content: It was determined that the unauthorized absence was not reported within the required 6 hour time frame.

Correction Narrative: 01/07/2022 Email received from operation stating that staff involved were reminded of reporting timeframes in standards & reporting charts have been given to programs for easy access. Directors will ensure that all serious incidents are reported timely.


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: Child in care contracted a communicable disease that was not reported within 24 hours after becoming aware of illness.

Correction Narrative: An email was received from the Executive Director stating that although HCYR took immediate action and provided the proper care once informed of a positive result, HCYR did not inform licensing within the 24 hour standard requirement.  HCYR will ensure that all children who contract a reportable communicable disease are reported to Licensing no later than 24 hours after receiving a confirmed report.  HCYR will continue to report confirmed cases to the child's guardian.


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

raw_content: One staff member used foul language towards a child in care. Another staff member laughed at a child in care.

Correction Narrative: An email was received from the Administrator stating that The Program Director met with staff involved. Staff understand that they are not to repeat foul language stated by residents and are to maintain a therapeutic atmosphere when children are present.


facility_name: TruLight Youth Village

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

raw_content: Fire Inspection was due 12/16/25 and as of today 01/13/26 the annual fire inspection has not been completed.

Correction Narrative: Administrator provided Fire inspection report dated 1/15/26 from Guadalupe Fire Marshall Office.


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

raw_content: Sanitation inspection was due 12/16/2024 and as of today, 01/13/2025 the annual inspection has not been completed.

Correction Narrative: Health inspection was completed and provided 2/12/26 by Guadalupe County Inspector.


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

raw_content: During an unannounced investigation inspection two refrigerators in two separate homes were seen to be missing the freezer handle. One of the refrigerators was found to have a sharp edge where the handle was missing.

Correction Narrative: Unannounced inspection completed 9/17/2025, all refrigerators and freezers were observed to open and close and there were no sharp edges observed.


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: A caregiver denied a child permission to contact the child's CASA worker for a length of time.

Correction Narrative: Unannounced inspection completed 10/23/25 with no concerns.  Administrator provided training agend and quiz for staff, including discipline, child's rights, de-escalation techniques.  4 staff interviewed had no concerns, including child's rights and discipline and stated they recieve updated training at least every 6 months. 2 children interviewed stated they felt safe at the operation and had no concerns and with supervision, child's rights, discipline and they are able to visit with anyone that has approved visits.


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

raw_content: During an interview a direct child caregiver admitted to yelling at a child in care during a verbal altercation, leading to the removal and re-training of the direct child caregiver.

Correction Narrative:
The staff involved no longer works for the operation. The operation is developing a training on discipline and child rights and all GRO staff will take the training. This will also be a pre-service training for incoming staff.
Unannounced inspection completed 10/23/25 with no concerns. Administrator provided training agenda and quiz for staff including child's rights, discipline, de escalation techniques, 4 staff interviewed stated they had no concerns and receive updated training at least every 6 months. 2 children interviewed stated they felt safe at the operation and had no concerns with supervision, discipline-and no staff yell at children, they had no concerns with child's rights and stated they are able to visit with anyone approved.


summary: 745.8447(a)(1) - Corrects a deficiency w/in the timeframe specified

raw_content: Operation was notified of deficiency and given a comply by date of 2/10/25 and as of 2/11/25 a compliance plan was not provided within the timeframe.

Correction Narrative: Email received from administrator stating a calendar task will be put on the calendar 5 days prior to due date. Director of GRO and Director of Contracts will both be on the task to ensure it is completed prior to the due date.


raw_content: Compliance plan was never provided and nothing was done to correct the citation.

Standard Number / Description: 748.1003(a) - Child/caregiver ratio-Caregiver may care for 5 children if any require tx svcs, 8 children if not; children under 5 yrs old count as 2 children

Correction Narrative: Email was received from administrator stating that staff completed the following ratio training: Supervision: ensure that when engaging in corrective action with kids, make sure to do so in common areas, where cameras can be visible.  When doing 10 minute checks, be sure to see kids physically, if in shower/bathroom, make sure to knock on the door every 5 minutes and get a verbal response. Discussed ratio: 1:8; use radio to call for help and sign in sheet was provided.


summary: 748.2551(e)(1) - EBI Implementation-As soon as possible, caregiver must explain to child the behaviors required for release or to have EBI reduced, as applicable

raw_content: A compliance plan was never implemented and the deficiency was not addressed.

Correction Narrative:
Email received from administrator that all staff have been trained in EBI. This is reviewed every six months. Staff has been reminded to do the following in the instance a hold is done:

EBI: What to do during a Restraint
When you are doing a restraint on a child, the following should be happening/be done:
	continue reassuring the child that he/she is safe
	monitor breathing
	explain to the child what he/she needs to do to be released (i.e. show safe hands/feet, use deep breathing, etc.)
	as soon as the child begins to to what is instructed, begin by releasing one arm, then the next, etc.
 We utilize Handle with Care as well as TBRI. In the incident that led to this investigation, the staff member can be seen patting JG on the back and talking with him. we utilized Microsoft Teams to remind the staff. This allows the staff to go back and see the post should a question arise.


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

Deficiency Narrative: Compliance plan was never provided and nothing was done to correct the citation.

Correction Narrative: Email was received from administrator with power point information from Serious Incident-Report training and sign in sheet was provided.


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

raw_content: Interviews confirmed multiple occurrences of rodents present and taking prolonged periods of time to address the issue.

Correction Narrative:
Email received from administrator stating that Mayday Pest Control comes out quarterly and treats the inside and outside of the houses. They will be out March 19th. Their last visit was 12/9/24. We can also schedule appointments in between. We buy our own mousetraps and check them ourselves. Unannounced inspection completed 04/04/2025 with outdoor- including play area's and indoor area's observed including kitchens, bedrooms, bathrooms. Mouse traps were observed outdoor and indoor throughout operation.  No dropping or any other sign of rodents or insects were observed.
3 children and 4 staff were interviewed and all stated there were no concerns with physical site and they have regular pest control/exterminators and there were no concerns regarding rodents or any other kinds of insects or pests.  Documentation was provided from Mayday Pest Control dated 03/19/2025 for quarterly service.


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

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

Correction Narrative:
Email received from administrator with Attached Form 7266 informing parents of each child that a former staff was issued an RTB.
Administrator also Emailed follow up stating the employee was suspended during the investigation and terminated when the RTB was handed down. 	Direct care staff are trained every 6 months on EBI and this will continue.
	A quarterly refresher will be done that will include: guidance on redirection, review IRs for the previous quarter, give staff the opportunity to discuss specific situations/give feedback.
	Supervisors/director will meet if concerns arise after an incident to discuss additional training or steps that may need to be taken.

The safety of the children at Trulight Youth Village is of utmost importance. If we suspect any abuse/neglect, we make the required reports and take the necessary disciplinary actions for the staff.


raw_content: Confirmation emails and serious incident reports were reviewed and showed the incidents were not reported to Licensing timely.

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


raw_content: A caregiver admitted to not giving a child in care any instructions on what behaviors or lack of behaviors were needed to get out of a restraint.

Standard Number / Description: 748.2551(e)(1) - EBI Implementation-As soon as possible, caregiver must explain to child the behaviors required for release or to have EBI reduced, as applicable


raw_content: A care giver admitted to being the lone caregiver looking after 10 children in care for at least 30 minutes.


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

raw_content: Three of three children interviewed stated a physical altercation occurred in the home and staff did not intervene. There were no injuries. Four additional staff responded but the incident was over when they arrived.

Correction Narrative: 4 children interviewed stated they feel safe at the operation, they are always supervised and staff intervene whenever necessary.  4 staff members interviewed stated that they had training within the last  week regarding -staff providing appropriate supervision and interveining as necessary to ensure children's safety.  The training agenda for supervision and intervening at gro was provided as well as  staff roster who attended training.


summary: 748.4003(1)(B) - General requirements-When transporting a child the operation must ensure each driver is covered by automobile insurance

raw_content: A caregiver who transports children without a valid drivers license may not be covered by automobil insurance due to not driving legally.  A caregiver who has been driving children had a their vehicle insurance expired 2/5/24. Children in care are placed at risk If an uninsured driver transports children and there is an accident and there are injuries.

Category: Transportation

Correction Narrative: Updated automobile insurance for caregiver was provided.


summary: 748.4003(1)(C) - General requirements-When transporting a child the operation must ensure each driver has a current driver's license for the type of vehicle used

raw_content: A caregiver at the opreration has been transporting children without a valid drivers license.  Caregiver's drivers license expired 08/21/2023.  During interview with caregiver it was confirmed that they have transported children without a valid drivers license.

Correction Narrative: Administrator stated caregiver who was transporting children without a valid drivers license is no longer working at the operation.  Operation staff stated that caregivers without valid driver license are placed on a list which states which staff cannot transport children and they are not scheduled for any transportation of children.


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

raw_content: The two most recent severe weather drills were reviewed. The operation conducted both weather drills almost two years apart with the dates being 06/16/2022 and 05/09/2024.

Category: Safety and Emergency Practices

Correction Narrative: It was verifed through interviews with children and staff and documentation that a severed weather drill was completed 11/14/2024.  Safety staff stated that future severe weather drills have been placed on the calendar to assure drills will not be missed in the future.


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

raw_content: Operation policy includes that each driver must be covered by insurance and have a current drivers license and follow the rules of the road.  During interview it was confirmed that a caregiver has been driving children in care contrary to policy.

Category: Organization and Administration

Correction Narrative: 5 children interviewed stated that they did not know if any staff member was not supposed to drive them, but all were asked about  staff  in question and stated that the  staff member has not driven them in a long time. Staff members interviewed stated that the  staff member is no longer allowed to drive children and it was confirmed the the staff member is no longer working at the operation since 11/15/2024.


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 in care with a history of self-harm was given unsupervised access to a razor by a staff member.

Correction Narrative: 5 children and 6 staff members interviewed stated that razors are kept locked in the office in bag with each child's name on them and when a child requests a razor the staff give it to them and the child returns it to staff right after shower.  Children and staff stated that if a child is on a safety plan or at risk of self harm, staff will not give the child a razor or access to sharp objects.  Staff also stated that at the beginning of each shift they are given the names of any child on a safety plan or at risk of self harm.


summary: 748.2301(b)(5) - Disciplinary Measures-must be appropriate to the incident and severity of the behavior demonstrated

raw_content: A child in care was threatened with discipline for refusing to take medication.

Correction Narrative: 5 children and 6 staff members interviewed stated there is no punishment if a child refuses to take their medication.  Staff and children stated that if a child refuses medicaiton they are asked a second time about 15 minutes later and if they continued to refuse medicaton it is documented in the log book.  Staff members stated that they also notify the child's case manager.


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

raw_content: A Serious Incident involving a 4 year old child in care being left alone - unsupervised in a van with no air conditioning and windows and doors closed occurred on 6/7/2024 and was not reported to licensing.

Correction Narrative: Administrator and staff stated that staff have been retrained on procedure for reporting serious incidents to licensing. Staff have also been retrained on importance of timely reporting.


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

raw_content: A 4 year old child was left unattended in a vehicle with no air conditioner, and with doors and windows closed in temperature above 90 degrees outside for a period of time beyond 15 minutes.

Correction Narrative: Administrator stated that staff have been retrained on importance of reporting of serious incidents and staff have been made aware that report must be made to licensing if any child is left alone in a vehicle. Administrator stated they review incident reports to be sure required incidents are reported to licensing.  Staff members interviewed stated they have been informed to report to licensing if a child in left unattended in a vehicle.


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

raw_content: 2 caregivers were taking children on an activity to go out to eat and left a 4 year old child unsupervised in a locked van.  Both caregivers assumed the other one was responsible for the child.

Correction Narrative: Administrator and staff interviewed stated that a form has been implemented where, before going on any outing it is documented which caregivers are responsible for which children during all activities.  3 children interviewed stated that staff have started telling them which staff are responsible for them when on outings.


summary: 748.705(b)(9) - Reasonable & prudent parent standard-must consider the supervision instructions in the child's service plan

raw_content: Plan of Service for a 4-year-old child requires that child be within vision or auditory supervision and child was left in the van unsupervised.

Correction Narrative: Administrator and staff reported that each child's Plan of Service will be kept in a notebook at each house with child's picture  on the cover and POS will be reviewed by staff and kept updated regarding child's care and supervision required.


raw_content: 4 year old child was left in van unsupervised.

Correction Narrative: Administrator and staff stated that staff have been retrained to remain in close proximity of each child they are responsible for, especially during outings and will conduct a head  count of children when departing and arriving at each destination. Staff members will also check in with each other every 20 minutes during outings to assure that all children are accounted for.  Children interviewed stated that staff are near them and supervise at all times.


summary: 748.535(3)(G) - Child-care administrator responsibilities- Ensuring a child in care is not assigned, utilized, or allowed to act as a caregiver.

raw_content: A staff member left a 4 year old child in a vehicle and stated that she thought another child would have gotten the child out of the vehicle.

Correction Narrative: Administrator and  staff members interviewed stated that staff have been re-trained to never leave a child responsible for any other child in care- under any circumstance. 3 children were interviewed and stated that they are not asked to be responsible for other children.


Correction Narrative: This standard was found deficient as part of a DFPS Investigation. Administrator stated that each parent was made aware of deficiency within 5 days. Administrator provided copy of email and form 7266  sent to parents.


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

raw_content: The operation provided annual unauthorized absences log, however it was missing the section stating how long the child was gone and/or when they return.

Category: Reports and Record Keeping


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

raw_content: The serious incident report was missing information regarding adults involved, witnesses to the incident and names of the treating licensed health care professional.

Correction Narrative: The operation provided a complinace plan on 07/08/2024. All GRO case managers received training regarding the information required in serious incident reports. Direct care staff will receive this training by 07/31/2024. Changes in their case management software will be made in which additional information will be required in serious incidents that involve a child needing medical treatment.


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

raw_content: The operation provided no documentation of reporting a child in care's arrest and detention to the DFPS hotline

Correction Narrative: 5 staff members were interviewed and stated that they have completed refresher training regarding Serious Incident Reports (SIR), time frames for reporting and who is responsible to making sure licensing is notified.  All staff members stated that the case manager or on call case manager is notified immediately of serious incidents and the case manager calls licensing.  Staff stated that standard 748.303(a)(6)(A) was reviewed that training specifically included 24 hour time frame to make report to licensing after becoming aware of a child being arrested or charged.


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

raw_content: Child in care did not have his necessary correctional lenses fixed in a timely manner.

Correction Narrative: Unannounced follow up inspection made at the operation on 2/20/24.2 children and 4 staff members were interviewed including Administrator, Case Manager, Caretaker and office staff.  All staff and children verified that child regarding this case has received their glasses and there are no other concerns.  Receipt was provided by Administrator for child s glasses dated 1/20/24, which was submitted prior to compliance due date of 2/2/24. Children and staff interviewed stated that if there is an issue with glasses or any other need, they notify the child's case manager who ensures that the identified staff member responsible for making appointments is aware and the matter is addressed within a day to ensure children s needs are met timely. Staff stated that they share information on Teams messages so that all staff involved with child's care are aware of issues or needs regarding children and they can ensure through communication on teams that children's needs are met in a timely manner.


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

raw_content: Operation did not report child runaway to licensing within the required time frame.

Correction Narrative: 13/13/2024 follow-up inspection completed at the operation. Administrator stated that staff have been retrained regarding standard 748.303(a)(10)(A) regarding reporting runaways including procedure and policies for timely reporting on 3/4/2024 and provided sign in sheet.  Administrator stated that they will continue to provide follow up trainings to staff on 3/19, 20 and 21.  Administrator stated if there is a runaway caretakers will immediately notify on call supervisor and on call case manager and the case manager will be responsible for calling in sir/runaway within time frame of 6 hours or less depending on age of the child.  3 staff members were interviewed said they had received training regarding timely reporting for sir/runaways and said that on call supervisor and on call case manager will be notified immediately of a runaway and the case manager is responsible for reporting runaway to licensing as per required standard and timeframe. 2 children were interviewed and had no concerns with supervision or anything else and felt safe at the operation.


summary: 748.453(b) - Unauthorized Absence - Maintain each annual summary log for five years

raw_content: An unauthorized summary log was not available for the runaway child.

Correction Narrative: Administrator provided a log which the Administrator will be responsible for recording and maintaining information including names, dates and times of unauthorized absence -as per standard 748.453(b)Unauthorized Absence - Maintain each annual summary log for five years.


summary: 748.685(b)(4) - Caregiver responsibility - when deciding how close to supervise take into account the surrounding circumstances, hazards, and risks

raw_content: The video provided shows 7 children were playing on stationary playground equipment described as teeter totter. The children were observed climbing and jumping on the equipment using it in an unintended manner and pushing it until the entire structure was broken from its base. The children were then pushing the structure a distance through the grass.  A child cut his leg on the broken base which was protruding from the ground and was taken to the ER where he received stitches. The staff member stated that they did not see the child fall and can be seen in the video as being physically present, however, is looking down at their phone the entire time and is unaware of the childs injury and broken playground equipment until the child shows the staff member their injured leg.

Correction Narrative:
12/07/2023; follow-up inspection completed at the operation. Administrator stated that training was completed with staff on 11/22/23 and provided staff sigh in sheet where staff were retrained regarding standard 748.685(b)(4)-caregiver responsibility and supervision, child's rights, and discipline. Administrator stated they will continue trainings as appropriate and remind staff of caregiver responsibilities.

11/21/23, Email received from Administrator stating: Attached is the training we are doing with our staff for the recent citation. I will send the sign-in sheets once completed. We will have completed by 11/30/23.


summary: 748.3563(a) - Protective Surfacing-Must have loose-fill surfacing material or unitary surfacing material in the use zones

raw_content: The equipment was placed on grass and dirt. .

Correction Narrative:
12/07/2023, follow-up inspection completed at the operation. Administrator stated the playground equipment is secured and kept where children don't have access. Inspector observed the equipment to have been moved to the area described which is not used by children. Administrator stated that if they decide to use the equipment again in the future, they will comply with minimum standards, utilizing correct surfacing material.

11/21/23, Email received from Administrator stating: Attached is the training we are doing with our staff for the recent citation. I will send the sign-in sheets once completed. We will have completed by 11/30/23.


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

raw_content: Child in care's belongings were thrown away as a form of discipline.

Correction Narrative:
12/07/23; follow-up inspection completed at the operation. Administrator stated that staff have been retrained on 11/22/23 regarding standard 748.2307 (1) other prohibited punishment and supervision responsibilities, child's rights, and discipline. Staff sign- in sheet was provided to Inspector.  Administrator stated that staff will continue to be reminded of minimum standards - caregiver responsibilities.

11/21/23, Email received from Administrator stating: Attached is the training we are doing with our staff for the recent citation. I will send the sign-in sheets once completed. We will have completed by 11/30/23.


summary: 748.721(b) - Volunteer personnel record-Include signed/dated statement that volunteer will report child abuse/neglect to Tx Abuse & Neglect hotline & administrator

raw_content: Two out of two volunteer records did not have a signed statement for reporting abuse and neglect.

Correction Narrative:
On 08/16/2023 the administrator submitted their compliance plan. The administrator stated the operation has added a tab for tracking in the extended reach program. She stated the two volunteers have signed the missing abuse and neglect & exploitation document that was missing. The administrator provided a screenshot of the extended reach program. RCCR Inspector requested the operation provide the two signed documents as well.

On 08/17/2023 the administrator provided the two signed documents the volunteers signed.


summary: 748.153(2)(B) - Notification - At least 15 days in advance - Changes to floor plan

raw_content: The operation notified licensing they were going to renovate some of the rooms in order to increase capacity on 4/4/2023. However, the operation started renovations on 4/7/2023 which is less than the minimum advance 15 days requirement.

Correction Narrative: The administrator stated the compliance plan is moving forward anytime there are plans for additions or renovations, will inform Licensing a minimum of 15 days prior to any renovation plans.


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

raw_content: Interview confirmed staff did not follow a safety plan regarding supervision and a child was able to leave the operation.

Correction Narrative:
07-17-2023. RCCR conducted an on site follow up inspection and interviewed the operation director about the compliance plan.

	Could you please have them explain how the Behavioral specialist specifically support the direct care staff? The specialist is on hand seven days a week and provide back up to direct care staff and supervisors and develop individual plans for each child in care and do life skills with the children in care.
	How will staff communicate with each other in crisis situations when they don't have teams in front of them? Cellphone? Walkie talkies? Staff use cell phones, house phones and walkie talkies.
	Are they doing head counts during transitions and shift changes? There's a head count at shift charge as part of the overall process of informing oncoming staff, they do head counts when they take the kids outside to play and on outings.
	Are they only going to maintain ratio? Or have extra staff for the children on special supervision? The behavioral specialist don't count in ratio but can support with direct care and there's a supervision on hand 10 hours each weekend and a night shift floating staff.
	Are the therapists contracted out or work for TruLight GRO? If they work for the GRO how do they help staff? The therapists are contracted in that they bill through Medicaid and come on campus for therapy. Each child in care's case manager meets with the therapist quarterly and there's communication when behavioral circumstances arise.
	Please have them be specific on what they are doing daily in real time to ensure supervision not just ratio and not what they would like to do. The operation has changed their safety plans. There was a link on teams, which remains. Additionally, the operation posts the safety plans in extended reach and case managers go over safety plans in person with staff by the next shift after the plan's creation and safety plans are updated and often extended. Safety plan for behaviors such as runaways and self harm are also consulted with the therapists and Trulight goes on the therapists' recommendations. Direct care staff/supervisors and therapists are required to notify Sondra and Tiffany immediately when such an incident happens after hours. The operation doesn't want to take away outside privileges for children in care, since it's often a coping mechanism which reduces runaways, so staff will follow children in care outside.

Email Received 7/5/23

Operation Plan for compliance is as follows:

For Safety Plans;
	consult with therapist and get feedback.
	talk with Behavioral Specialist assigned.
	Staff with supervisor
If it is an emergency, staff with administrators first. We need to make sure each safety plan is specific to the child.


summary: 748.1337(b)(1)(D)(iii) - Initial Service Plan-Include child's trauma triggers

raw_content: Initial service plan reviewed did not list the following items: Youths trauma triggers or plan to educate youth on STDs and human reproduction.

Correction Narrative:
On 04/28/2023 I e-mailed the administrator to follow up on the compliance plan. The administrator provided the following compliance plan. The caregivers were trained on Use common application, psych eval, CANS, and therapy notes to notate any trauma triggers the child
may have menƟoned. During the service plan, discuss trauma triggers with youth. If CANS/pscyh eval have not been completed, write a statement that trauma triggers will be included in service plan review. STDS/human reproduction will be discussed during Human Trafficking class (all youth 12 and older are required to take this class) as well as in Life Skills classes with behavioral specialists. Any concerns are
red flags will be discussed with child's case manager, case worker, therapist. Any referrals will be made.

On 04/24/2023 I reached out to the administrator the compliance plan for this investigation. The administrator was not available.


raw_content: Three of three children interviewed stated no staff were present during an altercation resulting in one child in care being injured.  One of two staff interviewed stated that she was outside, and one of two staff stated she wasn't assigned to children in care.

Correction Narrative: The administrator stated supervision training was completed today by the CEO. I interviewed caregivers and they stated they completed the training and confirmed the supervision protocols. The administrator is  in the process of hiring more caregivers to ensure there is more staff in the houses. The administrator added two behavioral specialist that will be on site six days a week to assist with any supervision needs. Compliance met.


raw_content: There was evidence to support two staff members were asleep during the day with children present.

Correction Narrative: Caregivers interviewed verified they were recently re- trained in awake supervision and if feeling tired or ill to immediately notify their supervisor. The administrator provided the letter provided to caregivers through teams and explained how procedures have been implemented or changed.


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

raw_content: Licensing observed and photographed a plunger in a bathroom sink cabinet with a child in care's shampoo. The operation removed the plunger and Licensing photographed the sink without it.


summary: 748.3395(b)(4) - Hand-washing-Provide hand-washing sinks equipped with soap & a personal towel, single-use disposable towels, or hot air hand dryers

raw_content: Restrooms in all 4 houses did not have hand towels available to children in care.

Correction Narrative: The inspector completed a walkthrough of all the restrooms. The administrator stated they have order extra types of items for hand drying, but they have not arrived. The inspector observed hand dryers in some of the restrooms and a hand towel in other restrooms. No concerns were noted.


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

raw_content: Refrigerator that was accessible to childen in care had mold inside.


summary: 748.303(e)(5)(A) - Serious Incident-Report to Licensing within 24 hours of awareness of abuse/neglect investigation by other entity of person under auspices of facility

raw_content: A DFPS investigation was not reported to Licensing within 24-hour timeframe.

Correction Narrative:
12/22/22 Administration emailed Inspector stating they do not want an Administrative Review.
12/19/22 Administration stated they understand any employee that has an investigation on himself/herself, must be reported to the hotline. Training happened when the inspector explained the standard to the operation. The operation does not have a history of not reporting. This refresher provided by the inspector is sufficient for compliance.


summary: 748.685(d)(3) - Caregiver responsibility- Child participating in unsupervised activity - caregiver must provide/arrange/ confirm transportation to & from activity

raw_content: Although transportation for a child in care was arranged, it was not confirmed from one shift to the next at the operation, resulting in a child in care receiving a ride home from a classmate's parent.

Correction Narrative: An email was received from Director stating Staff was late picking the child up.  Events are put on a group calendar.  The school also has contact information for several TruLight employees.  Information regarding pickup is passed along to the direct care staff to ensure each child is picked up on time.


facility_name: Davidson Respite House

raw_content: Although staff was present in the room with the children, the staff did not provide adequate supervision as required therefore the children were able to engage in inappropriate touching.

Correction Narrative: In person follow up was conducted at the operation. Two staff were interviewed. The compliance plan was reviewed regarding the following: the operation and supervisors will continue to encourage, reinforce, and enforce that staff remain actively engaged and attentive when caring for the children in our program to ensure their safety and well-being at all times. All staff will receive in-person Active Supervision training by December 20, 2025, which will include instruction on appropriate positioning, anticipating behaviors, maintaining line-of-sight and auditory supervision, and effectively responding to high-risk behaviors. Staff will be required to demonstrate competency through observation and coaching to ensure they can consistently apply these supervision practices during daily routines.


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

raw_content: Due to the child's previous high-risk behaviors towards other children in care the staff did not minimize the risk according to service plan. Although the staff were present in the room the video surveillance shows the staff were not positioned so that they can see the children in their care and react immediately.

Correction Narrative: In person follow up was conducted at the operation. Two staff were interviewed. The compliance plan was reviewed regarding the following: Respite Care of San Antonio/Davidson Respite House will continue to notify all direct care providers of the supervision requirements for children who exhibit high-risk behaviors. Additionally, the operation will continue to include high-risk needs and behaviors in each child's Service Plan and Supervision Plan as they occur, ensuring staff are informed of required interventions and strategies to reduce potential risks. Beginning November 2025, the operation will also begin collecting staff signatures through ADP to verify staff awareness and acknowledgment of updated supervision guidelines for children with high-risk behaviors.


raw_content: A direct-care staff left two children unattended in their highchairs for about 30 seconds before another direct-care staff member entered the room to supervise the children. Although an adult was in the room while the children were unattended, that adult was a therapist not counted in child/caregiver ratio.

Correction Narrative:
10/14/25 In person follow up completed at operation. Inspector Walk through conducted of Davidson and Najim house and both were in compliance of minimum standards. Davidson
Respite Houses is getting repainted, and three children have been relocated to their own beds downstairs to ensure the children have appropriate sleep space. There is currently 9 children at Davidson Respite House and 8 children at Najim House. Three toddlers are also in care in the nursery. There was no concerns for staff caregiver ratio. The Najim house is having a
restroom remodeled in one of the children's bedrooms. A staff stays in the room with the children to supervise the child and ensure children do not enter the restroom or other areas in the home that are being remodeled. Two direct care staff were interviewed as well as with Hailey OToole, Quality Improvement Specialist. Administrator Raven Lewis submitted the compliance plan on 10/9/25 which included retraining for direct care staff including supervisors during a staff meeting. The meeting consisted of topics related to effective communication between staff and retraining regarding active supervision, emphasizing the
importance of consistent communication between staff members during shift transitions, breaks, bathroom supervision, and offsite activities. Direct care staff did not have concerns regarding staff supervision at this time. All common areas also have postings with supervision protocols that are required in for each activity and what area it applies to as well as supervision requirements, and compliance notes. Supervisors are also utilizing a guidance and strengthening log for direct care staff who are not successful at applying the information that was provided during the meeting. One child was interviewed and they had no
supervision concerns and discussed never being alone or without a staff present while either inside or outside the home.

10/9/25 email received from operation to address this issue of noncompliance, all staff received retraining on September 25, 2025, regarding active supervision and effective communication expectations to ensure children are supervised appropriately at all times. The retraining included a review of RCSA's internal policy on Active Supervision, emphasizing the importance of consistent communication between staff members during shift transitions, breaks, bathroom supervision, and off-site activities. Staff were provided examples of situations where a lack of communication could compromise supervision and were given strategies to prevent such occurrences. Supervisors were instructed to reinforce these expectations daily during shift change meetings and to closely monitor adherence through regular walkthroughs and debriefs. In addition, the schedule has been modified to address the supervision concerns that occur during periods of transition for the children. The changes to shift times are as follows; 7am-3pm, 3pm-11pm and 11pm-7am. Also, a new shift was added (5am-1pm) to ensure there is adequate staffing at the time of bus pick up. Continued oversight will occur through monthly audits, documentation of coaching on the Guidance and Strengthening Log, and quarterly refresher trainings to prevent reoccurrence and maintain a high standard of supervision and communication among staff.


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

raw_content: Victim child was able to walk at least 20 feet away from the splash pad and was unsupervised for approximately three minutes. The child was known to wander off and required one on one supervision according to the childs Service Plan.

Correction Narrative: Two staff discussed whiile on outings the staff are required to provide one on one supervision according to the childs Service Plan. The staff will always have sight of the children in care and stay within ratio.


raw_content: Child had access to chemicals on more than one occasion and unknown if child was ingesting.

Correction Narrative: Three staff were and one child in care was interviewed and discussed chemicals being out of sight of children and how staff are disposing and securing chemicals after use. Staff discussed supervision of children in care. No additional concerns were noted. The chemicals were observed secured with an appropriate lock that does not allow for children to have access.  Compliance plan was provided via email on 9/8/25 with the following: additional locks have been placed on all chemical cabinets to ensure poisonous and flammable materials remain inaccessible to children at all times. Staff have been reminded that children must never have access to unsafe items while in care. Shift Supervisors will complete walkthroughs daily before the conclusion of their shift to ensure that all chemicals are stored properly and all cabinets remain locked, and they will document any issues in their end-of-shift notes. Supervisors will reinforce with their teams that active supervision practices, maintaining awareness of children's activities and ensuring that children are never left unattended in areas where chemicals or unsafe items are stored, are required at all times. In addition, all empty chemical bottles will be disposed of directly in the dumpster to prevent unsafe storage. The Quality Improvement Specialist (QIS) will verify compliance during regular facility walkthroughs, and the Director will review findings to ensure corrective measures are sustained. These measures will protect the health, safety, and well-being of children in our care and ensure ongoing compliance with licensing standards.


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

raw_content: Child had access to chemicals, and it was unknown to staff these items were being stored in the child's room.


raw_content: Caregiver was asleep while caring for a child.

Correction Narrative: Supervision protols which staff discussed as being helpful 20 minute checks and noted in the log by supervisor.


raw_content: Although staff was present with the child, the staff appears distracted by reaching for item from the drawer and was not aware the child had moved to roll over and fall onto the mat on the floor.

Correction Narrative: The staff have a new changing table and they have supervision protols which staff discussed as being helpful. Children are never to be unattended in or on the table.


summary: 748.1013(a) - Child/caregiver ratio-A caregiver must be awake when caring for a child needing constant supervision

raw_content: Caregiver fell asleep while caring for children in care.

Correction Narrative:
Email correspondence from Raven Lewis was received with the following compliance plan:  Respite Care has taken immediate corrective action to prevent recurrence. All direct care staff will receive refresher training on supervision levels, with a focus on the requirement to remain awake during supervision of high-needs children during the Team Member Meeting on 7/31/2025. Supervisors will review supervision assignments at each shift change to ensure clarity and accountability. Additionally, overnight monitoring checks have been increased from every 30 minutes to every 20 minutes to better ensure staff remain alert and children are appropriately supervised. Overnight supervisors will also continue to conduct and document regular walkthroughs to confirm that staff assigned remain awake and engaged. Staff found asleep during required awake supervision will be subject to disciplinary action in accordance with agency policy. Effectiveness of the plan will be evaluated through weekly reviews of shift logs and overnight walkthroughs by the Quality Improvement Specialist, along with monthly compliance audits and leadership meetings. Increased overnight monitoring began on July 8, 2025.

On 7/16/25 Inspector conducted two child interviews at DRH there were no concerns regarding staff being seen sleeping or falling asleep while children are in care. Neither child has seen any staff sleeping during their bedtime hours. Both children discussed feeling safe and the staff providing supervision while in care. Two staff supervisors were interviewed, and they discussed their role is to ensure that all staff are awake and there is a zero tolerance for staff who are sleeping while care for children. In addition, starting 7/8/25 the staff will conduct night checks every 20 minutes instead of 30 minutes. The supervisors and staff must initial their assignment in the overnight binder to ensure children are being supervised appropriately. Supervisors also discussed conducting walkthroughs and having communication with staff to ensure the staff are to remain awake though the working hours. The supervisors interviewed had no concerns regarding weekly reviews, monthly audits, and leadership meetings. Inspector revised the night log to verify staff are signing every 20 minutes. Exit was conducted with Administrator.


raw_content: A child in care was not appropriately supervised leading to the child leaving the residence and walking into a second building behind the residence.

Correction Narrative: RCCR Inspector conducted an in person follow up at Davidson Respite House on 4/23/25 for INV 3150413. Prior to arrival, inspector went to Cotton Academy Elementary and was unable to interview child due to non-verbalization. Child was observed wearing age-appropriate clothing. Child had a bruise on the outer right wrist area and severe swelling and bruising to her left index finger.  Investigation was being initiated by an investigator at time of inspector's arrival. A second verbal child was not in school therefore could not be interviewed. No other verbal children who attend school could be interviewed due to being nonverbal. Two staff and administrator were interviewed and a walk through of Najim House were conducted. There were no concerns for child's bedroom or clothing inventory. Three doors that allow entry and exit of the home were checked and had working alarms. Staff interviewed discussed new supervision protocol in place for child. Staff will ensure doors remain closed and locked securely as well as one on one supervision will be required.


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

raw_content: Two of the three files reviewed were missing Pre-employment affidavit document in staff personnel file.

Correction Narrative:
Program Director Raven Lewis emailed Licensing Inspector the plan for Standard 748.505(b)(5) with the following information: RCSA will implement a standardized checklist to ensure that all required documents including Form 2912 Pre-Employment Affidavits are accounted for during the hiring process. Additionally, all new hires will be required to complete Form 2912 through ADP during their preservice training period. Furthermore, RCSA's Human Resources Department will continue to conduct routine audits of personnel files to ensure that all necessary documents are present and readily available upon inspection.

Standard 748.505(b)(5) will be compliant as the plan meets the requirements.


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

raw_content: Two of the three employee files did not include required reporting abuse, neglect, and exploitation document.

Correction Narrative:
Program Director Raven Lewis emailed Licensing Inspector the plan for Standard 748.507(2) with the following information: the Respite Care of San Antonio, Inc. Reporting Abuse, Neglect, or Exploitation forms were not present in the physical copies of our personnel files. These files have recently been transitioned to our virtual HR system through ADP and will be provided with the submission of this corrective action plan to show compliance as of the audit date. RCSA has also taken steps to ensure that all team members responsible for facilitating monitoring visits are aware of the location of each file or document that may be requested, or that is not physically maintained within our personnel files.

Standard 748.507(2) will be changed to compliant as the plan meets the requirements.


summary: 748.1209(a) - Child Orientation-Provided to child who is 5 years old or older within 7 days of admission and geared to child's intellectual level

raw_content: Three child files did not include proof of orientation completed or documents verifying orientation was completed within the required time frame.

Correction Narrative:
Program Director Raven Lewis emailed RCCR Inspector the plan for Standard 748.1209(a) with the following information: to ensure compliance and provide the highest quality of care to the children in our facility, Respite Care of San Antonio has implemented a new preplacement document that is to be reviewed with prospective residents prior to the completion of the required DFPS forms. The intent of this document is to serve as a child orientation that is to be provided to children ages 5 and older. Within this document, RCSA will discuss policies related to:
	Visitation
	Mail
	Telephone Calls
	Gifts
	Personal Possessions
	Emergency Behavior Intervention (EBI)
	Discipline
	Religious Programing and Practices
	Education
	Program Expectations and Rules
	Daily Schedule
	Internal Grievance Procedures
This document will be discussed with each child and the information will be delivered in a manner that considers the child's age and developmental level. This will be done to ensure that each child is provided with a fair opportunity to advocate for themselves if it becomes necessary.

Standard 748.1209(a) will be marked as compliant as the plan meets the requirements.


raw_content: Child was unsupervised and left behind at the aquarium during a field trip. Staff did not realize child was missing until they returned to the operation.

Correction Narrative: All staff will complete a mandatory retraining on active, visual supervision and field trip protocols. The Field Trip Procedures and Form has been updated, requiring headcounts at four key intervals: before departure, upon arrival at the destination, before leaving the destination, and upon return to the facility. To ensure adequate oversight, an administrator or shift supervisor will be required to attend all field trips involving eight or more children. In addition, the Quality Improvement Specialist will conduct random audits of field trip documentation and will observe future outings when feasible. Lastly, supervision procedures will be reviewed during all team meetings over the next 90 days to reinforce expectations and promote accountability.


summary: 748.1017(a) - Child/caregiver ratio-Child/caregiver ratio applies to activities conducted by the operation, that occur away from the operation

raw_content: Staff left assigned children with another staff resulting in staff being out of ratio.

Correction Narrative: All field trip plans must include a ratio assessment specific to the children participating, with particular attention to any heightened supervision needs documented in their service plans. A caregiver-to-child ratio of 1:4 or less will be required on all future outings to ensure adequate supervision and safety. Supervisory staff will be responsible for reviewing and approving all staffing plans prior to any off-site activity. Staff are required to remain with their assigned groups at all times. If one child needs to be removed from an activity for any reason, the staff member must remove their entire group to ensure that appropriate supervision is maintained and caregiver-to-child ratios are not compromised.


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

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

Correction Narrative:
The team member directly responsible for the incident was terminated following the investigation. All remaining staff will complete a mandatory refresher on 5/29/25 on trauma-informed care, professional boundaries, and recognizing/reporting abuse or neglect. Staff will also review the Children's Rights Policy and acknowledge their understanding and responsibility. The Program Director and Quality Improvement Specialist will facilitate reflective supervision meetings to provide space for staff to discuss
challenges and receive coaching on appropriate responses to children's behaviors. Ongoing spot checks and observation reviews will be conducted to ensure policy adherence, with any concerns immediately addressed through corrective coaching or disciplinary action.