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: Operation did not report a child's allegation of abuse by a staff member until four days after the allegations were made.

Correction Narrative:
The Administrator's outbox email was observed where an email was sent to all staff reminding them that they are required to report any allegations of abuse, neglect and exploitation. In addition, interviews were conducted with staff in which they informed that they are aware and were reminded by the Director.
The operation provided the following correction: verbal guidance was provided to the staff who became aware of the allegation of abuse and the
importance of reporting to licensing as soon as becoming aware of allegations of abuse, neglect, or exploitation; the written guidance was also referenced to ensure each party was aware of how to make a report to licensing.


state: TX

facility_name: Shiloh Treatment Center

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

Category: Individual Standards Evaluated

Standard Risk Level: High

Corrected at Inspection: No

Correction Narrative:
On 06/09/23 I received an email from the operation LCAA with the following correctives.
I am responding to the findings from the investigation conducted at Shiloh Treatment Center on Thursday, May 25, 2023.
Standard 748.1531 (a)(2): Medical care  A child in care must receive medical care as needed for injury, illness, and pain.
Specifics: There was a delay in the child receiving medical care.
Shiloh received a verbal order from the physician for the child to receive an x-ray of his right hand due to swelling and complaints of pain. Shiloh did not obtain an x-ray of the child's hand until over 24 hours from initial verbal order, although nursing assessment and care was provided during that timeframe.
On Friday, May 26, 2023, the medical department received written guidance on the immediacy of providing medical care for a serious injury. In addition, the medical department also received written guidance on the minimum standards regarding medical care as well as a reminder of the timeframe for notification and reporting of serious incidents to licensing.
Technical Assistance was reviewed, and corrective action taken. If you need any additional information, please contact me.


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 the walkthrough it was observed in room #4 a dresser drawer and a window blind were damaged.  In Room#2 the window blind was damaged.  Work orders were submitted on 3/16/2023 during the inspection.

Standard Risk Level: Medium High

Correction Narrative: Shiloh staff replaced the damaged blinds and damaged dresser drawer in Room #2 and #4.  Photos were taken during the Follow-up.


summary: 748.1211(b)(2)(B) - Parent Orientation-Must review & provide written materials on type & frequency of notifications made to parents

raw_content: The parent orientation does not have any information on the frequency of notifications that will be made to parents.

Category: Admission, Service Planning, Discharge

Standard Risk Level: Medium Low

Correction Narrative:
Shiloh updated the parent handbook to include the section, Notifications to explain the
frequency of notifications that will be made to parents/guardians.


raw_content: A staff member witnessed a serious incident and did not immediately report it.

Standard Number / Description: 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

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


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: Operation employees failed to adhere to the child's rights to be free of abuse, neglect, and exploitation as defined in TFC §261.001 and further defined in TAC Rule §707.801, which resulted in an immediate danger to a child's physical health and safety.


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

raw_content: A staff member grabbed a child by the arm and dragged them off a couch and down a hallway. Then the staff member pushed the child into a bedroom.


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

raw_content: A staff member pulled a child by their hair.


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

raw_content: A staff member recognized another staff members actions were inappropriate and still failed to intervene.


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 failed to utilize proper de-escalation techniques when they realized a child was having a crisis and instead of professionally assisting the child, exhibited physical aggression to the child in care.


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

raw_content: A staff member failed to accurately depict the incident when completing the incident report. The staff member did not detail the role they played in the incident or the harm they caused to the child. The staff member falsified records by omitting dragging the child and portraying the child as the aggressor.

Standard Risk Level: Medium


summary: 748.1101(b)(3)(I) - Children's rights-The right to have personal items in the child's room and get additional items within reasonable limits

raw_content: A staff member removed items from a child's bedroom as punishment.


summary: 748.931(a)(1)(B)(i) - Annual Training-Must include 2 hours on trauma informed care

raw_content: Staff member only has 1 hour of the T.I.C training when the requirement is 2 hourss.

Category: Training and Professional Development

Correction Narrative:
Shiloh has chosen to request an administrative review for this finding.
Shiloh provides two one-hour training modules titled Posttraumatic-Stress Disorder and Effects of Separation and Loss on Child Development. The two training modules combined create two hours of annual training for Trauma Informed Care. Shiloh is compliant with the standard despite the title of the training module. However, Shiloh will combine these two related modules into a single training module titled Trauma Informed Care to assist in review of training compliance.


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

raw_content: Medication log does not have what time the residence medication is being given.

Category: Medication

Correction Narrative: Shiloh strives to administer all medications as prescribed and in compliance with the minimum standards. The staff were instructed to write the time below the evening mealtime dose administered on the monthly Prescription Medication Record


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

raw_content: Operation failed to assure staff Background checks are being verified every 3 months.

Correction Narrative: Shiloh submitted the validated employee list. The Human Resource Records Manager is responsible for quarterly review and validation of current employees on the provider site for Child Care Licensing.


summary: 748.3421(3) - Poisons-Ensure poisonous or flammable materials are inaccessible to children unless child has been evaluated as capable & likely to use responsibly

raw_content: During the walkthrough two bottle of cleaning supply where left in unlocked cabinets.

Category: Physical Site

Corrected at Inspection: Yes


summary: 745.621(a)(2) - AP Initial background checks submitted - At the time you hire someone

raw_content: There are 4 staff members currently working in the homes that do not have background checks.

Correction Narrative:
Background checks have been reviewed and the staff all have background checks at this time.
Shiloh submitted the background check requests for the four staff members to the CCL
CBCU on 01/11/22. All four employees were determined to be Eligible per the
background check results from CCL CBCU.
Shiloh's new Human Resources Record Manager was confused about the two versions
of required background checks for TDHHS and Office of Refugee Resettlement (ORR).
A background check was submitted and received from ORR via the Texas Department
of Public Safety for each employee prior to hiring. Shiloh did not allow any employee to
begin working with clients without an eligible background check. Unfortunately, there
was confusion about submission for TDHHS CCL and ORR employees. The
misunderstanding was clarified and the process for background checks resumed the
correct procedure on 01/11/22.


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

raw_content: During the walkthrough I observed toilets in 58C to not be cleaned properly, and the refrigerator door to be dirty. In house 58B I observed a cloth mattress to be without a mattress cover and exposed wire trimming.

Correction Narrative:
Shiloh staff cleaned all toilets and the refrigerator in 58C on 01/10/22.
The mattress in 58B was removed and replaced with a vinyl covered mattress on
01/10/22.
Shiloh has a House Checklist Monitoring Program that is in the process of being
reinstated in February 2022. Compliance with safety guidelines regarding the storage of
cleaning supplies will be monitored regularly.


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

raw_content: The operations policy advises that the facility administers drug test quarterly but multiple staff have not had drug test in a number of years.

Correction Narrative: The operation has revised their drug testing policy. copy of forms have been uploaded into SharePoint.


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

raw_content: One staff file lacks an valid drivers license/

Category: Transportation

Standard Risk Level: Low


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

raw_content: The facility is permitted to take children 3-17 years old but has excepted a resident who is 18 years old upon being admitted.


facility_name: The Ark Assessment Ctr & Emergency Shelter

summary: 748.1101(b)(4)(B) - Children's rights-The right to discipline that is appropriate to the child's age, maturity, and developmental level

raw_content: A caregiver used pore judgement when disciplining a young child, by hitting the child with a sock on the child's lower extremity.

Correction Narrative: corrections were set via email, the agency will be retraining staff and reviewing standards and policies with them on a quarterly basis to ensure that they are in compliance. The inspector had informed me that he would be citing the agency prior to closure. When I visited the facility I spoke to them about the staff in question because I got an investigation after that involved the same staff. It was mitigated. The staff is not counted in ratio and the staff will not interact with the children. I also spoke to the staff and she also understood. She will only be doing administrative duties.


raw_content: No one witnessed the incident that was reported, but witnesses were named on the incident report.

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

Correction Narrative: The administrator sent corrections via email informing me that she had spoken to staff about incident reports. I completed a physical follow up 4/25/2025 and spoke with staff. They were able to tell verbalize that the administrator had the discussion with them and informed them of making sure that incident reports need to be proofed to make sure all information is true and accurate.


raw_content: A caregiver did not exercise prudent judgement when they physically grabbed and turned a child's face towards a laptop used for virtual visits.

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

Correction Narrative: They operation had a meeting in discussing that the employees need to use prudent judgment, and they will not force the children to face the camera if they don't want to. A physical follow up was completed 1/23/2025. It was discussed that they will be reducing the time of the visits and increasing the number of days. So that children can sit easier for these visits instead of long periods of time. It was also discussed with the operation that we need to show patience with the kids when they are having these visits with parents. I informed them that if the kid is not paying attention to the camera then so be it. The parent and CPS worker will see that. It is not something we can control. Delma agreed.


summary: 748.753(d)(1) - Pre-Employment-You must document in the employee record each references name, relation, date completed, info obtained and name of interviewer.

raw_content: Fourt employee files were reviewed. Two of the employee files were found to be missing the date and contact method for references checks and employment verification. In One employee file referenec checks were not conpleted.

Correction Narrative: On 4-15-24, the administrator provided copies of the corrected reference checks. The administrator stated she would be responsible for ensuring both employer and reference checks would be completed.


raw_content: One of six medicaiton logs revewed was found to be missing the year, time and signature of the person who administered the medicaiton.

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


raw_content: A medication log indicated the medication for this evening had already been adminsitrered at 7pm and the time was only 2:37pm.


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

raw_content: Three  child records were reviewed during a monitoring inspection. The records do not have documentation of parent notification for the child's plan of service meeting.

Correction Narrative: On 10-14-23, the administrator provided a response to the citation. The administrator indicated she will be responsible for providing oversight, to ensure notice to parents is send two weeks prior to the service plan meeting.


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

raw_content: One of six employee files did not have record of an affidavit for employment.

Category: Personnel

Correction Narrative: On 4-26-23 the administrator sent an email, with a notarized copy of the missing affidavit for employment.


summary: 748.1337(b)(1)(N) - Initial Service Plan-Include signatures of service planning team members that were involved in development of service plan

raw_content: In the course of an investigation, a child's service plan was requested. The service plan does not have signatures, denoting who participated in the plan meeting.

Correction Narrative: On 4-25-23, I (Ruben Garcia) met with the administrator. The administrator informed me that corrections have been made. She also ensured that signatures for all service plan participants will be obtained, moving forward.


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

raw_content: The facilities Fire Inspection has lapsed, the last fire inspection was conducted on 6/7/2021.

Correction Narrative: On 8/9/22 the Administrator forwarded a copy of their Fire Inspection which was done on 8/9/22. Also sent was the Gas Inspection which was done on 8/8/22.


summary: 748.363(6) - Personnel records-Include notarized Licensing Affidavit for Applicants for Employment form as specified in Human Resources Code, 42.059

raw_content: One of six employee filed reviewed was found be missing the affidavit for employment.

Category: Reports and Record Keeping


summary: 748.931(a)(1) - Annual Training- Administrators, PLSP's, treatment directors and case managers who do not hold a prof. license must have 20 hours.

raw_content: Four of six employee records reviewed were found to have delinquent trainings for Normalcy.

Correction Narrative: The administrator forwarded copies of certificates for staff missing their annual normalcy training.


summary: 748.4213(d) - Emergency Care Discharge Plan-the preliminary discharge plan and weekly reviews must be available for Licensing review

raw_content: Two of four child records reviewed did not have a  of weekly reviews with signatures,  for the Emergency Care Discharge plans.

Category: Emergency Care

Correction Narrative: On 5/25/22 the administrator provided an action plan to address the citation. The administrator will ensure the weekly reviews are completed and signed by the responsible personnel.


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

raw_content: Two of six employee files were found to be missing proof of TB tests.

Correction Narrative: The Administrator provided copies of TB tested for the staff.


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

raw_content: During a monitoring inspection it was found the two the the four personnel files were missing proof of education.

Correction Narrative: The Director provided a memo advising that the employee has been reassigned to a non-caregiver  role. The employee will remain in said position, until the employee can provide proof of education.


raw_content: The annual fire inspection was expired.  Last date was 2/17/20.

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

Category: Safety and Emergency Practices

Correction Narrative: Administrator provided a copy of the approved Fire Inspection dated 6/7/21.


summary: 748.4657(1) - Annual Training-All caregivers must complete 50 hours

raw_content: Eight caregivers that transport children did not have current transportation training.

Correction Narrative: Delma Trejo, provided copies of certifications for the 8 staff who were missing transportation training.


facility_name: The Jim H. Green Kidz Harbor dba Kidz Harbor

summary: 748.303(a)(2)(B) - AP Serious Incdt- Report to parents any injury/illness that warrants treatment from a medical prof. directly after ensuring the safety of the child.

raw_content: Based on a review of the information, it was determined that an adolescent in care sustained an injury that warranted treatment by a medical professional; however, the incident was not reported to parent(s) within required timeframe.

Correction Narrative: 07/18/2025-The operation's Case Manager submitted via email the Corrective Action Plan to Licensing indicating that staff has been advised that any injury/illness that warrants treatment from a medical professional will need to be reported to the appropriate individuals (CPS, Case Workers, Supervisors) within the required timeframe.


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

raw_content: Based on a review of the information, it was determined that an adolescent in care sustained an injury that warranted treatment by a medical professional; however, the incident was not reported to Licensing within required timeframe.

Correction Narrative: 07/18/2025-The operation's Case Manager submitted via email the Corrective Action Plan to Licensing indicating that staff has been advised that any injury/illness that warrants treatment from a medical professional will need to be reported to the appropriate individuals (Licensing) within the required timeframe.


raw_content: During the inspection it was found that the operation has not yet had a fire inspection this year. The last inspection was on 8/17/2023.

Correction Narrative: An email from the operation was received with the fire inspection report from the Brazoria County Fire Marshal's Office. The inspection was completed on 10/6/2023


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

raw_content: During the inspection it was found that two of four child's records reviewed did not have a suicide screening administered at admission

Correction Narrative: An email was received from the operation with the new screening tool that will be added to the admission packet, ASQ Suicide Screening Tool from the NIMH toolkit


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

raw_content: During the inspection it was found that a child's medication log contained medication administration errors on five days

Correction Narrative: An email was received from the operation with an updated medication form to be used when a medication is missed or refused.


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

raw_content: During the inspection it was found that the operation has not conducted a severe weather drill

Correction Narrative: An email was received from the operation showing their updated emergency practices log. A severe weather drill was held on 10/3/2023


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: Two sinks in one of the girls restrooms had low water pressure, two dresser drawers in one bedroom were off the tracks, and wood paneling on one of the boys bedroom door was in need of repair.

Correction Narrative:
Email received from the facility stating the following: The faucets on the two sinks in the girl's bathroom have been replaced due to erosion in the old faucets that caused low water pressure.
The 2 dresser drawers in the girls' bedroom were corrected at the time of inspection by pulling them out and sliding them back on track.
The door in one of the boys' bedrooms where the wood was peeling has been replaced with another door.


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

raw_content: There was missing information from 2 incident reports reviewed; the physical address, telephone number, and date of admission of the children

Correction Narrative: RCCL received an email from the operation with an updated serious incident form that included missing information.  The administrator explained they will be combining two separate forms so that all information is found on one form for serious incidents. This form was revised and will be used to document future incidents.


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: An incident was not reported to licensing within 6 hours of an unauthorized absence.

Correction Narrative: RCCL inspector received an email that the administrator staffed with her workers regarding reporting unauthorized absence within 6 hours if the child is missing and their whereabouts is unknown.


summary: 748.3271(3) - First Aid Kits-Each one must be in good condition and not have expired medications or supplies

raw_content: There was expired medication found in the first aid box.


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

raw_content: During a walk through the inspectors could not open the bottom dressers in one of the girls bedrooms. There was a bottom drawer missing from a dresser in another girls bedroom.

Correction Narrative: RCCL Inspector received the following: The citation for bottom dresser that inspectors could not open were off the track and the drawer was pull out and placed back on track correctly so drawer could open properly. The dresser that had the missing drawer was removed. Photos were provided.


facility_name: ACH Child and Family Services Emergency Shelter

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

raw_content: Out of four staff EBI training reviewed, one was not current and three did not have documented EBI training every 6 months.

Correction Narrative: The operation met compliance by providing a copy of the caregivers/employees current EBI certificates and sending a response stating that a monthly review of all YES employees will be completed by the training department to ensure that each employee is compliant with EBI training requirements. In addition, the YES program manager will conduct 2 additional EBI training courses for YES program staff each month to ensure trainin compliance.


summary: 748.1539(b) - Immunizations-The operation must maintain current immunizations records for each child in care, including any exemptions or exceptions

raw_content: During the course inspection it was found that the operation vaccinated a child in care that had a signed affidavit stating for the child not to be vaccinations.

Correction Narrative: The operation came into compliance by the ACH YES Program Clinical manager retraining the Family Engagement Specialist and Clinical case manager at the YES program regarding the requirements around youth vaccination requirements as well as well as ensuing that they have access and login credentials to the ACH network to the due to the ACH VPN to have unlimited access to their email to ensure email communication remains uninterrupted during power outages and emergencies. Training logs were also provided with signatures.


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

raw_content: After reviewing the video, it shows staff sitting at a table on their cell phone. Staff never look up to see the child leaving from the common area.

Correction Narrative: The operation came into compliance by conducting a training on 1/28/2024 at the operation. Staff went over the importance of supervision. Training log was submitted. Training logs and staff sign in sheets can be found in the document library.


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

raw_content: During the review staff reported that he told victim he was lucky he wasnt 18 because he would have beat his ass.

Correction Narrative:
The operation is receiving an extension until 1/6/2025 due to the corrective action form needing HR approval before signatures can be provided.

The operation came into compliance on 1/2/2025 by providing a signature from the Supervisor showing proof that that the supervisor received counseling on the Corrective Action.

Copy Of the signed form can be found in Document Library.


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

raw_content: A child in care ran was absent from the facility 04/19, 04/20, 04/24, and an attempt on 04/25. The child stated that the running away was an attempt to obtain cigarettes. The incident report does not document how the operation planned to reduce the probability of additional absences.

Correction Narrative: Operation answered this deficiency stating that this  standard was in compliance due to the resident never left sight of staff who follow closely during the attempt and processed with the resident successfully as evidenced by his safe return. Operation stated they will appeal this decision concerning this standard


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

raw_content: On May 7th Christopher P. was administer Trazodone by staff member ASA,. ASA did not document the time the medication was provided.

Correction Narrative: Operation provided plan indicating that they will add a target time to each medication log ensuring that if initials are provided this does indeed indicate the medication was given within a 30-minute window (15 minutes either side) of the target time.)  Should the medication be administered outside of the 30-minute window, an exact time will be provided.


summary: 748.1437(1) - Discharge/Transfer Documentation-Must include date and circumstances of discharge or transfer

raw_content: 2 of  2 child files reviewed did not have complete discharge summaries completed to include required information including circumstances of discharge, assessment of child needs, support resources and aftercare plans.

Correction Narrative: Operation submitted plan stating that they intend to audit each and every chart following discharge within 72 hours to ensure all associated paperwork including the discharge summary is completed.


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

raw_content: A review of a child's medication log did not have required name and signature of staff who administered medication.

Correction Narrative: Operation stated in regards to this deficiency that every staff member is encouraged to sign the back of a medication log within the medication record so that the associated staff initials can be utilized as confirmation of a successful medication administration.  In this case we believe that the staff did sign the back of multiple medication logs within the medication record but that the reviewing licensing representative did not credit the signature of said staff associated with the specific log in question. Operation is appealing decision.


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

raw_content: Two staff members at the operation failed to prevent a child in care from assaulting other children in care with an object.

Correction Narrative: Operation indicated that one specific adjustment they have made since this incident is to place Ukeru pads in the ERC gym to be used as another tool in the de-escalation process.


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: While under the supervision of caregivers an 11 year old stabbed a 13 year old in the chest and back with a stick causing an injury.

Correction Narrative: Operation indicated that due to the seriousness of the allegations, both staff members named in the RTB have been suspended pending the resolution of this investigation and will have no contact with any children at the shelter as a result until that time.


summary: 748.1331(f) - Preliminary Service Plan-Implement and follow the preliminary service plan

raw_content: A child was escalated and the staff member failed to use coping mechanisms listed on the service plan.

Correction Narrative: The case manager who writes the preliminary plans of service will be expanding on content to ensure that a variety of coping skills are listed and not simply the first two that come to the child's mind.


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

raw_content: When a child had escalated behaviors, staff member pulled a child hair in order to gain compliance.

Correction Narrative: Operation response indicated that this in no way was proper EBI technique, because this grabbing of the child's hair was done not as a punishment but as an inappropriate knee jerk reaction to the staff member being grabbed by the hair by the child from behind, Standard 748.2307(6) does not apply and the appropriate standard that could have been cited actually covers Techniques staff members are prohibited from using on a child and includes, but is not limited to any technique designed to or likely to cause a child physical pain, 748.1119(2), would have been the correct standard to cite.   As such the standard that was cited in this deficiency does not apply and should be removed.  However, as stated previously the staff member who was in violation of implementing a prohibited technique has been suspended pending termination and will not have access to any children from this point forward.


summary: 748.459(a) - Unauthorized Absence-Triggered review of childs unauthorized absences must include, child, designated staff, and childs case manager

raw_content: two of the three triggered reviews did not indicate that the child's case manager was present for the triggered review. The child's case manager must participate in the triggered review.

Correction Narrative: The agency modified their Triggered review signature page to include the title of the persons that are required to attend the triggered review and added a date line for when the notification was sent to the required parties. The new form will be discussed in their meeting to ensure that everyone is aware of the process.


summary: 748.1117 - Documentation of searches-Caregiver documents searches in the child's record

raw_content: The staff conducted a search of the youths' room, took cell phones, and did not document the search.

Correction Narrative: Operation provided response to this deficiency including incident report showing the search was documented, operation stated that they would also be filing an appeal to this deficiency as they indicated that it was issued in error.


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

raw_content: Staff did not use any measure to encourage the children to not run away.

Correction Narrative: Operation provided response to this deficiency including IR report showing that staff did re-direct youth. Operation is requesting an administrative review indicating that this deficiency was issued in error.


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

raw_content: One initial service plan is missing several pieces of required information such as the child's personal trauma history, trauma triggers, plans for educating on STD's and human reproduction, and plans for preparation for independent living.


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

raw_content: A child's chronic condition of being epileptic or having seizures was not on the exterior of the file and was not clearly visidble in the file.

Correction Narrative: This child is no longer in placement. An inspection to the operation was completed on 06/06/2023 to determine compliance with this standard. 3 out 3 records reviewed were in compliance.


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

raw_content: A new preliminary service plan was not completed when a child discharged but then was readmitted to the operation several days later.


summary: 748.455(a)(4) - Unauthorized AbsenceDebriefing includes where child went, who was w/ child, childs activities & any other relevant info to childs health &safety

raw_content: Two debriefings do not include required documentation such as what occurred while the child was away, where the child went, and the child's activities. One debriefing does not include the child's condition upon returning.


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

raw_content: The unauthorized absence log is missing how long the child was gone or did not return, the name of the caregiver responsible for the child at the time the childs absence was discovered, the intake report number and the number of the police report.

Correction Narrative: The Inspector received an email from the director with an updated log to include all the required information for the unauthorized absence log.


raw_content: One of the service plans reviewed did not document the supervision in the preliminary service plan for the child.

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

Correction Narrative: The director sent an email stating that an audit all current client preliminary service plans will be conducted to ensure all fields are complete. Going forward, these will be reviewed for thorough completion during the existing monthly record review process.


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

raw_content: Two children were seen going in and out of the closet.


summary: 748.930(b)(2) - Annual Training- Caregivers must have 2 hrs trauma informed care.

raw_content:
One caregivers trauma informed care training expired on 5/3/2022.

Note: This was corrected at inspection due to the staff completing the training during the inspection.


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

raw_content:
One caregivers normalcy training expired on 5/3/2022.

Note: This was corrected at inspection due to the staff completing the training during the inspection.


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 24 hours following an unauthorized absences.

Correction Narrative: Operation director completed a meeting with all staff on 6/28/2022 to discuss the requirement to complete a follow up debriefing when youth go absent without permission within 24 hours of the youth returning. A copy of the meeting agenda and sign in sheet was emailed.


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

raw_content: A child in care was left outside of the operation.

Correction Narrative:
An email was received with an attachment with the operations YES overnight room and and Facility Check Protocols.

1.	 All youth should be in bed no later than 10:00PM, youth may be awake in their rooms but should not be in the common areas unless we are meeting with them or assisting them with something.
2.	Room checks should be completed every 0 to 15 minutes and should be completed in random intervals. Please make sure that we are staggering our check times to ensure that we are not developing patterns of supervision that the youth can pick up on throughout the night.  Checks should never be completed in the same time intervals to ensure that they are random, and they should never exceed 15 minutes.
3.	Please make sure that at least one member of the team is positioned where they can visually see the entry door to the shelter program when not completing rooms checks to ensure that we can see anyone approaching or attempting to access the front entry door.
4.	Headphones should not be worn during working hours to ensure that staff can hear the phone, doorbells, or anything else that may require their attention.  This also allows us to hear and respond to all emergencies as needed.
5.	While conducting a room checks please make sure that we are checking the porches of the shelter to ensure that no youth or visitors are outside of the shelter throughout the night.  These checks should be documented on the same check sheet being completed for the rooms checks.
6.	If we have a youth go AWOP during nightshift, please follow the YES AWOP and Runaway protocol.  If we have a youth go AWOP or if we have any youth on current runaway status, please make sure we notify campus security immediately so that they are aware of the situation.


raw_content: Children engaged in inappropriate contact due to the adequate supervision of the caregiver.

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: This standard was evaluated and found to be compliant.


summary: 748.3351(5) - Interior Space-provide bedroom windows with curtains, blinds, shades, or other provisions for rest and privacy

raw_content: One child's bedroom does not have blinds, curtains or anything covering the window to provide privacy.


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

raw_content: A caregiver slapped a child in care in the face.


raw_content: Children in care were able to gain access to staff keys and be unsupervised in the gym for several hours.


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 medication had two separate medication logs for the same medication prescribed. One medication log had documented medication given prior to iit being administered.

Correction Narrative: Operation Registered Nurse is not conducting weekly medication audits to identify any systematic errors and create a plan to address them.


raw_content: Two chidren did not have a debriefing within 24 hours of returning to the operation following an unauthorized absence.

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: A refresher training was conducted on how to properly complete an incident report including how to complete the debriefing. Meeting agenda was provided and will be uploaded to SharePoint. The operation also implemented a new procedure requiring the Director to ensure the debriefing section is completed prior to approving submitted incident reports.


summary: 748.2851(b)(1) - EBI Follow-Up-Caregiver involved in EBI must conduct post discussion with child to discuss child's behavior and circumstances that required EBI

raw_content: One child was restrained and there was no EBI post discussion with the child and the staff involved.

Category: Emergency Behavior Intervention

Correction Narrative: A refresher training was conducted on how to properly complete an incident report including how to debrief with youth following a containment.  Meeting agenda was provided and will be uploaded to SharePoint. The operation also implemented a new procedure requiring the Director to ensure the debriefing section is completed prior to approving submitted incident reports.


raw_content: One child's bedroom has been without window blinds for a month.

Standard Number / Description: 748.3351(5) - Interior Space-provide bedroom windows with curtains, blinds, shades, or other provisions for rest and privacy

Correction Narrative: This standard was found to be compliant. Blinds were observed in the bedroom.


summary: 748.3301(b) - Physical Site-Buildings must comply with applicable building, plumbing, electrical, fire, and similar codes

raw_content:
During the walk through a broken exit sign with exposed wire and broken furniture with exposed nails were found  the gym that the children had access to. Also in the bedroom two pollows did not have pollow cases. In one room a dresser drawer was missing.
Pictures were taken

Correction Narrative:
During the walk through a broken exit sign with exposed wire and broken furniture with exposed nails were found  the gym that the children had access to. Also in the bedroom two pillows did not have pillow cases. In one room a dresser drawer was missing.
Pictures were taken

Note: A follow up inspection was conducted and the broken exit sign had been repaired. Pillow cases were observed on all pillows and the broken furniture had been removed and discarded.


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

raw_content: A child was allowed to intervene with another child who was destroying property at the operation.  Staff did not intervene but stayed outside of the room as both children were in the room and one child was hitting the walls and door with a metal pole.

Correction Narrative: This standard was evaluated and found to be compliant. Staff were provided a refresher training on the basics of supervision and how to provide safe and supportive supervision when working with youth with the potential for high risk behaviors. Staff interviewed confirmed that training was provided and meeting agenda was provided and uploaded to SharePoint.


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

raw_content: A caregiver implemented a restraint when there was no emergency situation and the child posed no risk to himself or others.

Correction Narrative: A follow up inspection was conducted at the operation (Inspection #3831071) The employee involved is no longer employed at the operation.


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

raw_content: A caregiver placed a child in an uncomfortable position by placing her arm around his neck to escort him to his room.


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

raw_content: A caregiver used an inappropriate restraint as a form of discipline and not during a crisis.


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

raw_content: A caregiver uses inappropriate language in the presence of children in care.


facility_name: Guardian Angels I Residential Treatment Center

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

raw_content: A caregiver admitted to dozing off while supervising the children in care at nighttime.

Correction Narrative:
Administration immediately addressed the expectation that all caregivers must remain awake during nighttime sleeping hours, in accordance with §748.4703(b). The caregiver involved was counseled regarding supervision requirements and reminded that dozing or sleeping while supervising children in care is strictly prohibited.

Night shift supervisors will conduct supervisory checks during overnight hours to ensure staff are awake and actively supervising.


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

raw_content: Staff request help from a child in care to help separate two children engaged in a physical altercation resulting in the child engaging in the fight.

Correction Narrative: Operation had an all staff meeting and training with all staff on 12/12/2025 that included proper ways to deescalate residents and who should intervene in these situations. The staff involved was also terminated due to putting a resident child in danger. The additional training was held by an outside person hired to look over all policies and process for training concerning all requirements for EBI and any serious incidents that may concern children in care.


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: The operation failed to notify licensing of a child's elopement from the operation.

Correction Narrative: Guardian Angels will ensure that all incidents of runaways involving children 13 and older are reported to Licensing within the required six-hour timeframe. Case Managers have been reminded about reporting procedures and the Serious Incident Reporting Policy. Once made aware of an unauthorized absence the child's case manager will start a timer to ensure that reports are made in a timely fashion.   They will also communicate with Administrative team that the task is completed.


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

raw_content: The operation did not provide the unauthorized absence log or triggered review documentation after CCR requested the documents.

Correction Narrative: Administrator conducted a mandatory, agency-wide training on December 12th, reinforcing serious incident reporting requirements, parent notification obligations, and internal and external communication expectations. Attendance was documented. This was verified during the monitoring inspection.


summary: 748.303(a)(2)(B) - AP Serious Incdt- Report to parents any injury/illness that warrants treatment from a medical prof. directly after ensuring the safety of the child.

raw_content: Parent was not notified of child being seen by emergency services.


summary: 748.303(a)(9)(B) - Serious Incident- Report to parents within 2 hours of determining absence of a child developmentally/chronologically 6 to 12yrs.

raw_content: During the investigation, it was discovered the operation failed to report the runaway to the parent entity within the two-hour time frame.

Correction Narrative: On 10/1/25, the administrator provided corrections via email.  Initial corrections were submitted on 9/21/25, but the corrections were not detailed enough.  Administrator held meeting on 9/23/25 with administrative team to discuss the requirements of this standard.  Documented on the weekly admin agenda in the Meeting Agenda Log with the sign in sheet. All administration was present for the meeting, including case managers who are primarily responsible for communication with the children's guardians.


summary: 748.685(c)(5) - Caregiver responsibility - ensure continuity of care by sharing information concerning each child with incoming caregivers

raw_content: Based on the information gathered throughout the interviews, it was determined multiple employees were unaware of child's allergies.

Correction Narrative:
Corrective action letter submitted via email.

1. All allergies of residents are listed in the childs records that all staff has access to and are aware of. All youth files have been reviewed to verify that allergy information is clearly documented and remains accessible to staff.
2. A section has been added to the daily staff road map, documenting each childs allergy, which is provided to staff daily.
3. Management will ensure allergy information is accurate and updated in Extended Reach and road map.


summary: 748.535(3)(H) - Child-care administrator responsibilities-Ensuring persons whose behavior or health status presents danger to children are not allowed at operation

raw_content: A contract worker participated in the escalation of a verbal altercation with children in care leading to a child being triggered and injured.

Correction Narrative:
The contract worker was immediately removed from the schedule pending investigation. All contract staff will be screened and monitored to ensure professional conduct consistent with licensing standards and the safety of youth in care.

On 9/9/25 and 9/10/2025 several residences were interviewed and raised no additional concerns for staff or contract workers escalating or becoming involved in altercations with residents.


summary: 748.981(c) - First-aid-CPR training-Any new caregiver not currently certified in first-aid must be trained and certified within 90 days of employment

raw_content: A caregiver did not get CPR/first aid training within the proper timeframe.

Correction Narrative: During the inspection of the operation, the inspector was informed that all staff hired for the operation would undergo first aid/CPR training upon joining. An updated First Aid/CPR training was provided for the staff.


summary: 748.2151(a) - Medication Record-Maintain cumulative record of prescription medications dispensed to child, include nonprescription meds for child under five yrs old

raw_content: The operation did not have medication logs for five prescription medication.

Correction Narrative: The operation provided a corrective plan which consist of the lead caregiver conducting an audit of medication and medication logs at the begging of shift and end of shift. The operation will have a supervisory staff conduct medication log audit each Monday to ensure prescription and over the counter medication are be documented and current logs are in the records.


summary: 748.2101(6) - Medication storage & destruction-remove discontinued medication immediately & destroy it in a way that ensures children do not have access to it

raw_content: There operation had expired over the counter medication, medication for a child whom has been discharge and current children stored in the same box.

Correction Narrative: The operation provided a corrective plan which consist of the lead caregiver conducting an audit of medication at the begging of shift and end of shift. The operation will have a supervisory staff conduct medication audit each Monday. The audits are designed to catch any expired medication, inactive medication or medication of a discharge residents' medication still being stored with current medication. The operation has also developed a form to keep tracks of audits.


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

raw_content: 3 out of 4 files child files reviewed were incomplete.  72-hour service plans, initial service plans, and a signed copy of the child rights was not in the file.


raw_content: Licensing arrived at the facility at 10:30A to conduct an unannounced inspection. After a 2-hour waiting period there was access to active records.

Standard Number / Description: 748.399(a) - Records Available for Licensing-all active records immediately available for review and reproduction


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

raw_content: The operations physical address, and telephone number were missing from a serious incident report that was submitted.

Correction Narrative: Inspection ID 4060305 reflects an inspection was conducted at the operation on 6/9/2025. The operation shows that they have updated their incident report to reflect the missing information. The operation has implemented the usage of updated form.


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 resident in care was able to ingest objects on multiple occasions. A safety plan was put into place after multiple self harming incidents occurred, resulting in repeated hospitalizations and surgery.


raw_content: A physical altercation between 2 children in care occurred and a staff member was unable to intervene as she was the only staff member on duty.

Correction Narrative:
Guardian Angels will make every effort to ensure there is a shift supervisor and/or lead staff member present during the awake and evening shifts.

During an inspection at the facility, two children in care and one staff member were interviewed regarding supervision. Additionally, during the inspection, there were no concerns about supervision. Three caregivers were on duty, supervising seven children in care. There were no concerns.


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

raw_content: During an inspection, it was observed that two staff members were not practicing self-control, as a child was exhibiting escalating behaviors.

Correction Narrative:
The correction action letter was received with the following corrections:

1. Ms. Edwards, Director of Residential Services will ensure the two employees involved will receive an NCI Refresher

2. Ms. Falaki, Compliance Officer, will monitor incident reports and supervisory observations for signs of staff noncompliance and report patterns or concerns to leadership.

3. Ms. McGlory will support training by incorporating coaching on TBRI Principles into bi-weekly team meetings.


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

raw_content: Only 3 serious incident reports out of 8 children who went on an unauthorized leave of absence on two different days were provided to licensing.

Correction Narrative: Inspection ID 4060305 reflects an inspection was conducted at the operation on 6/9/2025. The operation shows that they will have a full review of all incident logs and ensure that any missing documentation related to unauthorized absences, or any other incidents is submitted promptly and accurately. The operation will implement a new tracking system to cross-reference incident logs with submitted reports to ensure none are missed going forward. Administrator will conduct monthly internal audits of incident documentation and provide corrective feedback to responsible supervisors when reports are incomplete or delayed.


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

raw_content: Staff were observed sleeping by children in care.


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

raw_content: An unauthorized staff gave a child the wrong medication.


summary: 748.2003(b)(11) - Administration of prescription medication-only the child for whom the prescription medication was prescribed may use the medication

raw_content: A child was given another child in care's medication.


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

raw_content: A suicide attempt that occurred on 04/01/25 was not reported until 04/03/25. Suicide attempts that occurred on 04/21/25 and 05/05/25 were not reported to Licensing.

Correction Narrative: As inspection was completed at the operation on 6/6/2025. Interviews with caregivers were conducted and caregivers were told they were informed of all reportable incidents including suicide attempts. Caregivers were also explained the difference between an attempt and ideation. The operation has reported that the operation will be reviewing the incident log weekly to ensure no reportable incidents are missed.


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

raw_content: Suicide screenings were not immediately administered on a child who attempted to self-harm on three occasions by swallowing inanimate objects.


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

raw_content: 4 triggered reviews did not contain all required documentation. This includes a review of the previous unauthorized absences and previous debriefings required in 748.461(1) and level of supervision as required in 748.461(2).

Correction Narrative: An email was received by the operation on 5.7.25. The following was explained- To address the deficiency cited under 748.461(1), the Compliance Officer and Case Manager, under the direction of the Administrator, will ensure that all triggered reviews following unauthorized absences include documentation of the child's previous unauthorized absences, previous debriefings, and a review of the child's level of supervision as required. Moving forward, this information will be consistently reviewed and documented to ensure compliance with licensing standards.


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

raw_content: 3 serious incident reports did not contain all required documentation regarding an elopement. This includes the time and date law enforcement, and parents were notified, along with the names of those notified.

Correction Narrative: An email was received from the operation on 5.7.25. The following was explained- To address the deficiency cited under 748.313(3)(B), the Assistant Administrator and Behavior Support Specialist, under the direction of the Administrator, will ensure all serious incident reports involving elopement include the date and time law enforcement and parents are notified, as well as the names of those contacted. Moving forward, this information will be verified before incident reports are finalized to ensure full compliance with licensing requirements.


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

raw_content: A staff member failed to follow policy and procedures. The staff member admitted to not conducting checks every 20 minutes as per policy.

Correction Narrative:
1. Assistant Administrator will reinforce the importance of policy adherence through mandatory refresher training for all direct care staff on supervision protocols and documentation procedures.

2. Compliance Officer will implement random audits of supervision logs to ensure 15-minute checks are being completed and documented as required.

3. Assistant Administrator incorporate policy reviews into staff supervisions and ensure all new hires are oriented thoroughly on supervision expectations during onboarding.


raw_content: Children in care were able to run away from the facility while being supervised by staff.

Correction Narrative: Inspection ID 4060305. An inspection was conducted at the operation on 6/6/2025. The caregivers reported the children are mostly supervised in the common areas and their bedroom doors are kept locked. Resident must asked staff to unlock the doors. The operation has reviewed expectations with staff to ensure more strategic staff placement during high-risk transitions, monthly incident trend reviews will be conducted to identify and correct supervision gaps, and address any other trends found. In case of an unauthorized absences the operation will updated supervision levels and individualized safety plans for the child involved.


summary: 748.3701(b) - Recreation responsibility-must have a written plan for ensuring that a range of indoor & outdoor recreational & leisure opportunities are provided

raw_content: During the monitoring inspection, the recreational chart provided did not contain a of indoor and outdoor recreational activities for the children daily.

Correction Narrative: 1.	Moving forward, the Assistant Administrator and Behavior Support Specialist will ensure the recreation schedule includes indoor and outdoor activities, as well as ensure the schedule is being adhered to. The recreation calendar has been updated.


summary: 748.1339(a)(3) - Initial Service Plan-Service planning team must include at least one PLSP who provides direct services to the child

raw_content: The initial service plan for a child in care does not have the signatures or dates of participation for a professional level service provider or managing conservator. Therefore, it is unknown if they participated in the initial service plan meeting or reviewed the initial service plan.

Correction Narrative: The operation submitted the following written correction: Treatment Director and or Professional Service Level Provider will ensure they capture all attending parties' signatures for ISPs to ensure compliance with state minimum standards moving forward.


raw_content: Multiple children and staff interviewed confirmed an inappropriate was made to a child by staff.

Correction Narrative: Children and administrative staff unanimously stated there has been no reports of insults since last visit.


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

raw_content: Multiple children interviewed confirmed a member of staff made an inappropriate comment to a child in care.


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

raw_content: Serious incident reports were reviewed and they did not contain the required minimal standard criteria. The serious incident reports did not discuss the interventions made after the child returned to the facility.

Correction Narrative: Operation has updated the serious incident reports in extended reach system to include interventions made after a child returns to an operation. INSP ID: 4040976


summary: 745.8411(b)(3) - Responsibilities - Provides access to all records

raw_content: During the team inspection, complete children's files, and the EBI annual evaluation were not available for review.

Correction Narrative: The complete child record will be available for licensing to review on our Extended Reach system. A username has been created for this purpose. There will also be an individual resident binder available for review. The annual EBI evaluation was completed and observed.


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

raw_content: During the incident / physical altercation, a staff member was heard to be cursing.

Correction Narrative:
Guardian Angels has implemented a corrective action plan that includes enhanced staff training in de-escalation techniques, conflict resolution, and maintaining self-control during resident interactions. This training was conducted during the staff meeting held on December 13, 2024. Additionally, all caregivers are required to complete mandatory refresher courses on appropriate behavior, effective communication, and managing confrontational situations, with a particular focus on Trust-Based Relational Intervention (TBRI) principles. These refresher courses were also conducted.

Following an internal investigation into the incident, the staff member involved was immediately placed on suspension and will remain so until the case is resolved, or further directives are provided by the state.

During the follow up (INSP ID: 4038025) conducted interviews were held with staff and children who reported that there is no cursing on behalf of the staff towards children or in the presence of children, in addition staff reported being trained on TBRI methods. The individual involved in this investigation is no longer employed at the operation.


summary: 748.2307(13) - Other Prohibited Punishments-denying basic child rights as discipline or punishment

raw_content: Children's clothing are still being taken away as a form discipline.

Correction Narrative: Interviews with children were conducted and their clothing are no longer being removed as a form of discipline.


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 had a high-risk behavior of suicidal ideation and was able to grab multiple objects and self-harm.

Correction Narrative: Received a corrective action plan from the facilities case manager stating that the facility will now ensure that the resident involved in this investigation will only be able to use markers and crayons for their art, no compasses or pens.


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

raw_content: A caregiver physically pushed and used a close fist to punch a child in care.

Correction Narrative: Refresher training was completed by all staff and a staff meeting took place to remind all staff of the expectations and prohibited punishment methods. In addition, the staff involved in inappropriate discipline methods was terminated.


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

raw_content: A caregiver became belligerent, yelled, and used profanity in reference to and at a child in care.


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

raw_content: A staff member became both verbally and physically aggressive with a child in care. A staff member with protective capacity physically positioned herself between the staff and child in care in an attempt to protect the child.


raw_content: During the investigation, it was found that a child was cursed at by a caregiver during a confrontation.

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


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

raw_content: During the investigation, there were multiple accounts of a caregiver pushing a child in care.


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

raw_content: During the investigation, a caregiver failed to maintain self-control when they positioned themselves for a physical confrontation with a child, and verbally provoked the child.

Correction Narrative: A TBRI method of switching out with another staff if they are overwhelmed has been reiterated that it is an available method to use while staff regain composure to maintain self-control. In addition the staff involved in innapropriate discipline methods was terminated.


summary: 748.303(b) - Serious Incident-Not required to report medically pertinent incident if not level of serious incident. Document same as a serious incident

raw_content: The incident report does not contain the required elements for reporting non serious medical incidents as required. The document does not have the physical address or phone number of the operation.

Correction Narrative: The incident documentation was updated in their extended reach system to add the elements that were missing, such as the gender, age, and date of admission. In addition, staff will be trained on incident reports on September 6, 2024, during the all-staff meeting.


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: Three children left the operation on 05/30 in the 4pm hour and the unauthorized absence was not reported until 05/31 in the 8am hour.

Correction Narrative: Guardian Angels will report unauthorized absences, as soon as possible but within the 6-hour timeframe; without delay.


raw_content: Child in care went on AWOL on 5-16-24 immediately after child got down from the school bus at about 3:25pm and did not return until the next day. Operation staff stated that AWOL report was made on 5-16-24 around 11:50pm which is more than 6 hours report timeframe.

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.

Correction Narrative: The operation sent its correction via email. In its correction, the operation stated that Guardian Angels will report unauthorized absences, as soon as possible but within the 6-hour timeframe; without delay.


summary: 748.3161(e) - Heating Devices-May not use stove to heat any part of operation, including portable camp stoves

raw_content: Staff is using an oven to heat the home on multiple occasions.


raw_content: Two children and one agency staff witnessed an agency staff member sleeping.

Correction Narrative:
HM inspector received an e-mail for compliance. The operation staff member that was sleeping is no longer at the operation. The operation also sent in a response for future compliance:
Enhanced Monitoring Procedures: We will conduct sporadic walkthroughs by team leads during all shifts to ensure adherence to supervision protocols.
Staff Training: All staff members will undergo a virtual refresher training emphasizing the importance of constant vigilance and the critical nature of their supervisory role.
Accountability Systems: We will introduce accountability systems, including regular performance reviews and incident reporting mechanisms, to promptly address any deviations from expected standards.
Support for Staff Well-being: Recognizing the challenges of caregiver roles, we are enhancing support for staff well-being, including reducing scheduled days and access to wellness resources to help manage stress and prevent fatigue by talking with our Clinical Director when necessary.


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

raw_content: During a review of external documentation, the operation did not complete a suicide screening, as well as a safety plan at the time of admission.

Correction Narrative:
I,RCCL Inspector Michonne Chandler received an email from Guardians Angels case manager stating the following:

Case manager will revise intake packet with a checklist to identify those needs instead of leaving for the caseworker to identify them.
Case manager has been retrained on completing the Intake Suicide Assessment at Intake, while caseworker is present.
Case manager will make the safety plan for each intake available to staff and retrain the staff on what to expect with the child's behavior.


summary: 748.601 - Treatment Director-Facility providing treatment services to 25 or more children or to more than 30% of children in care must have treatment director

raw_content: The operation does not have a Treatment Director to oversee the treatment program that provides treatment services for children with emotional disorders.

Correction Narrative:
01/31/2024-The operation's HR Generalist/Compliance Officer submitted via email licensing staff the Corrective Action Plan consisting of the operation's new Clinical Director's Employment Job Offer including start date of February 1, 2024, employment of full-time, expected work dates Monday through Friday signed by Clinical Director as well as additional attachment of the Clinical Director's signed Employee Acceptance letter.

In addition, the operation's HR Generalist/Compliance Officer submitted via email to licensing staff the Clinical's Director's required minimum qualifications including Master's Degree in Clinical Social Work, Psychology, Counseling, or related field, valid Texas license as Licensed Professional Counselor as well as three to five years of program management initialed by the new Clinical Director.

02/02/2024-The operation's HR Generalist/Compliance Officer submitted via email licensing staff the operation's new Clinical Director's license for Licensed Professional Counselor in the state of Texas with effective date of 12/29/2021 as well as expiration date of 05/31/2025.  In addition, the operation's HR Generalist/Compliance Officer submitted via email licensing staff the operation's new Clinical Director's transcript from Prairie View A&M University indicating a Masters in Counseling granted in May 2018.  Additional supporting documents based on the operation's new Clinical Director's resume indicates work experience as an Executive Director/LPC (therapeutic services), Care Coordinator/QMHP (targeted case management), CPS Supervised Visitation Coordinator as well completion of counseling practicum.

Based on the documents submitted, the operation's new Clinical Director meets qualifications and/or criteria as required by Minimum Standards including education level as well as extensive professional experience.


raw_content: Prudent judgment was not applied to a situation where a staff member immediately noticed a change and did not verify the information before preforming assigned tasks.

Correction Narrative: The follow up was completed by inspection (Insp. ID: 4013453) in which medication was observed to be double locked. There is a cabinet in the kitchen that is locked and the medication box itself is also locked. Interviews conducted with children and staff were conducted in which the children are aware of what they are taking, and the staff is also familiar with medication administration procedures.


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

raw_content: Medication was not accurately accounted for medication logs for children in care.

Correction Narrative: The follow up was completed by inspection (Insp. ID: 4013453) in which medication was evaluated and a medication count was conducted and was found to be in compliance.


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

raw_content: Scheduled II medication was improperly stored in a kitchen drawer that is not double locked.

Correction Narrative: The follow up was completed by inspection (Insp. ID: 4013453) in which medication was observed to be double locked. There is a cabinet in the kitchen that is locked and the medication box itself is also locked.


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

Deficiency Narrative: During a review of external documentation, the operation did not complete a suicide screening, as well as a safety plan at the time of admission.


summary: 748.2461(a)(1) - Short Personal Restraint-Caregiver must minimize risk of physical discomfort, harm, or pain to child

raw_content: Caregiver conducted restraint on a youth utilizing unapproved technique.

Correction Narrative: In person follow-up conducted.  Youth in care and staff were interviewed.


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

raw_content: Staff were not able to intervene which resulted in child self-harming herself with a sharp object.

Correction Narrative: Staff are intervening immediately during emergency situations and providing the necessary supervision.


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

raw_content: Two youth beds were observed to not have a mattress cover during a walkthrough of the operation.


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

raw_content: Caregivers at the operation are not physically intervening when children are engaging in a physical altercation.

Correction Narrative: The staff were retrained and discussed supervision and intervening in emergency situations. INSP ID: 4040976


raw_content: During a review of the investigation it was determined that a staff member threatened a child in care was threatened with corporal punishment verbally and with hand gestures.

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

Correction Narrative: Interview with victim confirmed no further incidents. Interview with Ms. McGlory confirmed Mr. Matthews no longer employed at operation. Review of corrective actions following investigation supports the operation increasing its initial new staff training to include the sharing of children's high-risk behaviors and ensuring staff are better trained to meet individual child needs.


raw_content: Three children in care expressed that a DCS used inappropriate language when talking to them.

Correction Narrative:
8/17/23: A physical follow-up was conducted at the operation. 3 of the 6 current residents were interviewed, none voiced any concern regarding staff using profane language. - MSLewis
8/4/23: Staff have been trained that profanity and other inappropriate language is not permitted at work and children should not be addressed using appropriate language. Staff will model appropriate language to residents, so that the resident can learn how to carry on conversations with appropriate language.

This topic will also be retrained during trainings on Cultural Competence and Abuse, Neglect and Exploitation on September 29th and November 3rd, respectively.


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

raw_content: Staff used unnecessary force when pushing a child before restraining her three separate times.

Correction Narrative:
8/17/23: A physical follow-up was conducted at the operation. 3 of the 6 current residents were interviewed, none voiced any concern regarding restraints. - MSLewis
8/4/23: NCI/CPI Training is a requirement upon hire for our facility. Employees are trained within the first 90 days of employment and are trained by our Certified Instructors here on campus. Our certified instructors conduct refresher trainings every month. Our last one was July 31st.  On August 22nd, we will conduct a refresher on proper implementation of relocating to a safe place, and also proper holds, ie.  Low-Level, Medium Level, and High Level Holding during a crisis or during aggressive behaviors. Our goal with our caregivers is to always use our controlled dynamics of managing the arms, managing the incline, and manage mobility when using interventions to get to residents' therapeutic stage.


raw_content: A staff member used profane language in an argument with a resident,

Correction Narrative:
Guardian Angels' (GA) sets policies and procedures for resident rights in areas including but not limited to: normal life, discipline, medical care, complaints, parent and sibling contact, privacy and search.

Discipline, including:
The right to be free from any harsh, cruel, unusual, unnecessary, demeaning, or humiliating treatment or punishment. The means the resident must not be:
Talked to disrespectfully, use of profane language (towards them and/or in front of them), slapped, shaken, hit, made to run laps, do sit-ups or push-ups, hold an unnatural position or do unproductive work. The use of mechanical and personal restraints and seclusions also are prohibited methods of discipline.
Moving forward, Staff will use strategies taught during and after training:

Strategies and Techniques Staff Can Use to Avoid Abusive/Harmful Behavior:
During orientation to the facility, Staff are taught strategies and techniques they can use to avoid Abusive/harmful behaviors; they are taught to:

	Be sensitive to the resident(s) feelings and recognize words and actions they are using that indicate a rise in frustration or anger.
	When these feelings arise, they must remove themselves from their assigned group by asking permission to go outside or someplace where they can calm down;
	Ask to talk to a supervisor and/or another staff member about their feelings;
	Ask to talk to Human Resources, Executive Director, and/or the Compliance Officer:
	Use all taught techniques that de-escalates any rising or heighten situations that caused these feelings to arise, and how they might avoid the situation in the future and/or positive actions they can take to the situations.
	Be sensitive to the resident(s) feelings and use words that are appropriate for the setting (work) to avert further crisis.
	Practice verbal techniques.
	Avoid name calling and any forms of disrespect

Moving Forward, after each incident has been managed;

Staff will ensure children report all altercations (physical and/or verbal) to an adult (be a direct care staff, Case-manager, LCCA, etc.), while refraining from any form of abuse without retaliation or defense.

Staff may be removed from work schedule pending results from investigation and/or allowed to work in another Unit, while working under a safety plan.


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

raw_content: A staff member got into a verbal argument with a resident.


raw_content: A staff member yelled at and subjected a child in care to humiliation by referencing the child's family and weight in a demeaning manner.

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

Correction Narrative:
2/1/23: Per the operation, the staff supervisor will ensure staff use strategies taught during and after training, including be sensitive to the resident(s) feelings and recognize words and actions they are using that indicate a rise in frustration or anger, allow the child to remove themselves from their assigned group by asking permission to go outside or someplace where they can calm down, allowing the child to talk to a supervisor, HR, Executive Director, the Compliance Officer and/or another staff member about their feelings, use all taught techniques that de-escalates any rising or heighten situations that caused these feelings to arise, and how they might avoid the situation in the future and/or positive actions they can take to the situations, be sensitive to the resident(s) feelings and use words that are appropriate for the setting (work) to avert further crisis, practice verbal techniques, and avoid name calling and any forms of disrespect.
2/15/23: A physical follow up was conducted, residents were interviewed at school. None of the girls expressed concerns with staff yelling or using demeaning language. The residents also expressed not seeing Ms. Leslie on shift within the past 2weeks.


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

raw_content: A staff member used profanity directed at a child in care during a heated exchange between the two.

Correction Narrative:
2/1/23: Per the operation, the staff supervisor will ensure staff use strategies taught during and after training, including be sensitive to the resident(s) feelings and recognize words and actions they are using that indicate a rise in frustration or anger, allow the child to remove themselves from their assigned group by asking permission to go outside or someplace where they can calm down, allowing the child to talk to a supervisor, HR, Executive Director, the Compliance Officer and/or another staff member about their feelings, use all taught techniques that de-escalates any rising or heighten situations that caused these feelings to arise, and how they might avoid the situation in the future and/or positive actions they can take to the situations, be sensitive to the resident(s) feelings and use words that are appropriate for the setting (work) to avert further crisis, practice verbal techniques, and avoid name calling and any forms of disrespect.

2/15/23: A physical follow up was conducted, residents were interviewed at school. None of the girls expressed concerns with staff using profanity. The residents also expressed not seeing Ms. Leslie on shift within the past 2weeks.


raw_content: A staff member failed to exercise prudent judgment and self-control by engaging in an argument with a child in care.

Correction Narrative:
2/1/23: Per the operation, the staff supervisor will ensure staff use strategies taught during and after training, including be sensitive to the resident(s) feelings and recognize words and actions they are using that indicate a rise in frustration or anger, allow the child to remove themselves from their assigned group by asking permission to go outside or someplace where they can calm down, allowing the child to talk to a supervisor, HR, Executive Director, the Compliance Officer and/or another staff member about their feelings, use all taught techniques that de-escalates any rising or heighten situations that caused these feelings to arise, and how they might avoid the situation in the future and/or positive actions they can take to the situations, be sensitive to the resident(s) feelings and use words that are appropriate for the setting (work) to avert further crisis, practice verbal techniques, and avoid name calling and any forms of disrespect.
2/15/23: A physical follow up was conducted, residents were interviewed at school. The residents expressed not seeing Ms. Leslie on shift within the past 2weeks. Per the operation and BGC, Ms. Leslie was terminated 1/31/23.


summary: 748.1385(9) - Service Plan Review-Must document in the child's record the review and update of the plan

raw_content: Four children's service plans were not updated at review to include therapy/skills training frequency, education changes, and/or medication changes.

Correction Narrative:
8/18/22: At the investigation inspection Addendums to all deficient services plans were received, created 8/15/22.
10/11/22: Per the Administrator, Guardian Angels' Case manager and the treatment team will be responsible for making sure that the service plans contain the most accurate and up to date information. The therapists have been notified about the therapy sessions requirements, skills training and will document when sessions are not held and the reason why. Any changes in the resident (s)' education will, also, be documented in the service plan by the case manager and checked for accuracy by treatment team. Caseworkers will be notified of the medication their resident may receive within 24 hours of seeing the Psychiatrist.


summary: 748.2553(2)(B) - EBI Release-Child released from personal restraint within one minute of implementation of a prone or supine hold

raw_content: According to the Incident Report, a child was restrained in the supine position for 3-10 minutes.

Correction Narrative: Staff will respond to the risk behavior using verbal, nonverbal, and physical approaches appropriate to the person, situation, and level of risk, communicate effectively to relief staff that the resident is indeed in crisis, ensuring that the staff is close enough to provide protection and intervene when necessary to ensure the resident's safety, and move for safety when a resident throws an object towards the target (HER) that could possibly cause bodily harm, and ask for assistance (EBI and releasing the resident every 1-2 minutes).


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

raw_content: Four of four reviewed Supervision sections of the children's Service Plans all have the same Supervision needs and goals.

Correction Narrative: Per the Administrator, Guardian Angels will ensure that no two residents have the same identical Supervision Plan. We do understand that even though some have similar behaviors, they are still individuals who react differently, as well as respond to treatment differently. Therefore, they should be Supervised differently.


facility_name: LifeWorks Emergency Shelter

summary: 748.2311 - Discipline-person in care must not discipline or punish another person in care

raw_content: During the course of this investigation, it was determined that staff allowed a child in care to restrain another child.

Correction Narrative: As per the Director, the operation acknowledge the concerns and safety regarding a youth intervening in the situation and restraining another youth. Management have discussed with staff that youth must never discipline or restrain another youth and that only trained caregivers should do so. This expectation is being reinforced with all team members through Handle with Care trainings scheduled for 03/14/2026 and for 04/18/2026 as well as continued discussions by the staff's assigned supervisors. As part of the operation's corrective actions, staff are currently participating in Handle with Care training to strengthen understanding of appropriate interventions and documentation requirements. Additionally, the supervisors, who also serve as the operation's EBI trainers, will be specifically addressing the expectation that youth are never permitted to restrain or physically intervene with other youth. It was noted that this will be emphasized in each training moving forward to ensure clear understanding and compliance.


raw_content: The operation provided two EBI debriefings dated the same day as the alleged incident after being informed by staff that they had not been completed.

Correction Narrative: As per the Director, the operation recognize the importance of conducting and properly documenting post-EBI debriefings with youth. Staff have been reminded that debriefings must be completed after the situation has stabilized and documentation must be thorough and completed within the required timeframe. The operation notes that they have reviewed documentation procedures with staff, in supervisions and in team meetings, to ensure that EBI reports and debriefings are completed accurately and contemporaneously following incidents.


summary: 748.1349(c) - Initial Service Plan-If plan or summary not shared with child, document justification in the child's record

raw_content: Three of five child service plans did not have the required information as to date provided and/or justification whether or not a copy was provided.

Correction Narrative: As per the Director of Emergency Shelter, management have met with case managers to reinforce the importance of obtaining signatures consistently. Together, they developed a streamlined process to ensure all DFPS-related documents are signed and properly filed. This improvement supports accountability and ensures youth and their supports are actively included in service planning.


summary: 748.461(2) - Unauthorized Absence-Triggered Review must include a review of service plan elements in 749.1309(b)(1)(D)&(H) & as applicable 749.1309(b)(2)&(3)

raw_content: One triggered review document did not have the required information.

Correction Narrative: As per the Director of Emergency Shelter, to ensure compliance and improve documentation quality related to triggered reviews, they have met with case managers to discuss expectations for documenting supervision details. After receiving clarification during monitoring inspection, the operation have implement necessary adjustments promptly. The operation notes being committed to using the guidance received to strengthen their documentation processes and ensure that supervision plans accurately reflect each youth's needs.


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

raw_content: Four of four Preliminary Service Plan documentation reviewed failed to the required information.

Correction Narrative: As per the Director of Emergency Shelter, to enhance the quality and completeness of preliminary service plans, lead youth care workers and direct care staff were engaged in a staff meeting focused on expectations at intake. All staff discussed how to use existing tools-such as common applications and psychological assessments-to gather essential information and create accurate, individualized preliminary service plans. This approach ensures that youth needs are addressed immediately and appropriately from the moment of admission.


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: Six Unauthorized Absences debriefings were not completed and/or documented.

Correction Narrative: As per the Director of Emergency Shelter, the operation is committed to improving their practices to ensure consistent, high-quality care and accountability. They recognize how crucial it is to complete incident debriefs with youth upon their return from an unauthorized absence and to maintain uniformity in how staff document and conduct these conversations. Since reinforcing these expectations, staff have been completing debrief forms in full, and leadership has reviewed each debrief within 24 hours of the incident. To sustain this progress, the operation will continue emphasizing timely and accurate debriefing during onboarding and ongoing training. These efforts reflect the operation's dedication to providing consistent, thoughtful follow-up after critical events.


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

raw_content: Staff failed to arrange and confirm transportation back to the operation for a child in care who called for assistance after traveling 50 miles away on their bicycle.

Correction Narrative: An email was received September 26, 2025 stating: moving forward, we ask that all organizations coordinate directly to avoid relying on youth to relay information. LifeWorks remains committed to supporting youth through structured activities and ensuring transportation is provided when appropriate.


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

raw_content: During the Walkthrough of bedroom #9, a whole in the wall was present. In another room, the vent is partially coming from ceiling.


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

raw_content: A child's unauthorized absence was not recorded on the Annual Summary Log.

Correction Narrative: The operation stated they had a glitch in the syncing of the systems but that all the unauthorized absences were logged appropriately.