raw_content: It was determined through the course of the investigation two children were in a physical altercation. During the time of separation in an attempt to de-escalate, one of the children came in where the other child was still upset and staff admitted to not intervening to ensure there would be no further altercations which allowed another altercation to occur and left one of the children with an injury.

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

Correction Narrative: 11/22/22 Compliance Manager sent email stating all staff will be re-trained/re-educated on documenting a Serious Incident Report and intervening when necessary to ensure a child's saftey. This is to be completed by 12/31/22. Inspector spoke with Compliance Manager about the staff that were involved and the concern of the length of time before the training was complete. The Compliance Manager stated the staff that were involved in the incident had already beeen retrained and sent an updated email with their completed trainings of 11/17/22 and 11/21/22.


state: TX

facility_name: HMIH CEDAR CREST, LLC

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

raw_content: In reviewing the Serious Incident Report several items were found to be missing. Names of all staff and children involved, names of all witnesses, description of the differences between the children in size, weight, mental level.

Category: Individual Standards Evaluated

Standard Risk Level: Medium

Corrected at Inspection: No


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: After reviewing documentation, it was determined that this was reported after 24 hours of being injured and receiving medical care.

Standard Risk Level: Medium High

Correction Narrative: An email was received from the operation's risk manager, Emily Bartek. Cedar Crest Hospital and RTC will ensure all serious incidents are reported to licensing within 24 hours of a patient being injured and receiving medical care by the date of 9/21/22.


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: On multiple occasions at the operation, a staff member sexually abused a child resident who was left in this staff member's care.

Standard Risk Level: High

Corrected at Inspection: Yes


summary: 748.1205(a)(13) - Admission Documentation-Includes copy of the placement agreement, if applicable

raw_content: 4 of the 4 child files read did not contain placement agreement documentation.

Category: Admission, Service Planning, Discharge

Correction Narrative: Director of Clinical Services, RTC Program Manager and Director of Admissions will collaborate to create a Placement Agreement form that will be completed during admissions. It will contain the appropriate sections and information. This document will be kept in patient's records and implemented on 11/1/2021.


summary: 748.1225(c) - Admission-Report and findings of dental exam must be documented in child's record

raw_content: 4 of the 4 child files read did not contain documentation/reports of dental exams in the child's records.

Standard Risk Level: Medium Low

Correction Narrative: Director of Clinical Services and RTC Program Manager will begin training RTC therapists on properly requesting and documenting dental records from family/guardians. Request will be made at orientation and at subsequent family therapy sessions. If no dental record is received after request, a "Refusal to provide records" will be documented by therapist and placed in medical records. This will be implemented on 11/1/2021.


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

raw_content: During the course of the investigation, staff admitted to reaching hand down victim child's pants to retrieve bouncy ball.

Correction Narrative: All RTC staff with be provided re-training on the existing Zero Tolerance Policy in reference to abuse, neglect, treatment, punishment, and exploitation as it pertains to Emergency Behavioral Intervention by 12/15/2021.


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

raw_content: During the course of the investigation, it was determined that the caregiver restrained the child for an inappropriate reason.


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

raw_content: During the course of the investigation, it was discovered that the child was given cleaning solution by a staff member without ensuring that the child needed it or that the child was being supervised while using it. The staff member who gave the child the cleaning solution did not notify the child's supervising staff that the child was in possession of the cleaning solution.

Correction Narrative: All of the staff on the unit will be provided re-education on requirements in references to utilization of cleaning solutions while on the unit. A attestation explaining the need for staff presence and supervision when patient(s) are helping with cleaning the unit or personal areas will be signed and completed by unit 2 by the date of 7/16/2021.


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

raw_content: During the review of the person's involved, it was discovered a person is currently working, but their background check has been inactive since November 2020.

Correction Narrative: Operation has re-run the background of the employee who's background check had been made inactive. Operation stated that they will check backgrounds weekly moving forward to ensure compliance.


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

raw_content: During the course of the investigation, it was determined a Serious Incident occurred in which a child injured themselves, but was not report to the Hotline for five days.

Correction Narrative: Operation stated that they will ensure serious incidents are reported within the required time frame for any injuries that require medical attention moving forward.


raw_content: During the course of the investigation, it was documented that several individuals interviewed stated that staff were on their phones constantly and not supervising correctly which might have contributed to one of the children in care being able to touch peers inappropriately.

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: Operation staff addressed this immediately with others. Operation also gave staff a refresher course on Electronic Devices Policy.


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

raw_content: During the course of the investigation, the children in care interviewed all stated that the staff has yelled and cursed at them or other children at the operation.

Correction Narrative: The staff involved will be required to complete mandatory HealthStream module training. Modules will provide educational refreshers on appropriate staff boundaries while working in patient care areas. All modules will be completed by 5/31/2021.


facility_name: Pathways Youth & Family Services,Inc. dba Habilitative Homes

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

raw_content: During the walkthrough, observations revealed there was no hand soap available at any of the sinks in the children's rooms.

Correction Narrative: A walk through was conducted and the operation hand placed hand soap at at every sink.


summary: 748.2151(b)(1) - Medication record - update cumulative record within 2 hours of administering medication

raw_content: One of the medication records for a child was not filled out and medication had been administered.

Category: Medication

Correction Narrative: Email was received on 12/18/24 Corrected at inspection. Employees involved will receive additional training on medication documentation. Training will be provided before January 10, 2025 and will be available to be viewed in the employees training file. Additional Training provided will be reviewed during the next inspection.


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

raw_content: Two of the childrens records reviewed had pill count incorrect.


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

raw_content: Staff did not try to deescalate the situation prior to implementing the emergency behavior intervention. The staff member was contradiction to trained de-escalation techniques.

Correction Narrative:
Operation response received on 06/14/24

Action taken: The caregiver is no longer employed with Habilitative homes as of 04/28/24. Caregivers at Habilitative Homes received four hours of training on EBI/CPI including de-escalation strategies on May 1, 2024. One hour of CPI Training on Holds and Blocks on 05/22/24 and one hour Children's Rights Training on June 6, 2024. Training records may be viewed in the employees' files upon request. Pathways Habilitative Homes intend to request an administrative review.

Inspector interviewed Program Coordinator; inspector verified the trainings were completed. The facility is completing trainings any time they have a deficiency.

Inspector met with Staff to confirmed they have completed training in EBI and going over Blocks, hair pulling and how to get away. The facility is completing trainings anytime they have a deficiencies.


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

raw_content: Through interviews it was confirmed a staff dragged a child in care by the hair to the bathroom to sprayed child off in shower as a form of punishment.


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

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


raw_content: In video footage staff members are taunting child in care as a way to get the child to comply.

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


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

raw_content: Staff used excessive force when preforming an emergency behavior intervention. Staff held child with knee on child's chest during restraint.


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

raw_content: Staff did not intervene when a child was repeatedly hitting head against wall.

Correction Narrative: During the follow-up inspections it was confirmed during interviews with staff they received training regarding TBRI refresher 04/11/24. Operation provided notes and sign in sheet for training.


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 child in care was physically disciplined.

Correction Narrative: During the follow-up inspections it was confirmed during interviews with staff they received training regarding physical discipline during weekly meetings. Operation provided notes and sign in sheet for discipline training. During interview with child in care, it was confirmed staff do not use physical discipline.


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

Correction Narrative:
Operation submitted plan of compliance:
Staff retrained during staff meeting on 11/30/23 on proper handling of children in care and CPI overview of the children .

Please find the response below to the unannounced inspection that occurred on 11-21-2023. We will not be requesting an administrative review.

Standard/Rule	Specifics	Completion Date	Action Taken
748.507(1) Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks.	During an incident a staff member pulled a child by their arms, as a form of redirection.
	11/30/2023	Program Administrator retrained all staff on how to properly redirect, guide, and handle the residents at Habilitative Homes during incidents and transitioning. The staff were retrained on not pulling the children by the arms and to lift then from under the armpits with their arms (inner forearms or where the elbow crease is) providing more support to child when getting them to a standing position. The staff were also retrained on guiding the children down to the floor during any incidents or transitions in which children drop to the floor supporting their drop; including lifting them from under the armpit with their arms (inner forearms or where the elbow crease is) to assist them back onto their feet.

Documentation of this training will be made available upon review or request.


summary: 748.2101(7) - Medication storage & destruction-remove medication on/before the expiration date & destroy it in a way that ensures children do not have access

raw_content: Multiple expired medication products were stored with current medications.

Correction Narrative: Inspector verified and facility has a new way to store and destroy medications that are no longer in use.


summary: 748.317(a)(2) - Serious incidents-Notify parents of each child admitted any time the operation is deficient for standards related to abuse/neglect or exploitation.

raw_content: Parents of children in care were not notified of recent deficiency related to abuse/neglect.


raw_content: Two medication logs reviewed did not have accurate counts.

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

Correction Narrative: Three medication records reviewed and all accurate.


summary: 748.2551(b)(2) - EBI Implementation-The caregiver must consider the permitted types of emergency behavior intervention

raw_content: The video footage shows a caregiver held a child in care in a supine position with the child in care's arms folded across their chest while the caregiver balanced on their own knee above the child in care. A collateral contact familiar with restraint training indicated this does not appear to be approved. The video also shows the caregiver use their legs to move the child in care's body across the floor similar to a shoveling motion.

Correction Narrative: This standard was followed up on 6/20/23 and found to be in compliance. EBI refresher was provided to staff members. Additionally, this inspector observed a child in care have a behavioral outburst in which he was a threat to himself and others, which was addressed with proper de-escalation by staff. Staff member involved in citation was terminated.


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

raw_content: The video footage reveals a care giver offering little other instructions to a child in care in a restraint other than repeating "Are you done?" repeatedly during the restraint.

Correction Narrative: This standard was followed up on 6/20/23 and found to be in compliance. EBI refresher was provided to staff members. Additionally, this inspector observed a child in care have a behavioral outburst in which he was a threat to himself and others, which was addressed with proper de-escalation by staff, who also assisted child in de-escalation. Staff member involved in citation was terminated.


raw_content: The video footage and care giver interviews indicate the staff initiated hands on physical intervention with a child in care, who in that moment wasn't displaying physically aggressive or high risk behaviors and was only refusing directives to stay in their room and there was a concern for other children in care's safety based on the child in care's previous behaviors.

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

Correction Narrative: This standard was followed up on 6/20/23 and found to be in compliance. EBI refresher was provided to staff members. Additionally, this inspector observed a child in care have a behavioral outburst in which he was a threat to himself and others, which was addressed with proper de-escalation by staff. Additionally, staff member involved in citation was terminated.


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

raw_content: 5 out of 11 records reviewed did not include time of medication for when the children missed a scheduled dose.

Correction Narrative:
On 6/12/23 an email was received stating that caregivers have been properly re-trained on the process of properly documenting medication errors when waiting on approval from DFPS (medical consenter), waiting on approval from the prescribing doctor to the pharmacy, and/or waiting on medication to be received.
This standard was followed up on 6/20/23 and found to be in compliance. Medication training was provided to staff members. Medication logs were reviewed and no concerns were identified regarding prescription medication.


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

raw_content: 2 out of 11 medication logs show a child in care did not discontinue their previous medication dosage soon after their doctor appointment which indicated a dosage change, but instead took anywhere from 3 to 11 days to comply with new dosage orders.

Correction Narrative:
On 6/12/23 an email was received stated that caregivers have been properly re-trained on the process of submitting the medical consenter form to the correct party that is able to make decision over the children's medication changes.

In the instance that the medical consenter is present during the psychotropic medication evaluation, the psychotropic medication approval form will be completed and signed on sight.

This standard was followed up on 6/20/23 and found to be in compliance. Medication training was provided to staff members. Medication logs were reviewed and no concerns were identified regarding prescription medication.


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

raw_content: 3 out of 4 training records reviewed showed current staff had expired Trauma Informed Care training while still in ratio.

Correction Narrative: The Administrative Team has developed an onboarding process to ensure that caregivers are completing their required trainings prior to being counted as ratio. This standard was followed up on 6/20/23 and found to be in compliance. Staff members counted in caregiver ratio are current on TIC training.


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

raw_content: 3 out of 4 training records reviewed showed staff had expired training for dispensing psychotropic medication.

Correction Narrative:
Psychotropic medication training was completed on 5/25/23 with Pamela Rosen, RN.
This standard was followed up on 6/20/23 and found to be in compliance. Staff members counted in caregiver ratio are current on psychotropic medication training.


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

raw_content: Licensing observed and phiotographed a wall niche fire extinguisher housing with a broken plastic door and a protruding plastic shard. The operation removed the damaged plastic screen to the secured staff room during inspection.


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

raw_content: Multiple bathrooms used by children in care had broken toilet paper holders.

Category: Physical Site

Correction Narrative: Compliance follow-up completed 11/29/22.


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

raw_content: Multiple food items were not stored securely.


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

raw_content: Multiple documents were not accessible by adminsitrator during visit.


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

raw_content: Two windows being used for ventilation were found without screens.


summary: 748.2151(b)(1) - Medication record - update cumulative record within 2 hours of administering medication

raw_content: Three medication logs were not updated with medication administered in required timeframe.

Correction Narrative:
The following response on how the facility will come into compliance was sent to Inspector by Administrator, Ms. Davis:
1.	All staff will be trained on medication administration and documentation on 4/12/2022. Any staff unable to attend the training will be trained no later than 4/15/2022.
2.	Supervisors and Management will request documentation monthly regarding medication administration from the school and upload to the child's file within the timeline set forth by minimum standards.
3.	All medication logs will be reviewed by Shift Supervisors and the Program Supervisor daily to ensure compliance.
4.	Shift Supervisor(s) and Program Supervisor will ensure all procedures regarding medication administration and documentation are followed, implemented appropriately by Direct Support Professionals, and compliance is maintained. The Program Manager will also conduct random audits of medication logs to ensure compliance.


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

raw_content: The operation failed to make a report within the required timeframe after 3 staff tested positive for COVID-19.

Correction Narrative: Administrator provided the following response via e-mail: Program Administrator and Program Manager are aware of the timelines for reporting COVID and other communicable diseases. Since these three all other reports have been made on time. Administration will continue to report all reportable incidents in accordance with minimum standards.


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

raw_content: It was found an employee did not have up-to-date EBI training.


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

raw_content: Staff fell asleep during overnight shift.

Correction Narrative:
Pathways is unaware of any staff sleeping
overnight. We have maintained a 100%
compliance rate with all unannounced visits
by residential contracts.
The expectation of staying asleep is taught
during new hire training, reinforced through
staff supervisions, and staff are also checked
on randomly by program supervisors.
Staff we will be reminded of this expectation
through a written email and will be provided
a copy of our Supervision Policy that clearly
outlines the requirement for awake night
staff.


Correction Narrative:
Health and Human Services Commission
Residential Child Care Regulations
3635 S.E. Military Drive
San Antonio, Texas 78233

The following Corrective Action Plan was developed in response to investigation
#2738158.
Standard Deficiency
Specifics
Date of
Correction
Correction Specifics
748.309 Reporting
Serious Incident - All
serious incident reports
to Licensing must be
made to the Texas Abuse
& Neglect Hotline
Staff did not report
serious incident.
6/30/2021 All staff will be trained on reportable incidents
and what incidents require a call to the hotline by
the Program Manager or the Program
Supervisor. All training will be completed on or
before 6/30/2021.
748.685(a)(4) Caregiver
responsibility - providing
the level of supervision
necessary to ensure each
child's safety and wellbeing
Children in care
were left
unsupervised for
approximately 5
minutes and when
found had no
clothing and about
to engage in sexual
act.
6/30/2021 The Treatment Director will review all service
plans to ensure supervision plans are appropriate
for each child in care. The Treatment Director
will relay any changes to a child's supervision
plan to CPS Case worker, Program Manager and
Program Supervisor by 6/30/2021. A service
plan addendum will be completed for any
changes to a child's supervision plan.
Although we have documented our efforts to come into compliance, Pathways is filing
for an Administrative Review the findings above.


summary: 748.309 - Reporting Serious Incident - All serious incident reports to Licensing must be made to the Texas Abuse & Neglect Hotline

raw_content: Staff did not report serious incident.

Deficiency Narrative: Staff did not report serious incident.

Correction Narrative:
Health and Human Services Commission
Residential Child Care Regulations
3635 S.E. Military Drive
San Antonio, Texas 78233

The following Corrective Action Plan was developed in response to investigation
#2738158.
Standard Deficiency
Specifics
Date of
Correction
Correction Specifics
748.309 Reporting
Serious Incident - All
serious incident reports
to Licensing must be
made to the Texas Abuse
& Neglect Hotline
Staff did not report
serious incident.
6/30/2021 All staff will be trained on reportable incidents
and what incidents require a call to the hotline by
the Program Manager or the Program
Supervisor. All training will be completed on or
before 6/30/2021.
748.685(a)(4) Caregiver
responsibility - providing
the level of supervision
necessary to ensure each
child's safety and wellbeing
Children in care
were left
unsupervised for
approximately 5
minutes and when
found had no
clothing and about
to engage in sexual
act.
6/30/2021 The Treatment Director will review all service
plans to ensure supervision plans are appropriate
for each child in care. The Treatment Director
will relay any changes to a child's supervision
plan to CPS Case worker, Program Manager and
Program Supervisor by 6/30/2021. A service
plan addendum will be completed for any
changes to a child's supervision plan.
Although we have documented our efforts to come into compliance, Pathways is filing
for an Administrative Review the findings above.
If you have any questions or need additional information, please feel free to contact me at


facility_name: Renewed Strength Inc

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

raw_content: It was found that several training certificates did not have the correct date format.

Correction Narrative: An email was sent to the inspector on 11/12/25 stating administration will verify at submission that all training documents have the correct format issued by DFPS/HHSC.  This will be verified by the Treatment Director and/or Administrator.


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: Personnel high school/university documentation was not present in the corresponding record.

Category: Personnel

Correction Narrative: An email was sent on 8/15/25 stating the staff provided the documentation of his high school diploma. Moving forward, the personnel file will be audited at least 14 days after the hire date. If we don't have the information, a request will be sent to the employee to provide the documentation, and we will follow up 5 business days later.


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

raw_content: Staff medication was left in the refrigerator and accessible to children.

Correction Narrative: During a follow-up inspection, there was no medication observed in the refrigerator. Additionally, all other medication was observed to be double locked and inaccessible to children.


summary: 748.363(7) - Personnel records-Include notarized Licensing Affidavit for Applicants for Employment form as specified in Human Resources Code, 42.059

raw_content: In one out of three staff files reviewed it was observed that one of the staff members did not have a notarized Licensing Affidavit for Applicants for Employment form.

Correction Narrative: A copy of the notarized Licensing Affidavit for Applicants for Employment has been received and a copy has been placed in employee file.


summary: 748.363(4) - Personnel records-Personnel records-Include current job description.

raw_content: In one out of the three staff files reviewed there was no current job description in the file.

Correction Narrative: A current job description copy has been received and filed in the employee's records.


summary: 748.1209(d) - Child Orientation-document in child's record when orientation occurred, any required information omitted, reason for any omissions

raw_content: Orientation documentation is missing from two out of the three files reviewed.

Standard Risk Level: Low

Correction Narrative: The children signed their orientation. Going forward audits of child's record will be completed after admission to ensure orientation has been signed.


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

raw_content: The information on the service plan reviews is not updated thoroughly.

Correction Narrative: All information from the previous plan of service will be eliminated and new information will be updated.


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

raw_content: Under the supervision section of the service plan, there are no indications what level of supervision each child requires.

Correction Narrative: Moving forward the treatment team will include instructions to caregivers about the level of supervision required.  These levels will indicate if they are to be one to one, within eyesight of staff, within earshot of staff or if they are to be at arm's length during waking hours.


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

raw_content: The bedroom located near the living  room had an outlet that was partially cover, There is a hole in the middle of one of the closet doors. There was a yellow substance found in the refrigerator located in storage area.

Correction Narrative: A follow up inspection was conducted and it was found that the buildings and outlets were structurally  sound, clean, and in good repair. There were no further concerns.


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

raw_content: There was no soap or papertowles or towels  located in either of the children restrooms.


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

raw_content: Roaches were observed in the  kitchen cabinet.

Correction Narrative: A follow-up inspection was conducted and there were no concerns for roaches in the kitchen cabinets. Furthermore, the Director provided a copy of the last three months pest control reports.


facility_name: Annunciation Maternity Home, Inc.

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

raw_content: It was observed 1 of 4 staff members did not have TB test results in their staff files.

Correction Narrative: An email from the operation was received and included the negative TB test for this staff member.Document can be found in SharePoint.


summary: 745.4151(c)(4)(A) - Mandatory drug testing-all applicants intended to be hired are subject to pre-employment testing, must have results prior to child access

raw_content: It was observed 1 of 4 staff members did not have results from drug testing in their case file.

Correction Narrative: An email from the operation was received and included the drug screening for this employee dated 2.14.2020. Document can be found in SharePoint.


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: During the inspection 1 of 1 direct care staff member files pulled did not have required EBI annual trainings.

Category: Training and Professional Development

Correction Narrative: An email from the operation was received and included EBI training certificates for this staff member. A schedule for all staff was received for the next EBI training. Document can be found in SharePoint.


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: It was observed that 1 of 4 staff members were missing the affidavit for applicants for employment form in their staff files.

Category: Reports and Record Keeping

Correction Narrative: An email from the operation was received and included this staff members notarized Licensing Affidavit for Applicants for Employment form. Document can be found in SharePoint.


summary: 748.151(1) - Operational responsibilities - Designate a qualified full-time child-care administrator

raw_content: RCCR was formerly notified on 04/11/22 that the operation did not have a designated full-time child-care administrator. The operation had until 07/12/2022 to hire/designate a full-time child-care administrator. As of 07/13/2022, this has not occurred.

Correction Narrative: The operation hired a full-time childcare administrator on 07/19/2022.


raw_content: RCCR was formerly notified on 04/11/22 that the operation did not have a designated full-time child-care administrator. The operation had until 06/11/2022 to hire/designate a full-time child-care administrator. As of 06/12/2022, this has not occurred.

Standard Number / Description: 748.151(1) - Operational responsibilities - Designate a qualified full-time child-care administrator


raw_content: The operation has been without a full time licensed administrator since April 29, 2021.

Correction Narrative: An individual has been hired to fill the position of the CCA. The individual has submitted the required documents and is the process of becoming licensed. Along with this, there are two other individuals that are completing the process.


Deficiency Narrative: The operation has been without a full time licensed administrator since April 29, 2021.


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

raw_content: There is no documentation in the child's file of providing notice and/or any responses for the parents of information regarding the initial service plan meeting for the child.

Correction Narrative:
Documentation for a new intake was submitted via email to show how the operation is notifying the correct entities of the service plan timeframes. Contact with these individuals are being stored in the child's file.
Along with this, current staff have been made aware of this standard and recognize what documentation needs to occur moving forward.


facility_name: Hearts with Hope Foundation-GRO

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

raw_content: Caregivers did not follow children's service plan when children in care stayed in the operation van without staff knowing.

Correction Narrative: On 01/09/2026, the operation conducted additional training on operation transportation policy. The transportation policy was reviewed with all staff and staff were reminded that they must count the youth when loading and unloading from the van/vehicle. Staff were also reminded of the different supervision levels and each childs supervision plan must be followed as documented in their service plan.


summary: 748.751(b)(2) - Pre-Employment Screening-You must document the results of any contact with an applicant's previous employers in the personnel file.

raw_content: Upon review of personnel records, one file lacked reference checks required for employees hired after August 2023.

Correction Narrative: Reference checks were completed for the employee who was missing them. Moving forward Human Resources will ensure that the pre-employment affidavit and reference checks are competed for any employee being hired


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

raw_content: During the course of this investigation, it was found that there was no report to law enforcement within the six-hour timeframe.

Correction Narrative:
In reference to Standard/Rule 748.303(a)(10)(A) and 748.303(a)(10)(C)
A staffing will be held with staff to go over serious incidents and the time frame of when
they must be reported to the hotline and police. Expectations of staff will also be
discussed by the Supervisor and Administrator.


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: During the course of the investigation, it was found that there was no report to licensing within the 6-hour timeframe.


summary: 748.311(3) - Serious Incident Documentation-Includes name, age, gender, and date of admission of the child or children involved

raw_content: Age, gender and date of admission of the child/children involved not found in document.

Correction Narrative: Agency sent sample documentation that reflect the appropriate changes and found to be in compliance.


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

raw_content: There was a bag of chicken left to thaw in the kitchen sink.


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

raw_content: One of the medication logs did not accurately reflect the pills counted.

Category: Organization and Administration

Correction Narrative: Medication audits were observed to be conducted by the Administrator and a spot check was conducted and the records were accurate and complete.


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

raw_content: While reviewing medication records, multiple medication logs for nasal spray were not administered daily as prescribed for 5 children out of 16.

Correction Narrative: Medication audits were observed to be conducted by the Administrator and a spot check was conducted and the records were accurate and complete. The PRN nasal sprays are documented.


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

raw_content: Three out of the four child files reviewed did not have a hearing screening.

Category: Child Care

Correction Narrative:
The case manager was informed to plan to get a hearing screening completed when the youth gets their TB test done. If the hearing screening is not able to be completed during
that time, the case manager will ensure to schedule an appointment as soon as possible but no later than 30 days from when the youth arrived to complete the hearing screening.
The administrator will be completing a binder audit within 14 days of the youth's arrival to ensure the hearing screening was complete and/or an appointment has been scheduled.


summary: 748.2255(1) - Operation does not employ professional who prescribes psychotropic meds-Operation gives required info to medical consenter before requesting consent

raw_content: It was determined that an unauthorized person consented to medication during a child in cares hospital stay.

Correction Narrative: The new case manager was informed of proper procreadure.


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

raw_content: During the investigation it was found that a child in care was left unsupervised.

Correction Narrative:
Three children were interviewed and reported that they are never left alone unsupervised. They take the bus to and from school. If they miss the bus they call and staff pick them up. When they go to doctors' appointments staff is always with them. If they are sick at school and they call the operation they always pick them up timely.
Shift lead will ensure to review the scheduled activities for the day and assign staff accordingly. Staff personnel will request a point of contact from the school in case of emergencies or to notify if and when a staff may be running late to pick up a youth from school. The Education Liaison will reiterate to the school that a child may not be left alone unsupervised until a parent/adult caregiver arrives.


summary: 748.151(2) - Operational responsibilities - Operate according to your approved plans, policies, and procedures

raw_content: A resident in care used a staff members cell phone to communicate with an individual.

Correction Narrative: On 12/12/2023 a meeting was held with the staff to go over the cell phone policy. The supervisor and shift lead will ensure that the staff continues to abide by the policy. In the event that the policy is not followed further disciplinary action will be provided.


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 was physically harmed while attempting to deescalate her peers from engaging in an altercation.

Correction Narrative: Interviews were conducted with staff in which it was disclosed that staff were reminded of ensuring that children are not de-escalating their peers or intervening during altercations. During the child interviews it was disclosed that children are not de-escalating their peers or intervening during altercations.


summary: 748.105(3)(C) - Personnel policies-develop professional staffing plan that documents staffing patterns/ratios/hours of coverage/plans for backup caregivers

raw_content: The staffing plan provided does not include a plan for back up care providers for emergencies.


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

raw_content: 6 out of 9 child medications reviewed it was noted that the reason the medication was prescribed, prescribing physician and the side effects were not documented on the medication record.


summary: 748.561(1) - Responsibilities of Professional level service provider-Completing an admission assessment or any other evaluation of a child for placement

raw_content: The Case Manager is  currently still performing the job responsibilities of a PLSP such as admissions assessments.


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

raw_content: A staff member is listed on the organizational chart as the Treatment Director & the Associate Program Director however there is no Treatment Director job description in the file.

Correction Narrative: A staff member is listed on the organizational chart as the Treatment Director & the Associate Program Director. The Treatment Director job description was signed and filed.


summary: 748.863(b) - Caregivers who have not completed all pre-service training may not be counted in ratio unless there is a qualified caregiver counted at same time.

raw_content: Two direct care staff have not completed all of their pre-service training.

Correction Narrative: Two direct care staff who had not completed all of their pre-service training have completed it and a certificate is in file to reflect this.


summary: 748.1217(c)(1) - Admission Assessment-Prior to initial service plan, add child's social history

raw_content: One of the files reviewed did not have any information regarding the relationship or approved/unapproved contact with the child regarding one of the birth parents.

Correction Narrative: The file previously reviewed was updated to include the relationship and approved contact with the child's birth parents.


raw_content: The Case Manager is performing the job responsibilities of a PLSP such as admissions assessments, discharge, and implementing restrictions prior to treatment director approval.

Standard Number / Description: 748.561(1) - Responsibilities of Professional level service provider-Completing an admission assessment or any other evaluation of a child for placement


summary: 748.861(b) - Pre-Service Training-If facility provides certain amount of tx svcs, caregiver must have 40 hours experience in operation that provides same tx svcs

raw_content: A caregiver did not complete the required hours of supervised child care and the completion date was not documented in the file. The start date of his supervised child care at Hearts with Hope was incorrect on the training log, the hours were verified by reviewing his schedule of worked hours.

Correction Narrative: All staff will receive 40 hours of pre-service training whether they have experience or not going forward. Currently there is a staff that has previous experience and is in the process of receiving all 40 hours of pre-service, she is currently at 32 hours.


summary: 748.869(d)(3)(A) - Training on EBI must at the end, require each participant to demonstrate knowledge and competency of the training in writing.

raw_content: All staff files reviewed did not contain written knowledge and competency of the training material.

Correction Narrative: An Emergency Behavior Intervention test has been created for staff to complete after the training prior to issuing the certificate of completion and was implemented with a new hire from 5/25/2023.


raw_content: The training logs that were observed were not accurate and did not match the training certificates observed in the files. A file was observed to not have a valid drivers license on file.

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

Correction Narrative: The training logs have not been updated to match the training certificates previously observed in the files.


raw_content: There was no staffing plan provided that included the plan for ensuring ratio, hours of coverage and plans to ensure child saftey if back up caregivers are needed to implemented 1 on 1 supervision.

Standard Number / Description: 748.105(3)(C) - Personnel policies-develop professional staffing plan that documents staffing patterns/ratios/hours of coverage/plans for backup caregivers


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

raw_content: One of the files reviewed did not have an updated notarized affidavit for a rehire. The affidavit in the file was from 2021 however the caregiver was rehiredd on 6/2022 and should have had an updated one.

Correction Narrative: Going forward a new affidavit will be completed for all rehires no matter how short of a time period they have been gone.


summary: 748.881(5) - General pre-service training curriculum-Includes location and use of fire extinguishers and first aid equipment

raw_content: The Disaster and Emergency curriculum does not have the required components such as the location and use of the fire extinguishers and first aid equipment.

Correction Narrative: The Disaster and Emergency curriculum was updated with the required components such as the location and use of the fire extinguishers and first aid equipment and can be found in the preservice training.


summary: 748.1101(b)(3)(F) - Children's rights-to personal care, hygiene, and grooming equipment and supplies and training in how to use them

raw_content: Children in care were observed to not have a toothbrush and not sufficient and adequate clothing, the child had long sleeve shirts and sweatpants.

Correction Narrative:
The annual summary log will be provided in a timely manner upon request for review.
An inventory sheet will be completed for all youth individually to document the amount
of adequate clothing, personal care, hygiene, and grooming they all have in their rooms
and lockers.


summary: 748.453(c) - Unauthorized Absence - Annual summary logs should be available to Licensing for review and reproduction, upon request.

raw_content: The annual summary log was not available upon request for review. It was requested at 4:30pm and was not recived until the exit of this inspection.


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

raw_content: The annual summary log does not include the time the absence was discovered.

Correction Narrative: The annual summary log will be updated to ensure all unauthorized absences include a time and date of when the absence was discovered.


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

raw_content: Four out of five kids interviewed disclosed staff has yelled at and used vulgar language in their presence.


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

raw_content: Three out of five kids interviewed disclosed physical discipline was used in the facility by a staff.

Correction Narrative: During the inspection three of four children denied staff used physical discipline. The administrator send an email stating, "A training will be held on Child Rights and will be going over the minimum standards regarding the Discipline and Punishment Policy by the Supervisor and Administrator. The administrator and Supervisor will ensure that all staff have a better understanding on Child Rights and the Discipline and Punishment Policy".


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 did not notify licensing of  a child's AWOL within the 6 hour time frame.

Correction Narrative: A staffing will be held with staff to go over serious incidents and the time frame of when they must be reported. Expectations of staff will also be discussed by the Supervisor and Administrator.


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

raw_content: Caregivers did not demonstrate prudent judgement when they left a child in care at the dentist office when she refused to get inside the vehicle. A caregiver arrived to assist but instead of staying and helping with the situation, the caregiver left.

Correction Narrative: On 5/30/22  Administration submitted the following correction: A training will be held on Prudent Judgement and the protocol to follow when in difficult situations. The training will be held by the facility Administrator on 06/01/2022.  A training roster and curriculum of training was provided reflecting that all staff took the training.


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

raw_content:
The victim's service plan states, "Due to the victim's intense level of care and unpredictable behaviors, she may receive 1:1 supervision when her
behaviors warrant." When the staff arrived to assist with the situation, instead of staying to assist the caregiver that was already there to provide 1:1 supervision, the staff left, leaving the other staff to handle the situation alone with 2 other children in care that were receiving dental treatments.

Correction Narrative: On 5/30/22  Administration submitted the following correction: A training will be held on Prudent Judgement and the protocol to follow when in difficult situations. The training will be held by the facility Administrator on 06/01/2022. A training roster and curriculum of training was provided reflecting that all staff took the training.


summary: 748.303(e)(4)(A) - Serious Incident-Report to Licensing within 24 hours of awareness of allegation a person under auspices of operation abused drugs in past 7 days

raw_content: The operation failed to report a child made allegations of a staff member allegedly using drugs.

Correction Narrative: A training was held on call in procedures and documentation by the Supervisor. Human resources will follow up with the Supervisor to ensure the training was held and documented. The administrator will follow up with the Supervisor to ensure that all staff have a better understanding on call in procedures and documentation.


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: Reviewing unauthorized absence log on date 10/25/2021 & 12/11/2021 it was noted that debriefing was not conducted as well as time/ date was not entered into the form on 12/11/2021

Correction Narrative: A training will be held on AWOL procedures and documentation by the Supervisor. Human resources will follow up with the Supervisor to ensure the training was held and documented. The administrator will follow up with the Supervisor to ensure that all staff have a better understanding on AWOL procedures and documentation. The Education Liaison will continue to keep an open communication with the school and collaborate on ideas of how to ensure residents get home safely. A training roster was received.


summary: 748.2551(b)(2) - EBI Implementation-The caregiver must consider the permitted types of emergency behavior intervention

raw_content: During a restraint a child in care was carried up the stairs which is not a permitted type of EBI.

Correction Narrative: The following correction was sent by the Administrator: When an EBI is being performed staff will make better prudent judgment going forward on the type of EBI to use.  The Supervisor will provide training to staff on how to better handle a crisis that may arise on the stairway. The Administrator will follow up with the Supervisor to ensure that staff all have a better understanding of how to handle the situation and the training will be documented with Human Resources. An inspection took place and interviews were conducted with children to ensure the operation is in compliance.


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

raw_content: Multiple medication records were observed to not have documented the reason the medication was prescribed.

Correction Narrative: The medication records included the reason the medication was prescribed.


summary: 748.2151(b)(1) - Medication record - update cumulative record within 2 hours of administering medication

raw_content: One child had her morning medication administered however was not documented. Other medication logs were observed to not have been completed to it's entirety or showing details when medication was sent home with the child when they go on home visits.


facility_name: Central Texas Table of Grace

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

raw_content: While reviewing child records, it was discovered that a child refused a medication 3 times and medications errors were not completed.

Correction Narrative: The errors found during the inspection have been corrected. Staff have been reminded to log each time a child refuses their medication at the time of attempted administration. Program director, case manager, and/or shift lead will review medication logs to ensure that logs are being filled out appropriately.


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

raw_content: One child in care's initial service plan within the 45-day timeframe.

Correction Narrative:
Email sent by Administrator: I have now implemented three levels of checks and balances to prevent this from happening again:
1.	Extended Reach triggers compliance dates,
2.	The Case Manager and Program Director conduct monthly checks,
3.	I perform random monthly checks to ensure everything is in order.


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: Medication logs for three children in care could not be provided.

Correction Narrative: Based on the email sent by the Administrator:  I immediately overhauled our Extended Reach system to ensure all compliance dates are triggered accurately. In addition to this, we now have the Program Director conducting monthly checks, and I personally perform random spot checks to ensure compliance is upheld at the highest standard. We also implemented weekly checks for medication compliance to add an extra level of security.


summary: 748.935(a)(2) - Annual Training Timeline-Each person must complete the required annual training during each subsequent 12-month period

raw_content: 4 staff members did not complete training within the required annual training period.

Correction Narrative: Based on the email sent from the Administrator: All staff have been retrained, and we've established monthly training sessions to maintain ongoing compliance. Additionally, I've implemented both paper and digital records for staff and children to create an extra layer of accountability and transparency.  We continue to track trainings based on the hire date, ensuring that all staff remain within their 12-month training period.


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

raw_content: During the investigation, footage was requested multiple times but was not provided, and it was lost due to retention issues.

Correction Narrative:
An email was received from the operation on 9.13.24.

It was explained the operation has updated their electronic system to ensure compliance triggers along with a paper system to ensure files are always complete and compliant. As of 9/13 the operation updated the electronic system with triggers as our first layer of compliance and record keeping. The Case Manager and Program Director will do weekly checks. The LCCA will do monthly spot checking to ensure that files are compliant.  If there is an investigation, the operation will immediately save any available footage to a USB drive.


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

raw_content: The operation did not create a discharge form for a child in care that was discharged, or have the location of where the child was going.

Correction Narrative:
An email was received by the operation on 9.13.24.

It was explained the LCCA has retrained the Case Manager on how to fill out a discharge/transfer document in our electronic system.  The operation now has a form built into their Extended Reach System.


summary: 748.705(b)(3) - Reasonable & prudent parent standard-must consider the child's behavioral history and ability to safely participate in proposed activity

raw_content: A 14-year-old, whom the operation had no time to build rapport with, was allowed to go to 3 stores merely 3 days after their elopement from the operation. During this outing, the child ran away again and took another child in care, an 11-year-old, with them.

Correction Narrative:
A phone call was had with the Administrator. It was discussed going forward if a child elopes from the operation and the child returns, they will be placed on a safety plan. Discussed within the safety plan will be supervision and outing privileges.

8/4/23- An in-person follow-up was conducted at the operation. A discussion was held with the administrator. She stated they still have a plan in place and will be implementing safety plans after a child has run away. She stated this will be done by a member of the administrative team. She stated there will also be a debrief held with the child and staff member following a runaway and if the child returns to the facility.


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

raw_content: A child accessed medication from a staff purse when in the bathroom.

Correction Narrative: Victoria Wrede, Administrator called and followed up with an email on the operation coming into compliance. The email stated that a training was completed to discuss the incident that occurred. They reminded staff to be sure to lock up all personal belongings, especially any necessary medications they might need. They also reminded staff about their supervision policy and making sure they are following the policy for intermittent supervision, with eyes on kids every 5-10 minutes. AR was requested.


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

raw_content: A copy of the child's immunization record was not found in the child file.

Correction Narrative: Victoria Wrede, Administrator, reached out the INV Alvarez, via phone call stating they have tried obtaining records from the hospital, school records, and CVS worker but records are unavailable. Will continue to attempt to obtain.


summary: 748.363(5) - Personnel records-Include copy of a cleared tuberculosis screening conducted prior to the person having contact with children in care

raw_content: A record of tuberculosis testing for a staff member was not found on file.

Correction Narrative: Victoria Wrede, Administrator, provided the copy of the TB Test for the employee in question.


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

raw_content: An incident report dated 04/10/21 indicating a child in care had a seizure in the home and was transferred to hospital via EMS was not reported to Licensing.

Correction Narrative: Victoria Wrede, Administrator, provided in an email stating the hotline report information that we have regarding the Serious Incident Report with J. Coronado going to the emergency room. Gary Badge ID# 5476 Report ID#74622805.


facility_name: Road To Wisdom LLC

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

raw_content: A child in care sustained an injury as a result of a physical altercation with another child in care while being supervised by staff.

Correction Narrative:
CCR Supervisor conducted a phone call with operation Administrator regarding compliance plan submitted. The Administrator shared that the operation completed a training regarding supervision and discussed with staff regarding the outcome of the investigation.

EMAIL: Operation submitted a document sharing that they understand and will adhere to minimum standard requirements regarding supervision.


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

raw_content:
All interviewed residents and staff members reported that caregivers left a child in care at a public bus stop on 4/14/25 when she refused to enter the van.
The child's safety plan indicates that staff will provide at least 1:5 supervision during awake hours and maintain line of sight of youth.

Correction Narrative: The administrator stated that staff did not leave child at school. She stated that the operation has 15 minutes wait time after school for kids to get inside the bus. She stated that staff called the school police and will do same in future.


summary: 748.3701(a) - Recreation responsibility-Must provide daily indoor/outdoor recreational & other activities appropriate to needs, interests, and abilities of children

raw_content: During interviews with staff and residents, it was determined that residents have zero outdoor time during the school week.

Correction Narrative: Road to Wisdom, LLC will ensure that outdoor recreation is offered daily and will document when residents or when it is not possible.


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

raw_content: Multiple youth interviewed advised that staff used profane language at or around them.

Correction Narrative: Road to Wisdom, LLC staff reminded all staff of our zero-tolerance profanity with residents via internal company communication on 2-5-25. We have a scheduled Child Rights training on 3-14-15 during which this will be addressed.


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

raw_content: The operation did not submit their EBI quarterly data within the required timeframe for quarter three.

Correction Narrative:
An email was received from the operation stating that the operation's quarterly data on EBI's will be reported to Licensing no later
than 15 days after the end of each quarter.


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

raw_content: Staff indicated that restraints are used as a means to deal with behaviors such as crying and screaming.


raw_content: Children interviewed at the facility mention staff consistently yells and cusses at or around the children. Children mention staff threatens children with corporal punishment.

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

Correction Narrative:
Road to Wisdom, LLC will ensure that staff is re-trained on our
Discipline policy within the month of August 2024, beginning on 8-2-24. Staff was re-trained on Child Rights on 7-19-24.

Interviews were conducted with children on 9/13/24. Four out of four children confirmed that staff are not cursing at them or threatened the use of corporal punishment.


summary: 748.2103(a) - Medication Storage & Destruction-Discontinued or expired meds & meds left at the operation must be inventoried & stored separately from current meds

raw_content: The discontinued medication is being stored right next to the active medication.

Correction Narrative: Medication was found to be in compliance and not stored next to discontinued medication.


summary: 748.535(3)(C) - Child-care administrator responsibilities-Having system in place to ensure an employee is available for emergencies

raw_content: The facility did not have an available employee to pick-up a child released from juvenile detention.

Correction Narrative:
The administrator provided an email correction stating the following: Road to Wisdom, LLC will have an available staff to pick up children
released from juvenile detention, as well as respond to emergencies.


summary: 748.2301(b)(1) - Disciplinary Measures-must be consistent with operation policies and procedures

raw_content: Based on 2 children and 1 staff interview it was confirmed that clothing is taken away as consequence due to child behavior.

Correction Narrative: Road to Wisdom, LLC will not take away children's clothing as consequence due to children's behavior. The operation will follow program policy regarding storing resident's clothing and property to ensure resident program safety and security.


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

Correction Narrative:
Email from Holly Lee-McCain at hleemccain@rtw-rtc.com

Road to Wisdom, LLC
6513 Morrow Street  Houston, TX 77091
713-360-7656
Inspection Citation Correction Report
Date of Response November 4, 2022
RCCL Staff Vanessa Reyes
Notification Date November 4, 2022
Operation Number 1708504
Investigation Number 2933388
Findings Detail
Standard Rule 748.2003(b)(3)
Description AP Administration of prescription medication-Administer medications according to instructions or a prescribing health-care
professional's orders  Specifics Staff need to follow the orders on medications as instructed by
the health care professional in order to avoid any harm to children in care.

Comply By Date November 4, 2022
Correction:
Standard Rule: 748.2003(b)(3)
Corrective Action: The staff involved were reprimanded on September 6, 2022 the
date the error was discovered. They also participated in a meeting regarding medication administration protocol. Medication changes
are more clearly communicated to ensure that all staff who administer medication are aware of the present orders. RTW conducts weekly medication audits and Administrative Staff is available during medication administration to answer any questions about medications.


summary: 748.881(4) - General pre-service training curriculum-Includes steps to preventing the spread of communicable diseases

raw_content: In one of the  three files reviewed communicable disease pre-service training was not completed as part of the curriculum.

Correction Narrative: Road to Wisdom, LLC will ensure that all staff have documented communicable disease training as a part of their pre-service curriculum.


summary: 748.2151(b)(1) - Medication record - update cumulative record within 2 hours of administering medication

raw_content: In one of the medication logs it was observed that the date and signature of the person administering the medication was documented however the time, amount given, and amount remaining were not filled out.

Correction Narrative:
Administrative staff met with the staff member who was responsible for the incomplete record. This record has been updated. The staff member will
double check each entry for completeness. The Staff Supervisors will also review medication administration records by April 25, 2022 with all staff who administer.


raw_content: Two staff admitted to not preforming timely and adequate checks of children during overnight hours resulting in two children, from two separate houses, engaging in sexual intercourse.

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

Correction Narrative: Interviews were conducted with children regarding supervision and staffing patterns and there were no concerns the children reported that staff are always able to see and hear them at all times.


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

raw_content: A direct care staff at the operation has a provisional background check that states that the staff cannot be the only staff responsible for supervising children. The Administrator identified that the staff is responsible for supervising children.

Correction Narrative:
RCCR Inspector-Tracy Robinson received an email from Ms. McCain that effective 4-15-21, at 5:00pm, Tabriana Francis would not be the only staff supervising children. Effective 04-16-2021, Tabriana F. had an eligible
background check determination from CBCU and could resume all duties. Tabrina F. next background check is due on/or before 01/29/2026.


facility_name: Guiding Hope Inc.

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: The facility has an odor of raw sewage coming from the broken dishwasher.  The bunkbeds are unsteady and lacking mattress protectors.

Correction Narrative: The operation has eliminated the sewage smell and the  broken dishwasher has been removed.  The bunk beds have been replaced and are now stable and  safe. All beds now have  mattress protectors.


summary: 748.863(a)(2) - Pre-Service Training-Administrative & professional staff must have 2 hrs normalcy training before designated or within 90 days of beginning duties

raw_content: Three of four employees required to complete normalcy training have not completed the training.

Correction Narrative: All employees completed normalcy training. Records were reviewed and saved with all follow up records.


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

raw_content: A bedroom door has removed from the hinges and the door to the hotwater heater is off the tracks.

Correction Narrative: The  bedroom door has placed on to the hinges, and the door to the hot water heater has been placed back on track.


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

raw_content: The external grounds of the facility have significant debris, a low hanging electrical line, and an old air conditioning unit that is falling from a building on the property.  There is also a large hole/pit which was used for cooking during a BBQ.

Correction Narrative: The external grounds of the facility has been cleared of all significant debris such as, a low hanging electrical line, and an old air conditioning unit that is falling from a building on the property.  The  large hole/pit which was used for cooking during a BBQ has been filled.


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: Three of three medication logs did not include the prescribing physician's name, the instructions for administering medication, the reason for the medication, or the pill counts for the medication.

Correction Narrative: Inspection #3826688 conducted by RCCR staff at the operation on May 28, 2021.  Current medication logs were reviewed a completed according to the Minimum Standards.


raw_content: A child at the operation missed two doses of his prescribed psychotropic medication on the date of 3-27-21 and 3-28-21.

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

Correction Narrative: The operation is no longer providing services for children and was closed on 6-4-21 through a RCCR notice of intent to impose adverse action towards the operation's request for a full permit. The intent to impose adverse action letter was hand delivered on 6-4-21 by the RCCR supervisor and assigned RCCR inspector. There are no children placed at the operation at this time.


summary: 748.393(b)(3) - Active child record - Ensure record is kept accurate and current

raw_content:
Three children's records had incomplete admissions assessments, preliminary service plans, and missing signatures as required per Minimum Standards.

One child's service plan and admission's assessment were missing documentation related to high risk behavior and supervision requirements as required in Minimum Standards.


raw_content: One child's medication record was missing the documented dosage, medication count, medication administration time, and the operational staff member's signature for a prescribed psychotropic medication.

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


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 13, 14, and 16 year old resident used illegal drug related substances in the external and internal areas of the operation while the staff were unaware of the children's activity. A child in care had specific supervision instructions related to high risk behaviors around other children. This lack of oversight posed a risk to this child and others in care.


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

raw_content: Three children at the operation were improperly supervised in accordance with the information that is described and documented in each child' s individual service plan.


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

raw_content: The administrator failed to ensure that staff were aware of supervision requirements and supervision patterns for children at the operation that exhibited high-risk behavior.


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

raw_content: During a walk through inspection of the operation, the following information was observed to be deficient, standing water due to a plumbing issue in the child's bath tub, dirty toilets in the child's bathroom, and a broken toilet paper bracket in the child's bathroom.

Correction Narrative: A follow up inspection was conducted on 05/28/2021 with Administrator Mr. Cuba. Compliance was met, phots were taken to support the concerns noted.


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

raw_content: Two children's preliminary service plan's failed to address the supervision requirements for each child in care at the operation.

Correction Narrative: Completed documents were Emailed to me be by Administrator Victor Sims compliance was met on 5/12/2021.


facility_name: Trinity Guidance Residential Treatment Center

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

raw_content: A staff member did not have a completed background check prior to working at the operation.

Correction Narrative: Background check has been completed and shows in CLASS.


raw_content: A medication record for a child in care is not accurately updated to advised if a medication was taken, missed or refused, however the remaining amount reflect as if one medication was taken.

Standard Number / Description: 748.2151(b)(1) - Medication record - update cumulative record within 2 hours of administering medication

Correction Narrative: Immediately after administering medication, Staff will note and log the time, note and log the updated med count, and initial. This will ensure cumulative medication records are updated within 2 hours to remain in compliance. Quality control of all medication logs will occur weekly to ensure there is no lapse in the records. Logs were reviewed and showed medication logs were up to date.


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

raw_content: Three fire extinguishers observed at the operations were last serviced in July of 2024.

Correction Narrative: Compliance plan: The facility will use a state fire marshal-licensed company to service all fire extinguishers annually with no lapses by closely monitoring tags that show last service date. Pictures were provided showing tags marked August 2025.


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

raw_content: It was determined that staff lacked prudent judgement by allowing a child in care to spend the day and nights at a sister RTC, which was not the child's permanent placement and there was no documentation in place allowing this.

Correction Narrative: A corrective action plan was recieved by the operation stating that: Proper channels for a child's removal will be adhered to immediately. All persons concerned will be notified before a child will be released to anyone or another location. Trinity Guidance RTC will continue to make decisions that is for the well being and safety of the child. The License Child Care Administrator will ensure that this protocol is followed. All necessary documents will be filled out to constitute any moving of a child according to Minimum Standards.


summary: 748.1481(a) - Release of Child-Except in emergency, only release child to parent, parent's designee, law enforcement, or person authorized by law to take child

raw_content: It was determined that a child in care was spending the day and night at another placement and was being transferred by placement staff.

Correction Narrative: Child interviewed regarding permanent placement and observed child's belongings in their bedroom and there are no concerns that the child is being moved placements.


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

raw_content: A staff member reported they were not informed a child in care was not to drink soda after being discharged from the hospital and therefore allowed the child to drink soda. This resulted in the child returning to the hospital.

Correction Narrative:
Email received from operation. To prevent further citations related to "748.685(c)(5) Caregiver responsibility - ensure continuity of care by sharing information concerning each child with incoming caregivers," office staff will update and share relevant resident information with all staff - including Direct Care Staff and Administrators - as it is received by the facility. This will be done through whiteboards, shift change logs, verbal communication, and posted notices in shared facility-wide electronic communications.
Additionally, as part of Trinity Guidance's office reorganization, clear and organized access to relevant resident records will be ensured, and documents will be provided in a timely manner. Pictures were received of white board and electronic shift reports used for communication.


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

raw_content: There are several staff personnel with active background checks that no long work for the operation.

Correction Narrative: Operation most recently validated their background check on February 20, 2025. Operation provided a copy of their active employee list, volunteer lists, and contractors who require a background check, and it was determined that none of the active background checks need to be inactive. There are currently no frequent visitors.


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

raw_content: Child was able to just out of window due to lack of supervision.

Correction Narrative: The operation stated that they expressed a miscommunication regarding installed window alarms on the upstairs window to alert staff when windows are opened or tampered with; instead, a screen was installed. A receipt of the screen was provided and a walkthrough of the home indicated that the screens have been installed.  Operation still expressed they will also add window chimes and apologized for the miscommunication. Licensing also interviewed two staff and two children in care who expressed that the children are never left unsupervised, and staff are escorting the children when they need to go to other areas in the home. No concerns for the safety and supervision of the children were expressed and no outcries were made.


summary: 748.2605(a)(5) - Personal Restraints Prohibited-Restraints that twist or place the child's limb(s) behind the child's back

raw_content: Multiple person interviewed advised of children being restrained with their hand behind their backs.

Correction Narrative: Trinity Guidance RTC staff attended a refresher training on De-Escalation, Crisis Intervention, and Restorative Intervention for the operation's approved EBI techniques in Physical Aggression and Physical Holds on 02/04/2025 and 02/11/2025. The operation provided a copy of the roster and certificates. Licensing also reviewed the operation's EBI policy, and no concerns were noted.  Licensing interviewed two staff and two children regarding supervision and restraints, and no concerns were noted, and no outcries were made.


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

raw_content: It was determined that the operation failed to report a child arrest. An intake (78855200) was received from law enforcement and not the operation to report a child arrest.

Correction Narrative:
The facility, through the Administrator, submitted the following Corrective Plan, to wit:

This plan is pertaining to citation inspection number 281376 that was issued on 5/13/2024. The staff failed to report a serious incident report of a youth that had been arrested within 24 hours. I, the administrator Derrick Thomas, will review standard number 748.303. When Must I Report A Serious Incident with the staff to ensure that they understand this standard.


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

raw_content: It was found in 1 of the staff files reviewed that a direct care staff did not have a CPR certificate.

Correction Narrative:
The facility has an instructian sheet that is giuen ts ail neyir hires hefor* thev are hired
explaining to them the steps of employment before they are hire to be completed.


summary: 748.864(d) - Pre-Service Training-Document the completion of each training requirement in the appropriate personnel record.

raw_content: It was found in one of the two staff records reviewed that there was no documentation of preservice training.

Correction Narrative:
The operation sent the following corrective action.:All employees will have their training document in their personnel files.
This will be implemented by the Administrator or Assistant Administrator


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: It was found in two out of two staff records reviewed there was no documentation of high school diploma or GED.

Correction Narrative:
The operation sent the following correction by email  All employees will have proof of education in their employee files from a
program recognized by TEA, TPSAC, other state or documentation of equivalency from home
schooling.


summary: 748.363(9) - Personnel records-Include proof of request for background checks

raw_content: It was found in two out of two staff files that were reviewed that there was no proof of a request for a background check.

Correction Narrative:
The operation sent the following corrective action by email :All personnel recerds will include their dat*s of employment and the proof of
the request for their backgrounds. This will be implemented immediately.


summary: 748.363(1) - Personnel records-Include date of employment

raw_content: It was found in two out of two staff records did not have the date of employment.

Correction Narrative: The operation sent the following corrective action All personnel records will include their dates of employment and the proof of the request for their backgrounds. This will be implemented immediately.


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: It was found that the operation did not have a written plan that included both indoor and outdoor activities per day.

Category: Recreation Activities

Correction Narrative: The operation sent by email a recreational calendar with both indoor and outdoor activities.


summary: 748.1703(c) - Menus-must date menus and keep copies for 90 days

raw_content: It was found that the operation has not been updating their menu.

Correction Narrative:
The operation sent the following corrective action:Trinity Guidance Emergency shelter will provide CCL with a recent copy o{
the updated menu. The facility will keep menus updated weekly.


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

raw_content: It was found that in two out of two staff records did not have documentation of an orientation.

Correction Narrative:
The operation sent the following corrective action by email:Trinity Hm*rgency Shelter have a practice during the hiring process that all
new hires have to complete nEw hire orientation before working with the children. This will be
implemented by the Administrator or CEO immediately"


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: It was found that the last time the operation validated background checks was in January 2023.

Correction Narrative: The operation sent the following corrective action Background checks was validated on 04/16/23.


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: It was found in two out of two staff records reviewed that the Affidavit was not notarized.

Correction Narrative:
The operation sent an email stating All new hires will have a notarized Affidavit in their personnel files upon their date of hire. No
 exceptions.


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

raw_content: It was found that the last health inspection was completed 12/15/2021.

Category: Safety and Emergency Practices

Correction Narrative: The operation sent a copy of their new health inspection that was completed. 1/10/2023.


summary: 748.1703(b) - Menus-must document food substitutions on the menu that are of comparable food value

raw_content: It was found that no food substitutions were found on the menu provided by the operation at inspection.

Correction Narrative: The operation submitted a recreational calendar with itemized daily activities.


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

raw_content: It was found that the operations policy included treatment services which was not allowed due to providing only emergency services. The demographic served was inconsistent throughout the operation's policy.

Correction Narrative: The operation submitted a new menu with food substitutions. The substitution is in comparable with the food value that is being served.


summary: 745.621(a)(1) - Initial background checks submitted - At the time you submit your application

raw_content: It was found at the inspection that there was no background check done for Administrator or owner.

Correction Narrative: The operation submitted background checks for the owner and Administrator.


raw_content: It was found at inspection that the operation did not have a recreational calendar for residents.

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

Correction Narrative: The operation sent in a copy of their itemized updated recreation calendar.


facility_name: Amor Purus II

summary: 748.1615(a) - Protective devices-may use with a licensed physician order that indicates the circumstances under which the protective device is permitted

raw_content:
The child is required to wear helmet during day not at night while sleeping.
Child was observed wearing helmet while sleeping.

Correction Narrative: The operation provided the K-906-2403 form dated 07/02/2025 stating child in care can wear helmet during awake hours only. Operation will trained staff on 08/19/2025 at 5 pm on proper wear and hours of when child in care can wear protective device and submit sign in roster to the licensing representative. Staff was also informed on 07/23/2025 and staff acknowledged child in care can only wear helmet during awake hours.


summary: 748.3233(b)(3) - Evacuation-Emergency evacuation & relocation diagram must include designated location inside operation to take shelter from threatening weather

raw_content: Emergency evacuation is placed throughout the home; however, a shelter in place is not indicated on the diagram.

Correction Narrative:
Operation provided the following response:
The Shelter In Place has been added to the diagram. Please see the attached diagram.


summary: 748.753(c)(3) - Pre-employment Screening- You must document your assessment of the applicant's suitability to work with or around children.

raw_content: Four of four employee files evaluated do not include all of the required information for pre-employment screening.

Correction Narrative:
The operation provided the following response:
This letter will be placed in all the current employee files stating, Amor Purus II employee files were cited on 4/10/2025 for not documenting the assessment of applicants suitable to work with or around children. The Human Resource Department will document the assessment of future/new employees and ensure that the required pre-screening information is being met by completing the Pre-Employment Screening Form.


summary: 748.751(b)(2) - Pre-Employment Screening-You must document the results of any contact with an applicant's previous employers in the personnel file.

raw_content: None of the four employee files that were evaluated did not include documentation of the conversation with their former employers.

Correction Narrative:
The operation provided the following response:
This letter will be placed in all the current employee files stating, Amor Purus II employee files were cited on 4/10/2024 for not having the above information. The Human Resource Department will ensure that the future/new employees will document the applicants results from their previous employer and place it in their personnel file.


summary: 748.753(a)(2) - Pre-Employment Screening-You must contact each of the two references to verify that the applicant is suitable to work with or around children.

raw_content: Employee files include the name and contact information of two references: however, none of the files evaluated include a documentation of the conversation with the references.

Correction Narrative:
The operation provided the following response:
This letter will be placed in all the current employee files stating, Amor Purus II employee files were cited on 4/10/2025 for not having the above information. The Human Resource Department will verify references to ensure that the future/new employees are suitable to work with or around children by completing the Pre-Employment Screening Form.


summary: 748.151(1) - Operational responsibilities - Designate a qualified full-time child-care administrator

raw_content:
The operation's administrator resigned effective 4/13/24.

On 4/22/24, the operation was provided technical assistance and given 60 days to hire a qualified administrator.

On 6/25/24, the operation was cited for administrator vacancy, provided technical assistance, and given 30 days to obtain an administrator.

On 7/31/24, the operation was cited for administrator vacancy, provided technical assistance, and given 30 days to obtain an administrator.

On 8/30/24, the operation was cited for administrator vacancy, provided technical assistance, and given 30 days to obtain an administrator.

The operation's administrator position continues to remain vacant. The operation has 30 days from the date of this assessment to obtain an administrator.

Correction Narrative: Upon phone and email verification operation verified LCCA information however the OP is having technical difficulties with their portal/system and are unable to input the new administrator within the system at this time. They were advised to contact their IT to fix this issue.


raw_content:
The operation's administrator resigned effective 4/13/24.

On 4/22/24, the operation was provided technical assistance and given 60 days to hire a qualified administrator.

On 6/25/24, the operation was cited for administrator vacancy, provided technical assistance, and given 30 days to obtain an administrator.

On 7/31/24, the operation was cited for administrator vacancy, provided technical assistance, and given 30 days to obtain an administrator.

The operation's administrator position continues to remain vacant.

The operation has 30 days from the date of this assessment to obtain an administrator.


raw_content:
The operation's administrator resigned effective 4/13/24.

On 4/22/24, the operation was provided technical assistance and given 60 days to hire a qualified administrator.

On 6/25/24, the operation was cited for administrator vacancy, provided technical assistance, and given 30 days to obtain an administrator.

The operation's administrator position continues to remain vacant.

The operation has 30 days from the date of this assessment to obtain an administrator.