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

raw_content: During inspection 2 of the 3 of the First Aid kit were missing safety  items.. one first aid was missing tweezer, and Thermometer. The second first aid kits was missing tweezer.


state: TX

facility_name: The Pride Lands Center of Hope

summary: 748.363(12) - Personnel records-Include record of training and training hours.

raw_content:
During Inspection 1 out of 3 staff did not have transportation training.

Corrected at inspection.

The operation director was able to print staff transportation certification.

Category: Individual Standards Evaluated

Standard Risk Level: Medium

Corrected at Inspection: Yes


summary: 748.3233(a) - Evacuation-Must have written emergency evacuation & relocation diagram specifying directions for egress on file at operation

raw_content: During inspection it was observed emergency evacuation and relocation diagram did not have the required outside and inside designated safe meeting area.

Category: Safety and Emergency Practices

Standard Risk Level: Medium High

Corrected at Inspection: No


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 operation sanitation inspection has expired.


summary: 748.453(a)(1) - Unauthorized Absence  Annual summary log must include name, age, gender, date of admission

raw_content: Upon inspection it was observed, the annual unauthorized absence log does not contain all of the required components such as date of admission, the time of incident, and when the absence was discovered,

Category: Reports and Record Keeping


summary: 748.393(b)(2) - Active child record-Includes known allergies and chronic conditions or

raw_content: One of three files were observed without the known allergies and chronic conditions indicated.


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: Three of three employees did not have documentation of attempted reference checks for previous employment experience.


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: Three of three caregivers did not have qualifications of education in the personnel files.


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

raw_content: The child list provided listed a childs first name completely inaccurate, the staff list had inactive staff as active, and the service plans dates of admission were inconsistent.


summary: 748.911(a) - Each caregiver must have a current certificate of training with an expiration or renewal date in pediatric first aid with rescue breathing and choking

raw_content: Three of three personnel files did not contain the required first aid training.

Category: Training and Professional Development

Standard Risk Level: High


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

raw_content: Upon inspection it was observed that trauma informed strategies section of the required debriefing was not completed in child in care files.


summary: 748.2857(a) - No later than 72 hours after the initiation of the intervention, you must provide written notice to the parent.

raw_content: A restraint was conducted on a child and there is no notification documentation.

Category: Emergency Behavior Intervention

Correction Narrative: Pride Lands Center of Hope will ensure that all appropriate parties will be informed of restraint via email no later than 72 hours of EBI.


summary: 748.2855(a)(4) - EBI Documentation-Must include the specific emergency behavior intervention administered

raw_content: The restraint report reviewed did not state what type of EBI was used. The form is also missing the person who performed the restraint, attempts to explain to the child what behaviors were necessary for release from the intervention, the actions the caregiver(s) took to facilitate the childs return to normal activities following the end of the intervention, If personal restraint is used, documentation must also include the specific restraint techniques used, including a prone or supine restraint used as a transitional hold.

Correction Narrative: Pride Lands Center of Hope will document a restraint report along with a serious incident report. The restraint report will include the person who performed the restraint, attempts to explain to the child what behaviors were necessary for release from the intervention, the actions the caregiver(s) took to facilitate the child's return to normal activities following the end of the intervention. The restraint report will also indicate what type of restraint technique was performed.


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

raw_content: During the physical walkthrough the freezer was observed to not have a thermometer. This was corrected at site by a staff member going to purchase a thermometer.


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

raw_content: Four of four child medications were reviewed and counted. One of the child's pill count did not match the medication log.

Category: Medication

Correction Narrative: This standards is found to be compliant.


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: Two staff files were reviewed. One staff file affidavit was not notarized.


raw_content: 1 out of 2 staff files reviewed did not have the affidavit notarized.

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


summary: 748.1217(a) - Admission Assessment-Must provide initial evaluation of appropriate placement & ensure that necessary information for service planning is obtained

raw_content: 1 out of 3 child files reviewed did not have an admission assessment.

Category: Admission, Service Planning, Discharge


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

raw_content: 1 out of 3 child files reviewed did not have a preliminary service pan.

Standard Risk Level: Medium Low


raw_content: 3 out 3 child files reviewed did not have a place to document allergies or chronic conditions.

Standard Number / Description: 748.393(b)(2) - Active child record-Includes known allergies and chronic conditions or


summary: 748.121(2) - Abuse and neglect policy-Methods for employee awareness regarding child abuse/neglect, including signs that a child may be a victim of abuse/neglect

raw_content: Multiple criteria for the abuse/neglect policy was missing.

Category: Organization and Administration

Correction Narrative: The operation e-mailed their updated abuse/neglect policy.


summary: 748.113(2) - EBI policy - the specific techniques that caregivers can use

raw_content: EBI policy did not contain the specific EBI technique caregivers will use.

Correction Narrative: The operation e-mailed the revised EBI policy.


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

raw_content: Serious incident report did not contain the physical address or telephone number.

Correction Narrative: The operation e-mailed their updated serious incident report.


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 and relocation diagram must include designated location inside the operation to take shelter.

Correction Narrative: The operation e-mailed the revised emergency evacuation and relocation diagram.


summary: 748.2101(4) - Medication Storage-make provisions for storing medication that requires refrigeration

raw_content: The operation needs a place to store cold medication.

Correction Narrative: The operatio e-mailed a picture of a locked container located inside the refrigerator where they will store medications that need to be kept cold.


summary: 748.3231(b)(2) - Evacuation-Plan requires person in charge during emergency to make an employee responsible for securing medical consents & medications

raw_content: The evacuation plan was missing who the operation will make responsible for securing medical consents and medications.

Correction Narrative: A revised plan was e-mailed and approved by myself, RCCR Hannah Trahan.


facility_name: Latrell's Landing

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

raw_content: Caregivers did not provide the level of supervision stated on the child's service plan.

Correction Narrative: Operation provided Compliance Plans and operation forms that will be uploaded to the Documents Library. The operation will provide plan reviews to ensure staff are aware of each child's Service Plan conditions, including supervision, to ensure each child's safety. In addition, a Service Plan protocol will be implemented, and administrative staff will conduct weekly checks to ensure compliance.


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

raw_content: The operation did not report to the hotline when law enforcement reported to the operation.

Correction Narrative:
Email from Owner/operator (to investigation inspector) received noting operation will report to Licensing no later than 24 hours after becoming aware that child is indicted, charged, or arrested or when police respond. Case Manager will report if its reportable.
LCCA and Executive Director will ensure that report is completed within the 24-hour time frame.
4/13/2026 Email with compliance plan and operation forms received. All documents will be uploaded to the Documents Library. Operation will conduct retraining and institute forms to ensure serious incidents are reported timely and administrative staff are completing reviews to verify reports are made.


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

raw_content: Staff list provided was not updated with current updated staff affiliated with the operation.

Correction Narrative: RCCR Inspector received email from operation providing multi step plan to incorporate new procedures and a two tier check system to ensure all records are accurate. The staff list will be reviewed bi-weekly and checked against employee schedules, payroll records and Background Check reports.


summary: 745.621(a)(7) - AP Initial background checks submitted - At the time you become aware of anyone requiring a background check under 745.605

raw_content:
Operation failed to timely submit the information required to conduct an initial background check. An administrative penalty in the amount of 100% of the daily maximum, per HRC §42.078 will be
recommended as a result of this citation.

Correction Narrative: RCCR Inspector received email from operation with Compliance Plan. The HR Manager and Compliance Officer will be responsible for primary and secondary oversight and will ensure BGCs are submitted timely as required by TAC.  A centralized Background Check Tracker will be implemented and reviewed regularly by the Compliance Officer. The operation will ensure no person will have access to the operation and the children without a valid BGC/determination letter. The Compliance Officer will also ensure all BGC renewals are completed timely.


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

raw_content: The operation was granted an extension and has failed to secure a fire inspection. The operation's owner stated she requested an inspection be conducted and was told it would be completed before 5/31/2025.

Correction Narrative:
6/9/2025 Owner/Operator emailed Fire Inspection Certificate for the inspection conducted on 6/6/2025. Certificate notes Foster GRO with capacity of 9-12.

Extension Granted. Harris County Fire Marshal's office confirmed they are behind on their inspections, and the operation is scheduled for inspection on Friday, June 6th.


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

raw_content: Employee files for the CEO and Treatment Director contained Job Descriptions for Direct Care Staff.

Correction Narrative: RCCR Inspector received email from owner/operator with Compliance Plan and outstanding Job Description of the CEO (Treatment Director previously provided). The operation will review files and ensure the correct and updated job description(s) are present in each staff member's file.


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

raw_content: All four of the employee files reviewed were missing the Pre Employment Affidavit.

Correction Narrative: RCCR Inspector received email with Compliance Plan from owner/operator. Operation will utilize a checklist to ensure all Pre-employment documents, including the Affidavit, are completed and signed.


raw_content: Operation does not have a current fire inspection last inspection dated 8/11/2023.

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


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: Operation did not report EBI numbers for the 4th quarter 2024 (October-December).


raw_content: The GRO does not have an appropriate fire inspection for their type of operation, their most recent fire inspection is a Foster Family Home Fire Safety Evaluation Checklist.


raw_content: It was observed on the current employee list provided by the operation that three of the active employees are inactive in the system.

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

Correction Narrative: The operation emailed a current list of employees to be kept on file at the facility.


summary: 748.3003 - Sanitation Inspection-Must keep most recent sanitation inspection report at operation; report must include name & phone number of inspector

raw_content: A copy of the operation's recent sanitation inspection report was not available.

Correction Narrative: The operation's current sanitation inspection was emailed.


summary: 748.3273(8) - First Aid Kits-Each one must contain thermometer

raw_content: There was no thermometer in the first aid kit.

Correction Narrative: The operation obtained the missing items. A photo was sent to show compliance. The operation will ensure these items are stocked in the first aid kit.


summary: 748.3319(a) - Required Postings-Residential Treatment Center's must have

raw_content: There were no "No Trespassing Signs" posted at the operation.

Category: Physical Site

Correction Narrative: The operation sent photos of the no trespassing signs posted.


summary: 748.3105(b) - Fire Inspection-Must comply with local code & all corrections, restrictions, or conditions specified by inspector in fire inspection report

raw_content: The operation's census exceeds the capacity listed on their fire inspection.


summary: 748.3273(3) - First Aid Kits-Each one must contain antiseptic solution or wipes

raw_content: There were no antiseptic solutions/wipes in the first aid kit.


raw_content: Operation is not in compliance with fire inspection report.

Standard Number / Description: 748.3105(b) - Fire Inspection-Must comply with local code & all corrections, restrictions, or conditions specified by inspector in fire inspection report

Correction Narrative: The operation has an approved fire inspection for a capacity of 7. The operation has reduced their admissions to 7 children until the operation can obtain a fire inspection for a higher capacity.


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

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


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

raw_content:
A caregiver did not demonstrate self control nor prudent judgement and interacted with a child in care inappropriately.
Additionally, a caregiver came to work under the influence of alcohol.


Deficiency Narrative: Operation is not in compliance with fire inspection report.


raw_content: The operation's Fire Inspection reads that it is for a foster home where there will be less than 7 children residing.

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

1.	True and Accurate Record Citation

1.	Latrell's Landing will conduct bi-weekly see and view unofficial audits of required postings.  Any inaccurate information will be immediately reported to CEO and/or LCCA
2.	Latrell's Landing will notify the facility's licensing agent, Aaliyah Fontenot with any potential or questionable information regarding postings immediately upon discovery
1.	Administrator/Treatment Director/Other Designated Employee/Casemanagement

2.	Administrator/Treatment Director/Other Designated employee/Casemanagement


summary: 748.1215(b) - Admission Assessment-Professional level service provider must sign & date assessment, which must be in child's record

raw_content: During the inspection, it was discovered that the admission assessment of one child in care was not present in the record.

Standard Risk Level: Low

Correction Narrative: During the follow up inspection, it was discovered that the operation was able to retrieve the admission assessment of one child in care that was not present in the record before. Compliance is now met.


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

raw_content: During this investigation, it was concluded that the child had a history of suicidal ideations and had been hospitalized due to suicidal thoughts. Therefore, a suicide screening should have been conducted, however, no evidence of a suicide screening was presented.

Correction Narrative:
1.	Latrell's Landing will conduct a suicide approved assessment when necessary per this standard
2.	The Administrator and Treatment Director will be notified immediately of any such gesture and/or ideation to determine if a assessment should be administered.  At that time, a determination of reporting to statewide hotline will also be assessed based on the events.


summary: 748.113(9)(A) - A person for filing a complaint, presenting grievance, or providing information relating to the misuse of EBI at the operation

raw_content: There is no policy regarding retaliation against anyone that files a complaint concerning EBI

Correction Narrative: The operation provided an updated policy


summary: 748.105(3) - Personnel Policies - Develop written professional staffing plan

raw_content: There was no staffing plan included in the operation's policies.

Correction Narrative: The operation provided an updated Staffing Plan.


summary: 748.111 - Child-care policy required

raw_content: child-care policies does not include all required components like how a child obtains clothing, what personal possessions they are and are not allowed to have,etc.

Standard Number / Description: 748.111 - Child-care policy required

Correction Narrative: The operation provided an updated child care policy that included all missing components.


summary: 748.3931(a)(1) - Weapons- Handguns are not permitted at an operation or during any type of activity.

raw_content: The operation's policy only states that weapons are prohibited at the facility during activities involving children in care. The operation's policy does not address the full component of this subchapter, therefore it is incomplete.

Category: Recreation Activities

Correction Narrative: The operation provided an updated weapons policy.


summary: 748.123 - Vaccine preventable policy - develop and implement written policy for vaccine-preventable diseases

raw_content: The operation does not address the full component of this standard. The operation's vaccine policy is incomplete.

Correction Narrative: The operation provided an updated vaccine policy.


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

raw_content: There was no documentation of child orientation in the child's record


summary: 748.113(3) - EBI policy - the qualifications for caregivers who assume the responsibility for EBI implementation

raw_content: The EBI policy does not mention caregiver qualifications, required experience & training, and evaluation component.

Correction Narrative: The operation provided an updated EBI policy.


summary: 748.113(5)(A) - EBI policy - For orientation, explain and document to a child in a manner that the child can understand

raw_content: The EBI policy does not detail how the operation will explain to a child in care who can use EBI, how to report inappropriate EBI, etc.

Correction Narrative: The operation provided an updated EBI policy


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

raw_content: There is no documentation of whether or not there are known allergies on the exterior of the child's record.

Correction Narrative: Operation provided a mock file that included whether or not a child had any known allergies.


summary: 748.109 - Admission policies must include description of each program you offer

raw_content: admissions policy does not include a description of each program offered, it does not mention the operation's program's goals and services provided, and is also missing other required information.

Correction Narrative: The operation provided an updated admission policy that included all missing components.


summary: 748.115 - Discipline policy - The discipline policies you develop for children in care must be consistent with Subchapter M of this chapter

raw_content: The operation's discipline policies does not include all required components. It does not include discipline methods, measures for positive responses, etc.

Correction Narrative: The operation provided an updated discipline policy.


summary: 748.119(1) - Volunteer policy - Include job descriptions and/or responsibilities for the volunteers

raw_content: The volunteer policy is missing required components such as the volunteer's job description.

Correction Narrative: The operation provided an updated volunteer policy.


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

raw_content: There is no space to document the child's age, gender, and date of admission


summary: 748.105(5) - Personnel Policies - Develop written policies on whether caregivers may take children away for  day/overnight visits, ensure policy meets requirements

raw_content: The operation's policies not state whether or not staff are allowed to take children away for overnight visits.


facility_name: Nexus Neurorecovery Center - San Antonio

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: Intake came in on 2/15/26 stating the incident occurred on 2/13/26 and received medical treatment for their injury on the same day. This was not reported to CCR within the allocated time frame.

Correction Narrative: In-person follow-up conducted. Staff interviewed confirmed that training for serious incident reporting and time frames was completed.


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

raw_content: A caregiver initiated a personal restraint on a child when it was not required, as de-escalation techniques appeared to be managing the situation effectively and the child was not displaying aggressive behavior at the time of the restraint.

Correction Narrative:
11/12/2025 - A follow-up was conducted in person, during which staff members were interviewed. They confirmed that they had received training on the "tap-out method," which instructs staff to use containment as a last resort and only in emergency situations, and to switch with staff when needed. Additionally, children were interviewed and provided examples of recent restraints, which corresponded to emergency situations.

10/31/25 - Operation completed a mandatory training for all caregiver staff regarding tap out procedures and a reminder that physical containments are always a LAST resort after all other interventions have failed. Operation attached the quiz, attestation, staff roster for the training and curriculum for review.


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

raw_content: During the walkthrough of the kitchen multiple dry and wet food items were expired and multiple food items were not stored properly.

Correction Narrative: Supervisor conducted a physical follow-up at the operation and a full walkthrough was conducted. Supervisor inspected the kitchen checking both dry and wet foods and no concerns with the expiration dates nor food storage were observed.  It was observed that the operation adds the received date on their foods items, which is different from the expiration date, and this is not a concern nor risk to children as none of food items were expired nor spoiled.  Supervisor also observed all refrigerators/freezers to be accurately reading at the time of the inspection. Supervisor reviewed the opening-closing checklist and interviewed the staff regarding the new process that the operation has implemented, and no concerns were noted.  Staff uses FoodSafety.org to ensure they are following the correct protocols and staff has access to the website at all times and it's reviewed to ensure they are correctly following the chart based on the food storage.


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

raw_content: Children in care were able to access razors from secured operation locations.

Correction Narrative: In person follow-up conducted and staff interviewed confirmed receiving training on admission policy changes.


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

raw_content: 11 of the 16 fire drills reviewed did not have required information.

Correction Narrative: Operation advised that they have reviewed the recent fire drill documentation and identified several instances where information was either incomplete or unclear. In response, they provided re-education to the Plant Operations Manager, who is in charge of the drills, to ensure these issues are addressed moving forward. Administrator will also meet with Plant Operations Manager to review all fire drill logs for accuracy and completeness during their weekly meetings.


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

raw_content: Operation has not provided corrected operational policy.

Correction Narrative: Operation provided updated policy for Licensing review and approval.


raw_content: It was confirmed that a staff member told a child in care to shut up.

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

Correction Narrative: Email received from operation advising that staff member involved was terminated. Operation also discussed expectations and professionalism with all staff in their meeting that was held on 12/18/24. Sign-in sheet for 12/18/24 meeting was provided.


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

raw_content: Staff member engaged in a verbal confrontation with a child in care.

Correction Narrative: Email received from operation that employee involved in the incident was terminated. Additional information was received on 2/6/25 that the incident was discussed with all caregivers in the weekly meeting regarding professionalism, tone, language, etc. Meeting agenda notes were provided.


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

raw_content: The initial service plan time frame was outside the window of date of placement.

Correction Narrative: Operation developed a tracking system for Initial Service plans. This was discussed in the clinical meeting on 12/13/24. Meeting agenda was provided by the operation.


summary: 748.1337(b)(1)(H)(ii) - Initial Service Plan-child w/ high risk behaviors, include specific safety contract developed btwn child & staff to ensure safety

raw_content: The initial service plan provided by the operation does not discuss the child's high-risk behaviors or a specific contract developed. The operation is aware of the child's high-risk behaviors as this is the second time at this operation.

Correction Narrative: Operation discussed the need for Initial Service Plans needing to contain high risk behaviors in the clinical meeting on 12/13/24. Meeting agenda was provided by the operation.


summary: 748.311(2) - Serious Incident Documentation-Includes time and date of incident

raw_content: Incident reports were missing some information regarding time and date and names of adults involved.

Correction Narrative:
An email on 8/22/24 with operation was received stating that a designated staff will now conduct audits and review the annual summary log weekly.

Clarification email received from operation on 8/26/24 that Activities Coordinator, who reports to the Treatment Director, will be completing the weekly audit of the operation's annual summary log. The operations log consists of EBI, unauthorized absences, 2991's, and triggered reviews.


summary: 748.1207(b) - Placement agreement - Must be signed by parent

raw_content: Two of two child placement agreements were reviewed, and neither were signed by the child's parent/managing conservator.

Correction Narrative: In person follow-up confirmed that internal checklist was created by operation to ensure that document is signed and correctly scanned and placed into residents file. Case Manager completed the checklist and Treatment Director verifies the document.


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: Residential Child Care Regulation observed a care giver's training record to be without 40 hours of on-the-job training. The explanation note read that the care giver had this at a previous operation.

Correction Narrative: In person follow-up confirmed that caregiver completed required hours. In person follow-up also confirmed that operation created a checklist of what all personnel files and employees need to meet requirements to include caregiver experience hours.


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: 2 of the 3 plans reviewed did not have confirmation that required parties were notified of the date the service plans would be completed and did not give those parties an opportunity to respond

Correction Narrative: In person follow-up confirmed that an internal checklist was created to ensure that notification of meeting were sent to all parties timely. Checklist is completed by Case Manager. Treatment Director will confirm checklist is completed.


summary: 748.1349(a)(2) - Initial Service Plan-Give copy or summary of plan to child's parents

raw_content: 2 of the 3 service plans reviewed were unclear as to who received a copy of the plan

Correction Narrative: In person follow-up confirmed that service plans for existing residents are being conducted at two per week until all residents have completed service plans however new residents will be completed as required.


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

raw_content: Two child files were reviewed. The orientation information provided to the children within seven days of admission did not include all information regarding operation policies.

Correction Narrative: Email received from operation on 7/19/24 advising that Residents and guardians are provided with copies of all required policies in their admission handbook. Operation has a resident version in a more easily understandable format, and one for guardians. Therapists meet with residents to go over the documentation in the handbook to ensure residents understand the material. Residents as well as guardians sign an acknowledgment that they have received all the required policies which are filed in resident files. The operation provided a digital copy of their orientation booklet that is provided to both the parent and the child on 9/3/24 and the acknowledgement form that they sign that they were reviewed and received.


summary: 748.1217(a) - Admission Assessment-Must provide initial evaluation of appropriate placement & ensure that necessary information for service planning is obtained

raw_content: Two child files were reviewed, there were multiple items that were missing within each child's admission assessment.

Correction Narrative: Operation recompleted the admission assessments for the files observed and a retraining was conducted with staff on 7/8/24 to ensure that all admission assessments are completed accurately.


summary: 748.1215(b) - Admission Assessment-Professional level service provider must sign & date assessment, which must be in child's record

raw_content: Two of two child admission assessments did not have a professional level service provider signature or date.

Correction Narrative: In person follow-up confirmed that internal audit was being completed weekly by treatment director.


summary: 748.1205(a)(8) - Admission Documentation-Includes allergies (food, medication, sting, and skin allergies)

raw_content: Two child files were reviewed. The children's files did not include all necessary information within the file at the time of admission.


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

raw_content: Residential Child Care Regulation observed the operation's emergency evacuation posters to be without documentation of a designated outside meeting point.

Correction Narrative: In person follow-up confirmed that new signs were posted at operation.


summary: 748.1339(a) - Initial Service Plan-Service planning team must develop the service plan

raw_content: 2 of the 3 plans reviewed did not specify who was included or present in developing the service plans

Correction Narrative: In person follow-up confirmed that an internal checklist was created to ensure that required signatures were present. Checklist is completed by Case Manager. Treatment Director will confirm checklist is completed.


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: Child in care on 1:1 supervision swallowed a foreign object which required medical treatment such as x-rays as this could result in an unhealthy condition of the body and mind.

Correction Narrative: In person follow-up conducted and 2 staff were interviewed who confirmed that additional training was received.


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

raw_content: A child in care cheeked medication and took more than the prescribed amount.

Correction Narrative: Operation provided additional medication administration training to employees and operation posted in-service training and medication administration reminders in the medical station. In person follow-up confirmed that signs were posted in the medication room.


summary: 748.753(b) - Pre-Employment Screening- At least one reference must be an employer who has supervised or familiar with the history of the applicant.

raw_content: An employee file had reference checks; however, it was not documented if the references were professional or personal.

Correction Narrative: Inspector received email from operation with compliance plan stating that the staff file in question has been updated to reflect which type of reference check was completed.  Operation states that in future to prevent this citation from re-occurring they will credit an audit checklist to be completed by HR to ensure which type of reference check was completed.


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

raw_content: Two serious incident reports did not have the operation's phone number.

Correction Narrative: Inspector received compliance plan from operation informing that modifications to serious incident report were completed to add the operations phone number. A request was also made to operations IT update serious incident report form to include phone number on online form.


summary: 748.4009(c) - General requirements-There must be emergency transportation available at all times

raw_content: Operation utilized a drive sharing service to transport a child who was accompanied by staff from the hospital back to the operation.

Category: Transportation

Correction Narrative: Inspector received email from operation with compliance plan stating that operation had received a van from sister location to use and have transitioned all necessary materials from one van to another.  The operation reported they are no longer utilizing the rideshare service and are only using the borrowed van or staff member's vehicles for transport while they are in the process of searching for a new vehicle for purchase.


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

raw_content: An employee file did not have documented the number of attempts made to contact the employees' former employers or the employers refusal to provide information. In the result area of contact it stated "NA"

Correction Narrative: Inspector received email from operation with compliance plan stating that the staff file in question has been updated to reflect all necessary reference completed reference checks.  Operation states that in future to prevent this citation from re-occurring they will credit an audit checklist to be completed by HR to ensure the number of attempts are marked for contacting previous employers.


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: During an inspection, record review for 1 of 5 staff files reflected only one reference was contacted instead of two.

Correction Narrative: Inspector received email from Administrator with competed reference checks (2). Administrator also reported in an effort to prevent this issue from reoccurring, they have developed a staff file audit, which reflects minimum standards. HR will complete the initial audit on each file. We then have a standing meeting on the first business day of the month where directors will complete a second audit on their employe files, utilizing the minimum standards checklist. The checklist will contain signature lines and dates to indicate who completed the audits and when. This double audit system will reduce the number of oversights and increase accountability significantly.


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

raw_content: During the inspection, record review of serious incident report reflected it did not contain all the required sections of a serious incident report to include: physical address, telephone number, names of adults involved and/or their role to child, witness information, interventions made during and after incident.

Correction Narrative: Inspector received email from Administrator who informed the operation would be adopting Form 2991 for serious incident reporting. It will be uploaded in our medical record system for ease of use. Blank copies will also be stored in the Annual Summary Log in the Serious Incident Log tab.


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

raw_content: During an inspection at the operation, it was found an employee did not have a completed initial background check.

Correction Narrative: Background check submitted on 1/11/2024. As of 1/16/2024 background is still pending. Extension granted for 1/26/2024.


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

raw_content: During an inspection, 1 of 5 staff files reflected the notarized affidavit was provided and signed but was not completed in the exception area.

Correction Narrative: Inspector received email from Administrator with completed notarized affidavit.  Administrator reported in an effort to prevent this from occurring again they have developed a staff file audit, which reflects minimum standards. HR will complete the initial audit on each file. We then have a standing meeting on the first business day of the month where directors will complete a second audit on their employe files, utilizing the minimum standards checklist. The checklist will contain signature lines and dates to indicate who completed the audits and when. This double audit system will reduce the number of oversights and increase accountability significantly.


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

raw_content: During walk through of operation it was observed that fire extinguishers had not been inspected for the month of October 2023. Operation staff admitted no monthly check was completed on during the month of October 2023.

Correction Narrative: Inspector received an email from administrator with compliance plan and attached fire extinguisher inspection log that will be used each month to track when fire extinguishers will checked by the 15th of each month.


facility_name: Dawn Rise RTC

raw_content: A direct care staff applicant was present at the operation and in the presence of children in care before the operation received an eligible background check determination.

Standard Number / Description: 745.641 - AP Background check results - Must receive notification prior to allowing subject to be present at your operation

Correction Narrative:
The operation sent an email with a letter of acknowledgement. The operation reports misinterpreting TAC that staff could attend orientation, introduction and training with residents present. Moving forward, all training and orientation will be conducted after the
background has cleared for an applicant. A schedule was sent showing the AP is not on schedule to return until 7/21/2024 OR the operation receives notification from CBCU that the individual can be present at the operation.


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

raw_content: During the investigation it was found that a caregiver was not in a position to visually supervise children in care leading to the children leaving the operation.

Correction Narrative: The operation held a discussion with staff on active supervision. Signatures were obtained. A night log for note taking was created for the staff on duty to document movement and checks conducted. A photograph of the location in which staff will be stationed at night was taken during the inspection. Night staff have a desk and chair situated in a manner that they can see down both hallways.


summary: 748.3235 - Evacuation-Must post the emergency evacuation & relocation diagram in a prominent/visible location in all buildings

raw_content: The emergency evacuation plan was not posted during inspection.


summary: 748.125(e)(1)(A) - You must immediately refer a child to a MH professional for a suicide risk assessment if screening finds child to be at a high risk for suicide.

raw_content: The operation policy and procedure manual must specify how soon the child will be sent to the LPC for a suicide risk assessment

Correction Narrative:
The operation updated their policy manual. (Page79)
If a suicide risk screening finds a child to be at a high risk for suicide, she will be referred to a Mental Health professional immediately for a suicide risk assessment, specifically our LPC and/or the 24 hour on-call crisis team vis Imagine Pediatrics.


summary: 748.125(c)(1) - Suicide Training-All caregivers and employees must complete at least one hour of annual suicide prevention training.

raw_content:
The operation policy does not state how long the training will be or indicate the training will be instructor led.
As well as 748.125(c)(1)(A) The risk factors, protective factors, and warning signs of suicide.

Correction Narrative:
The operation updated their policy manual. (Page 78)
Suicide Trainings twice a year will be instructor led and that the curriculum provided by the LPC. LCSW, or LSSP will include the risk factors, protective factors, and warning signs of suicide.


summary: 748.2101(4) - Medication Storage-make provisions for storing medication that requires refrigeration

raw_content: The operation does not have provisions to store medication that requires refrigeration.

Correction Narrative: The operation has purchased and placed a combination lock box in the refrigerator. The lock box is on the top shelf of the refrigerator. A photograph of this installment was provided on the corrective action plan submitted.


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

raw_content: The evacuation plan does not have a designated location inside the operation.

Correction Narrative: The operation updated the evacuation / floor plan that depicts (with blue boxes) where residents / staff can take cover in the event of hazardous weather.


summary: 748.119(2) - Volunteer policy - Address qualifications, screening, and selection procedures for the volunteers

raw_content: The operations policy manual does not make TB testing a qualification or requirement for volunteers.

Correction Narrative: The operation updated their policy manual. (Page 47) TB testing as a requirement for volunteers before having contact with our residents.


summary: 748.125(d)(6) - Suicide Screening- Must be documented.

raw_content: The operation policy and procedure manual is missing this component / section.

Correction Narrative: The operation updated their policy manual. (Page 79) All attempts will be immediately reported and documented as a serious incident as required.


summary: 748.105(1) - Personnel Policies - Develop a written organizational chart showing administrative/professional/staffing structures and lines of authority

raw_content: The Resident Director position with job description does not exist in witting or on the organization chart. Lead Resident Assistant position does not exist on the organization chart.

Correction Narrative: The operation added the position and job description of Resident Director and Lead Resident Assistant to the staffing plan, personnel policy manual and Organizational Chart.


summary: 748.105(2) - Personnel Policies - Develop written job descriptions including minimum qualifications and job responsibilities for each position

raw_content: The Chief Executive Officer position does not have a written minimum qualifications outlined in the operation's policy and procedure manual.

Correction Narrative:
The operation updated their policy manual. (Page 37)
The Chief Executive Officer position now includes the minimum qualifications for the position.


summary: 748.111(6) - Child-care policy - Personal possessions a child is or is not allowed to have, where stored, and search policies

raw_content: The operation policy and procedure manual does not designate a location for possessions to be stored that are prohibited.

Correction Narrative: The operation updated their policy manual. (Page 14) Residents may not bring literature, music, clothing, or posters which contain sexually explicit materials, gang themes, or themes which promote violence, drug/alcohol use, exploitation of others, or discrimination of race, creed or handicaps. Items will be given to the caseworker during intake or sent upon retrieval. Any items that are prohibited, yet they make it into the house will be placed in a name labeled bin located in the garage and/or mailed back to the case worker within 72 hours. (The garage is a restricted area for all residents.) This includes items that are confiscated during searches


summary: 748.125(d)(3) - Suicide Screening- Document that any person conducting a suicide screening meets the conditions and training requirements.

Deficiency Narrative: The operation policy and procedure manual is missing this component / section.

Correction Narrative: The operation policy manual was updated, and a copy was provided. (Page 78) All screenings are conducted in a private area out of earshot of other peers and in privacy,


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

Correction Narrative: The operation has updated their policy manual. (Page 78) will ensure that all screenings are conducted in a private area out of earshot of other peers and in privacy,


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

raw_content: Monthly Drill record does not include the type of drill being conducted.

Correction Narrative: The operation submitted an updated form. The new form now has fire drill or weather drill.


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

raw_content:
The operation policy and procedure manual is missing this component / section.
748.125(g)(1)(B)(I thru VI)(iii)
748.125(g)(2),(B),(D), E( i)(ii) and (F)

Correction Narrative:
The operation has updated their policy manual. (Page 79-80) 1. The Postvention Team is an extension of the Crisis Team that includes the Case Manager,
Treatment Director, Therapist, Psychologist, & Psychiatrist. The team will devise a written plan.
2. The Professional Service Level provider will meet within 3 hours to ensure safety, construct a
plan, and help the resident slowly transition back into the routine by completing daily hygiene and
participating in the scheduled program activities .
3. Information about the incident will be provided to the highest level Mental Health professional at
the school campus prior to her returning to school
4. A Safety plan /Action Plan will be implemented at school and home. This Safety Plan /Action Plan
will include a plan to help the resident transition back to her regular routine/program. This Safety
Pla n/Action Plan will also include a self-care plan that will identify coping skills and resident
identified activities that promote healing/restores hope/minimizes a reoccurrence.
5 . Increase in individual therapy services weekly. Weekly suicide risk assessments for 30 days or
until the child no longer reports suicidal thoughts for 3 consecutive weeks.


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

raw_content: The discharge summary is not available for review.

Correction Narrative: The operation created and provided a copy of the discharge form that will be used when children discharge from the operation.


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

raw_content: The 'Keeping Children Safe' sign was not posted during inspection.


summary: 748.125(f)(1) - A PLSP must meet with a child within 24 hours of their return to an operation post hospitalization.

raw_content:
The operation policy and procedure manual is missing the following component / section.
748.125(f)1, 2, A, B, C and 3.

Correction Narrative: The operation updated the policy manual. The professional service level provider will meet with a child within 24 hours of their return to Dawn Rise post hospitalization to discuss protocols that would help to ease the child's transition back into the operation, ensure the child's safety, and reduce any risk of suicide. The PLSP will complete a weekly suicide risk screenings for the first 30 days or until the child is no longer reporting suicidal thoughts, whichever is longer and the PLSP will create or review and update the child's safety plan. Upon removal of any harmful objects, chemicals, or substances that a child could use to carry out a suicide attempt or self-harm for a period to be determined by the treatment team, but not less than 30 days.


summary: 748.125(e)(2)(A) - You must refer a child to a MH professional within 24hrs for a suicide risk assessment if screening finds child to be a potential risk for suicide.

raw_content: The operation policy and procedure manual must specify how soon the child will be seen by the LPC for a suicide risk assessment.

Correction Narrative: The operation updated their policy manual. (Page 79) If a suicide risk screening finds a child to be a potential risk for suicide, she will be referred to a Mental Health professional immediately for a suicide risk assessment (within 24 hours), specifically our LPC and/or the 24 hour on-call crisis team vis Imagine Pediatrics.


summary: 748.105(3) - Personnel Policies - Include procedures for screening applicants to determine suitability.

raw_content: The operation policy and procedure does not have  Minimum Standard 748.105(3) procedure implemented.

Correction Narrative: The operation has updated their policy manual. (Page 42) The operation will ensure that applicants are suitable for any/all positions by verifying an applicant's employment history as required. The operation will conduct reference checks as required. This will be conducted by the LCCA contacting the last known employer to verify that the applicant previously worked at the documented establishment. Applicants are required to list three references on his/her application-the LCCA will call all references and document responses.


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

raw_content: The evacuation plan does not have a designated location outside the operation.

Correction Narrative: The operation updated the evacuation / floor plan that depicts (with a photograph outside) where residents / staff will meet in the event of a fire.


summary: 748.3391(c) - Bathrooms-Child must not have to cross a common use room to access a bathroom from the child's bedroom

raw_content: One upstairs bedroom would require occupants to cross the game room to the bathroom.

Correction Narrative: The operation confirmed the bedroom on the second floor will no longer be considered / used as a bedroom for residents. This bedroom is directly to the right of the stair top exit. The room is 12'9" x 10'3" and will be used and an all-purpose room. Residents in this bedroom would be required to cross the game room to the bathroom.  The operation will not be making modifications to the home. No new floor plan or measurement will be required.


summary: 748.111(4) - Child-care policy - Child's right to receive and give gifts

raw_content: The operation policy and procedure manual states residents are not able to give gifts to friends, employees, or other residents in while in care.

Correction Narrative: The operation updated their policy manual. (Page 13) Residents have the right to receive and give gifts to family members, CASA workers, Attorney Ad Litem, and/or caseworkers. Residents can give gifts to friends, employees, or other residents in Dawn Rise's care in the presence of the LCCA and/or therapist. The gifts given to employees or other residents associated with Dawn Rise cannot exceed $25 and cannot be a monetary gift. The resident is not able to utilize funds sent from family, Case Workers, Casa Workers, Attorney's, etc for specific purposes on gifts for Dawn Rise employees or fellow residents.


summary: 748.125(e)(1)(E) - You must adhere to recommendations of the MH professional and update the childs safety/service plan's if child is at high risk for suicide.

Correction Narrative:
The operation policy manual was updated, and a copy was provided. (Page 79) Upon completion of the risk assessment
the circle of support will be contacted with a follow up on the recommendation by the mental
health professional. The child's safety and service plan will reflect the most recent
recommendations.


summary: 748.111(14) - Child-care policy - Procedures for routine and emergency diagnosis, including treatment of medical and dental problems

raw_content: The operation policy and procedure manual does not state whether  it offers a religious program or not.

Correction Narrative: The operation updated their policy. (Page 15) While Dawn Rise would love for all of our residents to be involved in church, residents will not be punished/retaliated against for not sharing the same beliefs. Our girls will not be punished for not participating in church or religious activities. Personal beliefs will not prohibit medical treatment. Religion will not be a factor when considering procedures for routine medical visits, emergency diagnosis, including treatment of mental and dental problems.


summary: 748.105(10) - Personnel Policies- Must include either the model drug testing policy or a written policy that meets or exceeds the criteria in the model policy.

raw_content: The operation policy and procedure manual does not describe how random drug testing will be conducted.

Correction Narrative: The operation updated their policy manual on page 70. Applicants may not provide care or have access to any child in Dawn Rise's care until appropriate drug test results are obtained. In addition, random drug screenings will be conducted. Every employee is subject to random unannounced drug tests. Quarterly (January, April, July, October), Dawn Rise will put all employee names in descending order according to his/her hire date. The person that falls in the middle will be notified and given 3 hours to complete the random drug screening. The employee will need to report to any AnyLabNow location; Dawn Rise will settle the cost for all random drug testing.


facility_name: right at home care 2 Inc.

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

raw_content: A staff threatened to physically assault a child in care.

Correction Narrative: 2 staff reported they have completed training in the last month, in which they went over TBRI refresh, child safety procedures refresh, reporting and time frames, what needs to be called in to licensing. They stated they training was in person, and online. It was also stated someone comes and checks for staff to be in compliance at night. Staff reported training refreshers were provided after their incident in December 2025, they had to make adjustments. Owner is no longer able to help with staff activities until further notice.


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

raw_content: A staff involved in the incident did not make themselves available to be interviewed for the investigation. The staff was attempted to be contacted on 1.29.26, 1.30.26, 2.3.26, and 2.4.26. The operation was contacted on 1.29.26 to have the staff return their call. No attempts were successful.

Correction Narrative: Staff reported Owner is no longer able to help with staff activities related to children until further notice. Staff is unsure if related to the incident.


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

raw_content: A staff lacked self-control when they had to be held back from engaging with a child during an altercation. Additionally, during the same incident, the same staff used inappropriate language towards the child.

Correction Narrative: 2 staff reported they have completed training in the last month, in which they went over TBRI refresh, child safety procedures refresh, reporting and time frames, what needs to be called in to licensing. They stated they training was in person, and online. It was also stated someome comes and checks for staff to be in compliance at night. Staff reported training refreshers were provided after their incident in December 2025, they had to make adjustments. Owner is no longer able to help with staff activities until further notice.


raw_content: During the course of the investigation, it was determined that a caregiver argued with a child in care and used inappropriate language.

Correction Narrative: The LCCA and/or executive director will conduct training sessions for all staff on the importance of caregivers to understand the tone and words used towards children in care can be detrimental to a child's mental health as most of the children in care have experienced different levels of trauma. Staff exhibiting self-control and not engage in arguments with children in care may help minimize further trauma to these children.


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: The bathroom was observed with nothing for the children to use to dry their hands.


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

raw_content: The medication record does not match the count of the pills.

Correction Narrative: The operation sent an email indicating that in an effort to make sure the medication administration remains in compliance, they have minimized distractions during the medication distribution and signage of the medication log also ensure that medication error logs are quickly in place if needed.


summary: 748.1209(b)(9) - Child Orientation-Include policies on the educational program

raw_content: Upon reviewing the orientation given to the child upon admission, the education programs the facility provides was not found in handbook.

Correction Narrative: Agency added educational programs to the childrens orientation


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

raw_content: Multiple service plans were not signed or dated by the children in care.

Correction Narrative: Agency provided a scanned copy of the signed service plan.


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

raw_content: PLSP signature or dates were not found in multiple service plans.

Correction Narrative: Agency provided a signed copy of the service plan.


summary: 748.2151(c)(8) - Medication record-must include reasons for administering psychotropic medication or non-prescription medication/supplement for a child under 5 years

raw_content: Upon reviewing medication logs, multiple medication logs were observed to not have the reason for medication being prescribed.

Correction Narrative: "As result of deficiency 748.2151(c)(8) Medication record-must include reasons for administering psychotropic medication or non-prescription medication/supplement for a child under 5 years (Weight: Medium High). As an effort to make sure this does not take place again, we have highlighted the purpose section on the medication form so that this information is not missed moving forward and the nurse has been notified to double check her work before the sheets are printed out to be put in the medication log binder. "


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

raw_content: Caregiver stated that they "dozed off" during a time that they were in charge of supervising children.

Correction Narrative: Owner began to schedule 2 staff members at all times during the night, mentioned via phone call. Via email, owner mentioned that specifically when the worker involved in the investigation is to be scheduled, there would be additional staffing.


summary: 748.111(15) - Child-care policy - Routine health care relating to pregnancy and childbirth, if you admit or care for a pregnant child

raw_content: When reviewing the policies and procedures, this policy was not created.

Correction Narrative: Agency sent as policy: "Right At Home Care Inc. will not accept a child into our program who is pregnant.  If a child becomes pregnant then Right At Home Care Inc. will give a 14 day notice to discharge the child.  The Child's case worker will be notified immediately as soon as Right At Home Care Inc. is aware of the pregnancy.  Right At Home Care Inc. will make accommodations for the child to ensure the safety of the child and her unborn baby.  The nurse will make all necessary medical appointments that are needed while the child is still in Right At Home Care Inc.'s care.


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

raw_content: During the inspection, an admission assessment, a preliminary service plan, and the facilities evacuation route contained inaccurate information.

Correction Narrative: The operation submitted an updated admission's assessment form that accurate information.


summary: 748.1703(a) - Menus-must maintain daily menus showing all meals and snacks that the operation prepares and serves

raw_content: During the inspection, the monthly menu did not list the snacks provided by the operation.

Category: Child Care

Correction Narrative: The operation submitted an updated menu that listed snacks provided by the operation, as well as meal alternatives. No concerns


summary: 748.125(d)(4)(C) - Suicide Screening- Must be administered every 30 days after admission for children 10 years of age or older in a residential treatment center.

raw_content: A child in care did not receive a suicide screening every thirty days.

Correction Narrative: The operation provide suicide screenings for all active residents. Additionally, the operation stated, "The suicide screenings are now on the calendar and will alarm when it's time to get them done before the 30 day expires." No concerns.


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 children's prescribed medication did not have an accurate count of medication.

Correction Narrative: The operation completed med error sheets to accurately reflect the count. Additionally, the operation created a plan to ensure accurate counts are maintained: "For the medication everything is being counted daily prior to administering even those that are in the bottle. Comparing the medication in the blister packs to the medication log to ensure that the numbers are accurate as well as counting the pills in the bottle."


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

raw_content: Admission Assessments did not include children's home environments and family function, the children's birth and neonatal history, and the child's social history.

Correction Narrative: Compliance was met upon the agency sending an email containing the updated admissions assessment that contained the missing items.


facility_name: Tshepang Center Residential Treatment Center, LLC

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

raw_content: Based on the video observed, staff was seen pushing child towards the wall and grabbing him by the neck.

Correction Narrative:
The Administrator immediately sent staff (Chester Holmes) to attend another De escalation, EBI training Minimum Standard 748.2307 (1).

The LCCA and Program Director have ensured that the said staff member was retrained of Crisis prevention, de- escalation techniques, and restorative intervention course on November 21, 2025. Staff was a reassigned to another client. To prevent future occurrences, staff will continue to prioritize early identification of escalating behaviors and implement de-escalation strategies at the earliest signs of distress. Individualized behavior support techniques will be reinforced, and staff will continue to encourage the child to utilize learned coping and de-escalation skills.

Current EBI training certificate was submitted.


summary: 748.2855(a)(4) - EBI Documentation-Must include the specific emergency behavior intervention administered

raw_content: Based on video observed, there was no documentation indicating the type of restraint administered nor the accurate length of time for the restraint.

Correction Narrative:
The Program Administrator immediately conducted a refresher course for all caregivers on the Minimum Standard 748.2855(a)(4) and created a new document that encompasses all that the minimum standard requires.

In accordance with Minimum Standard §748.2855, the LCCA has implemented a standardized Emergency Behavior Intervention documentation form that captures all required elements of the rule. This form will be completed for each EBI incident to ensure consistency, accuracy, and compliance. The documentation will be reviewed by leadership to monitor patterns, assess effectiveness, and support ongoing quality improvement and child safety.

New form was submitted via email.


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

raw_content: Based on the video observed, there was no de-escalation methods used prior to restraint.

Correction Narrative: The LCCA and Program Director will ensure, staff will continue to prioritize and document de-escalation strategies and use EBI only when all appropriate interventions have been unsuccessful, in accordance with DFPS Minimum Standards.


summary: 748.2853(1) - EBI Documentation-Date and time the caregiver offered the post discussion to the child

raw_content: There was no post discussion documentation available for review.

Correction Narrative:
The LCCA and Program Director have ensured that all appropriate documentation will be provided to the responsible investigator conducting the investigation and a post discussion will be held with the client after each EBI intervention.

Post discussion with children was submitted, dated for 11/10/2025.


raw_content: Two children confirmed that they experienced mistreatment by staff during their time in care.

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

Correction Narrative:
The operation implemented corrective action stating the following information, The Administrator immediately sent staff (Micheal Uchenna) to attend another De-escalation, EBI training Minimum Standard 748.2307 (1). All clients were confirmed to be safe. Mr. Michael received additional training and was reassigned to work with other clients under appropriate supervision. Ongoing monitoring has been implemented to ensure compliance with DFPS Minimum Standards. The facility remains committed to maintaining a safe environment and upholding all standards to protect the children in our care.
* Additional training for the involved staff member has been completed, and documentation of this training is attached to this corrective action file.
The LCCA and Program Director have ensured that the said staff member was retrained of Crisis prevention, de- escalation techniques, and restorative intervention course. Staff was reassigned to another client. To prevent future occurrences, staff will continue to prioritize early identification of escalating behaviors and implement de-escalation strategies at the earliest signs of distress. Individualized behavior support techniques will be reinforced, and staff will continue to encourage the child to utilize learned coping and de-escalation skills.


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

raw_content: Children in care confirmed three staff have been observed sleep during overnight awake staff duties.

Correction Narrative: Corrective Action: The administrator created a corrective action plan that will ensure each shift will have adequate staff. The LCCA conducted a training session for all employees on the proper way of caregiving, the importance of not sleeping during shift and went over the minimum standards for 24-hour supervision. The LCCA has also initiated a weekly audit on all staff, this will ensure the 24-hour supervision is being met efficiently.


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

raw_content: The case was reported to statewide Intake but the staff did not place the Report number therein. Thus Law Enforcement called in the case and the Op made a subsequent Report anew, this time with a report number.

Correction Narrative: Upon telephone conversation, the Op informed Licensing that a re-orientation with all staff regarding proper reporting, including taking the Report Number, was done and strict compliance will be monitored by the LCCA and Case Manager.


summary: 748.1101(b)(7) - Child's rights-Make complaints/calls/reports w/o interference,coercion,punishment,retaliation,threats.Right to make them anonymously

raw_content: A caregiver interfered with a child's call to the Ombudsman's office by not interrupting the call and preventing privacy.

Correction Narrative:
Interviews were completed with three children in care and denied interference of a phone call has ever been an issue. Interviews were conducted with two staff, indicating they are aware they should not interfere with children' phone calls and discussion was held with staff about investigation concerns.

Correction letter and sign in sheet for refresher training was submitted via email.


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

raw_content: During the inspection it was found that the child's parent was not given two weeks advance notice of a service plan meeting.

Correction Narrative: The operation sent follow-ups via e-mail along with updated service plans.


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

raw_content: During the inspection it was found that a child's service plan did not have signatures of service planning team members.


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

raw_content: Staff member stated to have placed child in a head lock and according to officer that arrested child, child had visible marks on neck at the time of their arrest.

Correction Narrative: Agency retrained all staff on de-escalation techniques along with proper restraint techniques. Agency provided training certificates.


summary: 748.3351(2) - Interior Space-Provide personal storage space in the child's bedroom for each child's clothing and belongings

raw_content: At one point in time the operation did not have personal storage space for children in care. During the inspection on 7/11/24 the operation was observed to have 3 drawer plastic bins in each room.


summary: 748.685(c)(1) - Caregiver responsibility - be aware of children's habits, interests, and any special needs including supervision

raw_content: Children in care were able to smoke on the operations property while being left unsupervised.

Correction Narrative:
The controlling persons immediately contracted with staff to reiterate to them of the client's 1:1 supervision. This standard will be monitored and enforced at all times in each shift.
Per minimum standards there should always be 1 staff to every 5 clients. However, we have ensured to have 3 caregivers on shift at all times.


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

raw_content: During the inspection it was noted that the fire inspection had expired. The operation has had a new inspection however they do not have the results.

Correction Narrative: A new fire inspection dated 12/18/2023 was emailed on this day, where everything passed for this operation. See document library.


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

raw_content: During a review of the policies, it was determined that the policy manual identifies the CEO as a controlling person but does identify all board as a controlling person...

Correction Narrative: Administrator sent email stating that all members are now controlling person. A check was completed, and it appears as this has been corrected.


summary: 748.3273(7) - First Aid Kits-Each one must contain sterile gauze pads

raw_content: During the inspection of the first aid kit there were a few items missing. There was not a thermometer, tweezers, or waterproof gloves.

Correction Narrative: Administrator sent email with photographs that included all missing items from the first aid kit.


summary: 748.363(11) - Personnel records-For each person who transports a child, include copy of valid driver's license or DPS driver's license check done in last 12 months.

raw_content: Out of three personnel files reviewed all three files did not have a documentation of a driver's records check that is required. This was corrected at inspection as all driver's records were ran.


summary: 748.101(2)(B) - Plans to submit - Fiscal plan - documentation to reserve funds or available credit at least equal to operating costs for first 3 months

raw_content: During a review of the policies that the operation submitted there was not and fiscal plan or documentation to reserve funds or available credit for to at least equal cost for three months. Furthermore, there was no estimated 12-month budget of income or expense.

Correction Narrative: Administrator sent email with the budget form that shows estimated budget income for 12 months.


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

raw_content: During a review of the child's service plan, it was found that the plan did not include the following: cultural identity needs and plans, instructions to the caregiver about the child's trauma history or triggers, nor does it include methods of responding that increase trust, help them feel safe, and adapt to their environment. The service plan also does not include a mock safety plan or caregiver inclusion. Finally, the plan does not have all treatment services provided.

Correction Narrative: Administrator sent email with an updated service plan that meets all the minimum standards.


summary: 748.1339(a)(2) - Initial Service Plan-Team must include person designated to make decisions regarding a child's participation in childhood activities

raw_content: During a review of the service plan it does not identfy the normalcy decision maker in the team.

Correction Narrative: Administrator sent email with an updated service plan that meets all the minimum standard requirements including who is responsible for normalcy activities.


facility_name: Sarah's Landing LLC

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

raw_content: The operation admitted a child over the age of 17 prior to having their permit updated for young adult children.

Correction Narrative: A discussion was conducted with the administrator, and she understood that a permit must be issued prior to admitting a child that does not match their permit. The administrator understands a submission for permit amendment does not mean they are able to take the child with such services. The permit has been updated to include young adults up to age 18. Moving forward, all admissions staff will verify that each prospective resident meets the age requirements on the updated permit before placement. Staff will also be trained to review permit restrictions and DFPS admission policies to ensure ongoing compliance.


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

raw_content: Multiple serious incidents did not document name, age , gender or admission date of all children involved.

Correction Narrative: The operation has updated their form to ensure all required the information is documentation in the log.


summary: 748.1661(a) - Tobacco Products and E-Cigarettes -Children may not use or possess tobacco products, e-cigarettes or any type of vaporizers

raw_content: A caregiver had a nicotine vaporizer in her vehicle accessible to a child who gained possession of the vaporizer.

Correction Narrative: A caregiver had a nicotine vaporizer in her vehicle accessible to a child who gained possession of and used the vaporizer.


summary: 748.2101(4) - Medication Storage-make provisions for storing medication that requires refrigeration

raw_content: The operation did not have provisions to store medication that requires refrigeration.

Correction Narrative: The operations administrator provided three (3) images on 08.22.24 to show compliance with this standard. The operation has purchased a small, locked refrigerator that will be behind another locked door to ensure medications that require refrigeration are stored out of the reach of children and appropriately. Images will be uploaded to the document library.


facility_name: Make A Way RTC LLC 2.0

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: A staff member does not have a completed affidavit.

Correction Narrative: The operation submitted a corrective action plan for the cited standard. The operation will ensure that the signed and notarized affidavit are included in the employee binder on time, the LCCA will establish a clear timeline that aligns with the hiring process.  The LCCA will be responsible for compiling the affidavit conducting check-ins to monitor the progress.  Additionally, Make A Way RTC LLC 2.0 will implement a checklist to track the completion of each document, enduring nothing is overlooked before the onboarding date.


summary: 748.753(a)(1) - Pre-Employment Screening-You must complete reference checks by obtaining the name and contact info of two individuals who can serve as references.

raw_content: An employee chart did not have references on the employee hire form.

Category: Personnel

Correction Narrative: The operation submitted a corrective action plan for the cited standard. The operation is to ensure that reference check forms and pre-employment screening assessments are included in the employee binder on time, the LCCA will establish a clear timeline that aligns with the hiring process.  The LCCA will be responsible for compiling the reference check document and the pre-employment screening assessments conducting check-ins to monitor the progress. Additionally, Make A Way RTC LLC 2.0 will implement a checklist to track the completion of each document, ensuring nothing is overlooked before the onboarding date.


summary: 748.1661(c) - Tobacco Products-Adult may only smoke tobacco products, e-cigarettes, or vaporizers on premises at a safe distance from child living area

raw_content: An employee was vaping outside the operation by the garage area when inspector arrived.


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

raw_content: Operation does not have a full time administrator

Correction Narrative: On 12/3/24, all documentation for the assigned administrator for the operation was provided via email and confirmed by phone call. Documentation will be uploaded into the digital library.


summary: 748.103(b)(1) - Policies and procedures to submit - Related to record keeping, including where records will be located.

raw_content: The agency did not have a filing storage for record keeping.

Correction Narrative: On 11/29/24 the operation submitted a video of the storage office where child and employee documents will be placed. This will be where child suicide screening and required privacy will be taken.


summary: 748.3351(3) - Interior Space-Provide 40 sq feet of indoor activity space per child, including adult residents and children of caregivers residing at the operation

raw_content: Measurments did not provide the sufficient amount of space required for children in care and staff.


raw_content:
Employee/Children Records were not completed.

Policy did not have accurate information as listed on the application for title of organization, services, type of population.

Correction Narrative: The operation has emailed written notice informing all documents have been adjusted to reflect the operation name to reflect the application as Make A Way RTC LLC 2.0. A copy of the insurance has been submitted to reflect the operation name and correct address.


facility_name: Tomorrows Future Incorporated LLC

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

raw_content: A person who was identified to be the current license holder of the operation is listed as ineligible in CLASS.

Correction Narrative: The operation took steps to remove the ineligible permit holder from the controlling person's, inactivated the background check and did not allow the permit holder to be present at the operation. The operation has submitted on 3/13/26 a new application to complete and expedited change of ownership.


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

raw_content: 2 of 2 staff files did not have any reference checks completed.

Correction Narrative: The operation has implemented a checklist for newly hired staff that includes contacting references for new staff prior to staff being hired.


summary: 748.1113(e) - Child Rights Searches-Second caregiver must witness a search that involves the removal of clothing

raw_content: During the DFPS investigation, it was reported by children, staff involved, and administrator that outer clothing was removed for a search for prohibited items.

Correction Narrative: The administrator provided a copy of the corrective action plan for child rights searches that involves the removal of clothing. The administrator also provided an explanation of the reason for removal of clothing. Conducting a removal of outer clothing will not be associated with regular admission routine we will rely heavily on thorough documentation. In emergency cases only outer clothing will only be removed only when there is a reasonable belief that a child has sustained significant injuries or is at risk of self-harm, and only then removal is necessary to ensure the childs safety or to determine the need for medical attention. She reports that the staff were collectively informed of the standard and will follow 748.1113(e).


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

raw_content: The operation's Serious Incident Report is missing required information, including the documenting of the child's return.

Correction Narrative:
The compliance plan is to ensure all SIRs are fully documented, reviewed, and submitted in accordance with standard requirements. The operation will monitor SIRs by completing all spaces on the form, review SIRs by staff members, manager, and administrator. Conduct monthly audits, train staff on form completion, and administrator will oversee the compliance of forms.

An unauthorized Absence Debriefing was conducted on 7/23/2025. This document meets the requirement for an update regarding the unauthorized absence and the child's return in standard 748.311(11).

In regard to the SIR, Administrator Dr. Sneed on 9/16/2018, provided an addendum to update the incident report that explained the resolution of the incident included a debriefing with the child, addressing the child's coping skills, and hospitalization. It was explained to the Administrator that she may go back to already completed incident reports and add addendums to SIR to meet the cited requirement. The SIR contained all the elements of the standard 748.311. Dr. Sneed states that she will ensure that she signs all incident reports making sure they are properly completed by staff. The form lacked Dr. Sneed's signature and admission date. She will continue to provide training to staff to remind them of the importance of completing forms. On July 12, 2025, follow-up meeting was conducted with staff to continue discussions on preventing and addressing escape attempts. The team reviewed AWOL procedures, including recognizing behavioral indicators that a child may be preparing to leave and reinforcing the importance of consistent supervision and engagement every 15 minutes.


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

raw_content: The provided Debrief document did not contain multiple required components, including any information pertaining to where the child went, who they were with, or any other information relevant to the childs health and safety. Neither was it noted those questions were asked of the child.

Correction Narrative:
The compliance plan is to ensure all unauthorized absences are fully documented, reviewed, and submitted in accordance with standard requirements. The operation will monitor unauthorized absence reports by completing all spaces on the form, review the incident with staff members, manager, and administrator. Conduct monthly audits, train staff on form completion, and administrator will oversee the compliance of forms.

The operation provided a copy of an Unauthorized Absence Debriefing dated 7/23/2025. The report contained all the reporting elements required for this standard. Administrator Dr. Sneed states that it is their procedure to complete an unauthorized absence debriefing. July 12, 2025, the team reviewed AWOL procedures, including recognizing behavioral indicators that a child may be preparing to leave and reinforcing the importance of consistent supervision and engagement every 15 minutes. The training will be ongoing. The compliance plan will be implemented by Dr. Sneed, the administrator. The plan to avoid future violations is to train her staff to complete documentation and she will sign off on incident reports as a review of facts and completion of documents. The compliance plan will be implemented by Dr. Sneed, the administrator. The plan to avoid future violations is to train her staff to complete documentation and she will sign off on reports as a review of facts and completion of documents.


summary: 748.535(1) - Child-care administrator responsibilities-Daily supervision and on-site administrative responsibility for the overall operation

raw_content: It was determined during the follow-up process the administrator is not providing daily supervision. Administrator was not present for inspection and operation was unable to provide evidence of the administrator providing on-site supervision.

Correction Narrative: The operation hired new staff and ensured the staff member would be available for 30 hours weekly. There are two staff pending to also test for the LCCA license as backup.


raw_content: It was determined during the interview process the administrator is not providing daily supervision. Administrator was not present for inspection and operation was unable to provide evidence of the administrator providing on-site supervision.

Standard Number / Description: 748.535(1) - Child-care administrator responsibilities-Daily supervision and on-site administrative responsibility for the overall operation


summary: 748.1103(d) - Informing child of rights-Person being informed must sign statement indicating he read and understands the rights-signed copy filed in child's record

raw_content: Two children files were missing signatures on form K-906-2530. One file was missing child signature, and the other file was missing case worker's signature.

Category: Children's Rights

Correction Narrative: Administrator has created a checklist and retrained staff to ensure all required documentation is presented upon request. Administrator is also conducting bi-weekly audits to ensure all requirements are being completed in a timely manner.


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

raw_content: The medical count to one child file is not correct. The medication counts on the form stated 42 pills, but the actual count is 40.5 pills left in the blister.

Correction Narrative: Administrator retrained all staff to ensure proper documentation is done while administrating medication. The staff also conducts multiple audits during the day to ensure the count is correct. Staff has also changed the medication administration procedure to ensure one child in care is receiving the medication and documentation is properly being completed.


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

raw_content: Two staff files were missing reference check documentation.

Correction Narrative: Administrator has created a checklist and will be dated the date the items are inputted in the staff files. Administrator will conduct a monthly audit to ensure documentations are available upon request.


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

raw_content: Two staff files were missing notarized documentation.


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: One child in care's file that was placed on 01/08/2025 did not documentation of vision and hearing results.

Correction Narrative: Administrator has created a outlook calendar remainder to ensure they are to date with all medical requirements. Administrator also does weekly audits to ensure all required documentation is available upon request.


summary: 748.1501(a)(1) - Dental care-Children in care must receive dental care initially  according to the requirements in 748.1225

raw_content: One child in care's file that was placed on 01/08/2025 did not have a copy of her dental record.

Correction Narrative: Administrator has created an outlook calendar remainder to ensure they are to date with all medical requirements. Administrator also does weekly audits to ensure all required documentation is available upon request.


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

raw_content: One child in care's file that was placed on 01/08/2025 did not have a copy of immunization documentation.


summary: 748.1339(c) - Initial Service Plan-Child & parent must be invited to meeting to develop service plan & discuss participation in childhood activities

raw_content: It was determined the child in care did not participate in planning and developing the service plan as child in care did not sign the form K-908-3300.

Correction Narrative: Administrator is meeting with child in care weekly and reviewing the service plan and allowing child in care to assist in completion of the plan and development. Administrator conducts bi-weekly audits to ensure it is completed properly and available upon request.


raw_content: It was determined during the interviews process that staff is not present a minimum of 30 hours per week.

Correction Narrative: Administrator is required to clock in when present at the operation. CEO and treatment director conduct audits to ensure staffs hours are verified.