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 child records reviewed didn't have the daily count listed on the medication log.

Correction Narrative: A corrective action was sent from the operation staff on 12/12/2025 with the attachments of both children's medication log with the required documentation listed with the statement of: All forms are updated. The operation also adopted the newer medication log form mentioned as technical assistance.


state: TX

facility_name: Perfect Start Homes INC

summary: 748.125(d)(2) - Suicide Screening- Suicide risk screening tools must be supported by evidence-based research.

raw_content: The operation's suicide screening tool was created by the operation and cannot be verified to be an approved tool that is supported by evidence-based research.

Category: Individual Standards Evaluated

Standard Risk Level: Medium High

Corrected at Inspection: No

Correction Narrative:
A corrective action was sent from the operation staff on 12/12/2025 with the attachments of both children's suicide screenings attached with the statement of: Both evidence-based suicide risk assessments are completed.
(The operation adopted the ASK Suicide screening template)


summary: 748.1349(a)(1) - Initial Service Plan-Give copy or summary of plan to child, when appropriate.  At minimum must give copy to child 14 years and older

raw_content: In a review of the two service plans, neither child was provided a copy, nor was the plan signed by the children. There was also no justification documented for not sharing the plan with the child.

Category: Admission, Service Planning, Discharge

Standard Risk Level: Low

Correction Narrative: Operation submitted copies of service plans with child signatures.


summary: 748.605(a) - Treatment director-must meet specific professional qualifications if prevalent population has intellectual disabilities or autism spectrum disorder

raw_content: The Case Manager was signing off as the treatment director. They do not possess the qualifications of a treatment director for children with ID, ASD, or ED.

Category: Personnel

Standard Risk Level: Medium

Correction Narrative: The PLSP acknowledged that they are not qualified to be the Treatment Director, nor sign off as the Treatment Director. The operation is currently in the process of finding and hiring an appropriate treatment director.


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

raw_content:
In a review of the serious incident report, it was missing the following components:
3: The name, age, gender, and date of admission of the child or children involved.
4: The name of all adults involved and their role in relation to the child(ren)
7: The circumstances surrounding the incident.
10: The resolution of the incident

Category: Reports and Record Keeping

Correction Narrative:
A corrective action was sent via email from the operation staff on 12/17/2025 stating the following:
We have implemented the updated form to include all necessary components. (Form 2291)


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

raw_content: Two child records reviewed didn't have the reason the child was taken the medication listed on the medication log.

Category: Medication


summary: 748.123(4) - Vaccine preventable policy - include employee procedures for exemption based on medical conditions or CDC precautions

raw_content: The operation policies is missing Medical contraindications and religious beliefs.

Category: Organization and Administration

Correction Narrative: Operation submitted via email their updated vaccine policy reflecting the added medical contraindications and religious beliefs.


summary: 748.105(8) - Personnel Policies - Ensure employees report serious incidents and suspected abuse/neglect and exploitation directly to DFPS

raw_content: The required statement of employee may not delegate the responsibility to make a report wasn't included in the policies.

Corrected at Inspection: Yes


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

raw_content: The outside fence is in need of repair with protruding nails.

Category: Physical Site

Correction Narrative: The exterior fence is now in good repair and is no longer hazardous.


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

raw_content: The operation's policy does not address screening and selection procedures.

Standard Risk Level: Medium Low

Correction Narrative: The operation submitted an updated policy for volunteers that includes the screening and selection procedures.


summary: 748.113(1) - EBI policy - a complete description of EBIs that you permit caregivers to use

raw_content: The operation's policies has conflicting information regarding the use of restraints as well as missing information on the specific description of the interventions that are permitted.

Correction Narrative: Operation provided an updated policy with the types and techniques permitted for caregivers to use.


summary: 748.109(2) - Admission Policies - include characteristics of the population the program serves

raw_content: The operation's policy reflected they will be accepting girls, however the operation will be licensed to care for boys only, which wasn't correct on the operation's policies.

Correction Narrative: The operation submitted updated policies that reflect the appropriate gender that the operation wishes to serve.


summary: 748.121 - Abuse and neglect policy - You must develop policies on preventing, recognizing, and responding to abuse and neglect of children

raw_content: The operation's policies are missing the required components of standards 2-5.

Correction Narrative: The operation submitted updated policies regarding preventing, recognizing, and responding to abuse and neglect of children. Their updated policies include all components of the standard.


summary: 748.109(1) - Admission Policies - Include program's goals and services provided, including whether emergency admissions accepted

raw_content: The policies reflected  that the operation  will not accept emergency placements which needs to be corrected, the operation will be accepting emergency placements, but the operation isn't an emergency shelter.

Correction Narrative: The operation submitted updated admission policies that specify that the operation accepts emergency admissions, but is not to provide emergency care services.


summary: 748.105(5) - Personnel Policies - Personnel Policies - Develop written policies on the training requirements for employees.

raw_content: The policy is missing the preservice training requirements for caregivers as well as EBI components

Correction Narrative: The operation submitted updated training requirements pertaining to EBI 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 was missing the components in the policy--(2)-(5).

Correction Narrative: The operation submitted updated discipline policies to reflect the addition of the missing components.


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: The required information wasn't included in the operation's policies.

Correction Narrative: The operation submitted updated policies regarding complaint filings.


summary: 748.111(11) - Child-care policy - Program expectations and rules that apply to all children, including discipline

raw_content: The policy does not state the program rules and expectations that apply to the children.


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 required components were missing regarding orientation with a child in regards to EBI requirements. Missing (A)(i)-(ix)

Correction Narrative: The operation submitted updated policies regarding orientation in relation to EBI.


summary: 748.107(2) - Conflict of interest policies-statement that majority of members of the governing body must consist of persons who do not have a conflict of interest

raw_content: The requqired  statement that the majority of the voting members of the governing body must consist of persons who do not have a conflict of interest that would potentially interfere with objective decision making was missing in the policies.

Correction Narrative: The operation submitted updated conflict of interest policies regarding the governing body.


facility_name: Texas Pythian Home Inc

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: The operation does not have a background check on a person living in the operation.

Standard Risk Level: High

Correction Narrative: The background check has been submitted online.


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

raw_content: Caregivers admitted to cursing at the youth, guiding the youth by the neck when not following directions, and pretending to bite a youth's finger as discipline.

Correction Narrative: The operation has re-trained the dorm parents and had them re-sign the discipline policy as well as child's rights.


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

raw_content: The freezer in the boys dorm had two uncovered slushy cups with liquid and spoons in them.


facility_name: The Childrens Home Emergency Shelter

raw_content: During the investigation, it was found that a child in care was pushed by a staff member. Video footage of the incident was reviewed and showed a staff member pushing a child in care.

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

Correction Narrative: An unannounced inspection was completed. The staff stated they were retrained in EBI. The training records were reviewed and staff was trained in EBI the angry child and positive behaviors/understanding emotions.


summary: 748.2451(a)(2) - Emergency Behavior Intervention-Use personal restraint only if policies permit and requirements of this subchapter are met

raw_content: One employee inappropriately restrained a child in care at an operation with a no restraint policy

Correction Narrative: Interviews were completed and staff stated the Administrator went over policy again with them and are a no restraint operation.


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

raw_content: A child in care was picked up by the shirt collar by an employee from a sitting position.


summary: 748.2553(2)(C) - EBI Release-Child released from personal restraint as soon as child is not a danger to self or others

raw_content: A child in care was restrained after they were not in harms way

Correction Narrative: The administrator emailed documentation of two employees,  who did a prohibited restraint/went against the operations policies, termination. The operation retrained staff on all discipline and behavior management policies on 11/7/23


raw_content: Two employees restrained a child in care at an operation with a no restraint policy

Standard Number / Description: 748.2451(a)(2) - Emergency Behavior Intervention-Use personal restraint only if policies permit and requirements of this subchapter are met

Correction Narrative: The administrator emailed documentation of two employees,  who did a prohibited restraint/went against the operations policies, termination. The operation retrained staff on all discipline and behavior management policies on 11/7/23.


summary: 748.303(e)(9)(A) - Serious Incident- Report to CCL w/in 24hrs of becoming aware of an allegation of an employee using a prohibited or inappropriate EBI technique.

raw_content: The operation did not report in a timely manner when a child in care was restrained by two employees using a prohibited procedure.


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

raw_content: A child in care refused to get off of a playground and go inside the operation so two employes grabbed the child to get them down and carried them inside.


facility_name: STCH Ministries

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

raw_content: The operation did not submit 4th Quarter 2025, EBI report to licensing.

Correction Narrative: The Administrator submitted a CAP for this deficiency. It is as follows: The following is the corrective action taken to assure compliance with this standard. The Quality Improvement Specialist will check with Director of Social Services to assure that the EBI report is submitted online by the 10th day of the month following each quarter. The Director of Social Services and the Quality Improvement Specialist understand the intent of the standard is to ensure that the agencys use of EBI is collectively documented. The Director of Social Services is the employee designated to submit quarterly EBI to licensing.


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

raw_content: Two first aid kits were inspected and found to be missing thermometers.

Correction Narrative: On 9-15-25 the administrator submitted via email photos of the missing items required to be in all first aid kits. Staff will be training on the standard by 9-16-25.


summary: 748.363(12) - 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: There were  expired driver licenses in 4 or 6 employee files reviewed.


summary: 748.3239(a) - Evacuation-Must practice unannounced fire drill at least once every 6 months from date of last fire drill

raw_content: The operation was not able to provide records to show that a fire  or emergency relocation drills have been conducted for calendar 2025 for two cottages.

Category: Safety and Emergency Practices

Correction Narrative: The administrator submitted a corrective action plan   addressing the citation. A refresher training was conducted with the Director of Maintenance on 7-9-25. The Director will be tasked with calendaring the evacuation drills in advance for the year. In addition, the Campus Ministries Assistant will be the designee tasked with providing a second calendar check and distributing forms.


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

raw_content: Five preliminary service plans have been reviewed. The plans do not address supervision.

Correction Narrative: The administrator submitted a corrective action plan to address the citation. The Director of Social Services will communicate and re-train the HFC caseworkers regarding including supervision in the child's preliminary service plan to help caregivers adjust and guide in supervision and ensure safety of the children. On 7-10-25 the training to place.


summary: 748.3109(a) - Smoke Detector-Smoke detectors installed & maintained according to manufacturer's instructions or in compliance with fire inspector's instructions

raw_content: Two smoke alarms were not porperly maintained in 2 seperated cottages.

Correction Narrative: The two smoke alarms in the cottages have been repaired by the operaiton and the quartely maintenance report was completed.


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

raw_content: There was a hole on the side of the wall of Hoipe Cottage that required maintenance.

Correction Narrative: The operation has repaired the whole on the wall. The quartery maintenance sheet was completed.


summary: 748.2307(4) - Other Prohibited Punishments-using sarcastic or cruel humor, and verbal abuse

raw_content: A staff member made a comment of hitting a child in care with a shoe.

Correction Narrative:
A corrective action plan was submitted via email for this investigation on 11/25/24. STCH Ministries Homes for Children will re-train staff on appropriate ways to speak to children in care during the December 3, 2024, staff training. In addition, as of December 1, 2024, staff member in question will no longer be employed at STCH Ministries.

During the follow-up visit on 12/4/24, the following documents were provided by the operation:
Training staff signatures on 12/3/24; Child Rights Policy; Resignation Letter of staff member; Cottage House Parent and Child placement for December 2024; and Child Abuse and Prevention Policy.


summary: 748.685(a)(1) - Caregiver responsibility - knowing which children they are responsible for

raw_content: Caregivers forgot a child in care at home during an outing.

Correction Narrative: STCH Ministries Homes for Children has submitted a Corrective Action Plan via email regarding notification on 11/1/2023 standard 748.685 (a), to assure compliance with this standard. HFC Administration will be communicating to HFC Childcare staff on November 12th regarding caregiver responsibility for ensuring each child is accounted for prior to leaving the campus by having a cottage census check prior to leaving the cottage for outings.


raw_content: Preliminary service plan did not address supervision needed for children in care.

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

Correction Narrative:
The operation has submitted a corrective action plan for this standard via email. STCH Ministries Homes for Children Corrective Action Plan regarding notification on 11/1/2024 for standard 748.1331.
The Director of Social Services will communicate with HFC Caseworkers to included supervision in the child's service plan, to help caregiver adjust and guide to the type of supervision required and ensure the safety of the children in their care.


summary: 748.1101(b)(1)(C) - Children's rights-Adhere to the child's right to receive fair treatment

raw_content: A child was not moved cottages after disclosing she was being bullied by another child in care.

Correction Narrative:
STCH Ministries Homes for Children responded via email on 8-20-24 for compliance for this standard. STCH Ministries caseworker and counselor staff will have monthly cottage meetings and HFC administration will follow up to discuss placement needs.

___________________________________________

During the inspection the operation provided log for trainings and discussion on child and staff meetings biweekly as well as overall environmental staffing.


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

raw_content: Caregivers would not provide supervision checks as needed.

Correction Narrative:
STCH Ministries Homes for Children responded via email for the compliance date on 8-20-24. Staff will participate in supervision training on August 20th, that will discuss level of supervision ensuring child's safety.
________________

The operation provided re-training on supervision on 8-20-24. It was discussed how staff will be providing auditory and visual awareness to children in placement and be able to intervene when needed.


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

raw_content: A staff member grabbed the arm of a child in care for redirection when the child threw the finger.

Correction Narrative: The Administrator discussed with house parents the importance of not grabbing or touching a child in care in a negative manner or for corrections. The assigned Case Manager also met with both house parents and the victim discussing the issue and proper ways to use de-escalation avoiding any form of contact from either the child and/or house parents.


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

raw_content: The serious incident report did not have any documentation of adults present during the incident.

Correction Narrative:
Reference to inspection #4059024
The Administrator directed all staff to complete additional on line water safety training. Two house parents were interviewed and confirmed they completed the water safety training and also do annual water safety training.

The author of the SIR document was not familiar with the form and unintentionally left off the adults present on the day of the incident. The administrator provided the names of the adult present that day. The administrator also sent out correspondence to staff underlining the importance of documenting who is present and their roles during the incident.


raw_content: The Service Plan indicated a youth involved required constant supervision. In addition, change in psychotropic medication also indicated the youth required supervision as well for any health issues.

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

Correction Narrative:
Response from administrator: STCH Ministries Homes for Children Corrective Action Plan regarding investigation on 08/11/2023. 748.685 (a) (4) Caregiver responsibility  providing the level of supervision necessary to ensure each child's safety and well-being.

The following is the corrective action taken to assure compliance with this standard. We will monitor psychotropic medication for triggers for the safety of all children in care. Communicating when a child has a change of psychotropic medication to staff will occur prior to the change.
STCH Ministries Homes for Children staff will be aware of service plans of children who require heightened supervision by discussing with Primary houseparents, respite houseparents, caseworker, and counselor at weekly cottage staffing.


raw_content: The serious incident report did not document the names of all adults involved and their role in the relation to the child.

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

Correction Narrative:
STCH Ministries Homes for Children will be Director of Social Services will be staffing with the Social Services department that Serious Incident Documents must include names of all adults involved and their role in relation to the child(ren).
Additionally, our Quality Improvement Specialist will be viewing Serious Incident Documents for compliance with DFPS Minimum standards after being documented.


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

raw_content: While reviewing the serious incident report there were two deficiencies that were noted, all names of the children involved and adults that were present were not included in the report as required.

Correction Narrative: STCH will be holding a training to all employees to retrain them on how to fill out incident reports. They will make sure to include all information in the future.


summary: 748.1205(a)(1) - Admission Documentation-Includes child's name, gender, race, religion, date of birth

raw_content: Three charts evaluated did not contain the required information for religion.


facility_name: Central Texas Children's Home

summary: 748.3891(a)(1) - Trampolines-use of and the number of children allowed at a time based on manufacturer's instructions

raw_content: It was determined that 4 children were using a trampoline at the same time, instead of 1 at a time as recommended by the manufacturer's instructions.

Correction Narrative: 12/2/25 - An email was received with the following corrective action plan: On 12/3/25, LCCA and Director will review with all houseparent's the Minimum Standards for "high risk" activities with trampoline use included.


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

raw_content: In two of the medication logs reviewed, the reason for the prescribed medication was not documented.

Correction Narrative: An email was received from the Administrator on 11/19/25. A compliance plan was attached to the email, and it stated that the Residential Services Director will immediately review all current medication logs. The Director will also perform bi-monthly medication sheet inspections to ensure they are being filled out correctly in compliance with Minimum Standards.


raw_content: Review of the investigation found that the foster parents had a marital argument with children present.

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: On 1/2/2025, the administrator met with the house parents and created an emotional safety plan. The safety plan includes reaching out to supervisors when they get angry as a couple and supervisors will provide more direct and indirect supervision of house parents for the next six months. Further violations of standards may lead to disciplinary action.


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

raw_content: Review of the DFPS investigation found that the house parents were yelling at the children under their care.


raw_content: A caregiver ridiculed and yelled at a child in care.

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

Correction Narrative:
OP personnel submitted the following plan to ensure this does not happen in the future.
1. 2 hrs supervisor counsel on 7/27/2023 regarding his yelling at and in the presence of children. The counsel included minimum standards, agency policies, and best practices as it applies to dealing with traumatized children.
2. Central Texas Children's Home will be training regarding direct care discipline training and emotion management given to all staff over the next 3 months to include 5 hrs of TBRI training.
3. OP personnel will increase the number of in-cottage monitoring spot checks (in-person and remote video camera) to be done no less than twice a month over the next six months.
4. Staff was issued a written reprimand on 7/28/2023 for the yelling at the children and the use of profanity. A next-time offense could result in employment termination.


raw_content: A caregiver admitted to having an intense argument with their adult child in the presence of children in care.

Correction Narrative:
OP personnel submitted the following plan to ensure this does not happen in the future.
1. 2 hrs supervisor counsel on 7/27/2023 regarding his yelling at and in the presence of children. The counsel included minimum standards, agency policies, and best practices as it applies to dealing with traumatized children.
2. Central Texas Children's Home will be training regarding direct care discipline training and emotion management given to all staff over the next 3 months to include 5 hrs of TBRI training.
3. The OP personnel will increase the number of in-cottage monitoring spot checks (in-person and remote video camera) to be done no less than twice a month over the next six months.
4. Staff was issued a written reprimand on 7/28/2023 for yelling at the children and the use of profanity. A next-time offense could result in employment termination.


summary: 748.2101(1) - Medication Storage-Store medication in a locked container

raw_content: It was obsereved during the walkthrough that one of the two vehicles inspected contained a first aid kit on the console and it contained over the counter medication.


summary: 748.949(b)(4) - Annual Training Documentation-Includes the trainer's name and qualifications, or the source of the training for self-instructional training

raw_content: It was found during the monitoring inspection that the name and qualifications of the trainer was not documented in the employee's file.

Category: Training and Professional Development

Correction Narrative: Mr. Crowder sent an email and reported the forms have been changed so the trainer's information has to be entered before the form can be completed.


raw_content: Through interviews it was determined that a caregiver yelled at children in care. The yelling makes the children uncomfortable.

Correction Narrative: Per email from the operation- the caregiver received supervisory counsel on 10/15/21 regarding use of their loud voice used with children to include minimum standards, agency policies, and best practices. Over the next 3 months caregivers will receive 5 hours of TBRI training. Executive Director will increase spot checks of the cottages to 2 times per month for at least the next 6 months.


facility_name: Boys & Girls Country Of Houston

summary: 745.621(a)(5) - AP Initial background checks submitted - At the time a non-client resident 14 or older moves into your home or operation

raw_content: The operation failed to submit a background check for a household member.


raw_content: Residents and child in care reported a caregiver had a history of yelling at the residents at the operation. It was also reported the caregiver made remarks about a resident's choice of identify.

Correction Narrative:
During inspection #4003440, it was confirmed that the house parents are no longer employed, and the operation submitted the following written corrective action plan.
Correction: This information came out during licensing interviews with the Cottage 3 residents. Since the caregivers were no longer employed at that time, we were unable to address the allegations with him. But going forward residents have been assured that their safety and well-being is a priority, and they can report any concerns or issues without fear of retaliation from staff as their report will be kept confidential.


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

raw_content: A child in care and collateral residents reported a caregiver had pushed a child on multiple occasions while in care.

Correction Narrative:
During inspection #4003440, it was confirmed that the house parents are no longer employed, and the operation submitted the following written corrective action plan.
Correction: In this instance, houseparent was alleged to have pushed student on multiple occasions. Houseparents in cottage 3 gave notice of their resignation on January 17 and their last day was January 29. This allegation of abuse was not reported to staff until March 4 so we were unable to put in place any disciplinary action with house parent. On March 4 the cottage Case Manager met with a resident from cottage 3 as part of a regular check-in meeting with residents. It was during this meeting at Cottage 3 resident informed him of an incident (date unknow) when house parent shoved student. All our case manages meet with their residents once a week. Case managers are also available to meet with students at times other than their scheduled meetings if a student request a meeting. Case managers meet with their cottage teams every other week. These meetings, with residents and direct care staff, are a time to not only discuss cottage routines, activity planning, schedules, etc., but also a time to bring up and address any issues or concerns. Boys & Girls Country provides on-going support and development to caregivers by providing mandatory weekly*training on TBRI (Trust Based Relational Intervention) principles and strategies for managing behaviors and Trauma Informed Care. Training topics also include managing stress and self-care. *Training are held weekly during the school year but we cannot commit to a weekly training schedule during summer months when the residents are home.


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

raw_content: Meet-up locations inside the cottage home was not identified on the emergency evacuation maps.

Correction Narrative: The Point of Safety locations for both fire evacuation and severe weather shelter have been added to the emergency evacuation maps. Copy of signage was provided to Licensing.


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

raw_content: 9 staff members with permissions to transport children in care, have an expired driver's license on file.

Category: Transportation

Correction Narrative: In the future we will provide licensing with copies of current driver's licenses from the employee's personnel file rather than the I-9 binder.


summary: 748.863(a)(5) - Pre-Service Training- Caregivers who administer medication must have psych medication training before administering psych meds.

raw_content: One of four records reviewed did not contain psychotropic medication training.

Correction Narrative: The staff T. Warren had psychotropic medication training during her pre-service training in October 2020, again in October 2021, July 22 and June 2023.  Copies of certificates were provided to licensing.


summary: 748.4083(a) - Vehicle and maintenance-Must maintain a vehicle in a safe operating condition at all times

raw_content: 1 of the vans observed had a malfunctioned seatbelt. Also, seat belt covers were loose on 2 of the observed vans and creates a safety hazard.

Correction Narrative: Maintenance requests were sent to the Operations mechanic for immediate repair and inspection of all the seat belt component of the two vans. Copies of maintenance requests were provided to Licensing.


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

raw_content: One of four records reviewed did not contain a copy of normalcy training.

Correction Narrative: Staff Malcolm Guerra completed the normalcy training, and the certificate was provided to Licensing.


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: On 7/25/2023 the operation failed an initial inspection with outstanding hazards.

Correction Narrative: The next fire inspection is scheduled for 8/24/2023. The operation is responsible for making all corrections. For the safety and well-being of children in care, as instructed by the Fire Marshall, the operation will correct all yellow tags in fire alarm panels throughout campus and correct the tag in the Hamill Building fire alarm panel.


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

raw_content: Multiple food items in two different cottage homes were observed not properly stored.

Correction Narrative: The two cottages referenced were instructed to correct the food storage issue immediately as well as Administrator Malcom Guerra notified all cottages of the expectation for proper food storage.  A copy of the email sent to cottage homes was provided to Licensing.


summary: 748.363(8) - Personnel records - Include signed dated statement by the employee that he must immediately report suspected child abuse, neglect, or exploitation.

raw_content: The statement does not include the word immediately or give any time frame of when to make the report.

Correction Narrative: Our statement has been modified to include the word "immediately". Copy of statement was provided to Licensing.


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

raw_content: One of four records did not contain the prevention training.

Correction Narrative: The staff, T. Reynolds, completed the training and the certificate was provided to Licensing. The issuing entity did not indicate the length of training on the certificate-one hour- but it was verified by Administrator Malcolm Guerra, who also took the training to verify that was at least one hour of training.


summary: 748.1439(b)(1)(E) - Discharge Documentation-Discharge summary must include support resources for the child, including telephone numbers and addresses

raw_content: The student departure/discharge summary form reviewed did not contain all the required information.

Correction Narrative: The discharge form has been modified to include a section for listing resources with contact information. A copy of the form was provided to Licensing Rep.


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

raw_content: It was found that a staff failed to demonstrate self control while interacting with a child in care.

Correction Narrative: Corrective Action: The staff in this incident was a new employee and the operation already had concerns about their ability to meet the standards and expectation of the job. After this incident the decision was made to terminate employment.


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

raw_content: During the inspection there were several children with medication errors not getting medication as prescribed staff missing days.

Correction Narrative: A full walkthrough and inspection was conducted to inspect all medication records for each child being given meds and ensuring all staff have updated training.


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

raw_content: During the inspection this standard was found deficient due to the medication per child wasnt given in the time frame.


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

raw_content: During the walk through, it was observed in two cottages that hazardous cleaning chemicals were accessible to children in care and located under the kitchen sink. (corrected at inspection) (photos taken)


summary: 748.3113(c) - Fire Extinguisher-Fire extinguisher that has been used or has lost operating pressure must be serviced or replaced immediately with equivalent unit

raw_content: During a walk through of the facility one of the fire extinguishers in the hallway area had a needle on the red. A work order was completed during the inspection for the extinguisher to be charged or replaced.


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

raw_content: During a review of the children's records one of the records was missing an initial service plan. Service plan was over a month past due.

Correction Narrative: An email was received that entailed corrections to the deficiency in order to come into compliance with minimum standards.


facility_name: Methodist Childrens Home Boys Ranch

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

raw_content: In the process of the investigation staff admitted to mixing up the medication and accidentally administering the wrong medication to the victim. Staff interviews and the victim all verified this incident occurred.

Correction Narrative: Received email from the Program Director stating the staff that made the medication error was retrained 6, 11/16/22 before being allowed to administer medications again. All staff were retrained on medication/MARS. During times of Medication and documentation and aide will assist. An email was sent on 11/4/22 to all staff to remind of policies, procedures, and standards.


facility_name: Roy Maas Youth Alternatives Meadows

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

raw_content: Staff member was confirmed to be making inappropriate comments with a child in care.

Correction Narrative: Beginning March 1st, Program Managers will complete Check Ins with their direct employees two times a month. During the Check Ins Program Managers will go over a selected Childs Rights with the staff member. The Program Manager will go over in detail the rights that were selected. This will ensure that all staff are educated in DFPS Child Rights.


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

raw_content: During interviews, children corroborated a staff member did not attempt to de-escalate a child's behaviors before restraining a child.

Correction Narrative:
To ensure proper documentation and explanation of less-restrictive interventions, How to Write an Incident Report training will be updated to include a detailed description of various types of incident interventions. The training is offered monthly to new and existing employees.
In addition, all staff will receive refresher training in How to Write an Incident Report will be discussed in the All-General Staff Meeting scheduled on 2/18/2026.

In person follow up inspection completed on 02/20/2026: Interviewed four staff and three residents. Residents confirm that staff do talk to them and think about their goals, before staff implement a restraint. Staff confirm refresher trainings was completed on de-escalation before implementing a restraint.


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

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

Correction Narrative:
RMYAs Director of Training sent an agency wide email reminding staff of TBRI, Handle with Care, and Trauma Informed Care on November 7, 2025. This email was reviewed during a General Staff Meeting on 11/18/2025.

Moving forward, Program Managers will incorporate refresher training in one of the four topics mentioned above during all General Staff Meetings (these meetings are a mandatory monthly meeting for all staff). The topic will be reflected on the agenda and all staff in attendance will sign in. The next General Staff Meeting is scheduled for December 10, 2025.

All staff were be retrained on child's rights; sign sheet and agenda provided.


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

raw_content: A caregiver became irate and shoved and physically aggressed a child.

Correction Narrative:
RMYAs Director of Training sent an agency wide email reminding staff of TBRI, Handle with Care, and Trauma Informed Care on November 7, 2025.
This email was reviewed during a General Staff Meeting on 11/18/2025.

Moving forward, Program Managers will incorporate refresher training in one of the four topics mentioned above during all General Staff Meetings (these meetings are a mandatory monthly meeting for all staff). The topic will be reflected on the agenda and all staff in attendance will sign in. The next General Staff Meeting is scheduled for December 10, 2025.

All staff were be retrained on child's rights; sign sheet and agenda provided.


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

raw_content: Video revealed staff gave a second EpiPen dose to child 64 seconds after they had already received a first dose. Pharmacy confirmed the instruction label of second dose needing to be given after 10 minutes of a first dose.

Correction Narrative:
Inspection 4057079
Follow-up inspection completed on 5/15/2025, at the operation. Verified RMYA's objective is to ensure the well-being a safety of all our youth. The staff believed that they were following the prudent parent standard because the youth had complained that the first injection wasn't successful. The staff that had the error received disciplinary action and was counseled on our medication procedures. Nurse on site attended staff meeting on March 25th for the GRO and March 26th for the RTC to train on how to administer the EpiPen. This was submitted through compliance plan.


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

raw_content: Operation used another child in care for support during a restraint and another child attempted to sit on the resident's leg who was being restrained.

Correction Narrative: The operation will ensure that our staff are aware that they cannot utilize other children during restraints. In addition, they will try to ensure that other youth are not present, so that the youth do not experience any additional trauma. The staff that allowed the infraction will receive a refresher in Handle With Care (HWC) and be required to attend the HWC Class on December 11th. This will also be discussed during our Program Manager meetings (on December 12th) and staff meetings the week of January 12th , 2025.


summary: 748.2307(3) - Other Prohibited Punishments-threatening with the loss of placement as discipline or punishment

raw_content: Interviews confirmed staff threatening residents with loss of placement.

Correction Narrative: Our objective is to ensure that our residents deal with their trauma and to successfully complete their placement. Our staff do not have the ability to threaten the resident's placement, as this is determined by a team of Director's and Clinicians. We will discuss our processes with the Program Managers and the staff during their next meeting, which will occur the week of November 18th. This will also be updated and discussed in the Impact of Staff Behavior in-service.


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

raw_content: Interviews confirmed staff interfering on investigation by asking resident what questions licensing asked.

Correction Narrative: Our goal is to ensure that our staff do not interfere with any licensing investigation. This will be discussed during our Program Manager meetings and staff meetings the week of November 18th. In addition, we will update the Impact of Staff Behavior in-service to include staff being trained on not interfering in any investigations.


summary: 748.3713(5) - Higher Risk Activity-Supervisor must ensure that all necessary equipment is complete, in good repair, and safe to use

raw_content: Punching bag was not on the chain to hold it and left lying on the floor.

Correction Narrative:
An email was received by administrator on 11/7/24 in response to deficiency:

On the day that the youth injured herself, the punching bag was removed from the gym and will not be replaced. This will be discussed during the next staff meeting. Meeting will be held on 11/18/24.


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

raw_content: Staff allowed the resident to use the punching bag with no protective equipment when gloves were available for the resident when using the punching bag.

Correction Narrative:
An email was received by administrator on 11/7/24 in response to deficiency:

Our goal with the punching bag was to ensure that our children could release energy when they were upregulated providing a place where they could work out. On the day that the youth injured herself, the punching bag was removed from the gym and will not be replaced. This will be discussed during the next staff meeting. Meeting is to be held on 11/18/24.


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

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


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

raw_content: Staff shared their social media with the residents in a way to keep communicate with each other.  It was also observed in video footage that staff left children unattended for a period of time at an outing considering these children had high risk behaviors.

Correction Narrative: Three staff were interviewed, and three residents were interviewed. New policy enacted that staff who are employed for less that nine months will not be able to transport residents off campus without seasoned staff. Staff who are employed for more than nine months are able to transport residents off campus without two staff.


summary: 748.705(b)(8) - Reasonable & prudent parent standard-must consider the outside supervision of the activity, if available and appropriate

raw_content: Children using cart to play on is not intended for recreational use.

Correction Narrative: We strive to ensure that our children's health and safety is our main priority. Our staff will ensure that our children play on equipment that is appropriate for recreation and that all equipment will be used for its intended purpose.  This will be addressed agency-wide in staff meetings during the week of January 10th.


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

raw_content: When reviewing service plans child did have a history of harming others and getting aggressive twice in the last 60 days from the incident.

Correction Narrative:
On 11/3/23 an email was received stating the following:
We will ensure those children with high-risk behaviors have a plan in place which will be stipulated in their Admissions assessment, Preliminary Treatment Plan, and their SCPOS. We will also develop a safety plan if needed, which will be implemented to ensure safety. This will be addressed agency-wide in staff meetings during the week of November 6th.


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:
The incident occurred 08/09/2023 at 6:50 pm.

The incident was not reported to the hotline until 08/11/2023 at 9:11 am, by phone.

Correction Narrative:
A serious incident occurred on 8/9/23 the incident was not called in or reported to the Hotline until 8/11/23.

 It is our staff's intention to ensure transparency and that licensing is aware of all significant incidents and report them within the 24-hour time limit.  The staff that neglected to report the infraction received disciplinary action and the serious reporting aspect will be addressed agency-wide in staff meetings during the week of September 26-27th.
In addition, our Back-up and on-call staff will follow up and ensure that the Hotline is notified within the timeframe allotted.


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 were left unsupervised, for 5 minutes when staff went to the bathroom.

Video did show children were unsupervised from
7:15 pm - 7:20 pm.

Correction Narrative:
Administration provided an email stating they are going to provide a staff meeting on 8/8/23 to discuss with staff the need to either call another staff, administrator, or CATT to cover the shift while they are using the restroom.  In addition, staff responsible will be redirected and subject to disciplinary action.

Staff and child interviews confirmed staff check on them every 15 minutes.  Child interviews stated staff have eyes on them at all times.  A staff interview confirmed they have informed staff if they are going to use the bathroom to inform the staff covering for them when is the next check on the children to ensure they are checking on the children at the right time.  It was also discussed that staff taking over while another staff is away to automatically check on them.


summary: HRC42.056(g) - BGC-persons cannot provide direct care/have direct access to children without all required background checks unless they meet certain criteria.

raw_content: Staff member was counted in child in care ratio without proper background check.

Correction Narrative:
RMYA seeks to provide services for youth that are of the highest professional quality, to include safety, genuine care, and a nurturing environment. RMYA's HR department performed the following:
1. New employee personnel files were audited June 19 and 20, 2023 and the DFPS database was reviewed and audited June 21 and 24, 2023 for all three licenses to ensure current employees are up to date on background checks.
2. A checklist has been created to ensure all background checks are completed during pre-boarding and additional training has been provided to staff members involved in the recruitment, pre-boarding, and on-boarding processes. Please note: The checklist has been attached.
3. New employee files will be audited on an ongoing basis.
Additionally, the employee involved received disciplinary action for the error.


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

raw_content: I observed a medication log to have a missing time for medication administration in the Laurence and Davis Cabin, and this medication log had been checked by three staff to ensure accuracy.


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

raw_content: One of six medication records, indicated a discrepancy in the amount remaining for the medication from one day to the next day.

Correction Narrative:
The RTC programs will review the following procedures in staff meetings on January 11, 2023. The procedures will be effective January 15, 2023.
Med admin in the AM will be double counted before being admin. The med will then be triple counted and checked for accuracy by our Crisis & Trauma Team to ensure all spaces are filled and signed in correctly. In addition, they will check that the med was prepped and admin properly.
Med admin in the evening will be doubled counted before being admin.  In addition, they will check that the med was prepped and admin properly. The Campus Administrator for the day will triple count the med and ensure all spaces are filled and signed in correctly.
The med log has been updated to provide more space for signatures, etc. This will allow for clearer documentation on the med logs. The updated med log will be effective Sunday, January 15, 2023.  We will replace the old forms and start the new forms when the RX drug form has been completed.
The following excerpt of RMYA's policies and procedures will be reviewed agency wide in staff meetings during the week of January 9, 2023. The policy referenced below is located in RMYA's manual, Part 9: Staff Procedures, G. Medical/Dental Care, #2, page 40:

     Med Procedures
Meds will be admin as RX by the physician. Psychotropic meds are RX and monitored by the contracting psychiatrist, in accordance with guidelines established in the Psychotropic Med Utilization Parameters for Foster Children. When med is initially prescribed to a resident, the legal guardian will be notified and given a copy of the med evaluation as well as information on the recommended med regarding benefits, risks and other alternatives is available. Written consent from the legal guardian is obtained before any new med is started with any resident
      All  and non-RX med is to be kept double locked in a med cabinet in staff office at all times where access is limited only to program staff. All RX med is packaged and labeled with the following information:
 Resident's name
 Med name
 Dosage
 Prescribing physician's name
 RX number or code identifying written order
Administering any drug samples to a resident without a RX is strictly prohibited.
   The staff is responsible for distributing RX and non-RX med when necessary and in accordance with instructions on the med. All staff authorized to admin med must have completed the necessary training in med control and admin as well as have knowledge of all applicable legal requirements. Program staff will observe and assess all residents for possible med side effects. The staff will consult with the On-call Nurse or other medical professional as necessary regarding side effects observed.
    A separate log is kept on each med RX. Information on the RX Drug Form should include:
  resident's full name
  name, strength, and dosage of med
  pharmacy name, address, and phone number
  prescribing physician's name
  RX number
  reason for administering med
  expiration date
  number of refills remaining
 A copy of each RX's formulary sheet should be maintained in the RX drug log. This sheet provides helpful information on possible side effects and possible interactions with other RX and non-RX meds.
   When administering meds, the staff should record the following information on the log using black or blue ink pen only:
  signature of staff administering med
  date (day, month, and year) and time the med was administered
  amount of med given
  balance of med remaining
  child's refusal to accept med, if applicable
Staff should ensure that med is taken by placing the med in the mouth, watching the resident swallow the med, and then checking his mouth and under his tongue to ensure it has been swallowed.
   Additionally, the employees involved in the errors in documentation, etc., will receive disciplinary action in the form of a write up which will be placed in their personnel file.


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

raw_content: Several of the medication logs reviewed did not indicate if the medication was administered during the morning or night.   In the Poston, the medication was documented as being administered at PM but the prescription is for morning medication.


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

raw_content:
In Poston Cabin, one of three medication logs reviewed was missing a signature for the staff who administered the medication.

In Wright Cabin, one of three medication logs reviewed didn't include a staff signature or home pass indication for six days.


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

raw_content: Medication logs reviewed were incomplete. Medication logs were missing date and time. Medication log also reflected inaccurate date.


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

raw_content: Medication error occurred, there was not documentation of the error.


raw_content: Medication log reviewed a staff name and signature was missing on the entry log.

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


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

raw_content: Medication error occurred. It was not documented within 24 hours.


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

raw_content: Medication error occurred however documentation was not completed.


raw_content: It was determined that a Restraint Detail and Debriefing document had discrepancies from the Serious Incident Report. The child referenced throughout the document was not the same as the child identified in the header.

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

Correction Narrative: The following response was received from Roy Maas on 10/4/2022 at 9:18am. It is our staff's responsibility to ensure that our operational records reflect information that is clearly documented and accurate. On a weekly basis, the Program Administrators will ensure that they are proofing their operational records so that they depict information that is precise and exact.


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

raw_content: During administrating medications, a staff gave a child another child's prescribed medication by mistake.

Correction Narrative: Staff will ensure that they are taking their time whenever administering the resident's medications. This will prevent harm to the children due to inappropriate preparation or administration of medications. Staff will double check the medications and have the child verify the medications before administering them. This was discussed Agency wide during staff meetings between April 26-28th.


summary: 748.863(a)(4) - Pre-Service Training-Caregiver for tx svcs (not PMN) must have 16 hrs EBI training or 8 hrs if EBI prohibited, 1/2 pre-service & rest within 90 days

raw_content: 1 out of 6 staff did not have all of the required EBI training hours completed within 90 days of hire.

Correction Narrative: On 2/23/22, compliance response received via e-mail from the administrator. It is the staff's responsibility to ensure they have the training designed to help them provide appropriate care and to be educated on appropriate Emergency Behavioral Interventions (EBI) to ensure the child's safety. As an agency, we identified a need to improve our pre-service program to better support our staff in training & education, positively impact the safety of children and staff, as well as improving staff retention and reducing turnover.  Effective October 2021, we rolled out a 7-day pre-service program for all incoming staff.  As a part of pre-service, staff receive all required EBI hours.  Pre-service training is offered every month in a flexible manner to address staff's scheduling needs and limitations.  In addition, staff will be required to attend another four hours of EBI within six months (within 180 days) of their last EBI training.  Although staff are responsible for maintaining current required trainings, the supervisors are running monthly reports of training to ensure there are not gaps.  This will be discussed Agency wide during staff meetings on March 1-3rd.


summary: 748.307(1)(B) - Other occurrences-Report to parents within 7 days and document medically pertinent incidents, that do not rise to the level of a serious incident

raw_content: CPS caseworker was not notified of the medication error by the operation.

Correction Narrative:
Email from facility director

It is our staff's responsibility to ensure that any medically pertinent incidents, including medication errors are reported to the legal guardian immediately. The Youth Engagement Specialist (YES) or Program Administrator (PA) will be designated to notify the legal guardian or Caseworker in the event of a medication error or medically pertinent incident. This will be discussed Agency wide during staff meetings on March 1-3rd.


summary: 748.931(a)(2)(B)(iii) - Annual Training-Every 6 months a caregiver must complete at least 4 hours of training in EBI

raw_content: A staff failed to complete 4 hours of EBI training within six months from the last date of EBI training.

Correction Narrative: On 1/10/2022 compliance response received via e-mail. Response: It is the staff's responsibility to ensure that they are attending EBI training within six months of their last EBI training. The Agency has Pre-service every month, which has EBI classes that the staff will be required to attend. Each week the Administrator will audit and ensure that their staff are current on their EBI training. This will be reviewed and discussed Agency wide in staff meetings during the week of January 11 -13th.


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

raw_content: A staff ripped a child's poster as discipline.

Correction Narrative: Staff must follow RMYA policy and procedures which align with minimum standards, when disciplining a resident.  Staff should take care when removing a resident's personal property (whether for safety, security, or as a natural consequence) to prevent damage.  Staff should not damage, destroy, or throw away a resident's personal property as discipline.  This standard will be reviewed in staff meetings agency-wide April 12-14th.


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

raw_content: A staff member used unwarranted and excessive force on two children in care on two separate occasions.  One child sustained an injury.

Correction Narrative: When a personal restraint is necessary, staff must use the utmost care and caution in its implementation, to minimize the risk of injury.  The standard will be reviewed in staff meetings agency-wide April 12-14th.


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

raw_content: The freezer in a cabin was showing a temperature of ten degrees farenheit.


raw_content: A staff member harbored a child in care who was on runaway for several days. The employee failed to take proper actions which placed the child at substantial risk of potential harm.

Correction Narrative:
On 11/12/21, an administrative review of this deficiency was requested. The employee involved was terminated.
It is staff's responsibility to follow proper runaway procedures and report any information received about a missing youth to their supervisor, caseworker, and law enforcement.  Should a youth reported as a runaway or a missing person make contact with an employee of the agency outside of the facility or working hours, that employee is obligated to report such contact to the agency, caseworker, and law enforcement to facilitate safe recovery of the youth and prevent potential harm or exploitation.

This incident was reviewed with staff originally in the April 27-29th staff meetings (the incident occurred in March).  We will review this most recent finding in staff meetings agency-wide on November 30th, December 1st, and December 2nd.


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

raw_content: Current fire inspection was not completed within the required timeframe. The last fire inspection was completed on 6/10/20 and current one was completed on 7/20/21.

Correction Narrative: It is our Facilities Department's and staff's responsibility to ensure that all inspections are completed within the due date. We have created a Preventative Maintenance ticket that will prompt us to contact the Fire Marshal one month prior to the inspection due date to get us on their schedule.  It will also be discussed in staff meetings on August 24th and 25th.


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

raw_content: During the walk through inspection, shower in two cabins observed had mold.

Correction Narrative: During the walk through, the showers in the 2 cabins were cleaned.


summary: 748.3061(2) - Gas Inspection-Operation inspected at least once every 24 months from date of last inspection for gas leaks

raw_content: The current gas inspection was not completed within the 24 months from the last inspection. The last gas inspection was completed on 4/10/19 and current one was completed on 5/6/21.

Correction Narrative: On 8/24/21, e-mail received from the administrator. It is our Facilities Department's and staff's responsibility to ensure that all inspections are completed within the due date.  To correct this, we have created a Preventative Maintenance ticket in our system that will prompt us contacting the plumbing company 2 months in advance to schedule our bi-annual testing. It will also be discussed in staff meetings on August 24th and 25th.


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

raw_content: One fire extinguisher located in the upstairs laundry room was last service March 2020.

Correction Narrative: It is our Facilities Department's and staff's responsibility to ensure that all equipment is in working order. We had the fire extinguisher company come out to inspect the fire extinguishers, but one at the Maas Cabin was overlooked. With that being said there were six fire extinguishers that were inspected and checked at the program. Our Facility Department currently checks the fire extinguishers once a year.  We are upgrading this process and they will check the fire extinguishers once a month to ensure compliance. This will be discussed in the May 11th and 12th staff meetings.


summary: 748.535(2)(H) - Child-care administrator responsibilities-Ensuring persons whose behavior or health status presents danger to children are not allowed at operation

raw_content: Administrator was aware of on-going inappropriate relationship between a staff member at the operation and a child in care.


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

raw_content: A caregiver who was on a safety plan due to an inappropriate relationship with a child in care allowed the child to stay at their home while still employed at the operation.


summary: 748.1101(b)(1)(C) - Children's rights-Adhere to the child's right to receive fair treatment

raw_content: Child in care and staff admitted child was given preferential treatment over other children in care.

Correction Narrative: A follow up inspection was conducted at the operation. A walk through of Poston cabin was done and no concerns observed. The employee involved was terminated. Administrators discussed with staff about fair treatment during staff meeting. Attendance sheet of staff who attended the meeting was provided. It is our staff's member's responsibility to ensure that all of our children are treated fairly and equally. Staff should not exhibit preferential treatment to any one resident. This will be addressed agency-wide during the week of April 27-29th during staff meetings. Administrative review requested.


facility_name: SJRC Texas, Inc.

summary: 748.3441(b) - Food Preparation-Must sanitize food service equipment, dishware, & utensils after each use and store properly

raw_content: Licenisng observed a frying pan with dired bits of food in the under kitchen sink cabinet of A Wing house.


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

raw_content: The debrief following an unauthorized absence, containing all required components, was not completed within the 24 hour timeframe.

Correction Narrative:
During follow up inspection compliance was met after interviewing four staff members. All stated training was conducted and addressed timeframe and questions required to ask during debrief. One child was interviewed and confirmed they had been debriefed.

11/24/25 The administrator re-submitted the signature page with everyone's signatures on it.

11/10/25 The administrator submitted their plan and had completed re-training with the caregivers regarding unauthorized absences. A signature page with the caregivers names. The minimum standard 748.455(a) that was covered and provided a copy of the power point utilized during training.


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

raw_content: During a walkthrough inspection a bathroom commode was found to be in an unclean state, as mold was observed to be growing inside of the toilet. The wall of a shower area was observed to have mold growing from the surface. The curtain rod of a shower was also observed to not be apprpriately holstered to the wall allowing it to fall off if touched.

Correction Narrative: An unannounced inspection was completed on 8/14/25. A compliance plan was provided to the previous RCCR Rep. on 6/23/25 indicating supervisory staff completed a review of cleaning responsabilities. A training was completed on 6/18/25 and 6/20/25. During unnanounced inspection all restrooms were observed to be cleaned and without mold in Houses: Verette, A Wing, B-Wing (empty), and Harvey House ( empty and being remodeled).


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

raw_content: During a walkthrough inspection food was found to be stored in the refrigerator without a cover or in a container.


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

raw_content: During an walkthrough inspection the emergency evacuation relocation diagram was found to be without the rally point.

Correction Narrative: Operation submitted evacuation diagrams which now include the rally point and storm shelter location, bringing the standard into compliance.


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

raw_content: Records were found to be filled out as 15-minute checks completed however camera footage showed this to be incorrect as the 15-minute checks were not conducted.

Correction Narrative: Three records selected at random were observed to be completed with accuracy and in an appropriate time frame.


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 an Investigation it was discovered that the staff on duty did not conduct 15-minute safety checks on a child in care as instructed on her safety plan pertaining to supervision.

Correction Narrative: During a walkthrough inspection children in care were observed to be at eyesight and auditory view of the staff at all times.


summary: 745.8413(b) - Licensing may interview anyone relevant to inspection/investigation

raw_content: A relevant staff member was not interviewed because they failed to appear at scheduled meeting with Investigator and operation staff could not reach staff member either.

Correction Narrative:
The administrator sent and email with the following information:

1.Letter dated 4/07/2025 regarding findings for Investigation #3146981.
2.Email from Mrs. Strauther dated 3/21/2025 asking if an SJRC Texas, Inc. team member was going to appear for a meeting with her. However, the meeting was set directly with team member, Janessa Garza and thus Ms. Garza's supervisor and the campus LCCA had no prior knowledge of the meeting time and date.
3.Text messages between Ms. Strauther and Ms. Rendon-Lopez dated 3/24/2025 asking if team member would be on campus and available for an interview. Team member, Ms. Garza worked 10pm - 6am and departed campus at the end of her shift.  Unfortunately, the staff member was asleep due to working the night before and did not hear the phone ring.
4.Corrective Action issued to team member, Janessa Garza dated 3/25/2025.
5.SJRC Texas, Inc. Response Plan dated 4/11/2025.
6.Standard Operating Procedure: Licensing Investigation Protocols
7.Sign-in sheet for staff training on the newly developed Standard Operating Procedure that addresses the importance of cooperating with investigations and inspections.

The SJRC Texas, Inc. supervisory team will be meeting with all the campus staff to review and discuss the newly developed Standard Operating Procedure regarding Licensing Investigation Protocols.  We are committed to working collaboratively with all Licensing entities for the good of our children.


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: As of 10/10/2024 the data which was due by April 15th for restraints between January and March 2024 and data which was due by July 15th for restraints between April and June have not yet been reported to licensing.

Category: Emergency Behavior Intervention

Correction Narrative: Administrator sent Email stating that missing EBI entries have been updated. Phone call to operation and administrator stated that in order to preventing late EBI reports in the future, quarterly reminders have been placed on calendars and entries will be made by the 15th day at the end of each quarter.


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

raw_content: Reviewed 6 out of 6 child records and child rights only states searches being documented if personal items are removed.

Category: Children's Rights

Correction Narrative: Email from administrator stating Texas Youth Handbook has been revised to add the language that if caregivers conduct room searches, those will be documented in the child's records. In addition, a refresher was completed informing Shift Supervisors and Youth Care Specialists (direct care staff) on when room searches were permissible and how to properly document room searches in Incident Reports. The revised handbook is attached for your review, the change made can be found on Page five (5).


raw_content: Caregivers made the decision to direct a staff member to be in a home, and in the presence of a child in care, against the directions in a Safety Plan even though other staff members were available to go to the home.

Correction Narrative:
Administrator Emailed plan for Standard Operation Procedure (SOP) where safety plan between staff and youth must be implemented:1.
Notify Human Resources if a serious incident arises that necessitates the development of a staff safety plan to address a particular licensing investigation.
2.
The plan will delineate whether an employee may be present at the operation and in which capacity the employee may remain at the operation.
3.
The VP of Residential Programs and the Program Coordinator will meet with the staff member and inform them of the safety plan and any specific conditions of the individual safety plan.
4.
Staff member will sign that she/he is aware of the staff safety plan. A copy of the plan will be provided to the staff member and a copy will be kept in the employee's file.
5.
Staff member's immediate supervisor and all SJRC Touchstone management team will be informed of the safety plan for implementation purposes.
6.
Any staff safely plan developed will emphasize Prudent Parenting Practices. Please refer to the Texas Minimum Standards, §748.705. What is the reasonable and prudent parent standard.
7.
Staff safety plan will remain in effect until the Licensing investigation is resolved.
8.
Upon resolution of the investigation. The staff's supervisor will meet with that individual staff member and inform them of the resolution of the investigation.
a.
Staff member will return to regular schedule and duties without any conditions if the situation is resolved favorably.
b.
A consult with SJRC Texas, Human Resources staff will occur if the Licensing investigation concludes with a reasonable cause to suspect that a child was abused or neglected.


raw_content: A staff member had their personal computer at the operation and an inappropriate picture popped up which a child was able to see.

Correction Narrative: 4 staff members and 3 children were interviewed.  All 4 staff members stated that the operation has provided staff computers for staff to use at the operation and children are never to have access to any of the computers.  Staff members stated that they are no longer able to use their own computers at the operation.  Documents were provided which state that personal property, personal items are prohibited form use during work hours.  2 children interviewed stated that staff are no longer able to use their own computers at the operation and 1 child said she had no information regarding staff devices.


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

raw_content: Inspector observed fire extinguishers in 2 houses to not have initials or dates showing they were inspected monthly.

Correction Narrative:
SJRC Response: SJRC Texas Touchstone Program revised the Home Monitoring Checklist form include a line and date for signature of person conducting home inspection and a second line for the approving Supervisor/Program Manager.
A copy of the original Home Monitoring Checklist as well as a copy of the updated Home Monitoring Checklist is attached for your review. The updated signatures and dates can be found in the new form on Page 4. Also, updated is the section on Health & Safety on Page 1with clear verbiage from Texas Minimum standards that includes specific language that the program is monitoring to ensure there is no interference with access, that extinguishers are readily accessible, and they are serviced by the local fire inspector which meets Texas Minimum Standard §748.3115. (1), (2), & (3).
The updated Home Monitoring Inspection form will go into effect on 06/19/2024.


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: Child in care ran away from operation after exhibiting suicidal warning signs and was not assessed by the operation.

Correction Narrative: Treatment director for the operation is conducting monthly screenings with all children in care, in order to be proactive in meeting the emotional needs of a child in care. Children in care reported the monthly screenings are completed even if they are not exhibiting signs of wanting to self-harm.


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

raw_content: Suicide screenings are not being conducted as required for children in care.

Correction Narrative:
Treatment Director - Kenneth Sabourin, LCSW-S, LCDC met with clinicians at SJRC Texas campus and master's level Interns to discuss the new protocol and procedure for conducting suicide screeners at time of admission and every 30 days thereafter for the duration of their stay at SJRC Texas. The
instrument that will be utilized by the SJRC Texas program is the Columbia Suicide Severity Rating Scale (C-SSRS). All youth in care have been administered this instrument. Attached please find copies of the CSSRS
for every youth in placement at this time. Treatment Director - Kenneth Sabourin, LCSW-S, LCDC will assume responsibility for maintaining a
datasheet to track that monthly C-SSRS are completed every 30 days.


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

raw_content: Multiple child in care witnesses indicated a child in care was just standing around, not causing any harm or risk at the point of restraint. The video also shows the child in care was not engaged in any harmful behavior at the time of restraint. The staff who performed the restraint also admitted the child in care' s refusal to leave the house was the only reason the staff performed the restraint.

Correction Narrative: A supplemental training was provided to all staff regarding the proper and improper way to discipline a child in care. The operation is also providing de-escalation debriefs between staff members, in order for staff to appropriately discipline children in care. Children in care reported to being safe while placed at the operation. The staff member of concern has been terminated from the operation.


summary: 748.2307(15) - Other Prohibited Punishments-using or threatening to use emergency behavior intervention as discipline or punishment

raw_content: The video (audible) shows staff telling the child in care "You're about to be put in a containment". The staff confirmed in an investigation interview that they did say this.

Correction Narrative: Interviews completed with children in care resulted in no concerns notated regarding discipline and punishment. Children in care were able to verbalize the appropriate discipline measures taken when behavioral issues rise. The staff member of concern has been terminated from the operation.


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

raw_content: It was confirmed staff locked the door restricting children access to come into operation as a form of discipline due to children having dysregulated behaviors.

Correction Narrative: Operation staff were provided additional training on TBRI and discipline techniques.


summary: 748.1207(a)(1) - Placement agreement-Must include authorization permitting operation to care for the child

raw_content: During the unannounced monitoring inspection two child files were reviewed and both found to be missing the correct name for the placement authorization. The files reviewed showed names of previous placement.

Correction Narrative:
SJRC will review Placement Agreements with each new admission to make sure the form is filled out correctly.
2. The Case Care Coordinator will review Placement Agreements at the time of placements.
3. Since the non-compliance was identified on 07/05/2023, SJRC Texas has welcomed two new residents and the forms are filled out correctly.


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

raw_content: Medication errors were not documented within the timeframe for four medication logs. Two medication logs did not accurately reflect the directions for the medication, per the psychiatric note.

Correction Narrative: An unannounced walkthrough was completed at the operation, where medication bubble packs and medication logs were observed to be documented correctly for PM medication administration and AM medication administration. Staff signatures were also noted. With regards to medication refusal, documentation was also observed for accuracy and medication count.


summary: 748.1337(b)(1)(A)(vii) - Initial Service Plan-Include therapeutic needs, including plans for evals, follow-up treatment, testing and use of psychotropic medications

raw_content: Six child plans were reviewed. Three child plans were missing CANS information and one child plan had inconsistencies in documenting the child's therapy.

Correction Narrative: Two service plans were reviewed and found to have the required information regarding therapeutic services and treatment services.


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: Six child service plans were reviewed, four did not have the child's signature or documentation that the child refused to sign.

Correction Narrative: Two child service plans were reviewed and noted to have both children's signatures.


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

raw_content: Administrative staff admitted to having knowledge of the concerns of staff sleeping during work hours, however, did not report the incidents to licensing.

Correction Narrative:
Staff involved in the original incident of sleeping during shift hours has been terminated. Administrative staff held a all staff meeting to address the concerns of reporting incidents to licensing withing the appropriate timeframes. When new incidents rise, administrative staff will be conducting in house investigations to ensure there is sufficient evidence to address the concerns. All staff have reviewed the policy for mandatory reporting.

SJRC Response and compliance plan received:

1. SJRC management will review the policy of Reporting Serious Incidents (SJRC Policy 1.5) with
all staff.
2. SJRC, Administrative Staff, reviewed the SJRC Policy/Procedure
Reporting Serious Incidents (Policy 1.5) with the staff on 4/18/2023, 4/19/2023, and
4/20/2023.
3. SJRC is respectfully appealing this finding via administrative review

05/30/23, inspection follow-up completed. The following was confimred:

An all staff meeting was held at the operation on 4/24/23.

During this meeting the following was addressed
Reporting Serious Incidents and the chain of command regarding the reporting of serious incident reports. Youth transportation, code of conduct regarding staff remaining awake during shift hours, and the supervision of youth. All staff were provided with a copy of the operation protocol and policies were provided by paper copy.


raw_content: Staff admitted to observing another staff falling asleep during shift on 5 different occasions. During one occasion of staff falling asleep, the staff was working alone and solely responsible for the supervision of children in care. In addition, staff admitted to falling asleep for a duration of 3 hours, waking up for 1-2 minutes before returning to sleep.

Correction Narrative:
Concerns for staff sleeping during shift work has been addressed by the operation as the staff was terminated due to the safety concerns posed to children in care, by sleeping during the shift. Moving forward the operation will have administrative staff to include case coordinators, residential directors and contract administrators will be conducting monthly night audits by conducting unannounced night visits to the operation to ensure staff is awake during work hours.

SJRC Response:
1. SJRC will review protocols with all agency staff about overnight supervision.
2. SJRC management staff will remind and retrain staff about the importance of elevating and
concerns observed to management.
3. SJRC, Administrative Staff, reviewed the SJRC Policy/Procedure Adult
Supervision of Youth (Policy4.14) with the staff on 4/18/2023, 4/19/2023, and 4/20/2023.
4. SJRC is respectfully appealing this finding via administrative review.


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

raw_content: Licensing observed and photographed a toilet with the tank leaking and a small puddle behind the toilet.

Correction Narrative: During follow-up inspection, toilet was observed to be working properly.


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

raw_content: Licensing observed and photographed a broken bedroom window in Hall House covered by a piece of wood. There was an opening between the wood panel and the wall wide enough for a child in care to reach between and access the glass shards inside. During the inspection, the operation house and grounds specialist removed most of the glass and screwed down the wood panel suffiently to prevent a child in care from reaching in.


summary: 748.3021 - Tools-Dangerous tools & equipment stored so they are inaccessible to children; children use these with caregiver supervision as appropriate

raw_content: A care giver admitted that a child in care was in possession of a metal garden trowel during a behavior episode, which the care giver put away afterward.

Correction Narrative: SJRC Texas will be sending an email to staff reminding them of Minimum Standard §748.3021 How must I protect children from dangerous tools and equipment?


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

raw_content: Staff member was aware they had inappropriate photos on cell phone in which they were seen by child in care.

Correction Narrative: Children in care verified that the staff do not have personal phones in use during shift work.


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

raw_content: A child in care reported a reportable incident to the operation administration staff, however, this was not reported to licensing and no serious incident report was completed documented or could be provided to licensing upon request.


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

raw_content: Child in care with known high-risk behaviors as it was documented the childs plan of service shared a room with another resident in which led to inappropriate behaviors.


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

raw_content: Staff did not follow the operation policy and properly check the mouths of children in care after the administration of medication. Due to the improper mouth checks after the administration of medication, 2 children in care were able to obtain their prescribed medications and snort them.

Correction Narrative:
On 10/17/22, compliance plan was received by email.

While SJRC Texas is currently disputing the allegations concerning the citations at issue through administrative review and due process, SJRC Texas has reviewed all policies and the procedures regarding campus supervision and medication administration as well as the standards associated with the deficiency.

In conclusion, this concern was immediately rectified as all staff in the Program were met with to discuss the concerns that were brought forward. Next, they were retrained in medication administration (8/3/22-8/11/22) and the leadership team has continued to discuss the importance of following medication administration procedures during SJRC's all-staff meetings. In addition, medication administration was emphasized in the new shadowing checklist for all new staff who come aboard to observe before they are in ratio and with the youth alone. The training team has created a training plan which is identified as:

In accordance with 748.151(2)  During New Employee Orientation, new Touchstone staff receive Medication Administration and Documentation training targeted specifically to GRO Minimum Standards and contracts along with discussion of policies and procedures, prior to reporting to their job specific location(s).

Upon graduating from New Employee Orientation, new staff shadow field supervisors for On-the-job training to assess proficiency.  If staff are identified as needing additional training support, the need is communicated to the Director of Training and the Training Specialist designated to Touchstone.

Monthly meetings are scheduled to ensure new graduates successfully complete and understand implementation of all required training and to discuss training needs identified on campus.  Attendees include Program Coordinators, Director of Residential Services, and often Vice President of Touchstone and Chief Clinical Officer.

As a response to this investigation, the following will be implemented:
1.	Touchstone Training Specialist will oversee, supervise and retrain House Supervisors and staff on Medication Administration and Documentation.
2.	At 30-60-90 days of employment, Touchstone Training Specialist will observe house supervisors and staff administer medication and ensure proper documentation.
3.	Director of Training, Training Specialist and Program Coordinators will work closely with Lead House Supervisors thereafter, to ensure compliance with relevant minimum standards, administrative rules and statutes are maintained and that deficiencies are quickly identified and addressed.


summary: 748.1743(d) - Care requirements for infants-caregiver must ensure that the environment is safe

raw_content: Electrical outlets were observed not to have covers in a home where toddlers and infants are living.

Correction Narrative:
On 08/04/22, SJRC provided compliance response through email:

While SJRC Texas is currently disputing the allegations concerning the citations at issue through administrative review and due process, SJRC Texas has reviewed all policies and the procedures regarding campus supervision, physical site, and the fire extinguisher, as well as the standards 748.3113, 748.3115, and 748.3301.

In conclusion, this concern was immediately rectified and the covers have been replaced. Some of the outlets are temper resistant and did not require a cover. The fire extinguishers received maintenance on 7/18/2022 (3 days before the inspection). The tech came out, did the inspection, and stated that they do not provide replacement fire extinguishers on the same day. The tech returned on 7/26/22 to replace both of the fire extinguishers.

The leadership team will discuss the importance of both standards in the upcoming staff notes being sent out to all staff and during the staff meeting on 8/11. There was a staff email sent out as a reminder regarding continual checks of the fire extinguishers.


summary: 748.3113(c) - Fire Extinguisher-Fire extinguisher that has been used or has lost operating pressure must be serviced or replaced immediately with equivalent unit

raw_content: The pressure gauge for a fire extinguisher in a home where children in care including infants are living was not in the green zone and was observed to be in the red zone.


summary: 748.1757(b) - AP Prohibited for infants-Crib must be bare except for tight fitting sheet & crib mattress cover per 748.1757(c) for infant less than 12 months

raw_content: When conducting the walkthrough baby was observed in crib with a thick wool blanket in his mouth while mom was asleep.