facility_name: Aspire 2 Dream

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

raw_content: A child's preliminary service did not include the child's supervision requirements.

Correction Narrative:
A corrective action was received via email on 04/17/2026 stating the following: Aspire 2 Dream has updated the Intake Preliminary Assessment Form to ensure that all
children admitted into care have a documented preliminary service plan that clearly
identifies and addresses immediate physical, emotional, and behavioral needs, high-risk
behaviors, required level of supervision, and safety considerations within 72 hours of
admission.
An updated Preliminary service plan template was received with the required missing information implemented into the plan.


state: TX

facility_name: South Texas Adolescent Rehabilitation & Education - STARE

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

raw_content: There was no safety contract in place addressing high risk behaviors documented on service plan.

Category: Individual Standards Evaluated

Standard Risk Level: High

Corrected at Inspection: No


facility_name: Thompson's Residential Treatment Center

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: A child had a laceration on their head that was noted by a medical professional to be deep enough to require stitches and was already in the stages of healing, without proper treatment. This was not reported to child care regulation and no serious incident report exists.

Standard Risk Level: Medium High

Correction Narrative: A follow-up inspection was conducted on 12/5/2024.  There are no kids in care at this time. This operation is closed.


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

raw_content: Operation staff failed to provide proper care, supervision, and safety when multiple staff failed to respond to child's need for medical treatment and intervention and did not properly intervene when the child displayed the loss of motor skills.

Correction Narrative: A follow-up inspection was conducted at the operation on 12/5/2024.  There are no kids in care at this time. This operation is closed.


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

raw_content: A child in care urinated on himself during an outing and the operational staff that were present failed to address or properly intervene in this incident for approximately 2 hours.


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

raw_content: A child was showing signs of being lethargic during an outing, and two operational staff members responded by forcibly pulling the child up from the floor by his arms in response.


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: A child's medication instructions stated to "Take one (melatonin) by mouth at bedtime." This medication was given to the child at 7:09pm and the child was then taken to the movies.


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: One of three transportation vans used to transport children in care had a plastic covered, broken window, damaged weatherstripping, and tire iron and broom inside the cab of the vehicle.


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

raw_content: An interior door in House #2 was observed with a hole.  No work order or incident report was available at the time of inspection.


summary: 748.535(3)(A) - Child-care administrator responsibilities-Overseeing staffing patterns to ensure supervision and child-care services meet the needs of children

raw_content: The administrator failed to provide oversight to staff for a child in pain resulting in the child's medical needs going unmet.


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

raw_content: Incident reports did not contain all required information. such as witnesses, time, nature of incident, intervention and resolution of the incident as required by Minimum Standards.

Standard Risk Level: Medium


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

raw_content: The operation refused to provide additional records upon request during the investigation.


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

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


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

raw_content: Several interviews with children and staff indicated that a child was "screaming" in pain, complaining of a stomachache, lethargic, and tired. No medical treatment was sought for the child regarding these concerns.


summary: 748.1553 - Child must be immediately treated by health prof, contact emergency svs or take child to ER for injury/illness requiring treatment by a health prof.

raw_content: Operational staff failed to follow the policy and procedures of the operation by failing to render cardiopulmonary resuscitation and failed to notify emergency medical services for several minutes after discovering that a child in care was unresponsive.


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

raw_content: Two kids got into an altercation without staff supervision.

Correction Narrative: On 10/11/2024 Thompson Residential Treatment Center conducted a training session with all staffing about monitoring of clients and discuss the importance of supervision and not belng left alone.


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

raw_content:
In House 2 Room 2 a hole was seen in the wall.

In House 2 a hole was seen in the hallway.

Correction Narrative: In House 2 Room 2 the hole in the wall was repair. In House 2 the hole in the hallway was repair.  Pictures were taken of each and can be found in document library.


raw_content: During the investigation the supervision and the provision of child-care services needed to supervise children in care was not met.

Standard Number / Description: 748.535(3)(A) - Child-care administrator responsibilities-Overseeing staffing patterns to ensure supervision and child-care services meet the needs of children

Correction Narrative: In reviewing Thompson's staffling plan. Thompson's Residential Treatment Center will have staff coverage throughout the 24-hour period.  A staff to youth ratio of one staff for every five youths will be maintained during waking hours.  Staff will be in ratio during the awake night hours and have one awake staff. The staffing plan can be found in document library.


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

raw_content: During the investigation, it was discovered that staff did not adhere to the restricttons  placed by CBCU.

Correction Narrative: On August 7 , 2024 administrator had a staff meeting with his staff and discussed the importance that employee can never be left alone. Each staff sign and understoood that the employee will be always paired with another staff member at all times.


raw_content: A child received a cut under his eye as a result of an altercation with another child.

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


raw_content: In House 2 room 2 a hole was seen in the wall.

Standard Number / Description: 748.3301(a)(2) - Physical Site- Buildings must be clean and in good repair.


summary: 748.3443(b)(1) - Food Preparation-Must have a thermometer in refrigerators & store refrigerated food at 40 degrees Fahrenheit or below

raw_content: During the walk through it was observed that there was no thermometer in the 2 refrigerators and 1 freezer. The administrator corrected this at the inspection by placing thermometers inside the refrigerators and freezer.

Corrected at Inspection: Yes


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

raw_content: During the walk through it was observed that several beds did not have mattress protectors. The administrator corrected this at the inspection by putting mattress protectors on the beds.


summary: 748.3301(a)(1) - Physical Site- Buildings must be structurally sound and not pose a risk to the health and safety of children.

raw_content:
In House 2 Room 1 in the bathroom wires was exposed.

In House 2 Room 2 the exit sign is missing and wires were exposed.

In House 2 Room 3 a hole was seen in the closet. In House 2 Room 3 light fixutre is missing a cover.

Correction Narrative:
In House 2 Room 1 in the bathroom wires were cover.

In House 2 Room 2 the exit sign was replaced and wires were covered.

In House 2 Room 3 the hole in the closet was repaiired. In House 2 Room 3 light fixture is covered.


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

Deficiency Narrative: A child received a cut under his eye as a result of an altercation with another child.

Correction Narrative: An email was sent from administrator. Each staff signed the memo. Thompson's Residential Treatment Center staff will continue to keep children separated from each other until both sides have had time to cool off. If they start arguing again outside of the home. One kid will be asked to go into the house. If they start arguing inside the home, they will be separated. Staff will have time to intervene and minimize injuries. The compliance can be found in the document library.


raw_content: A child in care ran from the operation twice in one day.

Correction Narrative: An email was sent from the administrator regarding staff supervision. TRTC will do its best to discourage clients from running or leaving from the property. Staff will follow the client for a half of mile. Staff will talk to the client to encourage the child/children to return home. If child refuse to return home, staff will call the police department to inform them which direction the child is headed. Staff will have 24 hours to debrief the child in care.


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

raw_content: The operation did not follow child's service plan. The child's is to remain within eyesight of staff.

Correction Narrative: On 8/20/2024 Thompson Residential Treatment Center had a meeting with staff to discuss the importance of following each child's service plan. During waking hours staff will be in close proximity while being at the facility. During sleeping hours staff will do room check every 15 minutes. If a child leaves from the operation. Staff will complete a debrief form.  The staffing form can be found in document library.


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 operation did not conduct a debriefing with the child in care.

Correction Narrative: An email was sent from the administrator with the operation debriefing form. The debriefing form can be found in the document library.


raw_content: Staff failed to intervene in an altercation between two children that resulted in a child being injured.

Correction Narrative: I, RCCR Tommie Moore spoke with the administrator regarding the citations for supervision. Mr. Thompson's stated that staff will continue to keep the two clients separated from one another until both sides had time to cool off. If they start arguing outside of the home. One kid will be asked to go into the house. If they start arguing inside the house, they will be separated. This is so staff would have time to intervene and minimize injuries.


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

raw_content: All the service plans reviewed had the same information and wording used for the supervision section.   This was not specific to each child and that child's needs.

Correction Narrative: An email was sent by the administrator. Thompson's RTC has created a structure approach to create individualized treatment plans for children in care.  The treatment director will conduct thorough assessments for each child including psychological eval, behavioral assessment and medical history. The treatment director and treatment team will identify the unique needs, strengths and preferences of each child through interviews with them and their families. The plan can be found in the document library.


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

raw_content: One child did not have a preliminary service plan in his file.

Category: Admission, Service Planning, Discharge

Standard Risk Level: Medium Low

Correction Narrative: One child did a preliminary service plan in his file.


summary: 748.2151(g) - Medication record-medication records of prescription & non-prescription medication dispensed to the child must be incorporated into child's record

raw_content: Two kid files did not have their medication logs in file.

Category: Medication

Correction Narrative: Two kid files did have their medication logs in file. Pictures were taken of medication file.


summary: 745.4151(c)(8)(B) - Documentation-Drug test results must be kept for one year after employee's last work day or until any investigation involving person is resolved

raw_content: Two employees did not have their drug test in their file. One employee is no longer employed at the operation.

Correction Narrative: An email was received from the administrator regarding an employee random drug test result. The random drug test was taken on 6/17/2024 with negative results. The random drug test can be found in the document library.


raw_content:
In the back of house 1 there was a picture taken of screen torn. During the inspection the administrator replace the screen door.

In House 2 upstairs the word pen was seen written on the wall in blue ink. In House 2 the word pen was painted over during the inspection.

In House 2 Room 4 in the bathroom the cabinet door was missing. In House 2 Room 4 in the bathroom the cabinet door was replaced during the inspection.

In House 2 upstairs two small holes were seen in the wall. In house 2 room 3 there was a broken light fixture.

Category: Physical Site


Standard Number / Description: 748.3301(a)(1) - Physical Site- Buildings must be structurally sound and not pose a risk to the health and safety of children.

Correction Narrative: In House 2 in the living area there was paint chip seen on the wall. In House 2 Room 1 there is a hole seen in the bathroom door. The hole has been repaired.


raw_content:
In House 1 at the bottom of the stairways were seen loose.  In the living areas blinds were broken. In House 1  room 2 the bathroom cabinet was seen broken.   In House 1 room 3 there were holes seen in the wall and broken blind.

In House 2 there were broken blinds seen in the common area and game room. In House 2 the bathroom door will not close. In House 2 in the living area there was paint seen chip on the wall. In House 2 room 2 there was graffitti seen on the outside of the bathroom door. In House 2 room 4 there were broken blinds seen in the room. In House 2 room 4 there was a broken cabinet seen in the bathroom.


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

raw_content: Children's clothing and personal items are being stored in trash bags and on the floor throughout the operation. There are multiple empty suitcases in closets. Clothes are scattered across the floor in every room. Some closets do not have a place to organize or store clothing.

Correction Narrative: Children's clothing and personal items were seen stored in their own personal bins.


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

raw_content: Clorox bleach spray was sitting on the counter in two children's rooms.

Correction Narrative: During the walk-through there were no Clorox bleach seen in any children's room in House 1 and House 2.


raw_content: The operation had a hole in the wall, a damaged door, multiple broken blinds, soiled bathrooms, and various broken base boards.

Correction Narrative: The operation made repairs on damage door, multiple broken blinds, soiled bathrooms did not have a damaged and various broken base boards.


raw_content: A service plan states that a child must be kept in line-of-sight supervision during wake hours. This plan was not followed.

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


raw_content: Two children went from a verbal altercation to a physical altercation. One child sustained a black eye.

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

Correction Narrative: During the inspection each child was seen being observed by staff. Children were observed playing with video games and watching movies with staff.


summary: 748.311(10) - Serious Incident Documentation-Includes resolution of the incident

raw_content: A child in care's name was not documented on the SIR form.

Correction Narrative: An email was sent from the treatment director regarding updated SIR form showing that a the child's name was added to the SIR form. The serious incident report can be found in document library.


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

raw_content: A staff member's background check is showing inactive.


raw_content: In House 2, there were 6 blinds in six different rooms that were broken.


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

raw_content: A caregiver was physically aggressive and used inappropriate discipline with a child in care.

Correction Narrative:
An email was sent from the administrator. The administrator stated that:

Currently the staff is no longer working here at Thompson's Residential Treatment Center. The children are no longer at Thompson Residential Treatment Center.
TRTC will train all our employees for EBI, TBRI, de-escalation, child's rights, and kids triggers.  This will be done on January 25, 2024.  The whole company will be attending these trainings. Also, I will talk with the staff myself about not letting the kids get to them.


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

raw_content: During the course of the investigation, it was determined that a caregiver curse and yelled at children in care.

Correction Narrative:
An email was sent from the administrator. The administrator stated that:
 Currently the staff are no longer working at TRTC anymore and the kid are no longer here.
TRTC will train all our employees for EBI, TBRI, de-escalation, child's rights, and kids triggers.  This will be done on January 25, 2024.  The whole company will be attending these trainings. Also, I will talk with the staff myself about not letting the kids get to them.


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 caregiver engaged in a physical altercation with a 17 year old child in care.  The staff actions placed the child at risk for significant harm.


summary: 748.3359(1) - Bedroom Space-Rooms commonly used for other purposes cannot be used as bedrooms

raw_content: A child was sleeping in the common area over a week.

Correction Narrative: I spoke with the child he is no longer sleeping in the common area as of 10-24-2023


summary: 745.4151(c)(4)(B) - Mandatory Drug Testing-All Employees are Subject to Random, Unannounced Drug Testing

raw_content: The operation has not done any random drug test at this time.

Correction Narrative: I, RCCR Tommie Moore received 5 random drug tests from the administrator. Each employee who had a random drug test results came back negative. The random drug test can be found in the document library.


summary: 748.1303(8) - Education-Know what is in the child's IEP and support the schools efforts to implement the IEP, if applicable.


raw_content: During the follow up inspection the child stated that is no longer sleeping in the common area.

Standard Number / Description: 748.3359(1) - Bedroom Space-Rooms commonly used for other purposes cannot be used as bedrooms

Correction Narrative: A child is no longer sleeping in the common area.


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

raw_content: During the follow-up inspection, in House 1 Room 4. There were two holes not seen in the bathroom door.


summary: 748.1301(a) - Education-Arrange an appropriate education for each child

raw_content: The operation is working in conjunction with Lone Oak ISD to make sure that all of youth's educational needs are met. Thompson's Residential will provide school supplies and assist as needed with schoolwork, homework and school projects. To ensure the youth does not fall behind in school. Thompson's Residential Treatment Center will coordinate with teachers and/or counselor to make sure each child is encouraged to attend the Advisory Period which allows time for work to be caught up on during the school day. Thompson's Residential Treatment Center will also assist in scheduling tutorial time and providing transportation to and from as needed. Youth will be encouraged to communicate with their teachers and staff at Thompson's Residential Treatment Center.

Standard Risk Level: Low

Correction Narrative: The operation is working in conjunction with Lone Oak ISD to make sure that all of youth's educational needs are met. Thompson's Residential will provide school supplies and assist as needed with schoolwork, homework and school projects. To ensure the youth does not fall behind in school. Thompson's Residential Treatment Center will coordinate with teachers and/or counselor to make sure each child is encouraged to attend the Advisory Period which allows time for work to be caught up on during the school day. Thompson's Residential Treatment Center will also assist in scheduling tutorial time and providing transportation to and from as needed. Youth will be encourgaed to communicate with their teachers and staff at Thompson's Residential Treatment Center.


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

raw_content: During the follow up inspection in House 2 Room 2 there were no graffiti seen in the closet.


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

raw_content: During the inspection, there were no holes, graffiti seen on the children room.

Correction Narrative: During the follow-up inspection in House 1 Room 2 the was a red cross was removed about the light fixture.


summary: 748.3701(e)(2)(B) - Recreation responsibility-Child receiving treatment services-Ensure that children receiving treatment services has individualized recreation plan

raw_content: Children in care were not participating in extracurricular activities, as required in the service plans and psychological evaluations.

Correction Narrative: The administrator sent over a copy of the recreational plan for January and February 2024. The administrator stated that Thompson's Residential Treatment Center kids will go on an outing every week or every other week.  Every kid will be able to attend the outing or engage in the in-house activities if they feel like it.  If a kid is deemed unsafe to attend the outing due to his behavior, he will not attend because his safety is most important.  staff will stay back with them in order to supervise the client.


raw_content: Inspectors observed four bedroom doors and one bathroom door damaged. The damage included holes and broken pieces. One door was missing completely.

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


summary: 748.2101(8) - Medication Storage & Destruction-remove medication of discharged/deceased child immediately & destroy in way that ensures children do not have access

raw_content: Inspectors observed medication bottles from a child who had been discharged on September 19, 2023.

Correction Narrative: Inspector observed this standard to be compliant during the follow-up inspection.


raw_content: Several bathroom vanities, cabinet doors, countertops, beds, and couches were seen damaged during the walk though. This included one vanity that had nails sticking out.

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


raw_content: A child was sleeping in a main living area for months. This space was between the medication distribution, supervisor's office and living room and did not allow privacy.


summary: 748.2101(5) - Medication Storage - keep medication storage area(s) clean and orderly

raw_content: The medication storage, had several pills left out, and thrown in the bottom of the medication cabinet.

Correction Narrative: Inspector observed this to be in compliance during the follow-up inspection.


raw_content: During the inspection inspectors observed several holes in the walls, graffiti written in the bedrooms and water damage on the ceilings. Inspectors observed both houses to have damage.


raw_content: A 14-year-old child was grabbed by the neck by a caregiver.

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

Correction Narrative:
An email was received from the administrator stating that staff at Thompson's Residential Treatment Center will be taking the following trainings (Supervision, discipline training, child rights) three times a year by certified trainers. Staff will notify another staff member when they need to be relief.

The staff member is no longer employed at the operation as of 7-26-2023.


raw_content: During the course of the investigation, it was determined a caregiver used inappropriate discipline that could have caused harm to a child in care.

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


raw_content: During the course of the investigation, it was determined a caregiver yelled and cursed at a child in care.

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


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

raw_content: A child was not properly supervised and was able to leave the facility without staff awareness, according to the child assessment.

Correction Narrative: On 9-5-2023 administrator had a training with staff. During the training the administrator discussed with them the importance of supervision. Each staff sign the training form. The signature page can be found in the document library.


raw_content: During the walk through in house 1 there was a hole seen upstairs.

Correction Narrative: A picture was taken in  House 1 showing repairs to hole in the wall.


summary: 748.3443(a)(1) - Food Preparation-Food items must be covered & stored off the floor

raw_content: During the walk through in the kitchen, several food items were uncovered in refrigator.  There were several food items observed on the floor.


raw_content: During the walk through the homes, several walls had hole, broken furniture and window blinds, several of the window were missing screening, electric outlet were uncovered.


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: Three youth in care expressed feeling unsafe due to the mistreatment by staff members.

Correction Narrative: An email was received from the administrator. The administrator stated that he will speak with the children in care. The administrator will ask the children how the staff have treated them.


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

raw_content: Three youth in care indicated staff use inappropriate language when redirecting them.

Correction Narrative: An email was received from the administrator. The administrator will ask the children in care how has staff been treating and also talking with them.


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

raw_content:
The daily meal menus for December 2022 and January 2023 were not provided for review upon request.

The operation was not able to produce December 2022 and January 2023 menus.

Correction Narrative: An email was received from the administrator.  The administrator stated for the food for our kids will continue to be our priority. If the kids are out of school or home sick the children will eat what is on the menu or they will be able to eat the substitute meals.


summary: 748.3301(a)(1) - Physical Site- Buildings must be structurally sound and not pose a risk to the health and safety of children.

raw_content: In House 1, there was a hole in room 1. In House 2, there was a hole in the day room and broken blinds in room 1 and in the table room.

Correction Narrative: In House 1 pictures were taken showing the hole in the day room and broken blinds were repair.


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

raw_content: In House 1, there was a dirty ceiling fan filled with dust and a broken window blind in the front room. In House 2 there was a bathroom with a broken door, a bedroom with a broken door frame, a room had a hole in the wall and a broken outlet. Also the game room had a broken light switch.

Correction Narrative: In House 1, pictures were taken of clean ceiling fans. In House 2  a  picture was taken of the bathroom with a  In House 2  a picture was taken of bedroom door repair. A picture was taken of hole repair and outlet in House 2 game room.


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

raw_content: House 2 in one of the bedroom blinds were seen torn.

Correction Narrative: Pictures were taken in House 2 showing blinds repair.


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

raw_content: In House 1 multiple showers were seen unclean.

Correction Narrative: In House 1 pictures were taken showing that showers were clean.


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

raw_content: Food was seen house 2 refrigerator un-cover.

Correction Narrative: Food was seen cover in the refrigerator House 2.


raw_content: A shattered glass door was seen by the med room in house one.

Correction Narrative: A picture was taken of the repair shattered door in House 1.


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 was slapping and threatening to slap children in care.

Correction Narrative: I, RCCR Tommie Moore conducted an unannounced inspection at the operation. The caregiver is on a safety plan until 2/1/2022. The caregiver will not be left alone with any child in care at this time. The caregiver will be retrained in de-escalation techniques before the employee is allowed to be left alone with any of the children in care. The safety plan can be found in shared drive. I observe the caregiver being on his safety plan during the inspection.  The exit interview was conducted with the administrator.


summary: 748.1101(b)(4)(A)(v) - Children's rights- To be free from being subjected to remarks that belittle or ridicule the child or the child's family

raw_content: A caregiver was name calling children in care.

Correction Narrative: I, RCCR Tommie Moore conducted an unannounced follow-up inspection at the operation. The caregiver has been put on a safety plan until 2/1/2022.  The caregiver will not be left alone with no child in care. The caregiver will not be allowed to transport any children alone in care at this time. The caregiver will be re-train on de-escalation techniques. The safety plan can be found in the share drive. The exit was conducted with the administrator.


raw_content: There was a punch mark in the wall that occurred one month ago and two missing outlet covers.

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

Correction Narrative: An inspection was conducted of the facility and repairs were completed.


Deficiency Narrative: There was a punch mark in the wall that occurred one month ago and two missing outlet covers.


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

raw_content:
House 1 had a broken window in the garage that is located at the front of the house.

Administrator called the window repair man during the inspection. Administrator ask for extension until 5/7/2021

Correction Narrative: Administrator emailed over a picture showing that the window at House 1 has been repair. The picture can be found in shared drive.


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

raw_content: One employee file did not have a drug test in file.

Correction Narrative: Administrator emailed over employee drug test. The employee took the drug test on 2/28/2021. Results were negative. The drug test can be found in shared drive.


summary: 748.125(b) - All employees and caregivers must be aware of and follow your operation's policies and procedures

raw_content: It was found that a direct care staff traded shoes with a child in care, which is a violation of the policies for the operation

Correction Narrative: The administrator stated that he reviewed the policies and procedures pertaining to the relationship and conduct between staff and clients.


summary: 748.705(b)(2) - Reasonable & prudent parent standard-must consider the child's cognitive, social, emotional and physical development level

raw_content: A direct care staff used poor judgement when he traded his used tennis shoes for a pair of new tennis shoes with a child in care that has diminished cognitive skills.

Correction Narrative: The administrator spoke with his staff and explained to him not to ever trade with any of our clients. We reviewed the policies and procedures and conduct between staff and clients.


facility_name: Triple 7 Ranch GRO

summary: 748.4083(b) - Vehicle and maintenance-Each vehicle used must be registered and have a current inspection sticker for the state in which it is registered

raw_content: The operation's vehicle inspection sticker expired 7/31/2025.

Category: Transportation

Correction Narrative: Operation closed effective 11/5/25. There are no children present and risk has been reduced. Inspection was also conducted don 11/6/25 to verify, #	4084757


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

Correction Narrative: risk has been mitigated as the operation has closed


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


summary: 748.1009(2) - Child/caregiver ratio-Must employ adequate number of caregivers to meet their responsibilities regarding supervision of children in 748.685


summary: 748.315 - Serious Incident Documentation - Maintained on file for 2 years and accessible to Licensing upon request

raw_content: While conducting an investigation at the facility, external documents were requested such as incident report and was not received.

Correction Narrative:
A phone call to the owner of the operation was conducted on 11/18/2025 at 1:43pm. I introduced myself and explained the nature of my call and asked for corrections for citation 748.315. The owner informed me the operation is closed. No corrections were able to be obtained.

The operation voluntarily relinquished their license on 11/05/2025. No children remain in the placement.


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

raw_content: Medication records reviewed documented a different pill count remaining then counted.

Correction Narrative: Operation closed effective 11/5/25. There are no children present; risk has been reduced. Inspection conducted 11/6/25, 4084757 to confirm.


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

raw_content: The operation refused to comply with the request for documentation related to the investigation.

Correction Narrative: The operation voluntarily relinquished their license on 11/05/25 and sent email notification that they would not be emailing any documents to Licensing. No children remain in the placement.


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

Deficiency Narrative: The operation refused to comply with the request for documentation related to the investigation.


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

raw_content: An entry in the annual unauthorized absence summary log dated 09/14/2025 does not state what time the victim returned to the operation.

Correction Narrative:
A phone call to the owner of the operation was conducted at 1:09pm on 11/12/2025. I introduced myself and explained the nature of my call and asked for corrections for citation 748.453(a)(3). The owner informed me the operation is closed. No corrections were able to be obtained.

The operation voluntarily relinquished their license on 11/05/2025. No children remain in the placement.


summary: 745.8641 - Requirements during probation

raw_content:
Condition #1- Not Met
There is not documentation of at least two child records reviewed during the following weeks:
7/21/2025-7/27/2025
7/28/2025-8/3/2025
8/4/2025-8/10/2025
8/11/2025-8/17/2025
8/18/2025-8/24/2025

Condition #2- Not Met
As of 8/14/2025 the operation has not had a Medication Technician for the ongoing oversight of medication administration and documentation.

Condition #3- Not Met
There is no record within 30 days that two new hires completed a Serious Incident Reporting Training with a source outside of Triple 7. There is no proof of training, including a sign-in sheet and or a signed and dated certificate on file and available for review.

Condition #4- Not Met
There is not documentation of at least two staff records reviewed during the following weeks:
7/19/2025- 7/25/2025
7/26/2025- 8/1/2025
8/2/2025-8/8/2025
8/9/2025-8/15/2025
8/16/2025-8/22/2025
8/23/2025- 8/28/2025

Condition #6- Not Met
Triple 7 Ranch GRO has hired 5 new staff members and there is no record of them being informed about the operation being on probation and or a signed acknowledgement of probation conditions form on file. Although there are sign-in sheets for Monday Weekly Meetings being conducted on 8/25/2025, 8/18/2025, 8/11/2025, 8/4/2025, and 7/28/2025 there are no meeting notes on file.

Correction Narrative: To prevent recurrence, Triple 7 Ranch has implemented improved filing and tracking procedures to ensure that all required documents are accurately maintained and easily accessible for review. Additionally, administrative staff have been provided with clear protocols and accountability measures to strengthen record management and compliance with licensing requirements.


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

raw_content: On 8/15/2025 a youth in care was arrested and taken into custody. Although a written reportable serious incident report was completed by the facility, this incident was not reported to Licensing/Statewide Intake.

Category: Reports and Record Keeping

Correction Narrative: To ensure long-term compliance, Triple 7 Ranch has developed a Serious Incident Reporting Checklist to be completed for each incident. This checklist includes all required steps, deadlines, and verification signatures. The Program Director and CEO will conduct routine audits of incident reports to confirm adherence to the checklist. This dual review process establishes ongoing accountability and minimizes the risk of reoccurrence.


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

raw_content: On 8/20/2025 a youth in care eloped from school around 2:30p and did not return to the facility until the morning of 8/21/2025 at 11:00a. Although the operation contacted Law Enforcement to report the child missing, the incident was not reported to Licensing/Statewide Intake.


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

raw_content: Based on the information gathered and obtained throughout the investigation it was determined staff members use profane language towards children in care.

Correction Narrative: The operation is restructuring and the previous staff are no longer there. The current staff attend a Monday meeting at which the appropriate use of de-escalation including tone and word usage is discussed. Staff are being supervised by the LCCA with the youth to monitor interactions and provide feedback.


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

raw_content: During the inspection, multiple holes were observed in the walls of the operation in various places, including the bathroom and the bedrooms. Broken blinds and broken electrical wall plugs were also observed at the operation. Missing light bulbs were observed in two refrigerators on the property.

Correction Narrative: Follow-up inspection was conducted: It was observed that all holes, electrical plugs, and blinds were repaired. As well as the light bulbs.


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

raw_content: During the inspection, it was discovered that a former employee is no longer employed at the operation, but has yet to be inactivated.


summary: 748.3445(a) - Food Preparation-Food and drinks must be of safe quality, stored, prepared, and served under sanitary & safe conditions

raw_content: During the inspection, it was observed that multiple items in the refrigerator were not properly stored. Multiple expired items were also observed in the refrigerator as well.

Correction Narrative: Follow-up inspection was conducted; it was observed that all food was properly stored and nothing was expired.


summary: 748.3931(a)(2) - Children receiving treatment services or emergency services are not permitted to use weapons, firearms, explosive materials, or projectiles.

raw_content: The children at the operation engage in treatment services, therefore they should not be allowed to use any firearms due to the children's behaviors and trauma, as this can pose a risk to the safety of children in care.

Correction Narrative:
The following email was provided from administrator Earline Richburg:

Triple 7 Ranch takes compliance and child safety seriously and wants to clarify that while a hunting trip did take place, it was conducted at an external facility. However, we recognize that children were left under the supervision of hunting facility staff rather than being continuously monitored by our own personnel. We acknowledge this as a lapse in adherence to our own policies and HHSC regulations regarding supervision and the prohibition of firearms in child care environments.

o	Triple 7 Ranch has permanently removed hunting or any firearm-related activity from its programs.

o	All staff have been formally notified of this change, and policy updates reflecting this prohibition have been implemented.

Triple 7 Ranch is committed to creating a safe, structured, and regulation-compliant environment for children in our care. We appreciate the guidance from HHSC and are dedicated to fully aligning our operations with Texas Administrative Code standards.


summary: 748.683(1) - Caregiver Supervision-Provide oversight of caregivers to protect children's health, safety and well-being

raw_content: The management staff did not provide the direct care staff that accompanied the children on the hunting trip the proper supervision requirements to ensure that the staff that were in charge of the children were properly supervising the children at all times.

Correction Narrative:
The following email was provided from administrator Earline Richburg:
The following corrections were provided by email from administrator Earline Richburg:
 4.	Stronger Management Oversight & Auditing
o	Mandatory Weekly Supervision Meetings: Direct care staff will meet with management to review compliance expectations and discuss any concerns.
o	Routine Audits & Compliance Spot Checks: Monthly audits and random checks will be conducted to ensure adherence to supervision, weapons policies, and child safety regulations.
o	Signed Compliance Acknowledgments: Staff will be required to sign updated policy acknowledgments to ensure accountability. Violations will result in immediate disciplinary action, including termination.

Triple 7 Ranch is committed to creating a safe, structured, and regulation-compliant environment for children in our care. We appreciate the guidance from HHSC and are dedicated to fully aligning our operations with Texas Administrative Code standards.

We welcome any additional recommendations and are available to discuss this matter further as 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: The staff that accompanied the children on the hunting trip, were not supervising the children properly due to the children being with left with staff from the hunting grounds. The staff allowed the children to engage in high-risk activities by using firearms to hunt. Furthermore, the operations weapons policy states that no child may use a firearms during recreational activities.

Correction Narrative:
The following email was provided from administrator Earline Richburg:

3.	Intensified Staff Training & Accountability

o	Annual Training on Weapons Policies: All staff will receive mandatory training on state regulations prohibiting firearm use by children in care.
o	Supervision & Risk Management Training: Staff will be retrained to reinforce prudent judgment, self-control, and strict supervision requirements.
o	Signed Compliance Acknowledgments: Staff will be required to sign updated policy acknowledgments to ensure accountability. Violations will result in immediate disciplinary action, including termination.

Triple 7 Ranch is committed to creating a safe, structured, and regulation-compliant environment for children in our care. We appreciate the guidance from HHSC and are dedicated to fully aligning our operations with Texas Administrative Code standards.


summary: 748.3709(1) - Higher Risk Activity-There must be a person that is responsible for and supervises a higher risk recreational activity

raw_content: The staff that accompanied the children on the hunting trip left the children with staff from the hunting facility, while operation staff were in a different facility.

Correction Narrative:
2.	Enhanced Supervision Policies & Compliance
o	Mandatory Direct Supervision: Children will be supervised exclusively by Triple 7 Ranch staff at all times during off-site activities. No external staff will assume responsibility for our children.
o	Updated Staff-to-Child Ratio Compliance: A 1:5 staff-to-child ratio will be enforced for all off-site activities. Logs and check-ins will be conducted to document compliance.
o	Strict Oversight for Higher-Risk Activities: Activities deemed high-risk will be reevaluated, and only pre-approved activities with strict supervision guidelines will be permitted.

Triple 7 Ranch is committed to creating a safe, structured, and regulation-compliant environment for children in our care. We appreciate the guidance from HHSC and are dedicated to fully aligning our operations with Texas Administrative Code standards.


summary: 748.3709(3) - Higher Risk Activity-Must continue to meet the child/caregiver ratios and appropriately supervise children at all times

raw_content: The staff that accompanied the children to the hunting trip were not with the children while they were hunting deer, therefore ratio was not complaint.

Correction Narrative:
The following email was provided from administrator Earline Richburg:
2.	Enhanced Supervision Policies & Compliance

o	Mandatory Direct Supervision: Children will be supervised exclusively by Triple 7 Ranch staff at all times during off-site activities. No external staff will assume responsibility for our children.
o	Mandatory Direct Supervision: Children will be supervised exclusively by Triple 7 Ranch staff at all times during off-site activities. No external staff will assume responsibility for our children.
o	Mandatory Direct Supervision: Children will be supervised exclusively by Triple 7 Ranch staff at all times during off-site activities. No external staff will assume responsibility for our children.

Triple 7 Ranch is committed to creating a safe, structured, and regulation-compliant environment for children in our care. We appreciate the guidance from HHSC and are dedicated to fully aligning our operations with Texas Administrative Code standards.


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

raw_content: Several children in care admitted to going on a hunting trip where they were allowed to hold a real gun and pull the trigger.

Correction Narrative:
The following email was provided from administrator Earline Richburg:

1.	Permanent Ban on Firearm-Related Activities
o	Triple 7 Ranch has permanently removed hunting or any firearm-related activity from its programs.

o	All staff have been formally notified of this change, and policy updates reflecting this prohibition have been implemented.

Triple 7 Ranch is committed to creating a safe, structured, and regulation-compliant environment for children in our care. We appreciate the guidance from HHSC and are dedicated to fully aligning our operations with Texas Administrative Code standards.


raw_content: It was determined that the operation did not use prudent judgement when they picked up prescription medication for a child no longer in their care. The child was without medication for more than a day due to this. The operation also misplaced the child's cream and inhaler.

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:
1. Medication Protocol Enhancement:
A written policy has been issued clarifying that no staff shall accept or retrieve prescriptions for residents who are no longer in care at Triple 7 Ranch. In such cases, the pharmacy will be contacted to cancel or reroute the medication.

2. Medication Return Procedure:
If medications are received after a resident's discharge, they will be returned to the pharmacy. The parent or receiving facility will be notified and guided to request the medication from a pharmacy local to their home or new placement.

3. Employee Training:
All staff have received updated training as of April 17, 2025, on prudent medication management and judgment in alignment with §748.507(1). A copy of this training module and attendance log is available for your review.

4. Medication Chain of Custody Log:
Effective immediately, a chain-of-custody log for all resident medication will be maintained and reconciled during intake and discharge to ensure accountability
.
5. Administrative Oversight:
An internal medication compliance audit will be conducted monthly, overseen by our LCCA, to ensure ongoing adherence.


summary: 748.63(1) - Types of services-Operation must only provide services listed on permit

raw_content: Triple 7 Ranch is a GRO only licensed for emotional disorders treatment services. Records reviewed show five placed youth in care require ASD and IDD treatment services which the operation is not licensed for.

Category: Definitions and Services

Correction Narrative: The children have been removed from Triple 7 Ranch. T7R will only provide admission to children who we are permitted for now. Until we are able to change our permit license and add the additional services.


raw_content:
Condition #5 - Not Met.
There is no documentation that the 12/24/2024 scheduled emergency drills were conducted.
There is no documentation that the 12/24/2024 scheduled smoke detectors check was conducted.
There is no documentation that the 12/24/2024 scheduled first aid kits check was conducted.
There is no documentation that the 12/24/2024 scheduled fire extinguishers check was conducted.

Standard Number / Description: 745.8641 - Requirements during probation

Correction Narrative: In order to make sure that the requirements are being met for probation. The administration team will double check behind each other. To make sure that all documents in the emergency section of the probation binder are completely filled out and signed.


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

raw_content: Medication logs reviewed did not reflect an accurate pill count.

Correction Narrative:
The medication form has been corrected. Staff is now correctly documenting every pill that is
in the blister pack or pills bottle.


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

raw_content: Three fire extinguishers were observed to be out of compliance.

Correction Narrative: This standard was found complaint.


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

raw_content: Cleaning supplies were observed unlocked and accessible to children.

Correction Narrative: This standard was found compliant.


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 2nd. Quarter EBI Report has not been submitted to Child Care Regulation.

Correction Narrative:
08/02/2024-The operation's LCCA submitted to licensing staff via email the operation's Corrective Action Plan indicating the operation will have quarterly EBI's reported to licensing through the HHCS website on time, no later than 15 days after the end of each quarter. The LCCA reported ensuring that the operation is in compliance with the minimum standard rules.

08/12/2024-The operation's 2nd. Quarterly EBI Report was submitted into the system.  The report was reviewed in CLASS.


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

raw_content: The operation's evacuation diagram does not indicate a location designated inside the operation to take shelter in severe weather.

Category: Safety and Emergency Practices

Correction Narrative:
07/23/2024- The operation's LCCA submitted to licensing via email evacuation diagrams for each cottage outlining the location designated inside the operation to take shelter in the event of severe weather.

Additionally, the operation's LCCA submitted a Corrective Action Plan via email indicating the operation's Treatment team has added a safe location indoors on the evacuation diagram where staff and residents will go in the building in case they have to shelter in due to severe weather.


summary: 748.3273(2) - First Aid Kits-Each one must contain adhesive tape

raw_content: The operation's first aid kit did not contain adhesive tape, antiseptic wipes/solution, and scissors as required.

Correction Narrative:
07/23/2024- The operation's LCCA submitted to licensing via email the Corrective Action Plan indicating the operation has ordered five new first aid kits with all the required items as well as extra adhesive tape.  The LCCA anticipates having access to the first aid kits by 07/26/2024.

07/26/2024- The operation's LCCA submitted to licensing photographs via email of the operation's five new first aid kits displaying all required items including antiseptic wipes/solutions, scissors as well as adhesive tape.


summary: 748.3111(a) - Smoke Detector-Administrator or designee must test battery-operated smoke detectors monthly; date tested & name of employee that did test documented

raw_content: The operation did not have documentation indicating the battery-operated smoke detectors are being tested on a monthly basis.

Correction Narrative:
07/23/2024-The operation's LCCA submitted to licensing a photograph via email of an operable smoke detector displaying a new battery as well as a solid green light indicating the smoke detector is working properly.

Additionally, the operation's LCCA submitted via email the Corrective Action Plan indicating staff will test battery operated smoke detectors monthly to ensure that the smoke detectors are working properly. The staff will sign a document with a signature and the date it was tested.


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

raw_content: Two out of three youth files reviewed did not include known allergies or chronic conditions on the exterior or in an easily visible location on the file.

Correction Narrative:
07/23/2024- The operation's LCCA submitted to licensing via email the operation's revised Face Sheet for each child's record/file displaying Medication Allergies as well as Food Allergies have been added to the Face Sheet which is displayed on the cover of each child's record/file.

Additionally, the LCCA submitted the operation's Corrective Action Plan via email indicating all resident files will have a face sheet on the front with information such as birth date, date of arrival, insurance information, any allergies or conditions.


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

raw_content: One freezer in House 2 did not contain a thermometer inside.


summary: 748.3107(c)(1) - Smoke Detector-Must be equipped with battery back-up

raw_content: One smoke detector in House 2 did not have a battery in it causing it to continuously beep.

Correction Narrative:
07/23/2024-The operation's LCCA submitted to licensing a photograph via email of an operable smoke detector displaying a new battery as well as a solid green light indicating the smoke detector is working properly.

Additionally, the LCCA submitted via email Corrective Action indicating smoke detectors will be checked often to make sure they are equipped with back batteries and are not beeping.


summary: 748.4083(b) - Vehicle and maintenance-Each vehicle used must be registered and have a current inspection sticker for the state in which it is registered

raw_content: The vehicle registration has been expired for over a year, as it expired 01/2023

Correction Narrative: Unannounced follow up inspection conducted at the operation. Vehicle registration obtained and reviewed. Vehicle registration observed to be current as of 6/17/24 and expires Jan 2025


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

raw_content: The air conditioning vents in operations van only works in the front set and are missing from the remaining body of the van.

Correction Narrative:
06/24/2024-Licensing staff conducted a Follow Up at the operation in efforts to inspect the operation's van validating air conditioning vents were operable throughout the body of the van.  The operation's LCCA reported the operation's van was currently out for maintenance in addressing the air conditioning vents; therefore, licensing staff was unable to inspect van for repair of air vents.

07/25/2024:  The operation's LCCA submitted to licensing staff via email maintenance invoice indicating the van was taken for repairs (operable air vents throughout van) on 06/20/2024 as well as receipt date of 06/26/2024 verifying repairs were completed on 06/26/2024.

07/26/2024- The operation's LCCA submitted to licensing staff via email a photograph of the operation's van displaying operable vents throughout the van.


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

raw_content: In 4 out of 4 staff files there is no documentation regarding any drug testing being done prior to having access to children.

Correction Narrative: Unannounced follow up inspection conducted at the operation. Staff records reviewed were observed to have drug tests conducted.


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

raw_content: In a review of files for staff hired after 8/9/23, two staff records were observed to not have pre-employment screenings completed.

Category: Personnel

Correction Narrative: Operation was educated on the requirements for pre-employment screenings. Operation submitted corrective response detailing protocol for pre-employment screenings for any new employees hired.


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

raw_content: There is no unauthorized absence log and is non-existent at this time. In addition, there is no overall operation evaluation for unauthorized absences as required by 748.463(a).

Correction Narrative: Unannounced follow up inspection completed at the operation. The operation created an unauthorized absence summary log. The summary log was reviewed and observed to contain all required components.


summary: 748.869(c) - Training on administering psych. medication must be instructor-led. The instructor must be a health-care professional or pharmacist.

raw_content: 1 of 4 staff records reviewed did not contain instructor led psych med training.

Category: Training and Professional Development

Correction Narrative: Unannounced follow up inspection conducted. Staff records reviewed were observed to have had psych med training completed by a registered pharmacist.


summary: 748.863(a)(1) - Pre-Service Training-All caregivers must receive 8 hrs of general pre-service training & 4hrs before being counted in child/caregiver ratio.

raw_content: In 2 staff files out of the 4 reviewed the pre-service training was conducted untimely, in addition there is no indication in any of the files when staff was counted into ratio.

Correction Narrative: Unannounced follow up inspection completed at the operation. Staff training records observed to be current. Operation submitted corrective response to ensure all new caregivers received general pre-service training.


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

raw_content: All child bathrooms were observed with nothing for them to dry their hands.


summary: 748.363(9) - Personnel records - Include signed dated statement by the employee that he must immediately report suspected child abuse, neglect, or exploitation.

raw_content: In 1 out of 4 staff files there was a statement regarding immediately reporting suspected child, abuse, neglect, or exploitation however it was not signed or dated.

Correction Narrative: Unannounced follow up inspection conducted at the operation. Staff files were observed to have signed and dated statement.


summary: 748.3443(b)(1) - Food Preparation-Must have a thermometer in refrigerators & store refrigerated food at 40 degrees Fahrenheit or below

raw_content: In 1 of the refrigerator's there was no thermometer.

Correction Narrative: Unannounced follow up inspection completed at the operation. All refrigerators were observed with functioning thermometers.


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

raw_content: In 4 out of 4 staff files there was no job description in the personnel record.

Correction Narrative: Unannounced follow up inspection conducted at the operation. Staff records were observed to have job descriptions included in the file.


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

raw_content: The serious incident documentation is missing some of the required components such as the operations physical address, telephone number, individuals involved (children & staff), child's age and gender.

Correction Narrative: Unannounced follow up inspection completed at the operation. The operation revised the serious incident form to include all required components.


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 1st. Quarter EBI Report has not been submitted to Child Care Regulation.

Correction Narrative: The operation submitted the 1st Quarter EBI report and reported 2 personal restraints. The report was reviewed in CLASS EBI reports. -LJG


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

raw_content: At the time of inspection, 3 out of 4 files reviewed child's prelimanary plan was not completed within 72 hours.

Correction Narrative:
An email response was received stating Triple 7's Treatment Director ( Charles Laday) will assure that every 72 hour plan and
the assessment plan will be done in the required time allowed by minimum standards.


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

raw_content: At the time of the inspection, 2 out of 4 files reviewed were missing proof of child's orientation.

Correction Narrative:
An email response was submitted stating Triple 7's will have the orientation form inside every intake packet upon arrival for every
new child coming to Triple 7 Ranch from this day forward.


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: An email was received indicating accussed staff was terminated, and remaining staffs were retrained on facility policies and procedures on Crisis Prevention and De-escalation.


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

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


summary: 748.1217(b)(12) - Admission Assessment-At admission, must include services the operation plans to provide to the child

raw_content: One child's admission assessment reviewed did not list the services the operation planned to provide the child.

Correction Narrative: Received an email from operation stating Triple 7's Treatment Director will list all services provided by the operation to all clients' assessment plans.


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

raw_content: During the course of the investigation, documentation reviewed contained inaccurate information as well as incomplete sections.

Correction Narrative: Received an email from operation stating Triple 7's Treatment Director will assure that all Assessment Plans, 72 hours, 30 day plans, Child Service plans are maintained current, providing accurate information and all sections are filled in and completed in the time frame that is required by minimum standards.


summary: 748.1583(a) - TB exam-Persons over 1 yr old who live, work, volunteer at facility have exam w/in 30 days, unless person had previous exam that meets requirements

raw_content: 1 out of 5 children records reviewed did not consist of proof of TB test.


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

raw_content: At the time of the inspection, the medication administration records did not consist of reason for medication prescribed.

Correction Narrative: Operation submitted a corrective action plan stating Created new course of action for recording medication distribution. Ms. Ashley Webber oversees medication logs and performs weekly audit of medication distribution.


summary: 748.2151(c)(2) - Medication record - must include prescribing health-care professional's name

raw_content: At the time of the inspection, the medication administration records did not consist of prescribing health-care professional's name.

Correction Narrative: Operation submitted a correction action plan stating created new course of action for recording medication distribution. Ms. Ashley Webber oversees medication logs and performs weekly audit of medication distribution.


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

raw_content: 4  out of 5 children records reviewed did not consist of child's initial service plan.


summary: 748.303(a)(5)(A) - Serious Incident-Report to Licensing soon as aware of an incident of sexual abuse of a child against another child

raw_content: Review of incident reports revealed an alleged sexual abuse incident was not called in to Licensing.


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

raw_content: 2 out of 4 medication records reviewed were missing documentation of medication administration.


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

raw_content: Based on interviews conducted and records reviewed, it was determined that children were not administered their medications on multiple days.

Correction Narrative:
5/29/2024-The operation's LCCA submitted to licensing staff the operation's Corrective Action Plan consisting of the operation's revised Medication Administration Protocol.  According to the operation's Medication Administration Protocol, staff administering medication must ensure they are focused and paying attention, staff are required to read the child's medication container and/or bottle label as well as medication form ensuring the information is the same, when administering medication to a child, staff must remember the five rights (right child, right medication, right dose, right time, right route), staff will maintain individual medication logs for each medication a child is being administered, when there is a medication error staff must contact health-care professional immediately as well as follow health-care professional's recommendations, all medication errors must be reported and documented immediately with the following information (time and date of error, name of medication, time and date of call to licensed health-care professional, name and title of health-care professional, and health-care recommendations for ensuring child's safety).

Additionally, staff must notify the Medication Technician or LCCA in the event an error on medication label or form is found.  Medication refills are required to be filled on time as well as psychiatric appointments must be scheduled, and child seen by doctor before mediation runs out. If there are refills on the prescription, staff are required to contact the pharmacy a week prior to medication running out.  For any reason there is a situation where the pharmacy cannot fill the prescription on time, staff must inform LCCA immediately.  The operation will utilize an office memorandum which will be placed in a child's file why and follow-up calls or emails documenting efforts were made to solve the problem.

LCCA indicated the operation's revised Medication Administration Protocol has been reviewed with staff ensuring staffs' responsibility to administer medication(s) to a child as prescribed.


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

raw_content: Based on a review of medication administration records, it was found that medication logs were not completed properly.

Correction Narrative:
05/29/2024-The operation's LCCA submitted to licensing staff the operation's Corrective Action Plan consisting of Medication Form Training Certificates for all staff.  Each Medication Form Training Certificate reflected training was conducted on December 8, 2023, as well as the one hour and thirty-minute training was instructed by the LCCA.

Additionally, the operation's LCCA submitted the operation's revised Medication Log required information included in medication records consisting of the child's name, medication, medication dosage, directions on how to administer medication(s), reason medication was prescribed, medication time, amount of medication received, prescribing physician information, pharmacy information, date medication filled, date of expiration of medication, signature of person administering medication, medication date, amount of medication given to child, amount of medication remaining, comment section as well as quality check signature section ensuring an audit of medication logs by designated staff.

Lastly, the operation's LCCA submitted the operation's revised Medication Administration Protocol outlining steps taken in administering medication indicating each medication will have a medication log form for completion as well as each form will have important information that will match the information on medication container and/or bottle label.


summary: 748.1217(b)(10) - Admission Assessment-At admission, must include any applicable requirements of 748.1219

raw_content: 3 out of 4 children records reviewed did not consist of an admission assessment.

Correction Narrative: Operation indicated during intake a checklist page is given to participant to sign, notifying that we have gone over intake/orientation of the facility. A copy if placed in his folder and he is given the Triple 7 Ranch Code of Conduct book. Admin staff will oversee this objective is completed. Additional file reviewed consisted of assessment.


raw_content: 3 out of 4 children records reviewed did not consist of a preliminary service plan..

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

Correction Narrative: 1 out of 1 child record reviewed did not consist of a preliminary service plan..


raw_content: 3 out of 4 children's records reviewed did not consist of child orientation.

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


summary: 748.1225(b) - Admission-Dental exam for child 3 years old or older scheduled in 30 days and done in 90 days unless documentation of one within past year on file

raw_content: 2 out of 4 children records reviewed did not consist of proof of dental exam.


Standard Number / Description: 748.303(a)(5)(A) - Serious Incident-Report to Licensing soon as aware of an incident of sexual abuse of a child against another child

Deficiency Narrative: Review of incident reports revealed an alleged sexual abuse incident was not called in to Licensing.


raw_content: 3 out of 4 children records reviewed did not consist of proof of TB test.

Standard Number / Description: 748.1583(a) - TB exam-Persons over 1 yr old who live, work, volunteer at facility have exam w/in 30 days, unless person had previous exam that meets requirements

Category: Child Care


summary: 748.1223(a) - Admission-Medical exam by health-care professional within 30 days after admission, unless documentation of medical exam within past year available

raw_content: 1 out of 4 children records reviewed did not consist of proof medical exam with 30 days of admission.


raw_content: 3 out of 4 children's records reviewed did not consist of child's initial service plan.

Standard Number / Description: 748.1335 - Initial Service Plan-Complete the initial service plan within 45 days after admission


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

raw_content: 1 out of 4 children's records reviewed did not consist of current immunization record.


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

Deficiency Narrative: 2 out of 4 medication records reviewed were missing documentation of medication administration.


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

raw_content: During a CCI inspection, it was observed one staff member did not follow the condition of their provisional background while providing supervision of children in care at the operation.


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

raw_content: Caregiver observed corporal punishment of a child, and failed to intervene.


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 was observed using corporal punishment on a
child.


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

raw_content: A caregiver witnessed a child being hit with a belt by another caregiver and failed to report the incident.


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 caregiver failed to adhere to the child's rights to
be free of abuse, neglect, and exploitation as
defined in Texas Family Code
261.401.


raw_content:
A caregiver failed to adhere to the child's rights to be free of abuse, neglect, and exploitation as defined in Texas Family Code 261.401.
A caregiver failed to protect a child from abuse as defined in Texas family Code 261.401


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

Deficiency Narrative: Caregiver observed corporal punishment of a child, and failed to intervene.


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

Deficiency Narrative: A caregiver witnessed a child being hit with a belt by another caregiver and failed to report the incident.


raw_content: A caregiver was observed using corporal punishment on a child.

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


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 operation reported a serious injury of a youth in care that required professional medical treatment to Licensing more than 24 hours after the discovery.

Correction Narrative:
The corrective action plan for Triple 7 Ranch are as follows:
Parents will be notified, and client will be transported to assessed by medical provider the same day T7ranch is notified of incident.
Either LCCA or treatment director will make call to parent guardian informing them of incident and next actions.
LCCA or Treatment Director will call Hotline will be notified within 24 hours of the child having a medical emergency.
Follow-up with post appointment for treatment any medications will be sent to Bemij Pharmacy for prescription fill of receiving discharge paperwork.
Follow up with parent/guardian for update or treatment.
in-service staff on following through on medication services and corrective action plan. This information will be uploaded into ccl storage.


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

raw_content:
During a walk through the following area are in need of repair: Location East bathroom 5112 Door broken
5112 and 5110 check all outlet cover and replace covers. 5112 hole next to closet door and 5110 repair holes in walls in common area and rooms.  (Maintenance Report  provided.

Correction Narrative: We are having repairs completed to both homes (doors, sinks, holes in walls, outlets). Triple 7 Owner Mr. Anderson emailed the pictures, and they will be uploaded into digital storage.


summary: 748.936(1) - Annual Training-  Caregivers must have EBI w/in 6 months from the date they last received the training if operation provides treatment services

raw_content: During the monitoring inspection one of the two files reviewed was missing EBI training. The last documented EBI training for the staff occurred on 12.02.2021.

Correction Narrative: EBI training is taking place on 01/28/2023 (one staff) and certificates will be placed inside employee folders and emailed to the inspector.


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

raw_content: During a monitoring inspection, the operations health inspection was expired on 12/04/2021.

Correction Narrative: Health inspection on (1/13) by awaiting her results of the inspection. A copy will be placed in the CCL Digital Storage.


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

raw_content: During a monitoring inspections one of the two staff files reviewed the affidavit of application for employment was not completed.

Correction Narrative: On 01/20/2023 a copy of the Notarized affidavit for the staff was emailed to the inspector.


raw_content: During a monitoring inspections one staff member did not follow the condition of their provisional background while providing supervision of children in care at the operation.

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

Correction Narrative: As 01/13/2023 Per the Owner Mr. Anderson the Operation decided to combined the houses again which will then allow for Mr. Montel to be able to have eligible staff with him at all times during his shifts. The children have their own individual rooms and both staff will work together simultaneously for the greater good of the program.


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

raw_content: During a monitoring inspections one of the two staff files reviewed the TB testing was missing.

Correction Narrative: The staff TB testing results were emailed to inspector LyNetta Johnson-Neal on 01/30/2023.


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

raw_content: Operation's last fire inspection occurred on 02/17/2021. Operation failed to complete a fire inspection within 12 months of last fire inspection.

Correction Narrative: Operation provided fire inspection conducted on 7/25/22.


summary: 745.4151(c)(5)(B) - Drug testing procedures-Drug testing will use one of these drug-testing methods: certified lab, appropriate testing kit or other comparable method

raw_content: The operation provided documentation that they conducted their own drug tests on the four employees whose files were reviewed in this investigation.

Correction Narrative:
07-12-2022. The inspector telephoned the operation and requested the compliance response. The operation director returned the call and agreed to email documentation that the operation will ensure either a certified lab, appropriate testing kit or comparable method are always used for drug tests. The operation emailed RCCR documentation that they use the Reveal 12 home drug testing kit which shows the drugs for which the kit tests.

07-06-2022. The Houston RCCR supervisor advised that the San Antonio inspector who completed the inspection will handle the follow up and that phone follow up is allowed as long as proof is emailed.


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

raw_content: During the inspection four out of four medication logs reviewed had missing signatures for doses administered.

Correction Narrative: Staff were provided a written write up for not initialing after administering medication. Copy of policy is posted for all staff to review, It also stated that staff must sign the last page of the log when it is posted at the beginning of the month.


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

raw_content: During the inspection three out of four medication records did not include an accurate daily count for multiple medication doses.

Correction Narrative: An email from the admisntrator stated the following. "Staff will use the log online to sign for medication, staff that pulls medication will sign for the days that they are pulling. This way we one log with count and just a sign out sheet for medication pulled. Please see attachment A" Attachment A is the new form that will be used when logging medication.


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

raw_content: The operation does not currently have an administrator. The last administrator left the operation in October 2021.

Correction Narrative: Email received from the operation Ms. Dawn Washington has passed her administrators exam on 2/8/22. The operation has also advised Program Director Tari Shaw will also be taking the exam as a backup LCCA. We will also reach out to LCCA, as a contractor/Plan B in the event Ms. Washington or Ms. Shaw are on vacation


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

raw_content: The operation does not have completed preliminary service plans for the four children placed at the facility.

Correction Narrative: The operation sent an email with the preliminary service plans for the four children completed.


summary: 748.4083(b) - Vehicle and maintenance-Each vehicle used must be registered and have a current inspection sticker for the state in which it is registered

raw_content: The operation's vehicle used to transport the children registration expired  in October 2021.

Correction Narrative: Email was received from the operation Registration has been renewed on the van. It will not expire to 1/1/2023. The operation provided pictures of the registration and also indicated they would be transferring the registration from the church into the operation name.


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

raw_content: Four out four children's records did not have an admissions assessment completed for non-emergency admissions to the operation.

Correction Narrative: The operation sent an email providing the four admissions assessments.


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

raw_content: Several of the tubs has dead bugs in them. The toilet paper roll handle was broken in one of the bathrooms located in building 10


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

raw_content: There was a green lighter found outside of building 10


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

raw_content: A staff member who is no longer associated with the operation is still listed as active


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

raw_content: The  operation has not validated the background list in 5 months


summary: 748.2953(b) - Evaluation-Operation's quarterly data on emergency behavior interventions must be reported to Licensing quarterly

raw_content: The operation has not reported the EBI numbers.


raw_content: The health insepction was expired on 10/7/2021

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


summary: 748.153(3)(C) - Notification - Remove controlling person

raw_content: A controlling person is no longer associated with the operation and thus needs to be removed.

Category: Organization and Administration


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

raw_content: One out one personnel record reviewed was missing the affidavit form and several other components that should be in the personnel file. Including date of hire, orientation, normalcy training, job description.


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

raw_content: There was a hole in a bathroom located in building 10.


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

raw_content: There was a saw blade located behind unit 5110. The blade was removed and disposed of properly


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

raw_content: The operation does not have access to funds for the first 3 months of operating.

Correction Narrative: The Administrator for the operation provided proof of funds available for the operation/


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 doors to the hot water heaters did not have a lock. A wooden table located in the laundry room was damaged on the side with exposed wood that can cause splinters. There were chairs outside the units and a rug in the kitchen area of one of the units that had several stains.


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

raw_content: There were several cleaning items accessible to children in the laundry room.


summary: 748.3309(1) - Communication-Operation must have operable telephone with an outside line, accessible to employees, with listed number, and not coin-operated

raw_content: The operation did not have a telephone or any line of communication for the units that will house children.


raw_content: There were large  pieces of wood located on the basketball goal, large debris of rocks/bricks located on several areas of the grounds,  two wooden  boards with nails in areas accessible to children and a large trailer with debris inside.

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


raw_content: There was one toilet that had large brown stains in the laundry room bathroom. There were two showers/bathtubs that were unclean.

Standard Number / Description: 748.3391(a) - Bathrooms-Must be maintained in good repair & kept clean


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

raw_content: There were several bird nets  and wasps nets in the walking areas outside. Several spiders and spiderwebs found in the bedrooms. There were dead bugs in the closets and other area of the units. Overall there were area of the units that need to be cleaned.


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

raw_content: There was a mattress on one of the bunk beds that did not have a waterproof covering over the mattress.


raw_content: There was an outside light fixture that is damaged and had exposed wiring. There was also a smoke detector that was missing the cover with exposed wiring  in one of the bedrooms. On the back of one of the units there was a green and black substance at the bottom of brick wall.

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


facility_name: Southall Heritage Youth Home

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

raw_content: During the inspection, 2 employee files reviewed did not have verification of education.

Correction Narrative:
On 4/15/26The operation emailed the following compliance plan:

- The operation has implemented a monthly personnel file audit system to ensure all required documentation, including education verification is maintained in each employee file.
- A designated audit day has been established for the first Monday of each month.
-Audits are conducted by the LCCA or designee and documented using a personnel file checklist.
-Any missing documentation is corrected within 24-48 hours of identification.
Ongoing Monitoring:
-Audit logs will be maintained and available for Licensing review.


summary: 748.2003(b)(2) - Administration of Medication-Store medication in the original container unless there is an additional container with the same label & instructions

raw_content: Medications were in plastic pouches and did not have instructions for administering the medication.

Correction Narrative:
The operation responded with the following:
All medications are now stored in original pharmacy containers or approved secondary containers with identical labels and instructions.

Ongoing Compliance
Biweekly medication storage audits conducted.
MAR training reinforced with all direct-care staff.

Pending on Operation to submit Training agenda and training sign in sheet.


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

raw_content: The child's record did not have verification that the child was provided orientation.

Correction Narrative:
The operation responded with the following:
Orientation was provided, and signed verification is now maintained in each applicable childs record.

Ongoing Compliance
Orientation verification embedded into the 72-hour service plan process.
Administrator review within required timeframes.


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

raw_content: The child's binder only had initials on the exterior and did not notate if the child had any known allegeries or chronic conditions.

Correction Narrative:
The operation responded with the following:
All child records now clearly indicate known allergies, chronic conditions, or no known allergies in a visible location.

Ongoing Compliance
Allergy verification required during admission and medical review.
Staff trained on reviewing allergy information during intake.