summary: 748.2851(b) - EBI Follow-Up-Caregivers involved in EBI must conduct a post discussion with child

raw_content: Documentation provided stated the post discussion was held with the child and a staff that was not involved in the restraint.

Correction Narrative:
On November 22, 2022 an email was received from the Administrator stating the following: The following was sent to all supervisors concerning our deficiencies on this investigation.  We will also review this as a whole group at our next all-staff meeting.  I also met with our Quality Assurance Manager and reviewed the report and expectations for us as a facility moving forward.
I understand that the child refused to have a post discussion with staff involved in the restraint, however, this should be noted in the restraint report.  For example:  Child refused to process incident with staff and requested to de-brief with Treatment Director.  Or, youth refused to debrief, staff will follow-up after a cooling off period. Then go back and complete the information the next day when youth was debriefed.   If the person(s) involved are able, they should always be the one(s) who debrief with youth and document youth's response.
Please remind all staff that when a youth has a crisis, this is a teaching moment.  When everything has calmed down and the youth is able to regain control and be introduced back into the milieu, the teaching moment (debriefing) should be done.  Teaching our youth how to process crisis situations and discuss ways to handle future situations is vital to the success of our youths.


state: TX

facility_name: Creighton Oaks Residential Treatment Center

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

raw_content: All staff stated there were all in different location when the incident occured.

Category: Individual Standards Evaluated

Standard Risk Level: Medium

Corrected at Inspection: No

Correction Narrative:
To rectify this staff will be assigned areas of the common areas during their designated shift.  If they need to leave their area, they will have a co-worker or supervisor monitor their area for them.  We believe this will greatly decrease any opportunity for youth to become involved in an altercation without staff being able to correctly intervene before the situation escalates.

Additionally, staff will be having additional training on trauma informed care approaches to addressing youth's negative behaviors during our all staff meeting on August 18, 2022.


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: Two of seven children's medication file reviewed revealed a medication being administered not according to the label/order.

Standard Risk Level: Medium High

Corrected at Inspection: Yes


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

raw_content: The facility does not have a treatment director.

Category: Personnel

Correction Narrative: A treatment director was hired - Christopher Moses.


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

raw_content: There was no active record available for the operations administrator.

Category: Reports and Record Keeping


summary: 748.103(b)(13) - Policies and procedures to submit - Tobacco and e-cigarette

raw_content: The agency's policy does not address tobacco and e-cigarette.

Category: Organization and Administration

Correction Narrative:
The staff standards of
conduct form and policy
manual have been
revised to include a no
tobacco and e-cigarette
policy according to
minimum standards
requirements. (see
attached policy revisions
4.7 and 19.2 and staff
code of conduct form)
9/16/21


summary: 748.4653(a)(3) - Pre-Service Training- All caregivers must have 5 hrs of training on complex trauma of trafficking victims, 2 hrs pre-service and rest within 90 days

raw_content: Policy does not indicate complex trauma training for caregivers of human trafficking victims.

Category: Training and Professional Development

Correction Narrative:
Pre
-Service training form
and policy manual has
been revised to meet the
5 hours of training on
trauma of trafficking
victims and compassion
fatigue training. (see
attached policy revision
4.3 and Pre
-Service
training) 9/18/21


summary: 748.1205(a)(5) - Admission Documentation-Includes date of admission

raw_content: The date of admission is not listed on the admission documents.

Category: Admission, Service Planning, Discharge

Standard Risk Level: Low

Correction Narrative:
The admission
assessment was revised
to include date of
admission. (see
attached revised
admission form) 9/16/21


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

raw_content: The right refrigerator is at 50 degrees Fahrenheit

Category: Physical Site


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

raw_content: Bathroom sink for bedrooms two and three in Peach House are slow draining. Bathroom sink for bedroom six in the Grey House is also slow draining.


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

raw_content: Drug polices do not address all information provided in the model drug testing policy.

Standard Risk Level: High

Correction Narrative:
The drug testing policy
has been revised to meet
the DFPS drug testing
policy. Forms, staff file
and policy manual have
been updated. (see
attached revised policy
4.0 and drug policy form)
9/20/21


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

raw_content: The deep freezer in the kitchen does not have a thermometer.


summary: 748.1217(b)(1) - Admission Assessment-At admission, must include child's legal status

raw_content: The admissions assessment does not include the child's legal status.

Correction Narrative:
The admission
assessment has been
revised to include the
child's legal status. (see
attached Admissions
form) 9/16/21


facility_name: Kirby's Place

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: One child s record was missing medication logs for the period of 2/25 to 4/25.

Category: Medication

Standard Risk Level: Medium Low

Correction Narrative: The operation provided med log covering the dates 2/25 through 4/25. The operation also submitted valid CPR certificates of staffs, and suicide training and polices.


summary: 748.125(c)(1)(C) - Caregivers and employees must complete 1hr annual suicide training with curriculum that includes the understanding of suicide screening.

raw_content: Two staff file records reviewed were missing documentation of  the required  annual suicide prevention training.


summary: 748.985(a) - First-aid-CPR training-Certification must be obtained from specific persons/organizations

raw_content: The  EBI training was conducted by an instructor who was not certified.


summary: 748.1437(7) - Discharge/Transfer Documentation-For emergency discharge/transfer, document reason for discharge/transfer explained to child, and child's reaction

raw_content: 1 child file reviewed did not have the required discharge documentation.

Correction Narrative: The Clinical Director will ensure that all Discharge Summaries are completed for each Discharge and that they are place in the child's file upon completion.  The Program Director/Executive Director will sign off on the discharge file ensuring that the Discharge Summary is completed and in the file before the file is broken down and stored away.


summary: 748.983(b) - First-aid-CPR renewal-The caregiver counted in the ratio who must have current CPR certification must maintain a current certification

raw_content: During the inspection I observed that two of the staff members had expired CPR training.  Both staff members are direct care staff and are alone with the children in care.

Correction Narrative: Appropriate updated documentation was provided.


facility_name: Fostering Life Youth Ranch, LLC

summary: 748.535(2) - AP Child-care administrator responsibilities- Ensure the operation complies with current heightened monitoring plans, if applicable.

raw_content:
During a review conducted on February 10, 2025, it was determined that:
(1)	your operations administrator failed to ensure compliance with the current HM Plan; and
(2)	more than 12 months had elapsed since the effective date of the plan.
As you know, the heightened monitoring plan for your operation included a specific planned end date at the original 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of post plan monitoring.  As a direct result of the administrators failure to ensure timely compliance with the heightened monitoring plan, your operation was unable to successfully move to post-plan monitoring by the original planned end date necessitating previous extension.  Furthermore, due to your recent citations issued on January 15, 2025, your operations planned end date must now be revised again, and the period of heightened monitoring must be extended again.
Further details of the administrators failure to ensure compliance include the following:
Your operation received a medium high weighted citation in a pattern/trend category on January 15, 2025. Specifically, the operation was cited for 748.1101(b)(3)(C) Children's Rights-Adhere to the child's rights to have religious needs met. The operation met compliance on January 23, 2025.
-	Operation failed to satisfy the conditions of the plan.
-	Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring; and
-	Operation was unable to meet compliance with medium high and/or high weighted licensing citations.
Finding: 748.535(2)  The licensed administrator must ensure the operation complies with current heightened monitoring plan.

Correction Narrative: An HM extension was approved effective 2/10/2024.  In conjunction with this extension, a new deadline was established by which all requirements must be completed by your GRO in order for the operation to be released from its HM plan and move to the Post-plan Monitoring Stage of HM.  Because the extended deadline is now effective, HHSC has determined that the operation is compliant with the requirements of 26 TAC 748.535(2).  The HM deadline for your operation has been extended by 6 months and the new deadline is 08/11/2025.


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

raw_content: Two caregivers showed inappropriate videos/photos on their cell phones to children in care. Two caregivers failed to maintain personal boundaries with one another around children in care.

Correction Narrative: An email received from the operation's administrator stating the Mosaic campus is currently closed on a temporary suspension and the employees in question were terminated prior to the closure. The employees are not able to be rehired when the facility returns to open status. The operation provided termination documentation for the employees involved in the investigation. Per the administrator, they do not wish to admin review the citation.


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

raw_content: Children in care were found to be using vapes

Correction Narrative:
2/12/2025 Email received that the operation is being placed on suspension so an in person follow up is not possible but compliance information can be found below.

Email received on 2.12.2025 stating that the operation has updated their vape/tobacco policy, the two staff involved in the incident were terminated.  Other staff were retrained on how to receive a child for any intake, especially after a visit.


summary: 748.1661(b) - Tobacco Products-Adult may not smoke tobacco products, e-cigarettes, or vaporizers in children's living areas/inside any building on premises w/ kids

raw_content: Multiple staff were using vapes inside with children on the premises.

Correction Narrative:
2/12/2025 Email received that the operation is being placed on suspension so an in person follow up is not possible, but compliance information can be found below.

Email received on 2.12.2025 stating that the operation has updated their vape/tobacco policy, the two staff involved in the incident were terminated.  Other staff were retrained on how to receive a child for any intake, especially after a visit.


summary: 748.1101(b)(3)(C) - Children's rights-Adhere to the child's rights to have religious needs met

raw_content: A child in care's religious needs were not bet by having a child get vaccinated even though there was a documented exemption due to religious reasons.

Correction Narrative: Email received from the operation stating that the employe listed in the investigation has been terminated. The current staff have received detailed instructions on the importance of in depth reading of all information that is supplied to them. They are also required to ensure that the people involved are aware of all information necessary for each child.


raw_content: An employee did not read the child's documentation that showed the child had a religious exemption to not get vaccinated.

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


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

raw_content: Five children stated they saw a staff sleeping.


raw_content:
During a review conducted on August 9, 2024, it was determined that:
(1)	your operations administrator failed to ensure compliance with the current HM Plan; and
(2)	more than 12 months had elapsed since the effective date of the plan.
As you know, the heightened monitoring plan for your operation included a specific planned end date at the original 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of post plan monitoring.  As a direct result of the administrators failure to ensure timely compliance with the heightened monitoring plan, your operation was unable to successfully move to post-plan monitoring by the original planned end date necessitating previous extension.  Furthermore, due to your recent citations issued on July 8, 2024, your operations planned end date must now be revised again, and the period of heightened monitoring must be extended again.
Further details of the administrators failure to ensure compliance include the following:
Your operation received a high weighted citation in a pattern/trend category on July 8, 2024. Specifically, the operation was cited for 748.2003(b)(2) Administration of Medication-Store medication in the original container unless there is an additional container with the same label & instructions. The operation met compliance on July 22, 2024.
-	Operation failed to satisfy the conditions of the plan.
-	Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring; and
-	Operation was unable to meet compliance with high weighted licensing citations.
Finding: 748.535(2)  The licensed administrator must ensure the operation complies with current heightened monitoring plan.
An administrative penalty will be assessed as a result of this citation, in accordance with Texas Human Resources Code Sec. 42.078. The maximum daily penalty for your operation is $100.

Standard Number / Description: 748.535(2) - AP Child-care administrator responsibilities- Ensure the operation complies with current heightened monitoring plans, if applicable.

Correction Narrative: An HM extension was approved effective 8/9/2024.  In conjunction with this extension, a new deadline was established by which all requirements must be completed by your GRO in order for the operation to be released from its HM plan and move to the Post-plan Monitoring Stage of HM.  Because the extended deadline is now effective, HHSC has determined that the operation is compliant with the requirements of 26 TAC 748.535(2).  The HM deadline for your operation has been extended by 6 months and the new deadline is 02/10/2025.


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: Two bottles of melatonin contained pills of different sizes and colors.

Correction Narrative: In person follow up conducted during HM Inspection #4011317.  Three children's medications were reviewed. Bottle of Melatonin was observed and only had one type of pill and Inspector was informed that staff were retrained on medication.  Email received on 07/10/2024 from operation stating Four mismatched pills in each of the bottles were removed and replaced with identical pills so that all pills in the bottles were the same. All other over the counter medications were checked to make sure the same issue was not occurring with other medications. All other pill bottles had identical pills in the bottles. SPoke with case aide and case aide supervisor to let them know that all pills in over the counter medication containers need to be identical and refilled from the same brand with teh same label and instructions. This was all done on Monday, July 8, 2024.


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

raw_content: Two medication logs did not have documentation what the medication was prescribed for.

Correction Narrative: The reason for medication blanks were filled immediately upon request by HM. The case aide and case aide supervisor were spoken with regarding the importance of the medication logs containing complete information. To alleviate any issues in the future a staff training was completed on 3/7/24 regarding making sure all information is complete on the medication logs. The case aide and case aide supervisor will work closely to ensure all information is complete and accurate.


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.


raw_content: A caregiver permitted a child in care to view information that was intended to be accessible only to staff members.


raw_content: A caregiver permitted a child in care to assault another child in care and video recorded children play fighting which would sometimes turn into real altercations.

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:
During a review conducted on February 7, 2024, it was determined that:
(1)	your operations administrator failed to ensure compliance with the current HM Plan; and
(2)	more than 12 months had elapsed since the effective date of the plan.
As you know, the heightened monitoring plan for your operation included a specific planned end date at the original 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of post plan monitoring.  As a direct result of the administrators failure to ensure timely compliance with the heightened monitoring plan, your operation was unable to successfully move to post-plan monitoring by the original planned end date necessitating previous extension.  Furthermore, due to your recent citations issued on January 4, 2024, your operations planned end date must now be revised again, and the period of heightened monitoring must be extended again.
Further details of the administrators failure to ensure compliance include the following:
Your operation received a high weighted citation in a pattern/trend category on January 4, 2024. Specifically, the operation was cited for 748.685(a)(4) Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being. The operation met compliance on January 10, 2024.

-	Operation failed to satisfy the conditions of the plan.
-	Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring; and
-	Operation was unable to meet compliance with high weighted licensing citations.

Finding: 748.535(2)  The licensed administrator must ensure the operation complies with current heightened monitoring plan.

Correction Narrative: An HM extension was approved effective 2/7/2024.  In conjunction with this extension, a new deadline was established by which all requirements must be completed by your GRO in order for the operation to be released from its HM plan and move to the Post-plan Monitoring Stage of HM.  Because the extended deadline is now effective, HHSC has determined that the operation is compliant with the requirements of 26 TAC 748.535(2).  The HM deadline for your operation has been extended by 6 months and the new deadline is 08/08/2024.


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

raw_content: A caregiver engaged in a verbal altercation with a child in care, yelling at and shaming the child.

Correction Narrative:
The operation administrator has sent an email informing that the caregiver's role has been modified, and she will no longer be directly involved in providing care to children.

A walkthrough of the operation was completed, and a discussion was conducted with the caregiver and the operation administrator regarding her new position. There were no concerns noted.


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 shoved a child in care on the shoulder during an argument.


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

raw_content: One out of three service plans reviewed did not have psychological recommendations documented in the service plan.

Correction Narrative:
A TPR addendum was received from Administrator Mr. Kainer on 11/21/2023. The addendum states "Jasmine had a psychological evaluation on 09/05/2023. Psychological results were received on 09/19/2023. Identified strengths include that she gets along with peers, does well in school, communicates well with staff, and has stayed out of drama." The evaluation recommendations are also documented. This addendum will be attached to the service plan.
The case manager will ensure that this section of the treatment plan is completed with the strengths and recommendations from the psychological evaluation. In the event that the results of the evaluation have not been received at the time of the treatment plan begin date, this section will note that the evaluation results have not been received and will note the date the psych evaluation was completed or is scheduled.


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

raw_content: Caregivers created an unsafe environment for an escalated child by verbally provoking the child until law enforcement was called to intervene by arrest.

Correction Narrative: Follow-up by inspection was completed on 12/11/2023 in inspection 3979716.  Before the inspection, the administrator responded via email informing RCCR that the staff involved had been reassigned to an administrative/support position and no longer has direct, unsupervised contact with children in care. During the inspection, RC observed the staff was present at the operation but was not performing direct care duties or interacting with children on the unit. The staff was interviewed and confirmed the position change and denied working with children in care as direct care staff. The operation will further assess the staff's continued employment pending the completion and outcome of Investigation 3046712 involving allegations against the same staff.


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

raw_content: Staff failed to implement an EBI restraint when a child in care was engaging in self-harm.  Additionally, staff failed to de-escalate the behaviors and provoked escalation when an intervention could have prevented the injuries.


summary: 748.1101(b)(2) - Children's rights-Family contacts: maintaining regular contact with parents and siblings, unless restrictions needed because of child's best interest

raw_content: Multiple children in care were denied the right to contact their caseworker.

Correction Narrative: The training records, provided by the Operation Administrator and Vice President, confirm that all staff members have recently undergone training on the after-hours protocol for contacting children in the care of caseworkers, attorneys, CASA workers, etc. This training aims to enhance the support provided to children in care by ensuring their children's rights are upheld. To maintain accountability, the after-hours binder includes a sign-in sheet where staff members can verify their assistance in facilitating these phone calls with the children.


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

raw_content: Direct Care Staff and Administrative staff failed to follow the directives included in a child's service plan which calls for contact with the child's caseworker outside of normal business hours when the child is escalated.

Correction Narrative: The training records, provided by the Operation Administrator and Vice President, confirm that all staff members have recently undergone training on the after-hours protocol for contacting children in the care of caseworkers, etc. This training aims to enhance the support provided to children in care by ensuring their children's rights are upheld as well as their service plans. To maintain accountability, the after-hours binder includes a sign-in sheet where staff members can verify their assistance in facilitating these phone calls with the children.


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 in care was not given one medication for 3 days in a row and was also not given a lunch dose of another medication.

Correction Narrative:
On 9/22/2023 an email was received from Administrator James Kainer stating the following: "Completed written warnings to the staff that were responsible for the resulting medication errors
Implemented a new system to ensure all medication logs are accounted for at the beginning of each month
Implemented a new system to make sure all refills are filled prior to running out of any medication
Implemented a new system to verify the accurateness of each child's medications prior to administration of the medications by staff."
A follow up inspection was completed on 10/03/2023. Mr. Kainer explained they are tightening things up by changing who administers and validating the medication. He stated they are having less people involved in this process by assigning someone every shift to administer the medication and staff will no longer verify each other. He stated the case aid will verify morning and lunch and the program director will verify at dinner and on the evening and weekends it will be kitchen staff. By validating, the assigned staff will review the meds prior to being administer and then the assigned administering staff will give the meds. He stated the program director and case manager will also be reviewing the medication cabinet once a week and the case aid will put the med log book together each month and the case manger will verify it. There are signature sheets for the weekly checks and for staff validating the meds. He stated he will also be doing random reviews of the meds and med book each week. He stated this is what they do at the other operation so they are using it and it appears to be working well. He stated they also put a new system in place to help prevent running out of meds. He stated when meds are low right around the 10 day of running out, efforts to get the medication refiled will be documented and if they are still unable to then the last resort will be to take the child to the emergency room.


raw_content: A child in care has not been given two doses of her Clonidine medication.

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

Correction Narrative:
Email from Administrator James Kainer received 08/28/2023.  Stating that the doctor discontinued the medication until she saw her at her appointment. All medications are currently filled with adequate supply. We will continue to have the case aide work with the doctors and pharmacists to ensure prescriptions are filled. The case manager and program director will be doing checks on meds as well. The Case Manager will notify the Administrator if there are difficulties getting the medications filled. We will keep the caseworker informed of the difficulty and ask how they would like to proceed and follow their direction. Per your recommendation and upon caseworker approval, we may include an ER visit as a last resort.
Follow up by inspection was complete on 9/5/23 during HM inspection. No concerns were found.


summary: 748.535(2) - AP Child-care administrator responsibilities- Ensure the operation complies with current heightened monitoring plans, if applicable.

raw_content:
During a review conducted on August 8, 2023 it was determined that:
(1) the Administrator failed to ensure compliance with the current HM Plan; and
(2) 12 months had elapsed since the effective date of the plan.

The heightened monitoring plan for this operation included a specific planned end date at the 12-month mark by which the operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of post plan monitoring.  As a direct result of the administrators failure to ensure timely compliance with the heightened monitoring plan, this operation is now unable to successfully move to post-plan monitoring.  Furthermore, the operations planned end date must now be revised, and the period of heightened monitoring must be extended.

Further details of the administrators failure to ensure compliance include the following:
- Operation failed to satisfy the conditions of the plan

- Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring; and

- Operation was unable to meet compliance with Medium-High or High weighted licensing citations.

Correction Narrative: An HM extension was approved effective 8/8/2023.  In conjunction with this extension, a new deadline was established by which all requirements must be completed by your GRO in order for the operation to be released from its HM plan and move to the Post-plan Monitoring Stage of HM.  Because the extended deadline is now effective, HHSC has determined that the operation is compliant with the requirements of 26 TAC 748.535(2).  The HM deadline for your operation has been extended by 6 months and the new deadline is 02/07/2024.


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

raw_content: Two staff failed to follow the operations policies and procedures. One staff brought into the operation their personal prescribed medication.  The second staff failed to follow policy by allowing children into the kitchen.

Correction Narrative:
Email received from Administrator James Kainer.

After the events surrounding investigation #3015821, Fostering Life Youth Ranch took the following measures:
1.	Changed the door to the kitchen to a dutch door.
2.	Retrained staff Julie on the importance of proper supervision when working with children with trauma.
3.	Sent message to all staff reminding them of policies and procedures regarding personal medications.
4.	Staff Rose was initially suspended and eventually terminated from employment.

During the HM inspection on August 8, 2023 Inspector was able to observe the kitchen door had been modified and and that staff Rose was no longer employed with the operation.


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

raw_content: There were four children in care with medication errors that did not have a full explenation of what the errors were.

Correction Narrative:
The operation submitted corrections via email for the medication administration errors on 5/15/23.
Inspection interview with staff on 5/31/2023, medication administration.


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


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

raw_content: A child in care was administered prescription medications which were prescribed to another child in care.

Correction Narrative:
On May 18, 2023, RCCR received an email from the administrator indicating the involved staff was retrained following the medication administration error and all staff have been provided supplemental training regarding medication administration procedures since the error occurred.  A follow-up inspection will be conducted to review and assess current medication administration practices at the operation.

On May 19, 2023 Inspection 3947606 was conducted.  During the inspection, all current medication logs were reviewed.  A single medication error is documented on May 11, 2023.  This error was cited on May 15, 2023 and the operation provided a compliance plan to the HM Inspector who cited the error.  It will not be recited at this time.  For the error that occurred in December 2022, Compliance is noted as met per this inspection.  The administrator reports the operation will not request admin review for this citation.


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

raw_content: Child received medical attention for an injury to the knee three days prior to child reporting they had slipped and fell in the shower.  The incident, of the child falling in the shower was not documented and medical attention was not provided. Staff failed to use prudent judgement when decided to not document the incident or offer medical attention knowing that the child had received an injury three days prior to reporting the fall.

Correction Narrative:
Administrator submitted corrections via email on 06/01/2023. Stating that staff were reminded to document any injuries reported by the child and seek medical, when necessary, especially if they are previously injured.

5/31/2023 inspection and interview with staff medical attention and prudent judgment.  The staff involved in this incident is no longer employed by the operation.


summary: 748.1531(d) - Medical care-Obtain follow-up medical treatment as recommended by the health-care professional

raw_content: A child in care injured her knee at the operation and was transported to the hospital via ambulance the attending physician provided orders that the child receive a follow up within two days with the child's primary care physician. The operation did not take the child for a follow up appointment.

Correction Narrative:
Email was received from the operation on 05/11/2023 with a sign in sheet for the retraining of staff in regard to medical follow ups.

Inspection interview with staff on 05/15/2023 and 5/31/2023(due to the previous follow up not being documented on the 2936 from 05/15/2023),
aware of process for reporting serious incidents, personal belongings, water safety, medication administration and medical follow ups.


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 in care was injured at the operation and had to be transported to the hospital via ambulance and Licensing was not notified of the child's injury.

Correction Narrative:
Email was received from the operation on 05/11/2023, with a sign in sheet for the retraining of staff in regard to when serious incidents need to report to the Licensing (Statewide Intake Hotline).

Inspection interview with staff on 05/15/2023 and 5/31/2023 (due to the previous follow up not being documented on the 2936 from 05/15/2023),
aware of process for reporting serious incidents, personal belongings, water safety, medication administration and medical follow ups.


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

raw_content: A child in care was injured at the operation and had to be transported to the hospital via ambulance and the managing conservator was not notified of the child's injury.

Correction Narrative:
Email was received from the operation on 5/11/2023, with a sign in sheet for the retraining of staff in regard to when serious incidents need to report to the parent (managing conservator).

Inspection interview with staff on 05/15/2023 and 5/31/2023(due to the previous follow up not being documented on the 2936 from 05/15/2023),
aware of process for reporting serious incidents, personal belongings, water safety, medication administration and medical follow ups.


raw_content:
During a review conducted on 2/6/2023, it was determined that:
(1)	your operations administrator failed to ensure compliance with the current HM Plan(s); and

(2)	more than 12 months had elapsed since the effective date of the plan.

As you know, the heightened monitoring plans for your operation included a specific planned end date at the original 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of post plan monitoring.  As a direct result of the administrators failure to ensure timely compliance with heightened monitoring plans, your operation was unable to successfully move to post-plan monitoring by the original planned end date necessitating previous extension.  Furthermore, due to your recent citation issued on January 20, 2023, your operations planned end date must now be revised again, and the period of heightened monitoring must be extended again.

Further details of the failure of your operations administrator to ensure compliance include the following:
The operation received a High weighted citation in a pattern/trend category on January 20, 2023. Specifically, the operation was cited for 748.685(a)(3) Caregiver responsibility - being aware of and accountable for each child's on-going activity. The operation met compliance on January 30, 2023.
-	Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring; and
-	Operation was unable to meet compliance with Medium-High or High weighted licensing citations.

Finding: 748.535(2)  The licensed administrator must ensure the operation complies with current heightened monitoring plans.

Correction Narrative: An HM extension was approved effective 2/06/2023.  In conjunction with this extension, a new deadline was established by which all requirements must be completed by your GRO in order for the operation to be released from its HM plan and move to the Post-plan Monitoring Stage of HM.  Because the extended deadline is now effective, HHSC has determined that the operation is compliant with the requirements of 26 TAC 748.535(2).  The HM deadline for your operation has been extended by 6 months and the new deadline is 08/07/2023.


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

raw_content: A child in care was intimidated by staff regarding allegations of a previous investigation.  Children in care were offered incentives to provide information to staff regarding activity on the unit.


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

raw_content: The time medication was administered was not documeted for at least two children in care and for several of there medications.

Correction Narrative: Administrator spoke with staff and explained the importance of documenting and administering the correct dosage.


raw_content: A child in care was given a full tablet instead of a half tablet as prescribed by the doctor

Correction Narrative: Administrator spoke with staff and explained the importance of documenting and administering the correct dosage. The operation is also in the process of getting the blister packs for this particular medication to come in the exact half tablet dose to prevent staff from having to cut the tablets in half.


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

raw_content: A child in care was subject to a short personal restraint for throwing a water bottle and hitting staff.  The staff member failed to utilize any form of de-escalation prior to implementing the restraint.  Other staff present noted that de-escalation strategies should have been attempted prior to the restraint.

Correction Narrative: Staff was retrained on EBI, Supervision and Safety Plan.  A copy of the sign in sheet was provided via email.


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

raw_content: A child in care was placed in a short personal restraint in a bedroom, between two wooden beds.  During the restraint, the child complained of not being able to breathe.  After the restraint, the was observed with scratches on her face and bruising on her wrist and was later taken to the doctor for complaints of pain in her chest and arms.


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

raw_content: A caregiver performed a short personal restraint on a child in care as a means to get a child to comply in a non-emergency situation.  The caregiver grabbed the child's arm so that the caregiver could remove photographs from the child's hand.


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

raw_content: A caregiver implemented an emergency behavior intervention on a child in care through a short personal restraint in a non-emergency situation.


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: A child in care was taken into police custody following a motor vehicle accident on October 22, 2022.  The operation did not report the incident until October 24, 2022.

Correction Narrative:
On December 6, 2022 RCCR received an email from the permit holder reporting staff was suspended for 3 days following the incident and upon returning to duty was coached on reporting requirements for staff involved in serious incidents.  A follow-up inspection will be conducted.

On December 14, 2022 follow-up was conducted during inspection 3919458.  An interview with staff confirmed following this incident staff was suspended for 3 days and placed on a 30 day probation.  During the probation period, staff was not permitted to supervise any outings off campus.  Additionally, staff was coached on the operation's key policy and supervision guidelines during outings away from campus.  Staff confirmed understanding of the reporting requirements regarding serious incidents.  Staff was provided with the hotline phone number and website to complete reporting in a timely manner.


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

raw_content: During an outing, staff allowed two children with histories of elopements, to be out of visual range supervision.  Staff were also unaware the children had taken keys to the operation's vehicle.

Correction Narrative:
On December 6, 2022 RCCR received an email from the permit holder reporting staff was suspended for 3 days following the incident and upon returning to duty was coached on proper supervision and the operation's key policy.  A follow-up inspection will be conducted.

On December 14, 2022 follow-up was conducted during inspection 3919458.  An interview with staff confirmed following this incident staff was suspended for 3 days and placed on a 30 day probation.  During the probation period, staff was not permitted to supervise any outings off campus.  Additionally, staff was coached on the operation's key policy and supervision guidelines during outings away from campus.


summary: 748.535(2) - Child-care administrator responsibilities- Ensure the operation complies with current heightened monitoring plans, if applicable.

raw_content:
During a review conducted on August 5, 2022, it was determined that:
(1)	your operations administrator failed to ensure compliance with the current HM Plan(s); and

(2)	more than 12 months had elapsed since the effective date of the plan.

As you know, the heightened monitoring plans for your operation included a specific planned end date at the original 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of post plan monitoring.  As a direct result of the administrators failure to ensure timely compliance with heightened monitoring plans, your operation was unable to successfully move to post-plan monitoring by the original planned end date necessitating previous extension.  Furthermore, due to your recent citation issued on May 18, 2022, your operations planned end date must now be revised again, and the period of heightened monitoring must be extended again.

Further details of the failure of your operations administrator to ensure compliance include the following:
The operation received a medium-high weighted citation in a pattern/trend category on May 18, 2022. Specifically, the operation was cited for 748.2307(8) Other prohibited Punishments. The operation met compliance on June 2, 2022.
-	Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring; and
-	Operation was unable to meet compliance with Medium-High or High weighted licensing citations.

Finding: 748.535(2)  The licensed administrator must ensure the operation complies with current heightened monitoring plans.

Correction Narrative: An HM extension was approved effective 08/05/2022.  In conjunction with this extension, a new deadline was established by which all requirements must be completed by your GRO in order for the operation to be released from its HM plan and move to the Post-plan Monitoring Stage of HM.  Because the extended deadline is now effective, HHSC has determined that the operation is compliant with the requirements of 26 TAC 748.535(2).  The HM deadline for your operation has been extended by 6 months and the new deadline is 02/06/2023.


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

raw_content: A caregiver failed to comply with the operation's tobacco and e-cigarette policy by vaping in an operation owned vehicle when children were not in the vehicle.

Correction Narrative: Per an email from the administrator, all staff were retrained regarding the operation's tobacco and e-cigarette policy and supervision and ratio.  The staff identified as not following policy also participated in a one on one training regarding participation in outings and the operation's tobacco and e-cigarette policy.


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

raw_content: A caregiver yells and uses profanity in the presence of children in care.


raw_content: A caregiver failed to follow the operation's policies and procedures by bringing tobacco products onto the campus and into the facility.

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


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

raw_content: Three children in care accessed and used an e-cigarette lost by an employee in the facility.


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: There were two missed medications. One on 1/8/2022 and one on 1/9/2022.

Correction Narrative: This was followed-up on during HM inspection #3860029.  Medication logs were reviewed with no subsequent medication administration errors.  Additionally, the operation reported that a staff meeting was held on January 20th, 2022 to discuss the medication administration errors and reviewed the medication policy.


raw_content: This standard is being tasked as a follow up to inspection 3854778. There have been 12 different medications given in inproper dosages to children in care according to the instructions on the label. These medications were either not given to children at all or were given in a higher dosage than prescribed.


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


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: A caregiver did not complete a pre-employment drug screening prior to having contact with children in care.

Correction Narrative: During Inspection 3857901 on January 7, 2022, the Administrator and Owner provided a copy of a checklist developed by HR for personnel records.  The checklist will be a cover page retained in the personnel record and staff may not be scheduled on the unit until the checklist is completed.  A copy of the checklist is uploaded to the SharePoint for reference.  Admin Review is waived.


summary: 748.2855(b) - EBI Documentation-Supervisors of caregivers involved in EBI must document review of the intervention within 72 hours of the incident

raw_content: An emergency behavior incident report did not include a documented review by the supervisor  of the incident within 72 hours.

Correction Narrative: Documentation review of the EBI was completed as soon as the EBI form was finally filled out completely. The administrator will review the EBI form within 72 hours even if it is not fully completed by staff within the 24 hour time frame. Document was provided to inspector.


summary: 748.2855(a) - EBI Documentation-Caregiver must document EBI in child's record as soon as possible, but no later than 24 hours after initiation of the intervention

raw_content: Emergency behavior Intervention for a child in care documentation was not fully completed within 24 hours. Missing information includes any injuries the child sustained during the intervention and the action the caregiver took to help the child return to normal activity.

Correction Narrative: Staff was located and was able to fully complete the EBI form.  Copy of the completed documentation was provided to inspector.


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

raw_content: A caregiver pushed a child in care.

Deficiency Narrative: A caregiver pushed a child in care.

Correction Narrative: A caregiver pushed a child in care.


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: Children in care with histories of elopement disassembled a lock and eloped from the facility while unsupervised by caregivers.

Correction Narrative:
Follow-up extended pending due process.  AR requested.

An unannounced follow-up inspection was completed at the operation on 9/23/2021.  A walk through was completed with no concerns.  The administrator reported that the staff have been reminded about the importance of communicating with other staff on the shift to ensure that each child is appropriately supervised, specifically during medication time.  It was reported that the staff, at times, will also take their group of children with them to the hallway outside of the medication room while preparing medications.  The administrator also reported that the case manager is working to ensure that any high risk behaviors identified in the previous six months for the child will be included in their initial service plan.  The administrator reported that caregivers are provided the information from the admission assessment and the initial service plan during their weekly staff meetings.


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

raw_content:
Two Medication Logs were lacking information. The operation failed to document the reason for medication on the medication logs pertaining to prescription medication.

The evidence and supporting photos were issued to the investigator before the initiation of this investigation.


facility_name: Resolution Ranch

raw_content: A serious incident report provided by the operation indicates law enforcement had responded to an incident and licensing was not notified of the incident.

Standard Number / Description: 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.

Correction Narrative:
A discussion was had with the administrator. The administrator admitted forgetting to call licensing. The operation has an appropriate system in place for reporting incidents. The incident involving law enforcement on 05/15/2024 was called in on 10/09/2024 at 2:38pm.
Reference # 79361192


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

raw_content: A serious incident report provided by the operation indicates a child in care attempted suicide and licensing was not notified of the incident.

Correction Narrative:
A discussion was had with the administrator. There was a disagreement about the incident involving a suicide attempt. The definition of suicide attempt was explained. The administrator understood but wanted an administrative review. The operation has an appropriate system for reporting incidents. The incident on 06/03/2024 was called in on 10/09/2024 at 2:38pm.
Reference # 79361272


summary: 748.949(a) - Annual Training Documentation-Keep documentation verifying completion of training in the personnel record

raw_content: During the record review 4 out of 4 staff records did not have certification copies of personnel training. The records did indicate credit hours and the completion of all the trainings completed. The operation has never kept copies of their staff trainings and was unaware they had to do so.

Correction Narrative: Resolution Ranch has added certificates of completion for training classes such as Trauma-Informed Care, Human Development, and Normalcy.  Other type trainings that have an expiration date requirement, Resolution Ranch already issued certificates, cards, and/or a printout of completion proof with details for those trainings.  Moving forward, Resolution Ranch will include a copy of the new certificate of completion inside individual employee folders.


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: During the record review 4 out of 4 children's records did not include the chronic conditions on the exterior of the records or in a clearly visible location.

Correction Narrative: Resolution Ranch does put an indicator label on child record folders and an alert within our client database system for those that have any known allergies and/or chronic conditions. They did not have an indicator on the exterior of the child's record labelled "no known allergies".   Since the inspection, Resolution Ranch has placed a "no known allergies" label on the exterior of all current resident files with no allergies, and they will continue moving forward as well.


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

raw_content: During the walkthrough of the facility an electrical outlet was observed without an outlet cover and the outlet was exposed. In the bathroom a urinal was overflowing and a broken tile was observed on the shower floor.


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

raw_content: During the walkthrough of the operation medication belonging to a staff member was observed unsecured in a weekly pill container inside the staff courters room. The room does have locking door knob but the medications are not schedule 2 according to the staff member.


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: During the inspection 2 out of 4 children records did not have the 30-day medical exam documented.

Correction Narrative: Resolution Ranch has a method in place that helps reduce the chances of residents (in need of their initial physical) not going over 30 days before receiving a physical.  There was a transition from them using one doctor (location) that created obstacles to accomplish timelines, to a facility that has easier scheduling practices that meet their needs.  All residents are up to date at this time, and the plan is to continue this method moving forward.


summary: 748.363(2) - Personnel records-Include documentation showing that the person meets minimum age and qualifications for the position

raw_content: During the record review one staff record was missing the minimum age requirement. Another staff file was missing the qualifications for the job, and the job description.

Correction Narrative: All personnel files have a copy of the employee's driver's license and a copy of their job description.  This was resolved onsite before the inspection was complete. They have also looked through all the employee folders to make sure no other such info was missing from any employee folders.


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: During the record review 3 out of 4 childrens records indicated the children had their TB test over the 30 day period.

Category: Child Care


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: While reviewing personnel records it was found that a staff had not had a TB test.

Correction Narrative: Administrator, Neal Stabb, emailed me a copy of the TB test for Larry Mayo. Compliance is met now.


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

raw_content: The chemicla storage locker was unlocked. It was corrected at inspection.


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

raw_content: It was noted that in multiple interviews a staff did not follow protocol for restraints and things escalated.  While the child in care was not injured, alternative methods should have been used.

Correction Narrative: The staff involved in this incident has not been working at the operation for some time and will not return.


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: It was noted that two children in care had inappropriate contact when interviewed while at the operation.


facility_name: Southall Heritage Youth Home

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: It was found that the operation did not report to Licensing that a child was hospitalized due to illness.

Correction Narrative:
Citation: TAC §748.303(a)(2)(A)
Rule: Serious Incident  Report to Licensing within 24 hours after injury/illness that warrants treatment by a medical professional or hospitalization

Administration reviewed the incident timeline and verified that case manager and guardian notifications were completed. The required SIR documentation was completed to ensure regulatory compliance. Supervisory staff were re-educated on the 24-hour Licensing reporting requirement and the distinction between K-905 and SIR submissions.


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

raw_content: Children in care requires 1:1 supervision and it was confirmed by caseworker and staff that the child does not receive 1:1 supervision on the days the assigned staff is off.

Correction Narrative: An unannounced follow up inspection was conducted on 11/21/2025. Staff interviewed reported they received a training for supervision and 1:1 supervision protocol. Two children in care were interviewed and reported no concerns for supervision. Staff reported they maintain daily shift assignment logs and daily report forms. Staff are aware of the protocol for 1:1 supervision.


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

raw_content: During the course of the investigation, a staff member admitted to using inappropriate language towards a child in care.


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: The operation failed to inactivate a background check for a staff member who has not been employed by the operation for over three months.


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. It was also observed that multiple food items were expired.


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

raw_content: A caregiver with an inactive background check is working with children in care.

Correction Narrative:
The operation provided an email containing a background check for the staff member, who is cleared and eligible as of 03/12/2025. This was confirmed through email and background check verification therefore, compliance has been met.

The operation reported that staff member was removed from the operation upon discovering that the background check had been inactive. The operation reported that, to prevent this from happening again, a background check verification process will be implemented and a centralized log will be maintained to track all background check requests, statuses, and clearance dates. All administrative and human resources personnel are required to complete a training on background check policies and procedures by April 25, 2025.


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

raw_content: A closet door frame in one of the youth's bedrooms had nails exposed and sharp edges exposed from the door frame being broken.

Correction Narrative:
Inspector conducted a walkthrough at the operation and observed the door frame to be repaired and no hazards nor risk to children were noted, and no additional physical site concerns were noted.

Inspector also reviewed the email that the operation provided to their former licensing representative On March 24, 2025, with photo attachments of the repaired door frame.


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: Both fire extinguishers in the operation have not been serviced by a company licesned by the state's fire marshal in about 17 months.

Correction Narrative: Inspector reviewed the operation's compliance plan and evaluated the documents provided.  Inspector conducted a walkthrough of the operation and observed fire extinguishers to be in compliance and serviced as of February 2025, and fire extinguisher gauges indicated that they were not in need of service and all had their pull pins in place.  Inspector obtained training rosters and/or certificates.


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

raw_content: Staff files were not available during inspection.

Correction Narrative: Administrator has put all files in an area where staff can have access to them in case of an emergency or inspection. Administrator has created a selected employer per shift to have access to the files.


facility_name: Finally at Home LLC

raw_content: There was observed a fire drill prefilled for the current month.

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

Correction Narrative:
The following corrections were sent by the administrator:

A document was sent to the Licensing Representative with an updated fire drill log with the correct date the fire drill took place (07/01/2025).


summary: 748.505(b)(5) - Minimum qualifications for employees- Must complete a Pre-Employment Affidavit for Applicants for Employment.

raw_content: During the review of all employees file, it was noted that the required pre-employment affidavit was not present in the files at the time of the inspection.

Correction Narrative: The following documentation of corrections related to this deficiency was provided: All pre-employment affidavits were completed and provided to the Licensing Representative via email.


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 childs medication records reviewed indicated their bedtime medications were administered earlier than bedtime.

Correction Narrative: During this inspection, three child medication records reviewed were true and accurate. Medications are documented to be administered at the appropriate time.


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

raw_content: One prescription medication record was observed without a medication count completed for four consecutive days. Another medication record showed a med count of 10 pills. When the medication was observed, 12 pills were remaining.

Correction Narrative: Medication documentation reviewed and medication count completed. Compliance was met.


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

raw_content: One prescription medication was observed as the child recieving 1 capsule per day, however, the prescription required the child take 2 capsules per day. This occurred for three days. Another prescription medication observed had one day in which 1 capsule was given instead of the prescribed 2.


facility_name: Our Home House LLC

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

raw_content: 3 of 3 files didn't have completed reference checks.

Correction Narrative: As per the operation's Case Manager, the required references were completed for the employees in question and provided for review. As per the Case Manager, the operation will ensure that the required references are completed for all incoming employees and added to their file.


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

raw_content: 3 of 3 employee files did not have a pre-employment affidavit.

Correction Narrative: As per the operation's Case Manager, Form 2912 were completed for the employees in question and provided for review. As per the Case Manager, the operation will ensure that Form 2912 is used for all incoming employees and added to their file.


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: All of the children's records reviewed did not indicate if the children had allergies and chronic conditions in a clearly visible location of the record.


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

raw_content: It was determined no monthly inspections were conducted on 3 out of 3 fire extinguishers.

Category: Safety and Emergency Practices

Correction Narrative: Staff was trained on 07/26/2025 on proper ways to inspect a fire extinguished. Staff created a monthly checklist to ensure staff checks the fire extinguisher during their walkthrough of the operation. Staff will also conduct a quarterly audit to ensure the form is properly filled out and completed correctly.


facility_name: Radiant Springs Residential Treatment Center LLC

summary: 748.303(a)(4)(B) - Serious Incident-Report to parents immediately after ensuring the safety of the child.

raw_content: The operation failed to report a serious incident to a child's managing conservator as required.

Correction Narrative: The following corrective action was emailed by the operation: Radiant Springs RTC updates caseworkers regarding a child's behaviors, incidents, performance in school, medical, etc. so that we could collaborate on the needed care and what is best for a child.


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

raw_content: A staff member reported using profanity while intervening in a physical altercation between two children in care.

Correction Narrative:
The operation emailed the following corrective action: The employee involved is no longer employed at the operation. Monthly staff trainings are held to ensure professionalism is maintained at the operation.
An in-person follow-up was conducted on 03/26/26. Children in care were interviewed regarding staff's behavior and language; there were no outcries of abuse or neglect.


raw_content: During the investigation, it was determined the operation did not maintain true and accurate records as an incident report was written but the operation was not able to provide documentation of it.

Correction Narrative: Administration (e.g. LCCA, Caseworker, Administrative Assistant), will ensure these plans are carried out, along with Direct Care Staff. Radiant Springs RTC ensures true and accurate records by real-time documentation, standardized training, regular auditing, and training staff on proper documentation practices.


summary: 748.3237(c) - Safety Practices-Children must be able to open emergency exit doors easily from inside, unless written approval on file from fire inspector

raw_content: During the investigation it was determined the operation locks the front and back doors of the house from the inside with a key.

Correction Narrative: Radiant Spring RTC will ensure children are able to have access from the inside in case there is an emergency as Radiant Springs RTC will only use bottom lock.


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

raw_content: During the investigation it was determined that a child in care was utilizing eyesight glasses not in good repair for more than 30 days since being placed at the operation.

Correction Narrative: When a child comes into our facility with fractured glasses or any other devices that are presented as non-functional, Radiant Springs RTC will make sure these things are working properly. We will not wait on Insurance to cover the expenses. Child has also received new glasses that are operable at Radiant Springs RTC expense.


raw_content: A child was admitted into the mental health hospital for suicidal ideations. The legal parent was not notified of the hospitalization.

Standard Number / Description: 748.303(a)(4)(B) - Serious Incident-Report to parents immediately after ensuring the safety of the child.

Correction Narrative: Email received stating: In order to avoid this from occurring again, a plan has been implemented. Caseworker will notify the child's guardian via Email, phone call, and text. Failure to do so will result in immediate disciplinary action which could result in termination.


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

raw_content: The operation was not able to provide the serious incident reports for the last 90 days.


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

raw_content: It was determine a staff member departed the operation on 07/31/0225 and is still listed as a controlling person.

Correction Narrative: The operation removed staff on 08/11/2025 via the providers portal. The operation will remove any staff immediately once the staff departs the operation. The operation will also conduct monthly audits to ensure all controlling persons information is correct and accurate.


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

raw_content: Staff files were not available at the time of the inspection.

Correction Narrative: The operations will ensure the key is always available by putting the key in a lock box in the living room area so all staff can provide the records. The operation will also make sure all staff know where to locate all files required at the time of the inspection.


facility_name: Clairefontaine Care Center LLC

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

raw_content: The operation failed to meet the children's basic needs due to nonpayment of utility services.

Correction Narrative:
Email received from the operation with Corrective action plan.
In response the operation indicated that the operation's gas account became inactive due to missed payment. The account had been set up on automatic payment, and the credit card on file had expired.
Corrective action: The outstanding bill was paid in full and service was restored on 3/9/2026.  The operation has updated the account with a current credit card and added secondary payment method. Plan will be that the administrator will review utility account statements monthly, a calendar reminder was established to monitor payments and utility service monitoring checklist will be maintained. The Facility Administrator will monitor utility accounts monthly and will keep documentation of payments and service status. Any interruption in utility services will be reported immediately and corrected without delay.


summary: 748.3161(a) - Heating Devices-Gas appliances must be safe and in good repair

raw_content: During the investigation inspection, it was found that the gas is not working.


raw_content: Several requested documents were not provided by the operation.

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

Correction Narrative:
Email with the corrective plan from the agency.
The operation implemented corrective action was taken.  All files were reviewed, organized, updated and consolidated into a centralized filing system.  Internal audit was conducted to ensure compliance.  Preventive actions-develop and implementation of records management policy, implementation of a weekly records audit checklist and train staff on recordkeeping expectations, assign primary and backup staff member to maintain record accessibility at all times.  Transition to electronic record keeping system.
If compliance is not met or deficiencies are identified in the future: immediate corrective action will be taken within 24 hours to update files. Additional staff retraining will be conducted within 3 business day.  Follow up audit with 5 business for verification. Repeated noncompliance will result in disciplinary action, up to and including reassignment or termination.
Responsible personnel: program director/Administrator, Records coordination and Assistant director.


Correction Narrative:
An administrative penalty will be recommended as a result of this citation, per HRC §42.078 and technical assistance will be provided to the operation.

Upon review of two medication administration logs, it was determined that medications were not dispensed in accordance with the documented instructions,

The operation will have a nurse come in once a month to train staff regarding medication administration. The operation will implement policy change regarding medication administration for staff. All employee are expected to sign the update policy. Policy includes a write up if staff fail to follow policy. Staff and administrator will mplement a two person audit system to review medication logs to ensure on going compliance.


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

Correction Narrative:
Medication log for two youth had no documentation regarding the medication error.

The operation will have a nurse come in once a month to train staff regarding medication administration. The operation will implement policy change regarding medication administration for staff. All employee are expected to sign the update policy. Policy includes a write up if staff fail to follow policy. Staff and administrator will mplement a two person audit system to review medication logs to ensure on going compliance.


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

raw_content: During the walk through the operation, in the downstairs bedroom was a hole in the wall, in the upstairs bedroom the light in the bedroom was not working and there  a hole in the wall of the other bedroom.


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: The two staff files were missing the reference verification.

Correction Narrative: The operation emailed the corrective plan.   The program director has reviewed the standard and discussed it with Admin.  The required information will be recorded in file to ensure compliance.


summary: 748.455(c) - Unauthorized Absence-debriefing must be documented in childs record, including routine activity that would be inappt for child to return to and why

raw_content: Unauthorization log did not include the de- briefing documentation


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

raw_content: The two employee files reviewed had no employment verification documentation.


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: A bunk bed in one of the bedrooms is broken with sharp wood exposed.

Correction Narrative: Bunk bed was observed to be repaired.


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

raw_content: It was alleged that the therapist/administrator was making inappropriate remarks to a child in care.


raw_content: Staff made inappropriate comments to a child in care in the presence of other children, demonstrating a failure to exercise prudent judgment.


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

raw_content: The two staff files that were reviewed were incomplete and has some of the required documents missing.   Missing documents included; application, drug tests, operations policy acknowledgments.

Correction Narrative:
Email from the operations was received with the corrective plan.
The Program Director reviewed these standard numbers with the administrative team and discussed the importance of making sure that files are to be completed prior to their start date for each employee with Clairefontaine Care Center. All files are to be audited on a weekly basis to ensure that revised or updated documents are signed right away.


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

raw_content: During the inspection, it was observed that the medication was not double locked, as the cabinet was unlocked. The keys for the medication cabinet were found


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

raw_content: Staff member admitted to sleeping during his shift.

Correction Narrative:
The agency provided corrective plan for citation.
Each staff member will be trained in policy and procedures during the onboarding process and every week after that, with it being started on April 1, 2025.  Program director reviewed the standards at training with all staff member during meeting. Training was provided to ensure the importance of supervision while caring for children in care.  Program director will oversee that all staff are trained.  If staff are unable to provide the supervision, the director will move to take staff off schedule or termination.


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

raw_content: Staff failed to intervene when youth were involved in a physical altercation.


raw_content: The personal file had some required documents. Missing document included the Job description, Orientation, the Notarized Licensing Affidavit for Application for Employment, the statement signed and dated by the employee regarding reporting suspected child abuse/neglect.  and documentation showing the date of emplyment.

Correction Narrative: Corrective action plan from the opera will etion. Action plan- The CCC will ensure all required documents be collected prior to the employee's first active day on duty during the pre-employment process. Personal files will be completed prior to employee's start date but no later than 24 hours after first active day. LCCA will ensure all personal files are completed within 24 hours of an employee being active and on duty. The LCCA and Program Director will work in tandem to ensure this is not a reoccurring issue.


summary: 748.125(c)(2) - Suicide Training-You must promote suicide prevention training for non-employees, as appropriate.

raw_content: Policy does not indicate how suicide prevention training for non-employees will be promoted.

Correction Narrative:
11/15/2024  the agency emailed the corrective action/Administrative review.
The operation will require all caregiver and employees to complete the required training.


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

raw_content:
The designated location outside the operation was not included in the diagram.

The diagram was updated at the time of the inspection as the correction.


facility_name: Royal Heritage RTC, LLC

summary: 748.941(d) - Training Criteria-A health-care professional or a pharmacist must lead the training in administering psychotropic medication.

raw_content: Psychotropic medication trainings were not provided by a health-care professional.

Correction Narrative:
Corrections submitted via email 11/24/25:
Admin reviewed all prior psychotropic medication administration trainings conducted in the last 4 months to identify any trainings that were not led by a qualified health-care professional or pharmacist.  All psychotropic trainings are completed, updated and filed as of 11/21/2025. Refreshers have been scheduled for 12/21/2025, all future trainings will follow the updated policy.


summary: 748.505(b)(5) - Minimum qualifications for employees- Must complete a Pre-Employment Affidavit for Applicants for Employment.

raw_content: Three employee files reviewed did not have Form 2912 completed.

Correction Narrative: Admin reviewed all current employee personnel files to identify missing Form 2912. The required Pre-Employment Affidavit (Form 2912) documents were printed the same day the issue was identified. Each staff member that did have form completed and signed Form 2912 at the beginning of their next shift. All personnel files were updated immediately upon receipt of the signed forms, and a note of correction was placed in the Staff File Audit Log. All current staff files have been corrected as of 11/20/2025 and monthly audits are in place to ensure Form 2912 is consistently obtained. Form 2912 has also been placed in the new hire check list.


summary: 748.861(b)(3) - Pre-Service Training - Supervised experience must be documented in personnel record

raw_content: The training logs for two staff members were received and reviewed. Both training logs reviewed stated that the employees did not require 40 hours of supervision prior to being counted in ratio. Documentation of this supervised child-care experience was not provided.

Correction Narrative: Staff will not be allowed to provide care until they receive the required trainings and Admin has ensured the individual has the supervised experience required prior to providing care to children. Admin will efficiently review staff employment history to ensure they are experienced to care for children. Supervised experience will be documented in the staff file.


summary: 748.869(d)(1) - Pre-service Training- EBI training must be instructor led, instructor must be certified in recognized method of EBI.

raw_content: The owner of the operation was listed as an instructor of EBI training for a staff member. The owner failed to provide documentation on how he meets the requirements to train this subject matter.

Correction Narrative: Professional trainer was brought in for refresher EBI training for the staff. EBI trainings will be provided frequently to ensure staff are comfortable with EBI procedures and able to provide if needed. Trainings will be documented in staff files.


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

raw_content: Staff members at Royal Heritage RTC failed to adequately supervise a child in care while the child was on the roof of the operation, in addition the child was left alone on the roof.


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

raw_content: Operation did not submit staff trainings for investigation purposes.

Correction Narrative: Corrections submitted via email 12/28/25: Administrator Will create a check list for each investigator and ensure all requested documents are sent within 24 hours after such request is made. Administrator will also cc the owner of the facility in the email so he can keep track and ensure the task has been completed.


raw_content: Staff file reviewed did not have all the required documentation in the required time frame.

Correction Narrative:
Admin will Conduct a comprehensive audit of all records within 10 business days to ensure all documents are accurate, signed, dated, and current. Missing or outdated forms will be corrected immediately.
Training Admin will also provide training for all administrative and direct care staff on documentation standards, including how to maintain current, true, accurate, and complete records. Training to be completed within 14 days.

Incoming staff will not start employment until employee file is completed with mandatory orientation, pre-service training, and required documents based on minimum standards. Admin will establish a monthly internal audit system to ensure continuous compliance. Results will be reviewed during staff meetings and corrective steps documented.

The Administrator or designee will review audit summaries quarterly to verify compliance and address any recurring deficiencies.


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

raw_content: Fire inspection was not completed by the expiration date.

Correction Narrative:
Physical inspection at operation conducted. Spoke with Administrator, stated inspection had been completed by Fort Bend Conty Fire Marshall. Next years calendar has been marked as a reminder to have the annual inspection completed.

Fort Bend County Fire Marshall conducted an inspection at the operation 9/25/25. Operation passed.

Immediate Action Taken
-	Completed the overdue initial service plan(s) immediately upon discovery.
-	Notified case managers and treatment director of the deficiency and standard requirements.
-	Reviewed the current caseload to ensure no other service plans are overdue.

 Systemic Prevention Measures
-	Implement a service plan tracking on the agency's spreadsheet that automatically calculates due dates (40 days from admission) and alerts staff 10 days before the deadline.
-	Conduct refresher training for the case manager, treatment director, and supervisor on service planning requirements, including timelines and documentation standards.
-	Program Director/Administrator will conduct monthly audits of case files to verify service plan compliance.

 Person Responsible
-	Treatment Director will monitor service plan deadlines and ensure timely completion.
-	Program Director/Administrator oversees compliance, conducts monthly audits, and ensures staff accountability.


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

raw_content: Two child files did not have completed service plans within the 45 day time frame.

Correction Narrative:
Immediate Action Taken
-	Completed the overdue initial service plan(s) immediately upon discovery.
-	Notified case managers and treatment director of the deficiency and standard requirements.
-	Reviewed the current caseload to ensure no other service plans are overdue.

 Systemic Prevention Measures
-	Implement a service plan tracking on the agency's spreadsheet that automatically calculates due dates (40 days from admission) and alerts staff 10 days before the deadline.
-	Conduct refresher training for the case manager, treatment director, and supervisor on service planning requirements, including timelines and documentation standards.
-	Program Director/Administrator will conduct monthly audits of case files to verify service plan compliance.

 Person Responsible
-	Treatment Director will monitor service plan deadlines and ensure timely completion.
-	Program Director/Administrator oversees compliance, conducts monthly audits, and ensures staff accountability.


raw_content: Caregivers failed to provide adequate supervision resulting in inappropriate behaviors amongst youth in care.

Correction Narrative:
unannounced physical follow up conducted 9/2/25. Discussion with administrator revealed that several "reminder" posters have been placed at the operation in an effort to ensure calls are made to hot line when required and documentation is completed in a timely manner. Administrator also submitted documentation that trainings that were submitted as part of the corrections were in fact completed.

Corrective action plan submitted 8/11/25. Review current supervision policies and procedures to ensure they are comprehensive and clear. Update policies to address any gaps or weaknesses identified during the assessment. Communicate policy updates to all staff members and ensure they understand the expectations. Conduct an immediate assessment to identify specific instances where supervision was inadequate. Document the circumstances, including the date, time, location, and the children involved and discuss individually with the staff.
Schedule mandatory training sessions for all direct care staff on the importance of supervision, covering both auditory and visual awareness.
Implement training that will include real-life scenarios, best practices, and the consequences of inadequate supervision. Provide information on each child's development stages to help direct care staff understand appropriate age supervision levels. Designate lead staff to conduct regular and random checks to ensure compliance with supervision based on policy and minimum standards. Use checklists and performance forms to systematically document supervision practices. Provide feedback to direct care staff based on observations and identify areas for improvement.


summary: 748.2051(2) - Medication Self-Administration-Self-medication program must be in the child's service plan & include requirements for caregiver supervision

raw_content: Child was allowed to self-administer medication by staff. Childs service plan did not state child was allowed to self-administer medications.

Correction Narrative:
unannounced physical follow up conducted 9/2/25. Discussion with administrator revealed that several "reminder" posters have been placed at the operation in an effort to ensure calls are made to hot line when required and documentation is completed in a timely manner. Administrator also submitted documentation that trainings that were submitted as part of the corrections were in fact completed.

Corrective action plan submitted 8/11/25. Immediate documentation in the child's service plan when a self-medication program is authorized. -Provide training for all caregivers and management staff: How to document self-medication in the child's service plan. How to record and follow caregiver supervision requirements.
The importance of consistent monitoring to ensure child safety and compliance. -	Implement a monthly audit of all service plans for children in the self-medication program to ensure: The program is documented in the service plan. Supervision requirements are clearly stated and followed. Designate the Program Director or Case Manager to conduct and document these reviews. Any noncompliance identified in audits will result in immediate corrective feedback for responsible staff.
Repeat violations will be addressed through additional training, disciplinary measures, or separation as appropriate.


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

raw_content: Youth in care admitted to possession and use of a tobacco e-cigarette at the operation.

Correction Narrative: The operation conducted refresher trainings to reinforce its tobacco policy. An interview with a youth in care confirmed that the risk has been mitigated, as no tobacco products have been present in the home and neither the youth nor anyone else has had possession of one.


raw_content: Child was able to utilize an e-cigarette at operation and staff was unaware.

Correction Narrative: The operation has held a refresher training for staff regarding supervisoin as well as incident reporting. Child interviewed states supervisioin is adequate.


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: Youth care worker transported children in care with a Provisional background. Conditions stated worker was not allowed to transport children in care.

Correction Narrative:
Physical follow up conducted 9/2/25. Tracking system was in fact implemented and staff were provided supervision training.

Corrections submitted via email:
All CBCU eligibility determinations (provisional or with conditions) will be reviewed by the Administrator upon receipt. A tracking system will be implemented to log CBCU determinations, with notations on any restrictions.
Supervisors will receive mandatory training on interpreting and enforcing CBCU conditions and how to ensure compliance in staff scheduling and assignments. A checklist will be developed and used before an employee is scheduled to ensure their duties align with their CBCU status.