raw_content: A child in care was improperly restrained.

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

Correction Narrative: A phone call was held with the operation's Administrator, following an email received on 8/22/21 with the corrective action. The corrective action entailed that staff are to be trained on the areas of concern, where they are deficient. Additionally, the operation will be given a refresher course on reporting to be sure they are operating within the guidelines of the minimum standards to prevent posing risks to children in care.


state: TX

facility_name: DePelchin Children's Center-Richmond Campus

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

raw_content: A child in care was improperly Restrained

Category: Individual Standards Evaluated

Standard Risk Level: Medium High

Corrected at Inspection: No


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

raw_content: Children in care were sleeping in the gymnasium due to construction at the operation. Licensing was not aware.

Standard Risk Level: Medium Low


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

raw_content: During the walk through it was observed that 7 mattresses were missing mattress covers at the operation.

Standard Risk Level: Medium

Correction Narrative:
7/6/21-TCT the operation and email to the operation for corrections for this follow up, requesting copies of the receipts for the bedding mattress covers/correction plans. -LG
I received a response from the LCCA, Darien Phillips: This information has been corrected and we will continue to monitor the situation. The children complain that the mattress covers are hot and uncomfortable. We have placed a requisition in to upgrade mattresses but until then we have allocated shifts and personnel to be responsible for ensuring the mattress covers are replaced when need. -LG


facility_name: Turning Point Children's Social Service

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

raw_content: During the inspection of the operations vehicle, the windshield was observed to be cracked across the passenger side to the driver side.

Category: Transportation

Correction Narrative:
The operation provided a picture of the fixed windshield on the car in question.

The operation implemented the following plan moving forwards:

In response to the citation for stadard  748.4083(a) , the following action plan has been implemented

The Windshield on the Vehicle has been replaced, please see the attached photo

Going forward the vehicles used to transport children will be a part of the daily walk trough of the facility to ensure that they remain in compliance with minimum standards, please let us know if you have any questions


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

raw_content: The operation failed to report to licensing within the required timeframe.

Correction Narrative: The operation stated they will ensure Serious Incident reports are reported to Licensing no later than 24 hours. The operation stated the Program Administrator/Designated Administrative or Management Personnel will complete daily reviews of all SIR's received and ensure all required documentation and reporting has been completed within the required timeframes.


summary: 748.3471 - Safety Requirements-Outdoor equipment & supplies at the operation must be safe for the children

raw_content: A broken bench was observed in the backyard. Still water was observed in a kitty pool and in a pot in the backyard.

Standard Risk Level: High

Correction Narrative: The following response was provided by the operation: An observed broken bench has been discarded.   Observed standing water (in the kitty pool and in a pot in the backyard) has been emptied.  Going forward, administration will ensure the campus supervisors perform a daily campus walk-thru to ensure outdoor equipment is in good repair and that there is no water being collected hazardously.


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

raw_content: Multiple food items were expired and not properly stored, as frozen foods were open and freezer burn was present.

Corrected at Inspection: Yes


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

raw_content: Multiple drawers were observed to be broken.  A drawer was broken in one of the downstairs bathrooms. A hole was observed in the therapy room. A bunk bed was observed to be broken and missing a ladder. Broken blinds were observed in the downstairs bathroom.

Correction Narrative:
The following plan was provided by the operation: All broken drawers have secured, and the hole observed in the therapy room has been repaired.  The bunkbed observed as broken has been attended to and is in good repair; the ladder has been replaced, and the broken blind has been replaced.
To ensure closer attention to broken items, the administrator and shift supervisors will complete a daily walk-thru procedure, noting any damage and recording observed times into a maintenance log.  Items noted in the maintenance log will be attended to for repair as immediately as possible but withing 24 hours.


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

raw_content: A child's Individual Service Plan was not being following as directed, with regards to Supervision.


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

raw_content: A caregiver responsible for one to one supervision of a child failed to notice when the child entered another child's room on two separate occasions.


raw_content: Caregivers failed to ensure that the supervision level in a child's service plan was followed.

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

Correction Narrative: The administrator reports via email that the service plans will be reviewed on a quarterly basis during the child's service plan review meeting.  Monthly staff meetings will be conducted to ensure that all caregivers are aware of any supervision changes.


summary: 748.911(c)(1) - Each caregiver must be certified in first aid within 90 days of employment.

raw_content: One out of three employee files reviewed did not take their required CPR/First Aid training within 90 days of their hire date.

Category: Training and Professional Development

Correction Narrative: An email was received from the operation which included a copy of the training certificate for an employee to indicate the missing training had been completed.


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: Multiple youth reported they were forced to hold a physical position while in timeout as a form of discipline.

Correction Narrative:
On 7/25/25 an unannounced inspection (#4067611) was conducted. Interviews were conducted with multiple staff and children in care no concerns were noted.

CORRECTIVE ACTION PLAN:
The particular staff member named, and all other caregiver staff members will attend a refresher course on "Appropriate Discipline" by July 31, 2025. All staff will pass a post-test to ensure they have knowledge of allowable and prohibited discipline techniques.


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: A child in care developed several medical conditions while in care.

Correction Narrative: Corrected by victim being observed. Administrator also indicated they ensured youth went to doctor and obtained medical treatment after the discovery.


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

raw_content: One of three staff records reviewed employment affidavit was not notorized.

Category: Reports and Record Keeping

Correction Narrative: Corrected by affidavit for employee observed to be notarized.


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: One out of three employee files reviewed contained an outdated CPR training verification to suggest the training has not been renewed timely.

Correction Narrative:
An email was received on February 3, 2025 from the employee who has an outdated CPR/First aid training renewal which included a receipt of payment for the renewal class scheduled to be taken on February 19, 2025.
An email was received which included verification the employee's CPR renewal training had been completed on Feb. 10, 2025.


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

raw_content: A staff member put their hand around a child's neck as a means to get the child to comply, obstructing the child's breathing and resulting in injury.

Correction Narrative: Corrected by a corrective action  plan being provided regarding the operation's plan in regard to this citation moving forward.


summary: 748.1351 - Initial Service Plan-Implement & follow plan as soon as all team members have reviewed/signed it, but no later than 15 days after date of meeting

raw_content: The child's service plan is not being followed pertaining to supervision.


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

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

Correction Narrative: Corrected by employee no longer working at the operation.


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

Deficiency Narrative: One out of three employee files reviewed contained an outdated CPR training verification to suggest the training has not been renewed timely.


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

raw_content: Agency has not reported the EBI data for third quarter of 2024 as of assessment date.

Correction Narrative: A review of the operation's annual EBI data report was reviewed and observed to be up to date.


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

raw_content: Medication which expired July 2024 was not discarded on or before expiration date.

Correction Narrative: Corrected by medication and expiration dates being observed to be compliant.


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

raw_content: Review of one child record found youth did not participate in the service plan meeting, and there was no documentation of justification for no participation.

Category: Admission, Service Planning, Discharge

Standard Risk Level: Low

Correction Narrative: An email was received from the operation which included a corrective action plan indicating the Treatment Director will be responsible for ensuring the youth participate in their service plan meetings and document a reason on the service plan if the youth is unable to attend.


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

raw_content: There was no documentation that child's rights were explained to child within 7 days of placement in two of the children records.

Category: Children's Rights

Correction Narrative: An email was received from the operation which included a corrective action plan indicating intake personnel will ensure child's rights are reviewed with new youth placed at the operation. It also indicated a monthly audit of all resident records will be completed to ensure they're in compliance.


raw_content: Agency has not reported the EBI data for third quarter of 2024 as of inspection date.

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

Category: Emergency Behavior Intervention


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

raw_content: It was observed that fire inspection expired on 11/01/24.

Correction Narrative: An email was received from the operation which included a corrective action plan indicating the operation will maintain a spreadsheet to keep track of all inspection due dates and will review it monthly to ensure due dates are not missed. A receipt of payment for the annual fire inspection was also provided.


summary: 748.161(b) - Fiscal requirements - Maintain complete financial records that comply with Generally Accepted Accounting Principles

raw_content: Per conversation with the administrator, the agency does not maintain financial records for 2023 that comply with Generally Accepted Accounting Principles.

Category: Organization and Administration

Correction Narrative: An email was received from the operation which included a corrective action plan indicating management personnel will obtain a copy of the operation's financial statements from their Certified Public Accountant quarterly to maintain at the operation for Licensing to review upon request.


summary: 748.930(b)(1)(A) - Annual Training-Caregivers in operations other than cottage homes must have 4 hrs of EBI every 6 months.

raw_content: Review of two staff records revealed that the caregivers did not receive the required 4 hours of EBI training every 6 months.

Correction Narrative: An email was received from the operation which included a corrective action plan indicating all employees are up to date on their EBI training. It also indicated the compliance manager has created a spreadsheet to keep track of all employees' trainings and will review it monthly with each employee to ensure they are completing trainings timely. The training certificates verifying completion was also provided for the employees missing it.


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

raw_content: Review of 2 children records found PLSP did not date the prliminary service plan; initial service plan; and/or service plan review.

Correction Narrative: An email was received from the operation which included a corrective action plan indicating the newly hired Program Director will be responsible for ensuring all relevant treatment team members sign the youth's service plans accordingly.


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

raw_content: A volunteer to the operation does not have a background check completed by the operation.

Correction Narrative: Corrected.


summary: 748.3353(b)(1) - Monitoring Devices-Parent, or other person legally authorized to consent, must consent to the use of the video camera

raw_content: Observed during walkthrough a camera in children bedroom.


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

raw_content: A serious incident report requested from the operation was not provided for an investigation.

Correction Narrative: During the exit interview with the administrator via a phone call, the administrator stated she will be responsible for following up with their designee to ensure all requested documentation is provided.


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

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

Correction Narrative:
An email was received on 8/13/24 from the operation's administrator. The email included a letter written to send to all legal parents of the current youth in care. In the letter it was indicated the employee involved was terminated, the operation has updated their training curriculum, and they have increased management oversight of the operation to ensure the nature of the incident doesn't occur again.

On 8/15/24, current youth in care at the operation were interviewed and determined the reason for the deficiency is no longer occurring.


raw_content: A child in care was slapped by a caregiver in the face which caused a bruise.

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


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: It was found that a staff was not inactivated that is no longer working at the facility.

Correction Narrative: The operation sent in the following corrections by email:Turning Point will ensure that staff not associated with Facility are removed from Background checks 7 days after their last day of employment.  This task will be reviewed by Compliance and followed up by Administrator the last of employment, to ensure the background check has been removed from the system.


summary: 748.3395(b)(3) - Hand-washing-Provide hand-washing sinks with hot & cold running water under sufficient pressure to meet the demands of children

raw_content: One of the bathrooms does not have sufficient water pressure.

Category: Physical Site

Correction Narrative: The facility sent the following corrections by email:Turning Point will ensure that during the daily Facility walkthrough, water pressure throughout the house will be checked.  Any issues with water pressure will be written up and given to maintenance for repair.


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

raw_content: The operations Recreational Calendar does not contain daily indoor and outdoor activities.

Category: Recreation Activities

Correction Narrative: The operation sent the following by email:Turning Point will ensure that the Recreational Calendar contains daily indoor and outdoor activities.  PLSP has added task to Calendar, and it will be discussed in daily staffing to ensure that Calendar is completed prior to the month due. The operation also sent in an corrected calendar


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

raw_content: Dark colored growth was found on a ceiling of a child's bathroom.


summary: 748.2151(c)(1) - Medication record - must include child's full name

raw_content: It was found that a medication log was missing a child's name .

Category: Medication


summary: 748.2151(f) - Medication record-must include identification or prohibited prescription medication, non-prescription medication, or supplements for the child

raw_content: It was found on child medication logs no information regarding contraindications or side effects.


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

raw_content: It was found during the inspection that there was trash and broken furniture in the backyard accessible to children in care.


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: It was observed that 3 out of 4 child records reviewed the child's allergy and chronic conditions or "no known allergies" was not listed on the exterior of the record.


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

raw_content: It was found during inspection that the operation did not have an accepted physical or electronic cumulative medication log record and the name of the person and signature administering the medication or if the child refused. There was also a repetitive time for each of the dosages.


summary: 748.2705(4) - Mechanical Restraints Prohibited-Long ties, such as leashes

raw_content: The operation used a harness as a mechanical restraint on a child in care with runaway behaviors.  The use of mechanical restraint is not listed as approved for use on the operation permit.


summary: HRC42.048(b) - AP Restrictions on the License (Type of Children, Age Range)

raw_content: The operation has a child in care that requires treatment services that the operation is not permitted to provide.   The operation is providing treatment services not authorized by the permit.


summary: 748.3351(4) - Interior Space-provide bedrooms with at least one window with outside exposure to natural light

raw_content: One bedroom occupied by a youth in care does not have a window.

Correction Narrative: A team inspection of the home and outside physical site was completed at the facility by Licensing Inspectors, Carla McGowen, Carolyn Washington and Veronica Martinez. There were no children occupying the upstairs bedroom.


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

raw_content: Investigator reported several unsuccessful attempts to make contact with Administrator.

Correction Narrative: Turning Point Children's Social Service will ensure that Administrator's is always available to speak with Licensing staff.  Administrator will be responsible for this task.


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

raw_content: During the monitoring inspection: The name on the staff list was incorrect. The contract staff binder contained information from another operation other than Turning Point.

Correction Narrative: Turning point was able to provide accurate documentation proving that they the Staff list has been corrected and all members prove to pass the background check.


summary: 748.3441(c) - Food Preparation-Must keep furniture, equipment, surfaces & other areas where food is prepared, eaten or stored clean & in good repair

raw_content: During the inspection, there was a missing face plate/cover, which was located at the bottom of the kitchen freezer. There was a small opening with minor wiring exposed.

Correction Narrative: Turning Point sent a photo showing the exposed wiring had been covered on the back of the refrigerator as a correction.


facility_name: Embracing Destiny Foundation GRO

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

raw_content: 6 children's files reviewed were not accurate as they did not have required documentation as far as 2403.

Correction Narrative: It was discussed that after December 6, 2024 the Form 2403 is no longer needed to document Medical, Dental, and Behavioral Health visits. Embracing Destiny has opted to continue to use the Form 2403 as documentation that the visit has been done and they agreed to complete the form in its entirety.


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

raw_content: There were no staff initials documented in the Medication Administration Record.

Correction Narrative:
A corrective action plan was created and effective immediately, the supervisor on shift will ensure that all required signatures and initials are documented in the Medication Administration Record. The MARs will be checked daily following the administration of the medications to the children.
These will be checked for each shift and staff who administers and records each time the medication is given to the clients.
If for some reason the supervisor is unable to perform this duty, the facility manger will be next in line to review these documents to ensure all required signatures and initials are in place.


summary: 748.1337(b)(1)(A)(iii) - Initial Service Plan-Include intellectual functioning, including any testing and plans for recommended follow-up

raw_content: Two of six child files reviewed did not have documentation to support the implementation of the CANS Assessment recommendation.

Correction Narrative: It was discussed that referrals to the Developmental Disability Specialist must be made if this is a recommendation on the child's CANS Assessment. The operation agreed to include a copy of the email requesting that the referral be completed as well as a copy of the referral will be filed in the child's record.


raw_content: 4 staff files reviewed did not have current trainings. 5 children's files reviewed did not have required documentation.

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

Correction Narrative: It was discussed that anytime Embracing Destiny GRO staff is having issues with logging into the portal to complete the DFPS required trainings or to print out training certificates with a date on them, that individual should email or call IT as follow up to show that you are attempting to resolve this issue. The email or documentation of the phone call made to IT should be saved and filed accordingly in the staff records, as well as you can also escalate the IT ticket to your RCM while the issue is being resolved.


summary: 748.2461(b)(1) - Short Personal Restraint-Caregiver may not use a prone or supine restraint

raw_content: The restraint conducted was taken to the ground.

Correction Narrative:
The agency sent, "implemented immediately, no resident will be placed in a prone or supine restraint at any time. Containment positions used by Embracing Destiny will be the Hug containment/Escort and assist to ground from Elbow-to Hip containment. The agency was asked to clarify how this will be implemented or had been implemented since being cited. to complete the compliance.
5.24.24-"They will receive this training twice a year."


summary: 748.930(b)(4) - Annual Training- Caregivers must have 2 hours transportation safety training if caring for children younger than 9 yrs old.

raw_content: A review of the file of a staff authorized to transport children showed that the staff only had 0.15 hours of transportation training.

Correction Narrative:
Training on transportation were updated for all staff in both RTC and GRO.
Certificates as well as the training attendance are uploaded in Sharepoint.


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 resident was not administered his prescribed medicine on time (AM medicine).

Correction Narrative: Staff concerned on administering medicine was given a re-orientation on timely administration of medicines.


summary: 748.1101(b)(3)(L) - Children's rights-Based on child's age/maturity seek employment, keep own money/bank acct, paid for work done at op except for chores as discipline

raw_content: While reviewing the Children's rights the right to seek employment was missing from the document. 748.1101(4)(d)(C)-Confidential care was missing however the part regarding keeping medical records and operation records private was not  listed. 748.1101(5)(b)- Ombudsman and Youth currently in foster Care was not listed on the children's right document.

Correction Narrative:
On 06/29/22, compliance plan received by email with the following corrections:

Effective immediately upon admission all resident will be given a CPS Rights of  Children and Youth in Foster Care (Form K-908-2530) to sign. These rights will also be explain to each youth.


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

raw_content: While reviewing staff record the, Notarized Licensing Affidavit for Applicants for Employment form was not not found in the staff record.

Correction Narrative:
On 06/29/22, compliance plan was received by email with the following corrections:

Effective immediately, the office manager will ensure that all new hire paperwork is completed, signed and notarized before the employee is put on the schedule.


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

raw_content: The operation does not currently have a summary log for unauthorized absences.

Correction Narrative:
On 06/29/22, compliance plan was received by email with the following corrections:

As of June 15, 2022 Embracing Destiny Foundation GRO has created and will keep a summary log for unauthorized absences of all residents.  Copy of log was provided and located in share point.


summary: 748.2855(a)(3) - EBI Documentation-Must include the de-escalation attempted before and during the use of EBI and the child's reaction to those strategies

raw_content: While reviewing the EBI report it was found that the de-escalation during the use of EBI was not listed. 748.2855(a)(10)-attempts to explain to the child what was necessary for release from intervention was not listed on the report. 748.2855(a)(12)- the action the caregiver took to facilitate the child's return to normal activities was not listed on the report.

Correction Narrative:
On06/29/22, compliance plan received by email with the following corrections:

All EDF employee will be retrained on documentation of a physical restraint which will include:

Behavior necessary for release

Action the caregiver took to facilitate the child's return to the milieu

Operation also provided copy of restraint report they will utilize and this is located in Share Point.


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

raw_content: While reviewing the serious incident report it was found the physical address and telephone was not listed on the report.

Correction Narrative:
On 06/29/22, compliance plan was received from operation with the following corrections:

The Serious Incident Report Form was update to include the physical address and telephone number. Copy was provided and located in Share Point.


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

raw_content: It was determined that the children in care are not allowed to have individualized hair cuts.  Children are not provided with the normalcy, when they are not given a choice on their personal care  and this is causing emotional distress.

Correction Narrative:
Email received from the agency.
Corrective Action Implemented:
	Implemented immediately all client's will be allow to get the hair cut of their choice. Any client not wanting a hair cuts will also have that option.


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

raw_content: The operation currently does not have a full-time child care administrator.

Correction Narrative: The operation confirmed obtaining administrator.


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

Deficiency Narrative: The operation currently does not have a full-time child care administrator.


raw_content: The operation currently does not have a full-time child care administrator .


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: There is no record of a TB test in one resident's file.

Correction Narrative: The operation provided an email for the resident schedule date for TB test on June 30, 2021.


summary: 748.1331(b)(4) - Preliminary Service Plan-For child receiving treatment services, identify any issues or concerns child may have that could escalate child's behavior

raw_content: One of two child records did not identify any concerns the child may have that could escalate his behavior.

Correction Narrative: The operation provided one record of child in care which identified any concerns the child may have that could escalate his behavior.


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

raw_content: One of two records did not specify the child's existing relationship he may have with family.

Correction Narrative: The operation provided a revised admission assessment specifying the child in care existing relationship they may have with family on June 29, 2021.


facility_name: Caring Heart Residential Care Services LLC

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: During a monitoring inspection there was 1 serious incident report that indicated a child was arrested and taken to juvenile detention. The incident was reported to DFPS worker, but was not reported to licensing.

Correction Narrative: A compliance plan was provided via email by Administrator Adedamola Solawon indicating they had reviewed the Serious Incident section of the Minimum Standards. IT was also indicated the treatment team will ensure that any incident involving a child that results in an indictment, charges, or arrest is reported to Licensing within 24 hours of becoming aware of the incident. Treatment team includes the Administrator, CEO/Owner and Treatment Director. A signing sheet was provided dated 3/4/26.


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

raw_content: It was indicated a child was yelled at by a staff in a threatening manner without a reason during a zoom call the child had with bio parent and Case worker.

Correction Narrative:
Owner provided a compliance plan on 2/27/26 via email indicating all current staff have been re-educated and trained on appropriate, trauma-informed, and professional communication, including the use of respectful language when interacting with children in care. Ongoing supervision and reinforcement of these expectations will continue to ensure full compliance with Minimum Standards. The staff that was involved is  reported to no longer be working at the operation.
On 3/4/26 during an in person inspection, certificates for the training mentioned above were provided with corresponding dates of 2/7/26, 2/8/26, and 2/9/26.


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

raw_content: During the walkthrough of the home, multiple holes were observed that were covered with paper and had not been fixed. The carpet in the home appeared to be dirty there was a lot of dust collected on the baseboards of the walls.


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

Deficiency Narrative: During the walkthrough of the home, multiple holes were observed that were covered with paper and had not been fixed. The carpet in the home appeared to be dirty there was a lot of dust collected on the baseboards of the walls.


summary: 748.303(a)(9)(A) - Serious Incident-Report to CCL within 2 hours of notifying LE the absence of a child developmentally/chronologically 6 to 12 years old.

raw_content: An incident report was reported to the hotline 2 days after the incident happened.

Correction Narrative: CEO Raphael Solawon stated they will be adding more detail to incident reports to ensure all information about how long incidents take and/or extend, and information of when it's reported to the hotline is included in future cases.


summary: 748.3271(5) - First Aid Kits-Each one must be stored in a designated location known to all employees

raw_content: A first aid was not found during this inspection.

Category: Safety and Emergency Practices


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: Multiple children advised of being hit by staff.


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: The purpose of this rule is to prevent harm to children from risks associated with fire in the facility.

Correction Narrative: Fire extinguishers were serviced/inspected, and tags updated.  Executive director will do monthly walkthrough.


summary: 748.3303(a)(2) - Physical Site- Buildings must be clean and in good repair.

raw_content: Damaged doors & window blinds, broken furniture, and wall stains were observed.

Correction Narrative: Window blind has been changed. Staff were also reminded to complete Maintenance request when they notice maintenance need. Executive director would also do monthly walkthrough.


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

raw_content: Records reviewed show staff did not renew annual trainings timely.

Correction Narrative: Corrective Action Plan: We would review staff files and set reminders for when trainings are coming due and follow up with staffs to get them done timely.


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

raw_content: Records reviewed showed clerical errors.

Correction Narrative:
Corrective Action Plan: All staffs have been retrained on our AWOL policy and how to accurately document such incidents. We would also monitor these documentations.
The MAR has been reviewed to ensure all required information are on there.


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

raw_content: Children reported that one direct staff yelled at the residence, and threatened to hit the residence.

Correction Narrative:
5/11/24: Email received advised that staff was coached on the appropriate verbiage to use while interacting with the children in care.

5/16/24: The residence were interviewed and there were no concerns for physical discipline, staff cursing or yelling at the children.


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

raw_content: It was determined that a caregiver did not intervene when there was an altercation between three residents.

Correction Narrative: An in-person follow-up inspection was conducted on 01/19/2024. Please see inspection number 3984807. Multiple children were interviewed and stated staff members intervene timely to incidents at the operation. They also stated there are adequate staff members present with them at all times. Two child files and one staff file was reviewed at the inspection and there were no concerns.


summary: 748.363(4) - Personnel records-Include evidence of valid professional licensures, certifications, or registrations required for the position

raw_content: 3 out of 3 staff files reviewed did contain proof of education.

Correction Narrative: The operation e-mailed the staffs proof of education and stated they will ensure staff's proof of education will be in their staff file.


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

raw_content: The operation failed to report sexual abuse against a child in care by another resident.

Correction Narrative: The operation sent a statement stating they will ensure to report all sexual aggression incidents to the required entities.


summary: 745.8641 - Requirements during evaluation or probation

raw_content:
Condition 1: Condition Met/Partially Due
Condition 2: Condition Met
Condition 3: not due
Condition 4:  Condition Met
Condition 5: Condition Met/Partially due
Condition 6: Condition Met
Condition 7: Condition Met

Per condition 1 and condition 5, the operation was supposed to provide documentation to Licensing by 9/1/2022. This documentation was received late on 9/8/2022 and 9/13/2022.


raw_content:
Condition 1: not due
Condition 2: not due
Condition 3: not due
Condition 4:  Condition Met
Condition 5: not due
Condition 6: Deficient/not met
Condition 7: Condition Met

The operation did not provide all required documentation to meet the condition regarding physical site repairs (Condition 6). The operation has not provided a sufficient plan to meet the requirements of Condition 6, a physical site tracking log, and other documentation.

Standard Number / Description: 745.8641 - Requirements during evaluation or probation

Correction Narrative: The operation sent an email that contained their physical site tracking log, action plan, maintenance request form and checklist to satisfy condition #6.


raw_content:
Condition 1: not due
Condition 2: not due
Condition 3: not due
Condition 4:  Condition Met
Condition 5: not due
Condition 6: Deficient/not met
Condition 7: Deficient/not met

The operation did not have the probation notice posted near the entrance or anywhere in the operation. This was corrected once it was brought to the Director and Administrator's attention. Condition 7 states that the Administrator must submit to RCCR by 5:00 p.m. each Friday his/her schedule for the following week. The operation has not been providing their schedule by 5:00pm each Friday. Instead, it has been provided after the deadline at various times.
The operation did not provide all required documentation to  meet the condition  regarding physical site repairs (Condition 6). The operation also did not provide it once it was developed.


raw_content: The operation failed to report multiple serious incidents to licensing.

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

Correction Narrative: The operation sent an email stating, "We have since implemented reporting serious incident reports within 24hrs."


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

raw_content: Operation failed to send the required 14-day planning review notice in a timely manner.

Correction Narrative: The operation sent an email stating, "This notice was required within 7 days but we missed the standard being updated to 14 days. We have since started giving 14 days notice."


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

raw_content: During review of medication records -A.H. On 1/11/22 and 1/26/2022 Dr. Thompson did a medication review for the child and he was prescribed Trazodone 100 mg 1 tab @ PM (PRN). Medication log reviewed for January shows the staff incorrectly wrote the wrong strength. On 2/8/2022 Dr. Thompson did a medication review for the child and changed the Trazodone 100mg to 50mg 1 tab @ PM (PRN). February and March Medication log shows the staff gave the correct dosage and strength for the child.

Correction Narrative: The agency responded on today with the corrections once they were made aware it wasn't sent but they were aware about the citation and made corrections for it not to occur in the future. An email of a new structed form was created to implement mistakes from being made with the client's information and any changes that should occur by the doctor and pharmacy.


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

raw_content: A caregiver displayed a lack of self -control when he punched a hole in a wall.

Correction Narrative: On 8/8/22 the administrator sent an email in response to the citation. The administrator stated the staff in question was coached and has been terminated. The rest of the team were also trained on self control  as well as all new hires.


raw_content: Several medication records reviewed were missing the reason the medication was prescribed.

Standard Number / Description: 748.2151(c)(3) - Medication record - must include reason medication was prescribed, for prescription medication

Correction Narrative: The operation stated they will be sure to include this information going forward and will update the records as needed.


raw_content: There is a hole in a wall in the children's bedroom downstairs. The restroom downstairs has strong urine ordor.

Standard Number / Description: 748.3303(a)(2) - Physical Site- Buildings must be clean and in good repair.


summary: 748.1101(b)(4)(A)(vii) - Children's rights- Free from demeaning behavior to embarrass/control/harm/intimidate/isolate the child

raw_content: Staff recorded an exchange between an adult asking a child what day the incident occurred, the child says that he believes it occurred on a Friday, and is then asked how he was "scratched" and then the adult says that "he scratches himself, then why are you saying they scratched you."

Correction Narrative: The operation provided a corrective action plan stating, "moving forward, all children in care will be discouraged from discussing any ongoing investigation with staff."


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

raw_content: A caregiver failed to adhere to the child's rights to be free of abuse, neglect, and exploitation as defined in Texas Family Code 261.401 when the caregiver put a child in care at risk of physical harm when he slammed the child to the ground.

Correction Narrative: The director stated although he does not believe the allegations are true, the staff in question is no longer employed at the operation.


summary: 748.2301(b)(2) - Disciplinary Measures-must not be physically or emotionally damaging to the child

raw_content: A caregiver slammed a child in care to the ground as a form of discipline which caused the child physical pain.


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

raw_content: One of the bedrooms smelled of urine.

Deficiency Narrative: One of the bedrooms smelled of urine.

Correction Narrative: The Director stated all rooms have been cleaned.


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

raw_content: 1 of the 6 children's medication records reviewed contained medication errors and there was no documentation of the errors.


summary: 748.2605(b)(1) - Personal Restraints Prohibited-Prone and supine restraints except as a transitional hold that lasts no longer than 1 minute

raw_content: Personal restraint documentation reviewed states that a prone restraint was performed on a child in care but it does not indicate it was used as a transitional hold./Operation need to provide corrective action plan


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: All residents interviewed stated they have either been hit by the staff or witnessed the staff hit another resident. Also, a staff stated they have heard the same staff yell at children in care and 3 of the 4 children interviewed stated the staff yells at them./Operation need to provide corrective action plan


summary: 748.2553(2)(B) - EBI Release-Child released from personal restraint within one minute of implementation of a prone or supine hold

raw_content: One personal restraint documentation reviewed stated a child in care was restrained in the prone position for 5 minutes/Operation need to provide corrective action plan.


summary: 748.3307(b)(3) - Physical Site-Bathrooms must be lighted to avoid accidents

raw_content: During the walk through it was observed that the 1st floor master bathroom was missing 4 light bulbs over the sink.

Correction Narrative: The operation sent a picture of the master bathroom with all 4 lights.


summary: 748.2307(10) - Other Prohibited Punishments-placing a child in a dark room, bathroom, or closet

raw_content: A caregiver placed a child in a closet as a method of discipline.

Correction Narrative: The operation sent an email stating they had an inservice about the operation's discipline policy with the staff.


raw_content: A caregiver  used hitting as a method of discipline.

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


raw_content: All residents interviewed stated they have either been hit by the staff or witnessed the staff hit another resident. Also, a staff stated they have heard the same staff yell at children in care and 3 of the 4 children interviewed stated the staff yells at them.


raw_content: One personal restraint documentation reviewed stated a child in care was restrained in the prone position for 5 minutes

Standard Number / Description: 748.2553(2)(B) - EBI Release-Child released from personal restraint within one minute of implementation of a prone or supine hold


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

raw_content: 2 of the 3 staff files reviewed did not have a record of a TB screening

Category: Personnel


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

raw_content: Medication record documentation states that a child in care was administered 2 separate medications that belonged to another person.


raw_content: Personal restraint documentation reviewed states that a prone restraint was performed on a child in care but it does not indicate it was used as a transitional hold.

Standard Number / Description: 748.2605(b)(1) - Personal Restraints Prohibited-Prone and supine restraints except as a transitional hold that lasts no longer than 1 minute


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: Several children's medication records reviewed shows that a children missed at least 1 dosage of medication. Also, a child's record reviewed shows that a child in care was not receiving the correct medication dosage.

Correction Narrative: The director stated they have been double and triple checking the medication logs to ensure there are no more mistakes and missed dosages. He has also created a log for staff to keep up with refills.


raw_content: Several child records shows that children missed at least 1 dosage and there is no documentation as to why.

Standard Number / Description: 748.2203(c) - Medication Error-Operation must meet documentation requirements within 24 hrs

Correction Narrative: The director stated he and the administrator have been working to ensure these mistakes do not happen again. He is in constant contact with the pharmacy to ensure medications are refilled on time.


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

raw_content: 1 medication record reviewed was missing the time the medication was administered and the staff's initial/signature.

Correction Narrative: The director stated all staff have been retrained on medications so he's not sure why there keeps being errors but he has had a meeting with his staff regarding the medications.


raw_content: Staff did not demonstrate prudent judgment when 2 residents were administered medications after the medications had been discontinued by the provider.

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

Correction Narrative: The operation stated when the medication errors occurred, there was a new staff that just didn't do so well with paying attention to detail. The staff was let go.


summary: 748.2101(6) - Medication storage & destruction-remove discontinued medication immediately & destroy it in a way that ensures children do not have access to it

raw_content: 2 medication records reviewed shows that medication was not disposed of after being discontinued.


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

raw_content: During the walk through at the operation it was observed that the bathrooms upstairs and downstairs had a urine smell. The backyard had a a pile of (10) rocks right outside the door (photos taken).  The walls of the operation have writing through out the operation/home.  12/22 was provided due to the walls and writing.

Correction Narrative: A walkthrough was conducted and the hole in the backyard was observed to be filled in with dirt and the rocks were gone. The urine smell was also gone from the bathrooms.


Standard Number / Description: 748.3307(b)(3) - Physical Site-Bathrooms must be lighted to avoid accidents

Deficiency Narrative: During the walk through it was observed that the 1st floor master bathroom was missing 4 light bulbs over the sink.


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 thermometer in the refrigerator was above 40 degrees (photo taken).  Additionally, during the walk through the deep freezer stored in the garage did not have a thermometer.  The Freezer attached to the refrigerator did not have a thermometer (photo taken).

Correction Narrative: A walkthrough was conducted and a thermometer was observed in the refrigerator.


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

raw_content: 3 children described restraints with their hands behind their back and being placed on their stomachs, 2 of the children stated that this is how restraints are done. 1 staff member stated that restraints were done with hands behind their backs. A different staff stated that she placed one of the childrens hands behind their back to retrieve a comb. The child stated that he was on the floor with his hands behind his back.

Correction Narrative: The operation sent an email stating they have had an in-service about proper restraints with staff.


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

raw_content: The child-care administrator failed to provide oversight of staffing patterns, which resulted in the systematic failure, which in turn facilitated the physical abuse of a child in care by a caregiver that was previously believed to have physically abused a child in care before.

Correction Narrative: Both staff are no longer working at the operation. The operation has majority new staff and has ensured that all staff are trained.


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: Caregivers failed to adhere to the child's rights to be free of abuse, neglect, and exploitation as defined in Texas Family Code 261.401 when 2 caregivers caused physical harm and injury to children in care.

Correction Narrative: The operation has retrained all staff. Both staff are no longer working at the operation.


raw_content: 2 caregivers used corporal punishment on children in care when they punched the child/ren.


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

raw_content: 3 of the 3 children interviewed stated that a staff member pinches and pulls on the residents.

Correction Narrative: The director stated the staff has been removed from the schedule.


summary: 748.1101(b)(3)(G) - Children's rights-comfortable clothing suitable to age/size/similar to peers in community. Teenagers have reasonable chance to select clothing

raw_content: It was learned during an interview at the children's school that a child in care arrived to school wearing a female's blouse. All residents at the operation are boys. The school provided the child with a change of clothing.

Correction Narrative: During a walkthrough of the operation, I looked at the children's clothing. There were no concerns.


summary: 748.1693(a)(1) - Nutrition-Provide food of adequate variety, quality, and in sufficient quantity to supply the nutrients needed for proper growth and development

raw_content: During initial walkthrough the refrigerator contained no food of substance, when addressed, staff stated the residents were having left over from the day before, there was no food cooking and only a cake in the refrigerator.

Correction Narrative: The refrigerator was observed to be filled with different foods. There is a separate refrigerator/freezer in the garage that has a variety of food.


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

raw_content: While conducting interviews, children stated they are allowed to play shooting games. During the walkthrough, a PS4 was observed with video games rated MA and 17. These are not appropriate to the children's needs.

Correction Narrative: During my inspection, the video games were not present.


raw_content: Several children's medication record reviewed showed that children either missed doses of their medication or were not given at the correct time.

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

Correction Narrative: The operation stated, "MAR and medications will be reviewed weekly for accuracy. All staff also re-trained"


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: One child record reviewed did not have a documented TB test.

Correction Narrative: The child is scheduled to have his TB exam Wednesday August 4, 2021.


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

raw_content: Several children's medication records reviewed did not have an accurate count.


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

raw_content: There was no documentation regarding a post restraint discussion.

Correction Narrative: The operation stated that all staff have been retrained on EBI.


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

raw_content: One restraint report reviewed did not include the type of restraint that was used.

Correction Narrative: The operation stated via email that all staff have been retrained on EBI documentation.


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

raw_content: A new staff member is not documenting his name and signature on the medication records.

Correction Narrative: The operation stated via email that this is a new employee and that this employee has since been retrained on medication records.


summary: 748.2951(d) - Evaluation-Results of each overall  annual evaluation made available to Licensing for review.

raw_content: The operation does not have an overall operation evaluation for emergency behavior interventions.

Correction Narrative:
The operation provided an email stating, " In the year 2020, a total of 10 personal restraints were documented. For the most part,
children were successfully redirected with de-escalation and short personal restraints.
There weren't any incidences of physical injuries or any other negative side effects on
the child's behavior or emotional development resulting from the emergency behavior
interventions. All staff were trained on the safe use of emergency behavior intervention
as well as proper documentation. It was also reinforced that EBI should always be that
resort, staff should always try to de-escalate situations before they get out of hand. The
importance of keeping child(ren) safe during all forms of restraints was also discussed.
All staff are up-to-date with their SAMA training."


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

raw_content: Caregiver with a pending background check was present at the operation, supervising children and administering medication.

Correction Narrative: As of today, 7/29/2021, CBCU has granted the staff member a provisional with conditions.


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

raw_content: A caregiver failed to show prudent judgement when she slept while on shift. The caregiver was the only adult at the facility at the time and was responsible for the safety and well being of all the children

Correction Narrative: Has a camera that she uses to check on the staff at night. They're also planning to add a second staff to night shift. The staff is no longer on shift. The staff is no longer employed here.


raw_content: A caregiver failed to adhere to the child's rights to be free of abuse, neglect, and exploitation as defined in Texas Family Code 261.401 when the caregiver failed to properly supervise the children due to sleeping while on shift.

Correction Narrative: The operation stated the particular staff in question is no longer employed at the operation.


summary: 748.3(a) - The permit holder must ensure compliance with applicable minimum standards rules

raw_content: The permit holder failed to ensure compliance with minimum standards and rules and also failed to follow the conditions of a safety plan.

Correction Narrative: The operation stated that since receiving this citation they have been on stop of safety plans and ensuring they are being followed.


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

raw_content: CCI was unable to retrieve or view records while at the operation. Also, requested documentation was not immediately available.

Correction Narrative: I spoke to Director Raphael Solawon via telephone regarding the deficiency. He stated his treatment director was supposed to be at the operation to assist. He stated going forward he will ensure records are always available for review when he's not available at the operation.


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

raw_content: While at the operation, CCI heard staff yelling and cursing at and in the presence of children.

Correction Narrative: I had a phone conversation with Director Raphael Solawon, he stated he spoke to the employee about this behavior, and although the employee denied using profane language, he stated he would ensure it did not happen again.


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

raw_content: There is a white shelf in one of the residents closets  downstairs that has a broken bottom shelf and the side is cracked as well. There is a basketball goal in the backyard that has a broken backboard, with sharp pieces of hard plastic surrounded the frame of the backboard.


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

raw_content: During a walk though of the facility 2 out of the 4 bathrooms observed had toilets that where filthy and bathrooms held really strong urine odors.

Correction Narrative: The operation sent pictures via email of the corrected deficiencies.


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

raw_content: There were 5 medication records missing for 3 children in care. There was no way to confirm that the medication was administrated.

Correction Narrative: "All staff have been re-trained on proper documentation of medication whether given or not. A bi-weekly audit of the MAR will also be conducted."


summary: 748.2101(6) - Medication storage & destruction-remove discontinued medication immediately & destroy it in a way that ensures children do not have access to it

raw_content: From medication records it was determined that 2 children were given medication that was discontinued.

Correction Narrative:
"The medication storage was reviewed and reorganized to ensure that all discontinued
medications are immediately separated from current/active medications. The MAR will also be
kept up-to-date in compliance with the Med review."


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: While reviewing medication records it was determined that 4 children did not receive their medication because the refills were not made in a timely manner. As a result, medication was not administered daily as instructed. There was also 1 child who did not receive the correct dosage, the medication was to be given once a day but was given twice a day by staff. .

Correction Narrative:
"All staff have been trained to notify the treatment team whenever a child is left with less 10 days supply of any medication to allow an ample time for refill. A bi-weekly audit of the MAR and
medication supply would also be done as a backup for this."


summary: 748.2461(b)(1) - Short Personal Restraint-Caregiver may not use a prone or supine restraint

raw_content: EBI documentation stated that a prone restraint was used on a child in care.

Correction Narrative: Staff have been educated on how to document correctly.


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

raw_content: During a visit at the operation, CCI observed an electric saw sitting just outside the front door of the operation.

Correction Narrative: A follow up inspection was conducted at the operation. There were no dangerous tools or items left out. The Executive Director stated he has been making sure to tell contractors not to leave their tools laying around.


raw_content: Night shift staff are signing the medication logs when it is the day shift staff that administers them.

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

Correction Narrative: 2 medication records were reviewed. Compliance met


summary: 748.2003(b)(4) - Administration of prescription medication-Administer each child's medication within one hour of preparation

raw_content: Several staff stated the night shift pops out the 8am medication at night and the staff on day shift administers them.

Correction Narrative: The Executive Director stated he had a meeting with his staff and advised them that they can no longer pop the medication out at night for the morning shift to administer.


summary: 748.3303 - Physical Site-Living quarters, recreation & dining areas, bathrooms, bedrooms, & kitchens must be adequately ventilated

raw_content: All windows in the bedrooms and living quarters are nailed shut.


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

raw_content: A staff member has violated the conditions of a background check by administering medications and transporting children in care.

Correction Narrative: I spoke with the Executive Director and he stated he advised the staff member not to touch the medication at all and has assigned other staff the responsibility of transporting. I also spoke with 2 children in care that stated she has not administered them medication and has not transported them anywhere.


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

raw_content: After conducting several interviews it was learned that a staff member falls asleep during the night shift.

Correction Narrative: A follow up inspection was conducted on 5/5/2021. Supervision was observed. There were no concerns.


summary: 748.1386(2) - Single service plan is acceptable as long you continue to comply with the service plan review and update requirements

raw_content: One of the service planned reviewed appeared to be copied and pasted. The verbiage in the service plan does not match the RTC.

Correction Narrative: The Executive Director stated he is unsure how that happened with the service plan, but going forward he will ensure to double check the service plans so that it doesn't happen again.


facility_name: Legacy Youth

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

raw_content: The operation failed to timely notify Licensing of a child's arrest per the required timeframe.

Correction Narrative:
On 01/10/2026 the operation Administrator submitted corrections through email regarding their plan to maintain compliance with minimum standards.

The operation has reviewed all minimum standards, and all operation staff has been informed of serious incidents being reported timely and appropriately. A virtual training was held to remind all staff of reporting procedures.


raw_content: Two kitchen cabinet drawers were observed damaged with exposed metal staples. Two kitchen cabinet drawers were observed damaged with exposed metal staples. The operation corrected the issue by removing the exposed metal staples from the drawers.

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


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

raw_content: Child sustained an injury that resulted in a second degree burn and required medical attention on 7/4/25, and the operation did not report this to CCR.

Correction Narrative: On 9/04/25 an email was sent by the administrator stating the minimum standards have been reviewed, and all staff have been made aware of the fact that this should have been reported immediately. Additionally, a virtual training was held to remind all staff of the reporting procedures, and when in doubt contact either LCCA and/or Administrator.


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

raw_content: Medication record reviewed reflected multiple times not documented for one child record.

Correction Narrative: Administrator sent out an email stating they have a non-negotiable medication policy. An impromptu medication refresher training was conducted, and a review of facility policies as well as minimum standards was conducted.


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

raw_content: It was observed during the visit that the annual inspection of  both the van the and the car used to transport children have expired in 04/23 and 03/24 respectively.

Correction Narrative: During the follow up inspection it was noted that the facilities 2 vehicles used to transport children had an updated vehicle registration stickers with the following dates 10/25 and 10/25. The photograph of the updated stickers can be found in the document library.


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

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

Correction Narrative: The operation's 2nd. Quarterly EBI Report was submitted into the system.  The report was reviewed in CLASS.


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

raw_content: Child in care and the caregiver both disclosed that the restraint was a result of the child attempting to trip the caregiver.

Correction Narrative:
03/05/2024-The operation's LCCA submitted a Corrective Action Plan via email to licensing.  The LCCA explained the operation only performs one restraint which consist of the basket hold.  Additionally, the LCCA acknowledged residents are only restrained if they are a harm to self and/or others.

The LCCA communicated with the specific staff member to identify the concerns with the restraint and Crisis Prevention Intervention best practices. According to the LCCA, this incident was utilized as a teachable moment for all staff and challenged the team to devise plans to de-escalate real-life behaviors through role-play and whole group collaboration.


summary: 748.930(b)(4) - Annual Training- Caregivers must have 2 hours transportation safety training if caring for children younger than 9 yrs old.

raw_content: Two out of two staff records reviewed, were observed without the required number of hours for annual transportation training.

Correction Narrative:
02/07/2024- The operation's LCAA submitted to licensing staff a Corrective Action Plan via email.  According to the operation's Corrective Action Plan, the operation takes full accountability for the oversight in reference to non-compliance as related to Standard 748.930(b)(4).  A two-hour transportation training was conducted on October 29, 2023, from 3:00PM to 5:00PM with all employees.

Additionally, the LCAA provided licensing staff copies of each employees' transportation training certificate indicating a 2-hour training course as well as displaying instructor as the operation's Chief Executive Officer conducted on October 29, 2023.


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

raw_content: One of two child records was observed without the required signatures of acknowledgment of notification of rights. staff provided a signed copy of acknowledgement notification.


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

raw_content: During the course of the investigation, it was determined children in care are yelled at by staff.

Correction Narrative: A corrective action response was submitted via email stating we are firm, fair, and consistent. While we are not in agreement with this deficiency, the LCCA met with each employee one-on-one and reviewed Paraverbal Skills (Volume, Tone, Pitch and Pace) as well as expectations.


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

raw_content: When reviewing a child's record, there was 1 staff that documented a serious incident report, which shows that she was present at the operation, and administered medication to a child before receiving notification from the Centralized Background Check Unit that the staff was eligible.


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

raw_content: 1 EBI document reviewed showed that a child in care was restrained for an inappropriate reason which was for jumping over the couch. No de-escalation technique was used. Another EBI document reviewed also showed that no de-escalation technique was used.

Correction Narrative: Unannounced Follow-Up Inspection conducted at the operation.  Staff interviews conducted regarding EBI implementation, protocols, documentation, and training.  Recent EBI report reviewed and in compliance.  Licensing staff held conversation with LCCA.  LCCA provided a Final Legacy Youth Corrective Action Plan indicating  Legacy Youth only restrains children that are a harm self or others. LCCA indicated the de-escalation techniques used and identified on the incident report; but not specified on the EBI. LCCA did not agree that this was a fair deficiency given, it could have been better documented. A training on documenting all facts and details was performed utilizing the EBI in question. Overall operation EBI evaluation was requested for review.


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: Three medication records showed that medication was not administered as prescribed.

Correction Narrative:
Legacy Youth has operated nearly excellent in the area of medication administration for nearly three years. We've
recently switched pharmacies and there were a few errors that delayed medication refills, inaccurate labels were
provided, and inconsistent documentation, etc. Legacy Youth has met with the pharmacy, doctor's office, and Legacy
Youth's Med Team to discuss AGAIN the importance of accuracy and efficiency in addition documentation.


summary: 748.1101(b)(4)(A)(iv) - Children's rights-Free from being denied food, sleep, a bathroom, mail, or family visits as punishment

raw_content: During interviews with the children in care, 5 out of the 6 interviewed advised that part of discipline is receiving a sandwich in their bedroom while the other children eat something different.

Correction Narrative:
Legacy Youth does not deny residents of food. We do offer options and it is determined that residents over generalized and inaccurately communicated information. Peanut butter and jelly sandwiches are typically preferred
sandwiches by children; when offered as an option most girls choose it. Legacy Youth utilized our Girl Chat
processing group as an open forum to explain normalcy, food options-specifically PB&J sandwiches, consequences,
and explained how they will never be punished utilizing food. All residents were able to display a complete understanding of the topics discussed.


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

raw_content: In reviewing medication logs, two medication records were missing the reason for the medication being prescribed on two of eight children's records reviewed.

Correction Narrative: Legacy Youth created an internal audit form for med team members to utilize daily to ensure that all required data is provided.


raw_content: During my investigation and interview with children in care and staff, it was determined that direct care staff were not aware of an injury sustained by a child in care.  The preponderance of evidence supports this standard as being deficient.

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

Correction Narrative: no concerns noted, interviewed 2 children in care to discuss how they were being treated. no concerns found


summary: 748.2551(b)(3) - EBI Implementation-The caregiver must consider the potential risk of harm in using EBI versus the risk of not using EBI

raw_content: The operation staff initiated a two-person team controlled escort with victim that resulted in three persons (two staff & victim) falling down the stairs. During the fall, one staff member initiated a basket hold on the median level of the stairs; however, safety was not considered, as the staff member had the opportunity to step back first to distance herself away from being kicked by victim.

Correction Narrative: The operation completed staff training on 7/11 (signatures provided), implementation of the corrective plan is 7/13/2021


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

raw_content: Two operation staff initiated a controlled escort with victim; however, during the investigation it was stated that the child was at the top of the stairs in the operation nudging their knees forward.  The escort was utilized as a way to force the child to come down the stairs.


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

raw_content: During a team inspection walk through it was observed that one room contained two metal hanging wires over one child in care bed.


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: It was observed during the walk through that the fence in the backyard is broken and missing 1 picket.

Correction Narrative: photos provided


raw_content: It was observed during the walk through that the the operation had a pile of  loose bricks on the outside of the home, in the rear of the home near the side yard and in the backyard of the home near the corner.

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


facility_name: Amor Purus LLC

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

raw_content: A child in care was administered medication that was no longer prescribed to them.

Correction Narrative:
An email was received from the administrator with the following information:
Corrective Actions Implemented indicates a new intake medication verification process has been implemented to ensure all medications are current upon arrival. All incoming placements must arrive with a minimum of 14 days of prescribed medication and proper documentation. Staff complete a medication reconciliation at intake to verify accuracy before administration. Medication Quality Assurance audits are conducted multiple times per week by leadership. Staff have been retrained on medication administration procedures.
Preventative measure indicates no medication will be administered unless verified as current and prescribed and any discrepancies will result in immediate hold until verified by a physician or pharmacy.


summary: 748.311(5) - Serious Incident Documentation-Includes names or other means of identifying witnesses to the incident, if any

raw_content: The incident report dated 9-29-25 does not have the names of collateral children, who reported seeing the incident.

Correction Narrative: On 11-25-25 the operation submitted a CAP for the citation. Staff received a refresher training on report writing, their incident report was updated to include witnesses, a two person review process, leadership will complete monthly audits. Copies of the training certificates were provided.


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

raw_content: First child list received was missing current placements and had a discharged child still listed. Additionally, the staff list has an individual listed as a volunteer but the background check states they are staff. There was a staff interviewed and has an active background check but does not appear on the staff list.

Correction Narrative: The operation will audit records more frequently and make changes to records as changes occur such as loss of staff , background checks, and discharge of child in care.


raw_content: Three staff members who transport children did not have complete transportation safety training.

Standard Number / Description: 748.930(b)(4) - Annual Training- Caregivers must have 2 hours transportation safety training if caring for children younger than 9 yrs old.

Correction Narrative:
The following compliance plan was provided by the operation:

- Action Taken: Transportation safety training was reviewed and made mandatory for all staff responsible for transporting children under age 9.
- Preventative Measures:
   A quarterly training calendar now includes required transportation safety sessions.
   Transportation training completion will be logged and monitored using the training tracker system.
   Drivers without up-to-date training will not be permitted to transport any child.
- Completion Date: August 6, 2025
- Responsible Party: Jennifer Washington LCCA

Operation provided four transportation certificates to include the staff that were previously missing the training.


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

raw_content: Two of the reviewed personnel records did not include the suicide prevention training certficates.

Correction Narrative: All staff was retrained on 08/05/2025 on AS+K? Basic Community Helper 2025 - Texas training certificates were provided.


raw_content: None of the medication logs reviewed specified the reason for which the medication was prescribed.

Correction Narrative: Medication records include reason for medication on indication tab. Staff will conduct daily audits to ensure all records are compliance with minimum standard and law requirements. Staff was interviewed and confirmed medication training was conducted on 08/09/2025


summary: 748.1531(a)(1) - Medical care-A child in care must receive medical care initially according to the requirements in 748.1223

raw_content: One of the two child records reviewed revealed that one child did not receive the initial medical examination within the required timeframe.

Category: Child Care

Correction Narrative: Staff was interviewed and verified all staff was currently retrained. The staff was retrained on 08/09/2025. Staff will not allow children in care to be dropped off until medication count is completed with case worker/transports. Staff will ensure supervisors are present to ensure all children in care have proper medication prior to accepting at operation. Staff was interviewed and confirmed medication training was conducted on 08/09/2025.


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

raw_content: During an unannounced inspection at the operation, prescription medications were observed on top of a file cabinet next to the medication storage container that was unlocked.

Correction Narrative: Staff interviewed confirmed medication training is scheduled for 8 am on 08/23/2025 by a medical professional. Staff confirmed all shifts conducts medical storage checks and documents any deficiencies noticed prior to start of shifts.


summary: 748.1009 - Child/caregiver ratio-Must employ an adequate number of caregivers to meet the needs of children

raw_content: During an unannounced inspection at the operation 1 caregiver was observed with 3 youth in care. 1 out of 3 youth require 1:1 supervision. An additional caregiver did not arrive to the facility for 30 minutes.

Correction Narrative: Staff interviewed confirmed more staff are on call and there are more staff members on schedule. Staff also confirmed the staff are reporting to work at an earlier time.


summary: 748.1209(b)(1) - Child Orientation-Include policies on visitation, including family visitation & overnight visitation

raw_content: Operation staff admitted to taking youth in care to their personal home.

Correction Narrative:
The following compliance plan was sent on 08/28/25 by the Administrator.

1. Overnight Stays:
   - Staff will not be allowed to have any children stay overnight outside of the operation.
   - Only under extreme circumstances where safety is involved (e.g., inclement weather, natural disaster, or emergency evacuation) may an overnight stay be considered.
   - In such emergency situations, the LCCA (Licensed Child Care Administrator) must be notified immediately. The LCCA will contact the Conservator to inform them of the situation and ultimately obtain approval before any overnight stay occurs.
2. Day Outings:
   - Day outings will only be permitted when proper staff-to-child ratios are maintained in accordance with Minimum Standards.
   - All activities must be planned in advance and reviewed/approved by the management team.
3. Training & Communication:
   - All staff will be trained on this policy to ensure understanding that overnight stays are prohibited unless authorized through emergency procedures.
   - Staff will also be trained on requirements for day outings, including ratio compliance and management approval.
4. Monitoring & Compliance:
   - The Administrator/LCCA will review outing and visitation logs weekly to ensure compliance with this corrective action plan.
   - Emergency situations and any outings will be discussed during monthly staff meetings to reinforce policy adherence and accountability.
Completion Date
This corrective action plan will be implemented immediately and fully in effect by 8/30/2025
Responsible Party
- LCCA: Oversight and conservator communication
- Administrator/Designee: Policy training and documentation
- All Staff: Compliance with policy and immediate reporting


summary: 748.363(10) - Personnel records - Include signed dated statement by the employee that he must immediately report suspected child abuse, neglect, or exploitation.

raw_content: 1 of 3 employee records reviewed didn't have the required signed form.

Correction Narrative: Operation submitted required signed employee form via email.


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: 2 of 2 child records reviewed did not have the required tb tests completed.

Correction Narrative: On 09/30/2024 Operation staff sent medical form 2403 via email to show children went to doctor's office to get the required TB testing. On 09/30/2024 RCCR requested TB Testing results. On 09/05/2024 operation staff sent one child's tb test results and stated still waiting on other child's results. The other child tb tests was received via email on 09/25/2024.


summary: 748.363(11) - Personnel records-Include proof of request for background checks.

raw_content: 2 of 3 employee records reviewed didn't have the required  form.

Correction Narrative: Operation submitted required personnel record request via email.


summary: 748.363(9) - Personnel records - Include a statement signed and dated by the employee that he has read a copy of the operational policies.

Deficiency Narrative: 1 of 3 employee records reviewed didn't have the required signed form.


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

raw_content: The operations fire inspection was due on or before the last inspection of 6/2023. The fire inspection is out of date according to minimum standards.


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

raw_content:
The operation's administrator resigned effective 4/5/24.

On 4/9/24, the operation was provided technical assistance and given 60 days to hire a qualified administrator.

The operation's administrator position continues to remain vacant.

Correction Narrative: Operation hired an LCCA and submitted changes through provider portal.


summary: 748.3751(b)(2) - Swimming activities-If more than 6 children swimming, lifeguard must be on duty & 1 adult in ratio must be able to swim or trained in water rescue

raw_content: 12 children were taken to a community pool and there wasn't a lifeguard on duty.

Correction Narrative:
A corrective action/implementation plan was received via email on 10/07/2024 stating the following:
Lifeguard on Duty
- Action: Hire or designate a qualified lifeguard to be on duty during all swimming activities.
- Implementation:
  - Verify lifeguard credentials and ensure they are present whenever the pool is in use.
  - Establish a protocol for lifeguard communication with staff.

 Safety Briefing
- Action: Conduct a safety briefing for residents prior to any water activity.
- Implementation:
  - Create a standardized safety briefing checklist covering pool rules, emergency procedures, and expected behavior.
  - Schedule briefings before each swimming session, ensuring all residents are present.

Due to the incident having occurred at a community pool, there is not a need to conduct unannounced follow up at the operation as there is not a pool at the operation.
It is acceptable for the follow up to be completed by accepting the operations plans for correction for any future community pool events.


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

raw_content: A five-year-old was able to unsafely access the four-feet end of a community pool during a swimming activity while staff were present in different perimeters of the pool area.

Correction Narrative:
A corrective action/implementation plan was received via email on 10/07/2024 stating the following:
Staff Positioning and Assignment
- Action: Strategically position staff around the pool to ensure constant supervision.
- Implementation:
  - Create a supervision map indicating where each staff member will be stationed.
  - Assign specific residents to each staff member, ensuring that each staff member is aware of their assigned residents.

 Monitoring and Evaluation
- Action: Regularly review and assess the effectiveness of the supervision plan.
- Implementation:
  - Schedule monthly meetings to discuss any incidents or near misses.
Solicit feedback from staff and residents on safety practices and make adjustments as needed.

Due to the incident having occurred at a community pool, there is not a need to conduct unannounced follow up at the operation as there is not a pool at the operation.
It is acceptable for the follow up to be completed by accepting the operations plans for correction for any future community pool events.


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

raw_content: The operation's administrator resigned effective 4/5/24.

Correction Narrative: Operation inactivated the previous LCCA as a controlling person. Verified in CLASS.


summary: 748.153(3)(A) - Notification - Change in child-care administrator

raw_content:
The administrator of record for the operation notified CCR on 4/9/24, of resignation and no longer employed at the operation effective 4/5/24.
The operation has not reported the vacancy of the administrator position.

Correction Narrative:
Previous LCCA has been removed as administrator of record. Verified in CLASS.
Operation submitted requested plan for search for new LCCA and plans for interim administrator duties.


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: Multiple children reported being made to exercise as a form of discipline.

Correction Narrative: Several children in care and staff members were interviewed. The children did not disclose physical discipline being used or being made to exercise as a form of discipline, nor did the operations staff members.


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

raw_content: The door in room # 3 was observed to have a small hole.


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

raw_content: The blind of the door leading to the playground was observed to have a slat missing.


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

raw_content: One of the staff's records did not contain the required affidavit for employment.

Correction Narrative:
The agency developed a spreadsheet to track items
needed for personnel file. The spreadsheet will be
viewed weekly to ensure items are in the file. The
spreadsheet will be available upon request.  The affidavit was placed in filed on February 21, 2023.


raw_content: Rooms 3 and 2 were observed to have holes on the walls.

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

Correction Narrative:
The agency staff completed daily checks for repairs. The holes were
repaired on February 21, 2023. Staff will continue completing daily checks for future repairs needed.


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

raw_content: Of the four medication records, there was one medication record that was incorrect on their daily count on one specif medication administered.