summary: 748.2101(2) - Medication Storage-Keep medication inaccessible other than to employees responsible for stored medication

raw_content: During the investigation, it was discovered that a caregiver was leaving staff keys accessible to children and leaving the staff office door and medication closet opened and accessible to children.

Correction Narrative: On 12/19/2023, the Director, Paul Christman, provided corrections: Ms. Human has undergone retraining on proper security and management of medication and responsible action to take when interruptions occur during medication dispensing hours.


state: TX

facility_name: Hope Haven of East Texas

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

raw_content: During the investigation, it was discovered that a caregiver was yelling, screaming, and/or cursing at the children,

Category: Individual Standards Evaluated

Standard Risk Level: High

Corrected at Inspection: No

Correction Narrative: On 12/19/2023, the Director, Paul Christman, provided corrections: Ms. Human has undergone retraining on proper behavior intervention without using language that would be considered yelling or screaming. Ms. Human will also be included in the Pressley Ridge Professional Parenting class on de-escalation of children at the next session.


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

raw_content: During the investigation, it was discovered that a caregiver playfully spanked a child on the bottom making the child feel weird about the situation.

Standard Risk Level: Medium High

Correction Narrative: On 12/19/2023, the Director, Paul Christman, provided corrections: Ms. Human has undergone retraining on proper and prudent actions to take when supervising children including that touching on the bottom regardless of the innocent intent of such action is inappropriate.


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

raw_content: During the investigation, it was discovered that the operation did not follow their plans to restrict medication administration by a staff member after a medication error.

Standard Risk Level: Medium

Correction Narrative: On 12/19/2023, the Director, Paul Christman, provided corrections: Hope Haven has issued new policies and procedures to require that that all restrictions to the normal duties of Direct Care Staff must be issued in writing by the Residential Manager, Program and/or Administrator.  All restrictions in duties must be clearly communicated by the Residential Manager to the employee.


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

raw_content: During the investigation inspection, the administrator was not present at the operation. The administrator has not been present at the operation the last few times Licensing has been to the operation.

Correction Narrative:
Executive Director, Jamie Sanders, advised the operation requires its Administrator, Mr. Billy Roberson, to hold a current Child Care Administrator's License and to work full-time for the operation.  He oversees compliance with minimum standards, contract requirements, and internal policies and procedures.  He oversees both residential operations and therapeutic services, participating in staff meetings, treatment team meetings, and program leadership meetings.  He participates in placement and discharge decisions.  He, along with the Treatment Director, oversees safety and service planning, and interacts regularly with staff, residents, and state officials.

His duties require him to be present at the Gateway of Hope campus and also at our administrative offices which are located approximately 20 minutes from the actual home.  At any given time, he may be at the campus meeting with children, reviewing service plans, meeting with staff or program leadership, or he may be at the administrative office regarding training, legal and regulatory issues, finance, budget meetings, or community relations. The administrator does not maintain his work office in the home, but is present in the home regularly for meetings, crisis intervention, communication with staff and state officials, and training responsibilities. Additionally, Mr. Roberson is present for meetings, placement decisions, treatment decisions, and leadership collaboration at Hope Haven's administrative offices. He is available to staff and leadership by phone and email twenty-four hours a day, seven days a week and is consistently responsive to every call and request, providing leadership, advice, and supervision on a daily basis. Any time a state official has requested to meet with or speak to Mr. Roberson, he has been available.

Hope Haven will continue to require its administrator to provide supervision and direction for the operation in a manner that ensures the safety and well-being of the children served and the overall excellence of the operation.


raw_content: A follow-up inspection was conducted at the operation regarding an ANE investigation in which this standard was cited. The operation reported as a correction that a training had been conducted on 10/6/2023. The administrator reported the training had been conducted, however, there was no sign-in sheet to provide evidence the training had actually took place. The administrator stated the staff that led the training is no longer employed with the operation, and he was not aware if a sign-in sheet was completed.

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 held a training regarding prohibited items and confiscation of prohibited items. This training was held on 10/23/2023, and a sign-in sheet was provided.


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

raw_content: During the investigation, it was observed that the operation did not notify the parent about the child's serious injury, which resulted in seeking medical attention, until the following day and not directly after ensuring the child was safe.

Correction Narrative: Executive Director, Jamie Sanders, provided an email advising the operation will comply with requirements of minimum standards in reporting any serious incident to licensing, parents, or law enforcement.  When an injury occurs to a child resulting in a serious injury and medical treatment, licensing and the CPS Caseworker will be notified in a timely manner. An admin review was requested.


raw_content: Children in care and staff reported that children were allowed to possess and utilize personal sexual stimulators at the operation. A child in care admitted to using a personal sexual stimulator on another child while at the operation.


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: One of the four employee records reviewed had a transportation training that was at least three weeks late.

Category: Training and Professional Development

Correction Narrative:
The operation sent out an email to new hires to ensure completion of the required tasks. The Human Resources Director will send a list of online classes to staff. The training team will check with the new hires throughout the week to ensure completion of all items before their training is complete. If the trainings are not completed the new hire will be asked to stay later to complete the trainings, before being offered to complete job-shadowing hours in the home.

In addition, the electronic records system will be modified to notify the employee and supervisor, to update/renew training requirements prior to expiration.


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

raw_content: One of the four employee records reviewed included a normalcy training that was over a month late.


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

raw_content: Two children in care reported witnessing a caregiver was sleep while being the only staff on duty. One of the two children reported witnessing the caregiver with headphones on and asleep. The caregiver admitted to falling asleep while on duty.

Correction Narrative: The caregiver received written notice of the operation's decision to terminate employment on 2/21/2023. The caregiver was terminated immediately.


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

raw_content: There were two missing staff signatures (initials) on a medication record for a specific medication.

Correction Narrative: Treatment director sent corrections on the medication records and a note that they are reviewing the standard with all direct care staff, counseled the individual and gave her written consequences.


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

raw_content: When reviewing medication records, two of the children's logs did not include the reason the medication was prescribed.

Correction Narrative: Staff meeting included reviewing medication logs, bathroom cleanliness, bedding requirements, and encouraging the staff to use a "inspector's eye".  See digital storage.


raw_content: During the inspection it was found that one admission assessment was not completed within in 30 days after the child was placed. This is the policy of Hope Haven.

Standard Number / Description: 748.151(2) - Operational responsibilities - Operate according to your approved plans, policies, and procedures

Correction Narrative: Operation changed their policy on how they do there admissions assessments. See digital storage.


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

raw_content: During the inspection it was found that a package of potato's were rotten. The treatment director disposed of the potato's on site.

Corrected at Inspection: Yes


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

raw_content: During the inspection it was found that out of the seven fire drills reviewed not all  fire drills were six months or less.

Category: Safety and Emergency Practices

Correction Narrative: Operation changed their form to include the stop watch time.


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

raw_content: The first aid kits in the vans did not have thermometers, and this is a requirement per minimum standards.

Standard Risk Level: Medium Low

Correction Narrative: Amber Stringer sent the receipts for three thermometers that will be put in their first aid kits.


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

raw_content: One of the beds in room 1 was missing a mattress protector, and the child refused to put one on her bed.

Correction Narrative: A picture was sent of the bed that was without a mattress protector on my visit to the facility.  The child is no longer there, but the picture has been entered to digital storage.


summary: 748.1007(b)(1) - Child/caregiver ratio-Awake caregiver may care for 15 children if any child in group requires treatment services

raw_content: Interviews, staff schedule and director confirm that they have not followed the required ratio of 8:1 when residents wake up at all times.    Director stated this was done outside of normal plan as some staff needed to use leave.

Correction Narrative: A plan for the operation to be fully staffed during the evening and early in the morning at the very minimum has been put into place.  Please see digital file.


raw_content: The direct care staff member used poor judgment by bringing vape pens for a child to use while at the facility.  She also purchased two vape pens for two residents.

Correction Narrative: This staff member was fired due to her poor judgement and purchasing vape pens for the children she was caring for. Documentation in digital file.


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

Correction Narrative: The operation had all of the remaining staff review and sign on the tobacco policy that nobody will be bringing any tobacco products into Hope Haven.  If they have any tobacco products, they are to leave them in their locked car.


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

raw_content: A training titled "Felt Safety" was signed by A. Aaron, but no qualifications were on the certificate.

Correction Narrative: Director has had covid and has been out of the office. An extension was requested - now 8/26/21.This was corrected and entered into digital file.


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

raw_content: We were only able to check one of the vans, but  the first aid kit was missing several items, such as: cotton, a first aid guide, rubble gloves, scissors, and tweezers.

Correction Narrative:
Director has had covid and has been out of the office. An extension was requested - now 8/26/21.
New first aid kits are in the facility.


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

raw_content: There was a large strip of trim missing from one of the staff/therapy doors, and it has been broken since April.  Also noted were several small holes in one of the doors in the hallway,  It appears that a work order is now in. Please send any documented efforts to get these things fixed.

Category: Physical Site

Correction Narrative:
Director has had covid and has been out of the office. An extension was requested - now 8/26/21.
repairs were made and pictures were sent.


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

raw_content: Three of the staff records read had no proof of a high school or equivalency certificate.

Category: Personnel

Correction Narrative:
Director has had covid and has been out of the office. An extension was requested - now 8/26/21.
all education documentation was sent in and put in digital file


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 direct care staff had sexually inappropriate web searches on her phone (accessible to the kids) and used  adult/inappropriate language while driving three girls in the operation's van.

Correction Narrative: Hope Haven staff sent me the correspondence that took place with this staff member, and also the trainings that she had to repeat in order to move forward with this citation.  The staff member appeared to show remorse and asked for assistance in handling things like this.  See Digital file.


facility_name: Autistic Treatment Center, Inc.

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

raw_content: During an inspection it was found that the operation is only maintaining a current pill count on the controlled substance medications and not not all medication.

Correction Narrative: The operation completed medication training and how to count all medications prescribed on 02/20/26.  An inspection of 3 of 3 current MARS showed the operation is now counting all prescription medications the same as controlled substances.


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

Deficiency Narrative: During an inspection it was found that the operation is only maintaining a current pill count on the controlled substance medications and not not all medication.


summary: 748.2903(a) - Triggered Reviews-Must occur as soon as possible, but no later than 30 days after the review is triggered

raw_content: During an inspection it was noted the operation is not completing a triggered review for children in 3 Emergency Medication incidents have occurred within 30 days.


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

raw_content: A medication report was missing a time of when an emergency medication was given.


summary: 748.2951(a)(1) - Evaluation-Overall annual evaluation includes use and effectiveness of emergency behavior interventions at operation

raw_content: During an inspection, the operation indicated that it has not been completing an annual review.


facility_name: The Pride Lands Center of Hope

raw_content: It was determined that a staff member had sexually inappropriate communication with a child in care.

Correction Narrative:
As per the Administrator, the operation acknowledge concerns relating staff's conduct. All staff will received coaching regarding expectations for maintaining professionalism, emotional regulation, and appropriate responses when interacting with youth. Immediate reminders were provided regarding adherence to agency policy, TIC principles, and behavior management expectations. In addition, the Administrator noted that management will increase monitoring of staff interactions through observation, shift supervision, and review of incidents to ensure expectations are consistently met. The operation will review internal policies regarding staff responsibilities and reinforce expectations during
team meetings and supervision. The operation will be addressed through corrective coaching and/or disciplinary action as appropriate and documented if any future concerns involving staff conduct will be promptly reviewed.


facility_name: Zachary's House LLC

raw_content: The operation failed to demonstrate prudent judgment by placing a child in care identified to have a sexual behavior problem with a roommate, resulting in a disclosure of sexual abuse by the collateral child.

Correction Narrative: The operation submitted the following action plan in response to the citation received for 748.507(1) on 04/11/2026 via email: Staff have received refresher training on supervision protocols to ensure the safety of all residents. Additionally, (Attachment A), when applicable for each client, has been reimplemented to maintain compliance.


facility_name: Residential Care at the Summit, LLC

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

raw_content: The people list was reviewed and two staff members did not have their background check inactivated within 7 days of leaving the operation.

Correction Narrative: An email was received from the Administrator of the operation with the following compliance: both individuals background checks have been made inactive (this was verified in CLASS) and the following new procedures have been implemented: A tracking system has been implemented to document all staff separations, including the exact date of departure, the Director/Administrator will review the background check system weekly to ensure any separated individuals are inactivated within 7 days, A checklist has been added to the employee separation process to include immediate notification and follow-up for background check status updates and the staff responsible for records management have been retrained on the requirements of Rule 745.651(1). All documents provided have been uploaded to the document library.


facility_name: J's House

summary: 748.863(a)(3) - Caregiver for child-care or prog. svcs only must have 8 hours EBI training, 4 before counted in ratio, rest in 90 days; 16hrs for treatment svcs

raw_content: During the inspection, we observed two of four employee records to reflect only 12 hours of preservice EBI as opposed to the required 16.

Correction Narrative: On 4/24/26, the operation provided a correction plan indicating the outstanding EBI training hours would be completed for the identified staff before 5/15/26.  The LCCA will be administering the additional 4 hours needed.  This brings this standard back into compliance.


facility_name: ACH Child and Family Services

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

raw_content: A child in care did not receive a copy of their service plan.

Standard Risk Level: Low

Correction Narrative:
The operation came into compliance by the administrator retraining on policies and procedures related to service plan meetings. During the retraining, minimum standards were reviewed in detail to ensure consistency and compliance across the team.

Documents can be found in document library of training topics and participates.


facility_name: High Plains Children's Home

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

raw_content: A child's Service plan did not document supervision for the child.

Correction Narrative: The operation has provided a blank template with the updated section specific to supervision.


facility_name: Independence Farm

summary: 748.125(d)(4)(A) - Suicide Screening- A screening tool must be administered at admission for each child 10 years of age or older.

raw_content: In the review of 2 of 2 child records, suicide screening tools were not completd.

Category: Organization and Administration

Correction Narrative: The screenings were completed for the children required.


raw_content: In the review of 1 of 2 child medication records,  pill count did not match medication record.

Category: Medication

Correction Narrative: Medication logs were reviewed for two children. Counts were reviewed as correct.


facility_name: The Burke Foundation-Pathfinders RTC

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

raw_content:
748.535(2)-The licensed administrator must ensure the operation complies with the current heightened monitoring plan.
Narrative: During a review conducted on 03/24/2026 it was determined that:
(1)	the Administrator failed to ensure compliance with the current HM Plan; and
(2)	12 months had elapsed since the effective date of the plan.
The heightened monitoring plan for this operation included a specific planned end date at the 12-month mark by which the operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of post plan monitoring.  As a direct result of the administrators failure to ensure timely compliance with the heightened monitoring plan, this operation is now unable to successfully move to post-plan monitoring.  Furthermore, the operations planned end date must now be revised, and the period of heightened monitoring must be extended.
Further details of the administrators failure to ensure compliance include the following:
-Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring; and
-Operation was unable to meet compliance with Medium-High or High weighted licensing citations, including having an open investigation.

Correction Narrative: An HM extension was approved effective 03/24/2026.  In conjunction with this extension, a new deadline was established by which all requirements must be completed by your GRO in order for the operation to be released from its HM plan and move to the Post-plan Monitoring Stage of HM.  Because the extended deadline is now effective, HHSC has determined that the operation is compliant with the requirements of 26 TAC 748.535(2).  The HM deadline for your operation has been extended by 6 months and the new deadline is 09/25/2026.


raw_content: It was determined that a staff member did not allow a child in care go into the cafeteria to eat with the rest of the children because they did not directly inform them that they had washed their hands.

Correction Narrative: The administrator spoke with the staff and gave him other alternative options to include offering a child hand sanitizer if they refuse to wash their hands.


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

raw_content: It was reported and confirmed by staff that there is cursing while children are present.

Correction Narrative: The Administrator spoke with the management team regarding the use of curse words by staff and the Program Coordinator met with staff regarding the language used and being mindful that there are no children within hearing distance.


facility_name: The Hemple Shelter LLC

summary: HRC Sec. 42.068 - Required Postings-Residential Treatment Center's must have "No Trespassing Signs" posted.

raw_content: While completing the walk-through, it was observed the operation did not have "No Trespassing Signs" posted, and the operaion is classified as an RTC.

Correction Narrative: The operation sent an email with attached photos of the No Trespassing signs located in the front of the operation and on the side gate.


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

raw_content: While reviewing medication records, one of the four medication records reviewed indicated there were nine pills remaining when the actual count was ten. After careful review it was determined the dates were inaccurate. The child had been administered the medication; however, it was documented inaccurately. One of the four staff training records reviewed had incorrect spelling of the staff's name on multiple training records.

Correction Narrative: Supervisory staff will conduct weekly reviews of MARS and personal training files to ensure accuracy and completeness. A double check process will be implemented for medication counts and documentation at the end of each shift to identify discrepancies promptly. Administrative staff will review training documentation prior to filing to ensure staff names and information are spelled correctly and recorded accurately.


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

raw_content: During the walk-through, a waffle was laying in the freezer uncovered, and the actual waffle packaging was not properly sealed.


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

raw_content: A training certificate was provided for one of the four staff records reviewed that did not include the trainer's name.

Correction Narrative:
Supervisory staff will receive instruction on proper documentation requirements to ensure compliance with Minimum Standards.

Quarterly audits of training files will be conducted by administration to verify that all required information is present.


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

raw_content: During the walk-through it was discovered the refrigerator temperature was 42 degrees and the freezer temperature was 10, which are both above the requirement.

Correction Narrative: The operation emailed photos of the refrigerator and freezer temperatures that show compliance with MS.


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

raw_content: While conducting the walk-through of the operation, it was discovered ceilings in two bedrooms and around the fire alarm were dusty.


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: During the inspection, I observed three of four staff records reviewed showing EBI training at seven-month intervals and the fourth did not require EBI training by standards.

Correction Narrative:
The operation sent an email reporting the staff that are currently out of compliance will complete the required EBI training immediately.

The facility will implement a training tracking system to monitor staff training hours and due dates for the six-month EBI requirement.

The program Administrator or designee will review training records monthly to ensure staff remain in compliance.

EBI training will be scheduled in advance every six months and included in the facility training calendar to ensure all caregivers have access to the required hours.


facility_name: Boys to Men RTC

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

raw_content: Camera extensions were hanging over walls and cabinets. An orange extension cord, a basket of clothes and objects were on the floor in the common area.

Correction Narrative:
Corrective Action Taken Plan was submitted on 2/24/26 by Mr. Henderson informing the following took place to comply with minimum standards.
All cords were removed and properly secured following maintenance completion. The laundry staging area was reorganized to ensure baskets remain flush against the wall and away from traffic pathways. A full safety walkthrough was completed to confirm no additional hazards were present. Photographs
were taken to document compliance. Date Corrected: 02/19/2026. Corrected By: Dannon Henderson, LCCA.
Documentation must now be logged and supervised when maintenance requires extension cords to be removed immediately upon completion. Laundry baskets must remain against the wall and outside walking pathways, staff assigned is to clear staging areas after each shower rotation. A daily environmental safety checklist has been implemented along with weekly administrative walkthroughs
and monthly quality assurance environmental reviews.


facility_name: Adullam Homes, LLC

summary: 745.911(2) - Person cannot serve as a controlling person in a child-care op if ineligible for a permit because of adverse action sustained w/in previous 5 years

raw_content: A controlling person who was previously barred from serving as a controlling person until 5/8/2028 became associated with this operation in 2023.

Correction Narrative:
3/9/26 - The operation's administrator submitted a corrective plan stating that the operation will thoroughly research individuals for eligibility before assigning them as controlling persons. The change will be reported to CCR in a timely manner to ensure compliance.
New application submitted under different ownership.


facility_name: Kismet Residential Treatment Center

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: Child in care was not given 6 a.m. medication until after 11 a.m. and was not given a different prescription medication for 4 days due to operation error.

Correction Narrative: RCCR conducted a follow-up inspection on 04/24/2026 during which two staff and two children were interviewed. Both children expressed to take their medication as prescribed and expressed no concerns with medication administration.  Children also stated that they are required to cough, open their mouth, and stick out their tongues to confirm that they've taken their medication. Both children expressed to know their medication and staff have always administered to right dosage. Both children also expressed no overall concerns at the operation, and they feel safe. One staff interviewed doesn't administer medication; however, the staff confirmed that staff are required to take medication administration training. The staff expressed no concerns regarding medication. Additional staff, who is certified to administer medication, provided a detailed/mock medication administration during the interview and no concerns were noted.  Staff also confirmed that they verify all information during medication administration and ensure the children take medications by make sure they swallow and take their medication and verification is by coughing, opening mouth, and lifting tongue to show no visible medication. Staff also confirmed that access was removed from the medication administration system, audits are being conducted, and training is scheduled.


raw_content: Three out of four children medication records reviewed indicated a child was administered a prescribed medication at the wrong time contrary to the health care professional's order.

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: Staff will continue to complete daily running counts of all medications, and daily review of the medication records. Any errors including time stamp errors will be documented and corrected with written justification of the error that occurred.


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

raw_content: During the inspection 4 of the 4 child records reviewed medication log was inaccurate. Dates that the medication was administered did not match the medication instructions provided by the physician. Date typos for dates. on several medications.


facility_name: Alijah House Children's Services

summary: 748.3109(b) - Smoke Detector-Batteries must be changed annually or sooner, as required to maintain operable smoke detector units

raw_content: During the investigation inspection, the inspector heard the smoke alarm periodically beeping, indicating the batteries need maintenance.


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: During the investigation inspection, it was observed that three fire extinguishers were overdue for an annual inspection.


facility_name: Greener Pastures RTC

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

raw_content: A staff member was seen sleeping during the night working hours.

Correction Narrative:
The operation submitted a corrective plan via email on 3-31-26 for the cited standard indicating corrections will be as the following:

  All direct care staff retrained on 3/31/2026 on supervision requirements, with emphasis that staff must remain awake, alert, and actively supervising at all times during overnight hours.
  Staff were reminded of professional expectations, including maintaining visible and active supervision to prevent any perception of inattentiveness.
  Supervisors will conduct random and unannounced overnight checks to ensure staff are awake and fulfilling supervision duties.
  A night supervision log has been reinforced, requiring staff to document hourly checks and activities during overnight shifts.


facility_name: Revival Heart RTC

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

raw_content: 1:1 supervision requirements for a child in care were not consistently followed by childcare staff.

Correction Narrative: The operation voluntarily closed, but if the operation re-opens the operation will conduct supervision training with all staff. The training will provide information and identify strategies to prevent or reduce the risk of children and youth in foster care from running away.


facility_name: Cal Farley's Boys Ranch

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

raw_content: A caregiver failed to appropriately intervene when children in care were engaging in horseplay behavior, which resulted in injury.

Correction Narrative: This standard is found compliant.


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

raw_content: Eight of nine children report that supervision on the home is not being conducted per service plan requirements.

Correction Narrative: An inspection at the operation was conducted on 4/23/26.  During an interview with the operation administrator, it was discussed that supervision has been discussed with all house parents at the weekly staff meeting.   Operation policies and procedures related to supervision and following the child's service plan were discussed.  The administrative staff have spoken with the individual house parents and reviewed the citation and discussed expectations for the home.  CLS will continue to speak with children and house parents to ensure that appropriate supervision is being maintained in the home.


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

raw_content: Seven of nine children in care report caregivers utilizing profane language in the home.


summary: 748.125(d)(4)(A) - Suicide Screening- A screening tool must be administered at admission for each child 10 years of age or older.

raw_content: One out of eleven child records did not have suicide screening completed at intake.

Correction Narrative: This information had been added to the admission checklist to ensure that the suicide screening is conducted at the time a child is admitted to the operation.


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

raw_content: Two out of eleven records reviewed did not have the suicide screening completed within 90 days of prior screening.

Correction Narrative: This information has been added to a 90 day checklist to ensure that all case managers are aware that suicide screenings are completed in a timely manner.


summary: 748.2151(b)(2) - Medication record - update cumulative record within 24 hours of administering medication if operate on a cottage home model

raw_content: One child medication record reviewed did not show documentation of the medication being dispensed on 10/6/24 and 10/7/24.

Correction Narrative: Staff were reminded during a staff meeting of ensuring that medication logs are completely at the time the medication is dispensed.  The staff directly involved in this incident were also coached on medication requirements.  Medication administration training was also updated to include the updated information.


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

raw_content: The operation failed to ensure a medication was refilled in a timely manner which consequently resulted in the child not being given a psychotropic medication.

Correction Narrative: All staff have been made aware that medication refill request  must be requested within 7 days.  The medication form was also update to ensure that staff have a reminder of requesting a refill.


facility_name: Ben Richey Boys Ranch

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

raw_content: several of the childrens' records did not include documentation that they had a hearing examination.

Category: Child Care

Correction Narrative: Administrator emailed Inspector with the operation's plan moving forward stating that the house parents will keep with due dates for appointments, make the appointments, and take the children to their appointments. The Campus Directors will also monitor the due dates and remind the House parents of upcoming due dates.


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

Category: Admission, Service Planning, Discharge


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

raw_content: Child's Right Policy has missing documentation.

Correction Narrative: Email received by Administrator, updating Child Rights form. Moving forward the form will be used and stored in child's record.


summary: 748.363(13) - Personnel records - Include any documentation of the person's performance with the operation.

raw_content: No formal performance review is conducted for operation staff.

Category: Reports and Record Keeping

Correction Narrative: On 1/4/24 an email was received with an attachment stating that they will be conducting annual performance reviews going forward. The attached document sent is a newly implemented performance review form.


summary: 748.1381(1) - Service Plan Review-If child not receiving treatment services, review at least 180 days from date of last service plan

raw_content: It was found that one out of two children is 68 days past due for a service plan review.

Correction Narrative: Mashelle Ancell sent an email saying the child in care service review meeting has been scheduled for 8-27-21. The guardian was notified of the meeting. SH.


facility_name: Boysville Inc

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

raw_content:
During a review conducted on 4/9/2026 it was determined that:

(1) the Administrator failed to ensure compliance with the current HM Plan; and

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

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

Further details of the administrators failure to ensure compliance include the following:

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

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

Correction Narrative: An HM extension was approved effective 4/9/2026.  In conjunction with this extension, a new deadline was established by which all requirements must be completed by your CPA/GRO in order for the operation to be released from its HM plan and move to the Post-plan Monitoring Stage of HM.  Because the extended deadline is now effective, HHSC has determined that the operation is compliant with the requirements of 26 TAC 748.535(2).  The HM deadline for your operation has been extended by 6 months and the new deadline is 10/10/2026.


facility_name: Connections

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

raw_content: A child in care was not given her medication as prescribed.

Correction Narrative:
The operation provided compliance via email on 10.23.24 stating the following corrective action:

1. The operation revamped their Medication Refill Form to better track when refills are ordered.
2.	Residential Supervisors are responsible for auditing medications daily, reviewing all Medication Refill Request Forms, and following up with the pharmacy as needed until the refills arrive.
a.	Additionally, staff are to notify the on-call supervisor whenever medications are delivered so the supervisor can track and ensure the medication is started timely.

Additional in-person follow up was completed on 11.06.24. The operation has implemented medication refill forms within each medication binder. It appears the operation is documenting medication refill request at least one (1) week prior to the refill being needed. The operation is also conducting two (2) medication audits and documenting the findings within the medication binders on the MARs. These audits are being conducted at 7PM and 9PM.


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

raw_content: Dog Feces, tall grass, and protruding nails on walkway were present in the yard.

Correction Narrative:
The operation provided compliance via email on 04.18.24. The following response and corrective actions were provided:

Response:
All of the investigator's findings take place in areas in which our youth are not currently permitted.

Corrective Actions:
1.The nails have been hammered in on the plank on the side of the building near the construction fencing that youth are not allowed near.
2.The dog excrement was cleaned up and the supervisor reiterated to staff the importance of following through on chores if/when youth do not complete them satisfactorily, and then completing the task themselves when necessary.
a. The area in which the excrement was found (back corner of the yard) was the usual area the dog uses, and again, is not an area in which we allow youth activities.
3. The lawn care company is being called out ahead of schedule to mow the grass on the side of the building near the construction fencing that youth are not allowed near.


facility_name: Unity Children's Home - Girls

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

raw_content: It is documented that a child in care inflicted cuts on her arm on 08/24/2023, there is no documentation showing that a suicide screening was administered.

Correction Narrative: Unity Children's Home completes ASQ screenings after every incident where a child displays warnings, or attempts necessitating a suicide screening. The tools are then shared with the treatment team members and Managing Conservator.


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

raw_content: A child in care inflicted cuts on her arm during a crisis situation on 08/24/2023, this was not reported to Licensing until 08/30/2023.

Correction Narrative: Unity Children's Home reports all serious incidents to Licensing, Contract and DFPS Management as soon as aware of the required incident. The information after notifications is then documented and placed in the child's records for future references. Unity Children's Home understands the importance of this requirement and remains in compliance with this protocol and minimum standard rule.


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

raw_content: A child in care suffered self-inflicted cuts to her arm on 08/24/2023 and was not seen by a medical professional until 08/28/2023 where the determination was made to admit her into a behavioral hospital for evaluation.

Correction Narrative: Unity Children's Home agency understands and acknowledges the importance of follow up and immediate care for every incident where the child displays warnings or attempts that require an ASQ screening tool to be completed. The information is then communicated with Unity's treatment team members, managing conservators. Unity Children's Home will continue to follow screening tool protocol so that the agency remains in compliance with minimum standards.


facility_name: 2nd Chance Treatment Center

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

raw_content: It was determined that a basket hold was initiated and there was no supporting documentation completed or provided.

Correction Narrative: An email was sent from administrator. A mandatory training was conducted with staff on 2/15/2026. Staff was reminded of the hands-off policy in the facility.  Staff recognized that they would provide a physical barrier to assure the safety of all staff and residents. Staff and residents will not engage in physical restraints. The document and training signature list can be found in the document library.


facility_name: The One Discovery RTC

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

raw_content: The operation has not validated the current staff list. Last validation was 8/13/2024.


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: Record of TB screening was not observed to be present in one employee file.

Correction Narrative: The operation emailed a copy of the employee's TB Screening along with the following corrective action: Effective immediately, we will be conducting an audit of all active employee files to ensure they contain all required and up-to-date documentation. The employee file cabinet will be rekeyed to restrict unauthorized access. We are currently implementing an electronic record system that will enable us to track and manage documentation more efficiently. This system will provide automated notifications for any missing or outdated information, ensuring our files remain in compliance.


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

raw_content: Annual trainings that included Trauma Informed Care, Psychotropic Medication Normalcy, and Suicide were all found to be delinquent for one employee.

Correction Narrative: The operation emailed the following corrective action: Effective immediately, we will be conducting an audit of all active employee files to ensure they contain all required and up-to-date documentation. The employee file cabinet will be rekeyed to restrict unauthorized access. We are currently implementing an electronic record system that will enable us to track and manage documentation more efficiently. This system will provide automated notifications for any missing or outdated information, ensuring our files remain in compliance.


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: An employee who has not worked for the operation since 5/16/2025 has an active background check.

Correction Narrative: Effective immediately, we are conducting an audit of all active employees to ensure that their employment status and associated records are current. As part of this effort, we are implementing a new electronic record management system designed to streamline the tracking and management of access credentials and other essential information. This system will enable us to more efficiently identify and address areas where active id's should be terminate. Our current personnel person (Ms. Wilkins) will be responsible for this area.


summary: 748.1337(a) - Initial Service Plan-Base on needs identified in admission assessment; justify delay in addressing needs if service planning team prioritizes goals

raw_content: Two service plans reviewed contained the same needs for both children.

Correction Narrative: Ensuring that each service plan is tailored to a child's specific circumstances is a priority, and we are taking steps to prevent this issue from recurring.  Additionally, the individual responsible for the original plans is no longer employed with The One Discovery. Moving forward, we remain committed to maintaining high standards in service planning to ensure every child receives the care and support they need.


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

raw_content: Based on the information gathered and obtained throughout the investigation it was determined a staff member slammed a child to the ground.

Correction Narrative: The standard was evaluated and found to be in compliance.


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

raw_content: The operation's child-care administrator position has been vacant since May 28, 2024.

Correction Narrative: The operation's child-care administrator position was filled in August 2024.


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

raw_content: During interviews with the victim and staff members, it was discovered that the children in care are allowed to lay on and or sit closely with staff demonstrating inappropriate boundaries.


summary: 748.2605(a)(1) - Personal Restraints Prohibited-Restraints that impair child's breathing by putting pressure on child's torso

raw_content: Staff member place knee on ribs while trying to conduct a restraint on a child in care.


summary: 748.1333 - Preliminary Service Plan-Treatment director or PLSP must develop, sign, and date the plan for children receiving treatment services

raw_content: A child record reviewed did not have a signature on the preliminary service plan.

Correction Narrative: The correct document with the signature was not available during inspection but was later submitted. To ensure records are available upon request. Our records will be provided via a printed binder or access will be granted to our electronic records system to ensure timely access to records upon request.


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

raw_content: A child record reviewed did not have a signature on the admission assessment.


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

raw_content: A review of a staff files has no employee reference checks documented.

Correction Narrative:
The operation submitted proof of employee reference checks done prior to pre-employment. The following action has been taken: Each person hired after 8/09/2023 has their have their reference
and checked up included with in their employment file.


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

raw_content: Licensing arrived at the facility at 9:45 AM to conduct an unannounced monitoring inspection and was not provided records until 2 hours later. Several requested records were unavailable.

Correction Narrative: The following action has been taken: To ensure records are available upon request. Our records will be provided via a printed binder or access will be granted to our electronic records system to ensure timely access to records upon request


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

raw_content: Staff did not exhibit accountability or awareness when they allowed a child to elope from the facility.

Correction Narrative:
A physical follow up was conducted. One child and three caregivers were interviewed. No supervision concerns were noted.

CORRECTIVE ACTION PLAN: We aim to ensure the safety and well-being of all children in our care, while fostering a responsible and vigilant workforce committed to preventing such incidents in the future. Our youth has demonstrated the use of their coping skills which includes allowing them outside for walks or in the enclosed area. Many times, this de-escalates our youth without the use of restraint or any other incidents.


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

raw_content: Multiple children in care stated children are subjected to profane language.

Correction Narrative: CORRECTIVE ACTION PLAN: The One Discovery has conducted a training class on appropriate communication techniques and the impact of language on children. Encourage the use of positive reinforcement and constructive feedback.  Implement a monitoring plan to ensure that the individual adheres to appropriate behavior moving forward.


raw_content: Staff did not exhibit prudent judgement when they did not attempt to de-escalate or restrain a child in care ready to harm themselves, property, or others.

Correction Narrative: CORRECTIVE ACTION PLAN: Schedule regular check-ins to discuss progress, address any ongoing issues, and provide constructive feedback. Use these meetings to reinforce positive changes and offer additional support if needed. Ensure the employee is fully aware of and understands all relevant policies and procedures related to professional behavior and responsibilities. Staff regular de-escalate and redirect the youth to prevent them from harming themselves and others.


summary: 748.2151(e) - Medication Record-must document non-prescription medication or supplement given to child and how often given

raw_content: The children and staff state that the children were given over-the-counter vitamins, but there is no documentation of them.

Correction Narrative: All over the counter medications including vitamins will be recorded/logged.


raw_content: Two staff members admit that they repeat the curse words that the children use against them.

Correction Narrative: Staff was given a training class on de-escalation 2/7/2024 to provide redirection, eliminate rephrasing, or better words choices.


summary: 748.1013(a) - Child/caregiver ratio-A caregiver must be awake when caring for a child needing constant supervision

raw_content: Two of two children interviewed stated that they saw a staff member sleeping at night and one child requires 24-hour supervision.

Correction Narrative: The operation has implemented shift changes.


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

raw_content: A child in care required medical attention for allegedly ingesting bleach and the incident was not reported to licensing.

Correction Narrative: Email was received on 06/05/2024 stating that this was a serious incident report and was reported to the hotline, the police and EMT were contacted. All serious incidents are reported to the hot line and other professional service providers as soon as possible.


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

raw_content: A child in care required medical attention for allegedly ingesting bleach and the incident was not reported to the parent.

Correction Narrative: Email was provided on 06.05.2024 stated that the caseworker was notified in this incident with details with the police incident number and hotline report number. This information is provided via text, voicemail and email.


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

raw_content: Two serious incidents occurred and where not documented as required by minimum standards.

Correction Narrative: Email received on 06/05/2024 stating that all serious incidents that occur are documented as required, reported to the casework, hotline as well as contacting the EMT's or police when necessary.


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

raw_content: Child in care was able to access chemicals and ingest them.

Correction Narrative: Email was received on 06/05/2024 stating that stating the closet where our cleaning products are kept was changed the next morning to a dead bolt lock.


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

raw_content: An overnight caregiver did not follow the operation's 24 Hour Continuous Supervision policy when they were found to be asleep while present at the operation.


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

raw_content: Overnight operation staff failed to provide adequate supervision due to the staff sleeping while on duty.


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

raw_content: An unauthorized individual is present at the operation and has direct access to children in care.

Correction Narrative: An unauthorized individual was deactivated from CBCU 02/14/2024.


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

raw_content:
Regarding IMPACT case # 49930701, information in class stated that the AWOL incident occurred on 12-24-23 but was reported to the hotline on 12-26-23 at 5:40pm.

Regarding IMPACT case # 49930963 (Merged), in formation in class stated that the AWOL occurred on 12-23-23 but was reported to the hotline on 12-27-23 at 6:44am

Correction Narrative: CORRECTIVE ACTION:  AWOL reporting is serious at The One Discovery.  ALL residents not at their designated location up for pick up or elopement are reported promptly to the appropriate authorities, reporting to the hot line and texting, calling and following up with and email to the caseworker.  These actions are taken immediately.


summary: 748.453(a)(5) - Unauthorized AbsenceAnnual summary log must include the intake report number, if report was made to CCR or DFPS

raw_content: The unauthorized annual summary log does not include the intake report number for the report made to the hotline, it does not have the child's age as required in 748.453(a)(1) in addition does not indicate how long the child was gone for as required in 748.453(a)(3).

Correction Narrative:
CORRECTIVE ACTION PLAN
The following action has been taken: The age of the child has been added and was the only information missing from the Annual AWOL Summary Log. All other information was being recorded.


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

raw_content: Staff open the door and encourage the children to walk out while they are attempting to run away.

Correction Narrative:
CORRECTIVE ACTION PLAN
The following action will be taken: The staff does not encourage the youth to walk out. When a youth indicate getting fresh air is part of their coping skill to calm down. The youth under the watchful supervision of the direct care staff can and will be utilized. This action will allow the youth to de-escalate without restraint, assault on staff members, bodily inquire or property damage. This decision will be made prudently and on a case by case bases.


raw_content: Between 9/18/2023 and 11/10/2023, DFPS made multiple requests to obtain operation documents for review. Operation documents were not received until 11/17/2023 and 11/29/2023.

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

Correction Narrative: The operation provided a copy of their written corrective action plan on 3/2/2024. Additional staff has been given access to operation records to ensure records requests are completed in a timely manner.


raw_content: A child in care at an RTC was neglectfully supervised.

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:
The agency submitted corrections via email. In response to the citation, all staff were required to participate in a safety training. This training was scheduled and attended on July 1, 2023. All new employees will also be required to complete.
the training. Safety plan has been put in place to avoid disruption during medication administration. The One Discovery RTC will have all residents go to the common area during distribution of medicine. The One Discovery RTC will continue to update trainings and provide teachings to the
staff as we see fit and to ensure that no other issues of this nature arise.


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

raw_content: Two serious incident reports were missing the information as to what staff were present during the incident.

Correction Narrative: I, Ashley Williams, RCCR made face to face contact Administrator Carla Johnson. Ms. Johnons stated moving forward the operation will submit both completed incident report along with serious incident report call in sheet.   The form now contains all components in alignment with minimum standards.


summary: 748.311(8) - Serious Incident Documentation-Includes interventions made during and after the incident, i.e. medical interventions, contacts made, other actions

raw_content: Two serious incident reports were missing information in regard to what interventions occurred during the incident.


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

raw_content: Two serious incident reports were missing the time that the incidents occurred.


summary: 748.1003(a) - Child/caregiver ratio-Caregiver may care for 5 children if any require tx svcs, 8 children if not; children under 5 yrs old count as 2 children

raw_content: During an outing there was only one staff member with six kids and one if the children's service plan states that the child but have supervision of one staff to five children.

Correction Narrative: RCCR Ashley Williams, completed a full walk-through during inspection and observed staff/resident ratio in compliance.  Ms. Carla stated in the future the operation will ensure ratio standards are aligned with child service plans. The operation will ensure staff availability for 1:1 supervision as needed.


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

raw_content: CCI requested staff records that were needed for the ANE investigation, on June 29, 2023, and multiple times after.  The documents were not received until July 21, 2023.

Correction Narrative: The operation has assured that all administrative staff has access to records/documents in the absence of LCCA Carla Johnson.


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

raw_content: Two serious incident reports reviewed were missing information in regard to the child's gender and the child's age.  The report does include the child's date of birth.


summary: 748.363(10) - Personnel records-For each person who transports a child, include copy of valid driver's license or DPS driver's license check done in last 12 months

raw_content: The staff did not have a current valid driver's license..

Correction Narrative:
An email was sent from operation Administrator stating.
CORRECTIVE ACTION PLAN

The following Deficiency was corrected:

Correction: All staff driver's license were reviewed to ensure that that were update to date. A spreadsheet was created to be reviewed monthly and to give notice to employees' at least 30 days prior to expiring driver's license to be renewed and new copy of driver's license updated in the employee's files as of March 19, 2023

***The One Discovery RTC will continue to review and update our records of staff to ensure that no other issues of this nature arise.


raw_content: Witnesses advised that the child was left unattended by the staff member.

Correction Narrative:
An email was sent from the operations administrator stating.
CORRECTIVE ACTION PLAN
The following Deficiency was corrected:
Correction: All staff were required to participate in a training for Child Safety and Supervision. This training was scheduled and attended on March 19, 2023. All new employees will also be required to complete the training.


raw_content: Incident report documentation was missing information, such as the correct address, nature of the incident and conclusion of the incident.

Standard Number / Description: 748.311 - Serious Incident Documentation-Documented in written report

Correction Narrative:
All staff were required to participate in a training for "Report Writing". This training was scheduled and attended on May 27, 2022. All new employees will also be required to complete the training.

-Report Writing.
-The One Discovery RTC


summary: 748.4041 - Driver & passengers must follow all laws when driving, including laws on use of child passenger safety seat systems, seat belts & liability insurance

raw_content: It was confirmed that children in care were not wearing seat belts while being transported in a vehicle.

Correction Narrative: The operation provided a follow- up response. The operation stated that when transporting children staff will ensure that children are properly secured and the number of children in the vehicle will not exceed the seating capacity. A second vehicle will be utilized if needed to ensure that all children are properly secured while in a vehicle. Staff will ensure that all children remain in their seats and seat belted until the behicle arrives at its destination.


summary: 745.621(a)(3) - AP Initial background checks submitted - At the time you contract with someone who requires a background check

raw_content: The current treatment director did not have a background chick on file. The treatment director is currently hired as a contractor and is assisting the operation with the treatment services they provide.

Correction Narrative: On 12/22/2021 the operation submitted a background check for Bobby Price, Treatment Director. According to CLASS there Bobby Price in Eligible and the background check is complete.


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: One out of three staff records did not include TB screening documentation in the staff record. The TB record was provided by the administrator once they were notified it was not in the record.


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

raw_content: During a walk through inspection the freezer in the storage room was at two degrees Fahrenheit. The freezer was brought down to zero degrees after the operation staff was notified.


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

raw_content: A caregiver admitted to not completing documentation of serious incident.

Correction Narrative: The One Discovery RTC LCCA will complete a documentation training with all staff to ensure all serious incidents are documented and turned in to the administrator by 9:00 am the next morning.  Once submitted, all incidents will be reviewed by the LCCA to ensure all documentation is thorough and completed prior to being filed in the client binder. This training will be completed by all staff by January 27, 2022.  A copy of the training roster will be kept in the Administrator's office for review.


facility_name: Tree of Life RTC

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

raw_content: The operation failed to employ a full-time administrator for the operation at the expiration of the 60 days given to them in technical assistance issued by assessment on 11-17-25. As a result, the operation was cited on 1-16-26 and given another 60 days to employ a new administrator.

Correction Narrative:
Tree of Life RTC has formally identified a qualified Licensed Child-Care Administrator candidate who has accepted the position and is scheduled to begin employment May 1, 2026.
An offer letter has been issued to the identified LCCA candidate. Upon receipt of the signed offer letter, Tree of Life RTC will:

Submit a copy to Licensing as verification of designation

Add the administrator to the DFPS Child-Care Licensing (CLASS) caregiver portal

Update organizational records to reflect administrator assignment

Ensure all administrator responsibilities transfer to the designated LCCA effective start date
This action restores compliance with administrator designation requirements and strengthens leadership continuity within the operations regulatory framework


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

raw_content: During the revierw of a childs file, 2 nitial service plans were noted in the childs file with 2 dates of initial service plan completion. One date of plan completions says 1-26-26 and another date of initial service plan completion was 11-26-25

Correction Narrative:
Tree of Life RTC will conduct weekly supervisory reviews of active child records, including service plan documentation, to confirm accuracy and proper designation of plan type. This process will support timely identification and correction of documentation errors and help ensure that all active child records remain accurate and current.
Staff responsible for completing service plans have also been reminded to verify correct form selections prior to finalizing documentation to prevent similar clerical errors moving forward


facility_name: Kensley Care LLC dba Kensley Care South

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

raw_content: During the investigation inspection, paint was observed peeling from the wall and the paint on the bathroom door is stained and needs to be repainted.

Correction Narrative: On February 7, 2026, painting at Kensley Care South was completed to ensure the facility remains in good repair. To ensure ongoing compliance, the administrator or a designee will conduct a daily physical plant walkthrough. The results of these walkthroughs will be documented in the physical plant log


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

Deficiency Narrative: During the investigation inspection, paint was observed peeling from the wall and the paint on the bathroom door is stained and needs to be repainted.


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

raw_content: The staff trainings were taken late for Preventing and Recognizing Youth Sexual Abuse training and The DFPS Psychotropic Medication Training

Correction Narrative: The following corrective plan was provided by the operation: The Kensley Care South administrator will ensure that all staff members complete their annual training in a timely manner. To assist with compliance, a reminder email will be sent to each staff member 30 days before their current training expires. Additionally, all current staff will retake the necessary training at the beginning of each year to ensure compliance for the upcoming calendar year.


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

raw_content: The couches in the living room were observed to be broken and in not good repair.

Correction Narrative:
New couches were purchased for the living room, and the broken ones were disposed of properly. Furthermore, the operation provided the following correctivve plan via email: Kensley Care South LCCA will ensure all physical site
equipment and furniture is maintained in safe and
functional condition. As part of this responsibility, a
replacement couch was delivered to the facility on
November 3, 2025.


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

raw_content: There are multiple food items expired, and uncovered food in the fridge.


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: The operation is not providing children in care with sufficient pairs of underwear.

Correction Narrative: Kensley Care South will complete bi-monthly clothing inventories that will be reviewed by administrative personnel to ensure all children have adequate clothing including underwear. Kensley Care South has purchased an overflow of underwear to have readily available.


summary: 748.685(c)(2) - Caregiver responsibility - provide a safe environment

raw_content: Staff did not provide a safe environment for residents as a weapon was brought into the facility.

Correction Narrative: 1 out of 7 children present at the facility spoke to RCCR. The child stated that he feels safe, and the operation is a safe environment. The child stated that he has not observed any contraband on campus, and staff search the boys with a wand and a pat down. He further stated that staff do weekly room checks and staff check the outside of the premises daily. The children were observed to be supervised by the staff at all times. Shift lead stated that she is always supervising the boys and she is always within line of sight. Regarding searches, male staff conduct the searches and if the boys are being sneaky in their rooms, staff will search their rooms. Shift lead, stated that staff are checking inside and outside the premises daily for any hazards that may be present. The case manager provided me the last 4 serious incident reports, and there were no concerns with supervision. Case manager stated that at night there are 2 staff present who do 15 minute checks. She stated that all other shifts always have 3 staff on shift. Case manager stated that staff can hear and see everything the children are doing at all times. Regarding searches, she stated that they use the wand and if staff have a reason to search them such as seeing contraband, staff announce that a search will be conducted and staff go into the rooms and search. She stated that staff walk the inside and outside of the premises on each shift, and the walkthroughs are documented and turned into administration.


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

raw_content: During the inspection, the shower in a bathroom downatirs was observed to have dirt and grime present, and potentially mold can be present due a shower leak.


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

raw_content: During the inspection, it was observed that multiple food items were expired and not stored properly.


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

raw_content: Staff was using derogatory language, including shaming, ridiculing, and yelling at a child in care.

Correction Narrative:
Kensley Care South staff will participate in a
de-escalation training held on September 10, 2025. A sign in sheet will be available for RCCL review.
Staff of concern was placed on a safety order and removed from the schedule throughout the duration of this investigation. Kensley Care South has separated employment with staff of concern.


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

raw_content: One child in care's updated dental records were not included in his file.

Correction Narrative: Received corrective action plan from Executive Director stating the following: Kensley Care South will ensure that all clients receive dental care according to the requirements of 748.1225. When dental requirements are not met the Treatment Director will ensure that the appropriate documentation is in the client file.


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

raw_content: Four individuals hired after September 1,2023 were missing the Pre-Employment Affidavit in their personnel file.

Correction Narrative: An unannounced inspection was conducted on 6/23/25, Four individuals hired after September 1,2023, Pre-Employment Affidavit which was originally missing is now included in their personnel file.


summary: 748.3239(b) - Evacuation-Must practice severe weather drill at least once every 6 months from date of last severe weather drill

raw_content: During the inspection, the opertion failed to provide documented records verifying that required severe weather drills are being conducted.

Correction Narrative: An unannounced inspection was conducted on 6/23/25. The operation has now included a section that touches on severe weather drills and will now be doing them more frequently.


summary: 748.1437(3) - Discharge/Transfer Documentation-Must include name, address, telephone number, and relationship of person to whom child is discharged

raw_content: During the inspection conducted on 6/13/25, it was determined that the discharge documentation for a child in care was incomplete and did not include who the child was discharged to .

Correction Narrative: An unannounced inspection was conducted on 6/23/25. The discharge form now includes information such as who the child in care will be discharged to, address, phone.


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

raw_content: All employees files reviewed did not have a photo copy of the actual drug test results.

Correction Narrative: An unannounced inspection was completed on 6/23. All employees' files reviewed now include photocopies of the actual drug test results.


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

raw_content: During the inspection conducted on 6/13/25, it was determined that the operation failed to document accurate circumstances surrounding a child's discharge.

Correction Narrative: An unannounced inspection was conducted on 6/23/25, The operation has now added a section to the discharge form that includes the circumstances.


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

raw_content: During the walkthrough conducted on 6/13/25, several maintenance and safety concerns were observed. Specifically, a broken kitchen cabinet, damaged curtain rods in a common area, visible cracks in a dining room window, chipped paint around a bedroom window, a missing light switch cover in one of the bedrooms and exposed screws in a bedroom wall were noted.

Correction Narrative: An unannounced inspection was iniated at the operation. A physical site walkthrough was conducted. Several of the concerns mentioned originally have been corrected.


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

raw_content: Information gathered and obtained throughout the investigation determined a staff member used inappropriate language towards a child in care.

Correction Narrative: Two Children were interviewed at the operation. Children confirmed that they have never been cursed at or witnessed any staff cursing.


summary: 748.303(a)(4)(A) - Serious Incident-Report to Licensing as soon as aware of an incident of physical abuse of a child against another child

raw_content: A child in care physically assaulted another child in care by punching the victim in the head several times. This resulted in the victim being taken to an urgent care center. The child was diagnosed with a mild concussion.

Correction Narrative: Received corrective action plan from Executive Director stating the following: Kensley Care Staff will participate in a refresher training on July 2,2025. The Executive Director and LCCA are to hold the training. A sign in sheet will be available for RCCL to review.


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

raw_content: During a review of the operation's current inspection, the fire inspection has not yet been completed and expired on 3/19/2025. The facility has already purchased the necessary items for the inspection. They are currently just awaiting completion.

Correction Narrative: I received a corrective action plan from the Executive Director. Kensley Care South will set a calendar reminder to ensure the fire inspection is completed before the expiration date of the last inspection.


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

raw_content: A caregiver failed to intervene and take appropriate action to separate a child from other aggressive children after a physical altercation.

Correction Narrative: Two Children were interviewed at the operation. Children confirmed that supervision has improved. Two staff confirmed during interviews that they received training on 07/02/2025 on providing adequate supervision to children in care. Reviewed the sign in sheet that confirmed a refresher training was held on 07/02/2025.


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

raw_content: Multiple discrepancies were discovered in the active child records for discharge summaries, safety plans, and admission assessments.  The discharge summaries for 3 children were verbatim copy and pasted information, including another child's name.  A safety plan implemented after a physical altercation included contradictory information about the incident and resolution. Admission Assessments included contradictions regarding the medical care for each child.  The assessments also include blanket, copy and pasted statements.

Correction Narrative: Received corrective action plan from Executive Director stating the following: Kensley Care Staff will ensure they are maintaining current, true, accurate and complete records through quality assurance (QA). Their ongoing QA efforts will ensure that they consistently meet the highest standards for accuracy and completeness. Additionally, scheduled audits of client files will help them identify any areas for improvement and ensure adherence to all relevant guidelines and regulations.


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 treatment team staff for the operation did not delegate or provide the appropriate direct supervision for a child in care with history of suicidal behaviors after the child expressed suicidal ideations and scored high on suicide screening.

Correction Narrative: Two Children were interviewed at the operation. Children confirmed that supervision has improved. Two staff confirmed during interviews that they received training on 07/02/2025 on providing adequate supervision to children in care. Received documentation that confirmed a refresher training was held on 07/02/2025.


summary: 748.1437(2) - Discharge/Transfer Documentation-Must include date and time the child was informed of his discharge or transfer

raw_content: 3 of 3 discharge forms did not document when the child was informed of the discharge.

Correction Narrative: Received a corrective action plan from Executive Director stating the following: Kensley Care South has updated their discharge form to a discharge packet. This packet includes the placement summary which has all required information according to standards and includes the time and date the child was notified of his discharge/transfer.


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

raw_content: A child was involved in 3 serious incidents that were not documented fully as required by 748.311(1-11).  One incident was not documented at all.  Two incidents did not include all required information about the incident, witness, or resolution to the incidents.

Correction Narrative: Received a corrective action plan from the Executive Director stating the following: SIR training was completed with staff on July 2, 2025. Sign-in sheet was confirmed and will be placed in Document Library.


summary: 748.457(a) - Unauthorized Absence - Triggered Review of childs unauth absences must occur ASAP, but no later than 30 days after third absence within 60-days

Correction Narrative:
Received a corrective action plan from the Treatment Director stating the following:  The Treatment Director will ensure that additional staff training is conducted for all relevant staff to identify trigger events and execute timely reviews.

A tracking system will be implemented to monitor incidents and flag them for potential trigger review. The Treatment Director will conduct monthly audits to ensure that updates on AWOL behaviors are implemented to provide the trigger review/assessment. The treatment team will also be held responsible for overseeing compliance, documentation, and follow-up actions.

Updated documentation templates will include checklists and clear guidance on trigger review procedures.


summary: 748.3441(m) - Food Preparation-Food must be thawed in the refrigerator, in cold water in a leak-proof bag, or in the microwave

raw_content: There was meat observed in the kitchen sink defrosting and there was food not properly stored in the pantry.

Correction Narrative: Received corrective action plan from Executive Director: Kensley Care South Executive Director held a meeting with staff who regularly prepare meals reviewing the proper way to defrost and store food on March 19, 2025.


raw_content: It was reported that a victim child was injured during AWOL, however, the serious incident report completed reports that there were np injuries upon return.

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

Correction Narrative: A corrective action plan was received and documents that Kensley Care Staff will complete a refresher training reviewing documentation of incidents with staff on May 7, 2025. A sign in sheet will be available for licensing review.


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

raw_content: A serious incident report was completed for both children on 3/7/2025 at 5:40pm. The intake came in on 3/08/2025 at 7:24am which was about 14 hours after the children had gone AWOL and almost 8 hours past the time frame in which the facility was to report to licensing.

Correction Narrative: A corrective action plan was sent and documents that Kensley Care South will complete a refresher training with staff on May 7, 2025, reviewing the AWOL protocol and licensing standards for unauthorized absences. A sign in sheet will be available for licensing review.


summary: 748.1113(b) - Child Rights searches-Search a child, his possessions, or his room only when reasonable suspicion exists

Correction Narrative: The operation is now in compliance.


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

raw_content: A child was not properly supervised and was able to maintain a knife in their possession without the knowledge of staff.

Correction Narrative: Two Children were interviewed at the operation. Children confirmed that supervision has improved. Two staff confirmed during interviews that they received training on February 26th on providing adequate supervision to children in care.


raw_content: Staff did not document the results of the search conducted on their debriefing form. Staff confiscated a knife from a child in care.

Standard Number / Description: 748.1113(b) - Child Rights searches-Search a child, his possessions, or his room only when reasonable suspicion exists

Correction Narrative: Kensley Care South will ensure that searches are documented when needed including searches conducted when clients return from an unauthorized absence. These searches and its findings will be documented on the unauthorized absence debriefing form. On February 26, 2025, a training/meeting was held with direct care staff reviewing these findings and the proper way to document searches moving forward


raw_content: Three staff files were reviewed and were missing drug test results.

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

Correction Narrative: I, RCCL Inspector Michonne Chandler received a corrective action plan via email stating: Kensley Care South Administrator or designee will ensure all employees receives a drug test prior to employment and the drug test is filed in the employee file timely.


raw_content: During a review of the operation's current inspections. It appears that the fire inspection has not been completed as of yet and expired on 11/23/2023.

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

Correction Narrative: I, RCCL Inspector Michonne Chandler received an email from the administrator with the fire inspection report that was completed on 3/19.


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

raw_content: At the time of the monitoring inspection, there was not proof of a current health inspection.

Correction Narrative: I received an email from administration with a completed inspection report.


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: During the course of the investigation this standard was found to be deficient when a caregiver threatened to physically harm a child in care and pulled him by his hoodie.

Correction Narrative: The agency responded with a corrective action plan on March 1, 2023 a training was held for children rights in foster care with all staff. All staff who didnt attend will be trained on the upcoming staff meeting before the end of the month.


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

raw_content: The bathroom window inside of room 3 was observed uncovered.


raw_content: During the course of this investigation this standard was found to be deficient due to the operation failing to complete and report an incident where on child in care choked another child in care.

Standard Number / Description: 748.303(a)(4)(A) - Serious Incident-Report to Licensing as soon as aware of an incident of physical abuse of a child against another child

Correction Narrative:
Kensley Care South LCCA employees participated in a
peer-to peer abuse prevention webinar hosted by
OC-OK on December 7, 2023. On this date staff were
also trained on serious incidents and documentation
protocol. These trainings were held to ensure staff
understood what peer-to-peer abuse is called, the
importance of documentation and reporting through
the chain of command to ensure we are always in
compliance with minimum standards.


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

raw_content: Policy states that they can use emergency medication for PMN kids.  Also says they can use mechanical restraints.

Correction Narrative: Kensley Care sent and updated EBI and restraint policy. This information was added to their policies binder.


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

raw_content: Need to add time medication occurred to the form.


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

raw_content: The form was missing a spot for what occurred while the child was away.


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

raw_content: The Admissions policy must include all genders that the operation will be excepting.


facility_name: Rejo Helping Hands Inc.

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

raw_content: A caregiver witnessed and recorded a physical altercation while on duty but did not report the serious incident to the Hotline when became aware.

Correction Narrative: The operation ensured that all staff have received a refresher training on reporting serious incidents.


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

raw_content: A caregiver was captured by video standing close by as physical altercation was occurring and did not intervene.

Correction Narrative: The operation ensured that the current employees were trained or received a refresher on behavior interventions such a deescalation and observation to prevent or intervene when necessary to keep children in care safe.