summary: 748.2003(a) - Administration of prescription medication-inform medical consenter of benefits/risks/side effects/treatment/consequences of refusing them

raw_content: A child in care was injected with Medroxyprogesterone 150MG on 1.31.22 without consent from their medical consenter.

Correction Narrative: This Inspector received compliance from the Administrator via email. Staff members will be re-educated (on 4.28.22 and 5.15.22) on the current birth control policy, which requires consent to be obtained after admission on an individualized basis.


state: TX

facility_name: San Marcos Treatment Center

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

raw_content: Physician Progress Notes completed for 4 weeks did not have the correct medications for the client being treated. The medications were from a previous client and were not deleted when the template was used for the next client.

Category: Individual Standards Evaluated

Standard Risk Level: Medium

Corrected at Inspection: No

Correction Narrative: This Inspector received an email from the Administrator with compliance. The operation ensured no medication error occurred and they documented an error involving medication was printed on a physician's progress note. Along with this, moving forward, all facility physicians will be re-educated (on 4.28.22) on procedures to ensure accurate information is entered and saved on their progress notes.


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

raw_content: A child in care did not receive medical care as needed for an injury when the child had an incident on 1/8/22 of punching walls and did not have an X ray of his hand until 1/11/22, where it was discovered the child had a fractured finger. Following X-rays the child did not see a doctor for their fractured finger until 1/25/22.

Standard Risk Level: High

Correction Narrative:
Email from the operation:
The patient involved in the incident fractured his finger by briefly punching a wall on 1/8/22 when he was angry. The patient did not complain of pain the evening of the incident, and had full range of motion when assessed.

When the patient did complain of pain on 1/10/22, he was assessed, provided with an ice pack, and an x-ray was ordered. X-ray results obtained on 1/11/22 confirmed a fracture to a finger on his right hand. The patient was provided with a brace for the injured finger and the process for him to follow up with an orthopedic surgeon was started.

Due to the patient's medical insurance requiring a referral from his primary family physician to see a specialist, there was a delay in getting him to an orthopedic follow up, which occurred on 1/25/22.

Before his follow up, the patient was also seen by the facility nurse practitioner on 1/20/22, who noted the patient having full range of motion to all fingers, and wrist, on his right hand. The patient did not have any complaints of pain or discomfort during his assessment on 1/20/22.

Although the patient did receive medical care in response to an injury, moving forward, the facility will work to provide medical follow up in a timelier manner. This will occur by the facility nurse practitioner immediately assessing and evaluating patients with confirmed fractures to determine the need and time-frame for additional follow up, based on the injury.


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

raw_content: Hand sanitizer was left accessible to a child in care who then ingested the hand sanitizer.

Standard Risk Level: Medium High

Correction Narrative: All facility caregivers will be re-trained on the current policy regarding storage and accessibility of hazardous/ poisonous materials. The training will be documented using an attestation form and it will be available for review in employee personnel training records located in the Human Resources Department. Re-training for this policy began on 11/8/21 and the target date for completion is February 15, 2022. San Marcos Treatment Center, Human Resources Director in coordination with Unit Managers, will track completion of the training and help identify and train any individuals in need of the training prior to the completion target date.


summary: 748.2907(1) - Triggered Reviews-Must include the same items that must be included and documented in an initial service plan

raw_content: A child in care was restrained five times in a six day period. The triggered review documentation associated with these incidents did not include all elements of an initial service plan, or a review of the records/orders associated with the emergency behavior interventions.

Category: Emergency Behavior Intervention

Correction Narrative:
The operation provided the following information:
Although verified during the inspection that each restraint and application of emergency behavior interventions were justified, and despite discussion of several interventions occurred in response to the triggered review, including medication adjustments and milieu based interventions, additional documentation required for a triggered review was missing.
Moving forward, all required documentation for a triggered review will be captured in one location within the patient's treatment plan by assigned therapists with oversight from the facility Clinical Director.


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

raw_content: One of three staff files reviewed did not have a signed/dated statement indicating the employee is responsible for reporting suspected child abuse, neglect, or exploitation to the Texas Abuse and Neglect Hotline, and to the operations administrator or administrators designee.

Category: Reports and Record Keeping

Correction Narrative:
The operation provided the following information:
Although verified during the inspection that the employee completed the Texas state licensing mandated abuse, neglect, and exploitation training prior to the employee transferring to the operation from another facility, a signed and dated document verifying reporting requirements was missing from the employee's personnel file.
Moving forward, the facility Human Resources Department will continue requiring the signed and dated document for all employees, including transfers.


summary: 748.685(c)(5) - Caregiver responsibility - ensure continuity of care by sharing information concerning each child with incoming caregivers

raw_content: Staff did not demonstrate continuity of care with a child that was displaying multiple physical symptoms. The child went to the emergency room on 8/2/21. Multiple staff that worked with the child in the week following their emergency room visit were not informed of how to monitor the child or what the ER discharge paperwork reported would prompt a need for immediate medical attention. In a week the child continued to lose weight and medical issues progressively worsened.

Correction Narrative:
Email from the operation:

Our facility has requested an administrative review to begin the appeal process in this area.  San Marcos Treatment Center personnel were informed and were provided with information with how to appropriately supervise and care for the patient, based upon each discipline's respective roles. A clinical dietician provided dietary services, 24 - hour nursing care was provided with appropriate nursing follow ups after the hospital discharge, and mental health technicians were informed of this patient's medical issues that resulted in her transfer to hospital level of care.

Despite the request for an appeal of this citation, for continued ongoing performance improvement, the facility is also currently reviewing policies and procedures for any necessary changes that will better address patient medical issues in a timely manner.


summary: 748.1337(b)(1)(A)(viii) - Initial Service Plan-Include cultural identity needs, including assisting children in connecting with their culture in the community

raw_content: Three of the three child files reviewed did not have specific information about how each child's cultural identity needs would be met. There was a generic statement in all three records about having weekly meeting with the unit manager to address cultural identity issues.

Category: Admission, Service Planning, Discharge

Correction Narrative:
The following response was received from the operation's administrator:
The Initial Treatment Plan and Psychosocial Assessment assesses for religious, cultural, and ethnic considerations during treatment. Staff facilitate weekly cultural groups and activities for all patients which are documented on a daily Milieu Progress Note. Cultural groups and activities will begin being documented in the monthly Recreational Therapy Summary section of the treatment plan, beginning July 15, 2021.
Cultural needs in the service plan will also be added to the current medical record audit process. Patient medical records will continue to be audited on an ongoing basis by the Medical Records Department and facility Management Team. Any identified deficiencies will be assigned to the appropriate supervisor for correction in a timely manner.


summary: 748.1337(b)(1)(A)(ii) - Initial Service Plan-Include dental needs, including scheduled dental exams and plans for recommended follow-up treatment

raw_content: Two of three child files reviewed did not have dental needs addressed in their master treatment plan.

Standard Risk Level: Medium Low

Correction Narrative:
The following response was received from the operation's administrator:
All facility nurses will be re-educated on the process of identifying and documenting patient dental needs in the treatment plan by July 15, 2021.
In addition, a dental consult for each patient will be completed on admission. The date of the last known dental visit will be documented on the consult before being submitted to the facility Medical Coordinator for scheduling. The consult forms will be filed by the month they are due and will be scheduled to occur the same month. This procedure will be reviewed and demonstrated at monthly nursing team meetings.
Dental needs in the service plan will also be added to the current medical record audit process. Patient medical records will continue to be audited on an ongoing basis by the Medical Records Department and facility Management Team. Any identified deficiencies will be assigned to the appropriate supervisor for correction in a timely manner.


raw_content: One of three staff files reviewed did not have a signed and dated statement that they must immediately report suspected child abuse, neglect, or exploitation.

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

Correction Narrative:
The following response was received from the operation's administrator:
Although licensing was able to verify that the staff member attended and participated in all required trainings during their orientation process, the staff member did not sign an acknowledgment form stating he/she knows how to report suspected abuse.
The facility Human Resources Director revised a Personnel File Checklist form on 6/28/21 to include all necessary licensing requirements, including the patient abuse reporting acknowledgment form. The form will be used to monitor completion of all licensing requirements related to the pre-employment and hiring process starting 7/15/21. Any missing requirements identified on the form will be completed by the end of the new hire orientation process.


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

raw_content: One of three master treatment plans reviewed did not have documentation that parents were notified two weeks in advance of the meeting.

Standard Risk Level: Low

Correction Narrative:
The following response was received from the operation's administrator:
Therapist's will notify guardian(s) of all upcoming treatment plan reviews in family therapy sessions 2 weeks prior to the review. Notification of the meeting will also be documented on the family therapy note. Notification of the meeting will also be documented on the treatment plan signature page. In addition, copies of completed treatment plans with notification of the next meeting, will be sent to guardian(s) within the required time frame. All facility therapists will be re-educated on this process by July 15, 2021.
Notification of treatment plan meetings will also be added to the current patient chart review audit process. Patient charts will continue to be audited on an ongoing basis by the Medical Records Department and facility Management Team. Any identified deficiencies will be assigned to the appropriate supervisor for correction in a timely manner.


summary: 748.1207(b) - Placement agreement - Must be signed by parent

raw_content: Three out of three child records reviewed did not have a placement agreement with parent's signature.

Correction Narrative:
The following response was received from the operation's administrator:
The facility will revise the current Admission Authorization Form to include reason for treatment, anticipated length of stay, and parent signatures for an implementation date of July 15, 2021.
The revised form will also be added to the current patient chart review audit process. Patient charts will continue to be audited on an ongoing basis by the Medical Records Department and facility Management Team. Any identified deficiencies will be assigned to the appropriate supervisor for correction in a timely manner.


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

raw_content: A child in care was restrained when they were peeling paint off a wall and would not listen to staff when asked to stop

Correction Narrative:
Although video of an incident that occurred on 4/14/21 verified several staff members using a variety of verbal de-escalation strategies for over 40 minutes in response to a patient engaged in significant property damage (peeling large areas of paint and damaging sheetrock) just prior to a second incident involving the same patient peeling additional paint on a separate wall, the facility identified additional strategies that may have been used instead of restraint.

The staff member involved in the incident was provided with an Emergency Behavior Intervention (EBI) re-training by the facility Risk Manager on 4/23/21. The re-training focused on alternative interventions to consider before use of restraint, in response to property damage. The staff member was receptive to the re-training and has since used the information to enhance his job skills. All other caregivers that work with the patient involved in the incident also received the same information, provided by the facility Risk Manager, in a team meeting held on 4/15/21.

All applications of EBI, including restraints and emergency medications, will continue to be monitored on a daily basis, by use of video camera and documentation review. The facility will continue to reinforce all safe and justified applications of EBI, in addition to providing feedback, re-training, and formal supervision (including possible termination) for employees engaging in EBI without proper justification or use of improper technique.

The facility Childcare Administrator and Performance Improvement Director will also continue to monitor EBI data on a daily basis to help identify any trends and patterns needed for further improvement.


facility_name: Pegasus Schools, Inc.

raw_content: A caregiver performed an escort restraint on a child in care when the child did not respond to a directive.

Standard Number / Description: 748.2463(3) - Emergency Behavior Intervention-Never used as a means to get a child to comply

Correction Narrative:
November 6, 2025, the operation provided a copy of the completed training transcript and certificate by staff member for Nonviolent Crisis Training.

The staff member also received a 7-day unpaid suspension prior to conducting the training.


summary: 748.1103(a) - Informing child of rights-Review rights with child/parents within 7 days of child's admission; provide child/parents with written copy of rights

raw_content: During the inspection of Child's Rights,  two child files did not have a signed child rights form.

Category: Children's Rights

Correction Narrative: Pegasus treatment director met with the two children about their child rights and had them sign the rights for the child files. The operation met with all children on campus and explained their child rights and had them sign the document for their files.


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

raw_content: It was determined that two children in care were able to expose himself to another child due to lack of staffs supervision.

Correction Narrative: RCCR met with the Administrator to discuss the compliance plan provided on 09/16/2025. As per the Administrator, close supervision of children within sight is a policy for the operation given the high-risk history of the children. The Administration have given the employee subject to this investigation, a disciplinary action which is kept in their employee file. The Administration have spoken to staff about the related supervision concerns and reminded all staff to follow the operation's supervision policy and intervene when high risk behaviors are present.


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

raw_content: The 4/19/25 medical report states that the child was to be seen by primary care physician within 2-4 days and he was seen 12 days later on 5/1/2025.

Correction Narrative:
The operation provided a letter with the following steps that will be implemented to address the concern of getting children to follow up appointments. The letter was dated 6/22/2024. I received the info after date and will not cite due to accident of forwarding to worker.

From this date forward, when a Pegasus Schools, Inc. resident goes to the Emergency Room for treatment and is required to follow up with their Primary Care Physician, the medical staff attending the appointment will:

1. Clarify with the ER Physician if the follow up appointment with the PCP can be done during the PCP's normal visit to the Pegasus campus (generally a rotating schedule every other Thursday). If the follow up appointment can be done during the regular rotation, medical staff will ensure that the paperwork provided by the ER showing the correct time frame listed under follow up recommendations.

2. If the follow up appointment is needed before the PCP's normal scheduled visit to the Pegasus campus, the medical staff will:
Attempt to set up a virtual appointment with Olivia during the appropriate timeframe mandated by the ER discharge paperwork (if acceptable and appropriate to do so), or; Have the resident return to the Emergency Room for a follow-up within the timeframe mandated by the ER discharge paperwork.


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

raw_content: During the investigation, it was reported that staff was out of ratio when incident of a child hitting another child with a stick.

Correction Narrative: I had a phone discussion with Eric Deyhos, Administrator regarding the citation. He asked questions about the citation. He says that he has been struggling to address the issue as he needs to hire new staff as he is short staffed. We talked about how he addressed issue in the past. He states that he met with staff on 5/2/2025 in a prior citation and told them to call for help before taking breaks. He provided a letter in regard to how he will continue to meet ratio. During a staff meeting on the week of 6/24/2025 to 6/27/2025, staff were given reminders to provide the level of supervision necessary to ensure each child's safety and well-being at all times.


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: It is determined staff become out of ratio when attending to high-risk situations of restraints, as well as smoke breaks.

Correction Narrative: Administrator, Eric DeHoyos, provided the following compliance on 5/2/2025: During staff meetings the week of 4/28/25 - 5/1/25, all staff were reminded always providing the level of supervision necessary to ensure each child's safety and well-being. A discussion was held with administrator about how they will work on covering gaps in ratio when needed. He states that they have informed staff to call for help if they needed to step away. He says that they maintain 1 to 5 ratio at all times.


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

raw_content: It was confirmed a staff member providing overnight supervision fell asleep while caring for children.

Correction Narrative: In person inspection completed at the operation. No concerns noted and operation was able to confirm compliance plan implemented is in place and seems to be doing well.


summary: 748.303(a)(5)(B) - Serious Incident-Report to parents immediately after ensuring the safety of the child.

raw_content: The operation did not report to a child's parent, in a timely manner, that their child made an outcry of abuse due to incidents involving another child in care.

Correction Narrative: The operation provided a compliance response due to citation regarding serious incident notification to parent. Additional training was provided to the staff who failed to complete the notification. Standard and policy regarding requirements for serious incidents was reviewed with the employee.


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

raw_content: During the course of the investigation, it was determined that de-escalation techniques were not used.

Correction Narrative: The operation provided a follow-up regarding the citation for failing to use de-escalation prior to an EBI. Caregiver completed a 4.5 hour refresher EBI course focusing on verbal de-escalation techniques. An additional course, Recognizing, Reporting and Preventing Child Abuse Training was also completed by this caregiver. All other staff was reminded of the specific behaviors that would warrant an EBI and only as a last resort.


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

raw_content: During the course of the investigation, it was determined that a child was restrained without an emergency situation.

Correction Narrative: The operation provided a follow-up regarding the citation for EBI use outside of an emergency situation. Caregiver completed a 4.5 hour refresher EBI course focusing on verbal de-escalation techniques. An additional course, Recognizing, Reporting and Preventing Child Abuse Training was also completed by this caregiver. All other staff was reminded of the specific behaviors that would warrant an EBI and only as a last resort.


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

raw_content: It was observed that an expired medication was left in the medication locker and was still being used.


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

raw_content: During the physical site inspection, several concerns were observed throughout all of the dorm's bathrooms and shower areas. Showers were observed to have mold and other bacteria growing, dripping shower heads, shower heads that squirt water out of the shower area, leaking soap dispensers,  bacteria growing on water fountains, and rusty screws on both toilet seats and faucets.


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

Category: Physical Site

Deficiency Narrative: During the physical site inspection, several concerns were observed throughout all of the dorm's bathrooms and shower areas. Showers were observed to have mold and other bacteria growing, dripping shower heads, shower heads that squirt water out of the shower area, leaking soap dispensers,  bacteria growing on water fountains, and rusty screws on both toilet seats and faucets.


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

Category: Medication

Deficiency Narrative: It was observed that an expired medication was left in the medication locker and was still being used.


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: Review of the Serious Incident Report, Medical Documentation, and CLASS showed the incident occurred on 9/24/24 and was not reported until 9/26/24.

Correction Narrative: The person on call is responsible for reporting all Serious Incidents. In the event an emergency arises for that person there will be a back up person put in charge to ensure everything is reported timely. This was discussed with the Administrator.


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

raw_content: Evidence supports that multiple children in care were able to engage in sexual activity while the same caregiver was supervising those children on multiple occasions.

Correction Narrative: The operation provides a corrective action plan stating how they addressed staff during a staff meeting and went over the importance of being highly alert at all times, maintaining proper supervision of the children under their care at all times and not remaining stationary, moving around to better supervise the residents. One of the staff members involved is no longer with the operation and the other was given disciplinary action and placed on probation.


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

raw_content: In their interviews staff stated that they have either seen or have nodded off while on shift.


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

raw_content: Evidence was provided showing that staff member provided their personal number and social media to a child in care.  In addition, communication with a discharged child was deemed inappropriate.

Correction Narrative: The operation provided a correction action plan and stated that after reviewing the citation and the incident, they are updating their employee standards of conduct. The operation has also conducted a staff meeting going over the incident and instructing staff how to conduct themselves going further, an additional training will be provided to staff on 09/27/2024. The staff member involved in the incident was given disciplinary action and was terminated.


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

raw_content: In an interview, a staff member admitted that they had on occasion fallen asleep. In an additional interview, a child in care stated that they witnessed the staff member sleeping during school hours.

Correction Narrative: The operation has provided an email covering the different areas they will cover to ensure staff members are not sleeping on their shifts. The operation has also counseled listed employees and given them documentation.


raw_content: During the course of the investigation, it was determined that a caregiver allowed children to be unsupervised in the community for short periods of time.

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: During an in person follow up inspectiton 2 staff and 10 residents were interviewed. All were consistant in stating that staff are always supervising them and that residents have never been left alone or unsupervised. Staff and residents reported that while off campus staff will always maintain line of sight on the resdients.


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

raw_content: Multiple children and staff reported that a staff member placed a child on an escort hold because they were cursing, threatening peers, and threatening to run.

Correction Narrative: During an in person follow up inspectiton 2 staff and 10 residents were interviewed. All were consistant in stating that staff have only restrained residents if the resident is attempting to hurt themselves or fight other peers. All residents were consistant in stating that they are not restrained as a method of getting them to comply.


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

raw_content: It was determined that a staff member was heard yelling at a child in care to comply with their request prior to conducting a restraint.

Correction Narrative: During an in person follow up inspectiton 2 staff and 10 residents were interviewed. All were consistant in stating that staff do not yell or curse at them to get them to comply. All stated that they will get hours assigned to them if they are not following directives.


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

raw_content: During a physical inspection is was observed that the door to medication room and the medication cabinet were left unlocked.

Corrected at Inspection: Yes


raw_content: During the investigation, it was found that two children in care went behind a golf cart outside during recreation time for a period of approx. 5 minutes and staff were unaware of their whereabouts during this time. It was reported the two children were supposed to remain within eyesight of staff. Additionally, the staff that was reportedly responsible for watching one or both of the children involved is currently on Provisional status with conditions.

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

Correction Narrative: During and in-person follow up inspection, interviews with 5 resdients and 5 staff reported that resdients will be in line of sight and in earshot of staff.


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

raw_content: It was found that a staff who was reportedly supervising one or both children in care involved during this incident is currently on Provisional status with conditions.

Correction Narrative:
During an in person follow up inspection interviews with 5 staff and 5 residents, staff with provisional background checks or background checks with conditions are never left to supervise children alone.

6.3.2024 licensing received an email from the operation stating the following: Staff that are provisionally eligible with conditions or eligible with
conditions, were reminded that they have to follow the conditions set forth, at all times, as it reads on the documentation they received.


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

raw_content: During the review of medications, it was found that 4 children had med counts that didn't match the count that the med log noted.

Correction Narrative: During an in person follow up med logs and med counts were reviewed with no concern. Medication recertification training was reviewed and interviews with staff and administration were conducted discussing the medication administration training.


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: Through interviews it was determined that, while in the PPL room, staff and residents were out of ratio for a period of time.

Correction Narrative:
The department received an email from the operation stating the following compliance plan.

The operation has reviewed the incident during staff meetings and passed on to all staff that ratios have to be met at all times. The operation also spoke about maintaining proper supervision and being vigilant at all times when on duty.
Staff member supervising the children at the time of incident, JM, was counseled and received a documentation of supervision for lack of supervision and not maintaining ratio.

On 12.19.2023 an in-person follow up inspection was conducted at the operation. A walkthrough was conducted of the operation's 3 school buildings to observe ratio with no concerns. Interviews were conducted with staff and 12 residents, 2 from each dorm, to discuss ratio and supervision. There were no concerns noted during the interviews.


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

raw_content: Through information gathered, it was determined that staff members subjected children in care to inappropriate and obscene language.


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

raw_content: It was reported and confirmed that staff instructed and directed children in care to walk a lap by the staff parking lot while it was raining because they were chatty and particularly talkative, and they did not comply with the staffs warning. It was also confirmed that although not while raining, this form of punishment has occurred on multiple occasions and was described as very ordinary.


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

raw_content: It was determined and confirmed that children in care were not provided raincoats to protect themselves from the rain, staff members attempted to persuade children in care from submitting grievances, staff displayed and fidgeted with a knife while caring for children, staff threatened EBI if the children touch their knife, staff threatened children after being released, staff used their personal cell phones to send text messages and make personal phone calls, while leaving the dorm out of ratio, and released confidential information to the children in their care.


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

raw_content: Through video surveillance and interviews it was determined that residents were not adequately supervised and were able to have inappropriate contact.

Correction Narrative:
The department received the following corrective action from the operation:

In response to the citation received, Pegasus Schools, Inc. has taken the following actions:
Staff member involved in incident was terminated. During staff meetings the following week,
we discussed what transpired during the incident and the importance of proper supervision. We
also addressed the supervisors on being aware of which residents are not allowed to interact with
one another and making sure they are not part of the same ratio groups.

On 1.11.2023 RCCR Inspector Melanie Forsyth conducted an unannounced follow up inspection at the operation. Interviews were conducted with CEO Chris Moody and Asst. CEO Nick Sedlachek discussing a strategy of reminding newer staff the importance of supervision and the demographics of the residents. Employee Christopher Hill was confirmed to be terminated the day of the incident. Interviews with 7 residents were conducted discussing supervision with no concerns. A walkthrough of the Comanche dorm was conducted with no visible hazards.


summary: 748.1337(b) - Initial Service Plan-Document in child's record and include preliminary service plan requirements

raw_content: While reviewing the service plan it was observed that a significant portion of the requirements are missing.

Correction Narrative:
An email was received from the Administrator stating, We will be start utilizing DFPS/CPS Form K-908-3300 for all residents, including
those placed by juvenile probation. All changes will be made and in place campus
wide by 2/01/24.


raw_content: During the course of the investigation, it was determined that caregivers are subjecting children to profane language on a regular basis.

Standard Number / Description: 748.2307(9) - Other Prohibited Punishments-subjecting a child to abusive or profane language


raw_content: During the investigation, it was determined that a caregiver have been observed yelling at the children and shaming them for behaving inappropriately.

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


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

raw_content: During the course of the investigation, it was determined that a caregiver failed to treat all residents fairly in terms of consequences for their actions which may have negatively impacts a childs positive success in the program.

Correction Narrative:
RCCR recevied the following email from Pegasus:

During Core Staff (supervisors) meeting on 8/17/23, we went over the citation received in this investigation, along with the others that were cited which we are requesting an administrative review for. The Core Staff were instructed to talk to their teams and ensure that all staff on duty are adhering to all PSI Policies and Procedures
at all times, including HHSC Minimum Standards. We also discussed using appropriate language at all times when on duty.

We will also be going over this deficiency with all other staff during staff meeting
next week on 8/22/23 and 8/24/23.

All the Core Staff in attendance at this meeting were provided with a copy of the investigation determination and we went over, in detail, what was cited as being deficient. We spoke about being consistent when giving out consequences for negative behaviors, not yelling at the children or shaming them. One of the core staff members that was named in the investigation, admitted to saying that the child was acting stupid by doing stupid things when he knew better and had been doing better. I then explained to the staff that I had requested an admin review and would keep them posted on the progress and outcome of that review.

The operation has requested an Administrative Review for this citation.


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

raw_content: During the course of the investigation it was determined two children in care were able to speak to each other from their bunks in an inappropriate manner during sleeping hours for six consecutive days.

Correction Narrative:
RCCR received the following email from Pegasus:

In response to the deficiency on standard §748.2307(9), the following is the corrective action response by our facility:

During Core Staff (supervisors) meeting on 8/17/23, we went over the citation received in this investigation, along with the others that were cited which we are
requesting an administrative review for. The Core Staff were instructed to talk to their teams and ensure that all staff on duty are adhering to all PSI Policies and Procedures at all times, including HHSC Minimum Standards. We also discussed using appropriate language at all times when on duty.

We will also be going over this deficiency with all other staff during staff meeting
next week on 8/22/23 and 8/24/23.

All the Core Staff in attendance at this meeting were provided with a copy of the investigation determination and we went over, in detail, what was cited as being deficient. We spoke about being consistent when giving out consequences for negative behaviors, not yelling at the children or shaming them. One of the core staff members that was named in the investigation, admitted to saying that the child was acting stupid by doing stupid things when he knew better and had been doing better. I then explained to the staff that I had requested an admin review and would keep them posted on the progress and outcome of that review.


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

raw_content: It was found one staff person was falling asleep for short periods of time while at work.

Correction Narrative: On 8.22.23 the department conducted an in-person inspection and interviews at the operation. 7 staff and 12 residents were interviewed regarding night shift staff supervision and staff sleeping. 12 of 12 resident's stated they have never witnessed a staff member sleeping and confirmed that staff walk around conducting checks all night. The operation reported that the staff involved has been terminated and that the operation has hired additional staff to allow staff to work shorter shifts and fewer days.


raw_content: When completing the walktrhough, a staff was observed yelling and tellling a kid to shut up.

Correction Narrative: Documentation was received from the operation to show "documentation of supervision on the staff member" yelling at the child. Corrective action was taken to discuss with the staff member what was done and review standards and what it allowed and prohibited.


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

raw_content: During interviews and review of video footage, it was determined that a child in care was restrained due to not wanting to get up from sitting on the floor.

Correction Narrative: The staff member who initiated the restraint is no longer employed by the operation. The operation stated that all staff members will continue to take  EBI training 3x a year.


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

raw_content: Multiple food items were stored in open bags.

Correction Narrative: During follow-up it was observed concerns with food storage was properly addressed


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: It was determined that a staff member used threats of getting physical if residents didn't calm down.

Correction Narrative:
Licensing received an email from the operation stating their compliance plan.

Staff member JP is placed on a 90 day probationary period which ends on 4/24/2023. JP was removed from working at the Apache Dorm, additionally JP was required to go through an EBI refresher course which also focuses on verbal de-escalation techniques.


raw_content: During the course of this investigation, it was determined that staff did not adequately supervise a child at the operation during recreation time and the child sustained a serious injury.


raw_content: During the investigation, it was determined that staff members used profane language in front of or directed at children in care.

Correction Narrative:
An email from the operation was received with the following :
Employee will be placed on
a 90-dav probation that ends on February 5th. 2023. Any other infractions
involving the mentioned above will result in further disciplinary action, in and
UP to termination of employment with Pegasus Schools Inc


raw_content: There is sufficient evidence to show a staff member was sleeping while being counted in ratio.

Correction Narrative: Administrator sent an email the staff stating received disciplinary action on 10/21/22 for inattention to duty. This was his first incident of inattention to duty and was told that any other incidents of inattention to duty will result in further disciplinary action, up to and including, termination of employment with Pegasus Schools, Inc. He stated they will not be requesting an administrative review.


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

raw_content: During the course of this investigation, it was determined that a caretaker gave over-the-counter medication to children in care on multiple occasions and did not document it in the childrens medication record.

Correction Narrative: Information provided by the administrator, all over-the-counter medication, relating to this investigation, sent to each dorm, have been placed in bubble packs to ensure that the medication is approved and provided by Pegasus Schools, Inc. and able to keep an accurate count of the medication. The staff member involved in this incident was terminated immediately after notification of the incident.


summary: 748.1101(b)(6)(B) - Children's rights-The right to be free of unnecessary or excessive medication

raw_content: It was determined that a caretaker gave multiple tablets of over-the-counter medication at once, on multiple occasions, to numerous children in care without the approval of a healthcare provider and/or management.

Correction Narrative: As per the Administrator, during staff meetings the weeks of 8/29/22 to 9/07/22, they addressed the incident and went over the Pegasus Schools, Inc., Policy on medication as well as the standard.


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

raw_content: Medications were not being properly documented in two dorms. In one dorm the medication had already been documented for night medicine that had not been administered and in another dorm the staff put their initials but did not fill out the rest of the documentation.

Correction Narrative: Administrator sent an email stating "The weeks of 6/6/22-6/17/22, we discussed these deficiencies during our Core Staff and Direct Care Staff meetings. We reiterated that all supervisors need to be mindful of basic medication dispensing procedures and they are to be followed at all times. Medical department was also notified and will continue to monitor for any and all discrepancies. "


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

raw_content: During the course of the investigation, four (4) individuals reported one particular staff uses language towards the children in care that is ridiculing and/or belittling in nature.

Correction Narrative: Called and spoke to the administrator who stated he has requested an AR. He stated after the citation they had a staff meeting with management then another with branch staff to discuss the allegations. He stated the staff are trained to point out thinking errors. When a child makes a thinking error like one that led to their offence they will help the kids identify the error.


raw_content: There is sufficient evidence to show that night staff are not providing an appropriate level of supervision and are being distracted by paperwork.

Correction Narrative: Spoke to operation staff who stated they had a staff meeting and they discussed that the staff should be doing paperwork on shifts not all at once. When two people are doing paperwork two others should be walking around. The night staff should be walking around every 10 minutes alternating.


raw_content: After conducting the investigation, two children in care reported that they touched each other inappropriately on top of clothing and the staff supervising either did not see and/or was not paying attention and this may have been due to the staff either being on their phone and/or sleeping in the classroom when supposed to be supervising. It was also reported that this staff and multiple other staff close their eyes/nod off/sleep in the classroom for short periods of time when supposed to be supervising and at times wear a cap and/or sunglasses which may be preventing them from supervising properly.

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

Correction Narrative: During staff meeting week from 4/18/22-4/22/22, the operation covered the specifics of the citation received and that it had also been reported that staff would either be on their phones and/or sleeping in the classroom when supposed to be supervising the children. The Administrator reiterated to staff that employees are required to remain fully alert and attentive during duty hours. The Administrator spoke to their on campus charter school Principal and passed on this information as well. The Principal emailed all teachers instructing them to notify the Principal if they observe staff sleeping while in the classrooms.


summary: 748.685(c)(5) - Caregiver responsibility - ensure continuity of care by sharing information concerning each child with incoming caregivers

raw_content: During the course of this investigation, it was determined that a caretaker did not follow protocol in checking children in care as they entered the shower and/or latrines. It was also determined that a caretaker was not made aware of an active Safety Plan for a child under their care.

Correction Narrative: During staff meeting week, all staff were advised of the findings and reminding all staff to follow set protocol when the boys use the restroom and showers. Also, every staff member must read and sign the general log at the beginning of their shift to ensure that they are all aware of the overall behaviors in the dorm and any restrictions or safety plans set in place for certain residents.


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

raw_content: A caregiver did not demonstrate self-control when they cursed at a child to get them out of bed and then forcefully pulled the child out of their bed.

Correction Narrative: Email from the operation- staff went through EBI refresher concerning verbal de-escalation. All staff had a meeting regarding how they speak to children in care, particularly how they address the boys when confronting them on their action/behaviors.


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

raw_content: Multiple training records showed staff were getting sometimes more than 20 hours of training in a day.

Category: Organization and Administration

Correction Narrative:
Staff sent an email outlining how they will come into compliance he stated
To Correct the errors, I had in the training department I have implemented the following
corrective actions immediately.
1. Pre-service and orientation training schedule with daily hours required for training for
five days of training. Schedule attached.
2. We have begun auditing all employee training files.
3. We will be doing monthly audits of new hire employee files for training and monthly
audits for training records.


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

raw_content: During the course of the investigation, it was determined that a staff member subjected a child to insulting, offensive language.

Correction Narrative: Staff were advised of being aware of their professionalism at all times and to be mindful of not only what they say but also how they say things when addressing their children un-der their care. The staff member involved in this incident was terminated after admitting that she had disrespected and insulted resident.


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

raw_content: There is sufficient evidence to show a staff member cursed at and threatened a child and allowed other children in care to curse at the child.

Correction Narrative: Staff sent the following plan staff will receive this Documentation of Supervision and in addition will need to attend a Crisis Prevention Intervention refresher course dealing with facing conflict with confidence and how to exhale in verbal de-escalation. Staff was also written up.


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

raw_content: Licensing requested EBI training for the two direct care staff involved in this incident on 6/23/21 and one of the two staff EBI training complete records/current records was not provided to licensing by the operation until 8/16/21. On 6/24/21, the operation provided EBI records for this staff from 2018 and 2019. On 8/11/21, the operation provided additional EBI training for this staff from 2019 and 2020, then on 8/16/21, the operation provided current EBI training for this staff from 2021.

Correction Narrative: The operation reported they will ensure that all active records are available for review and reproduction when requested. It was reported by phone on 9/13/21 that the Training Coordinator uploads EBI certificates to the operation's record keeping system and either the Administrator or the Associate CEO can obtain the records from here to send to licensing. If for any reason the records are not available on the system they will contact the Training Coordinator to ensure the needed records are obtained.


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

raw_content: There is a preponderance of evidence that a staff member allowed inappropriate contact between themself and children in care.

Correction Narrative: Op Personnel informed licensing that the staff was terminated as soon as the allegations were disclosed.


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

raw_content: After reviewing the child's service plan, it was found that several required sections of the service plan were missing.

Correction Narrative: The Placement Director reported meeting with their Clinical Director about the issue raised with the citation. The operation has modified the treatment plans to now have a section that will address the necessary items to meet compliance with the standard and they will begin using this new treatment plan template as of 6/14/21.


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

raw_content: Staff instigated a child to react violently when they physically attempted to remove their shoes resulting in the child being restrained.

Correction Narrative: Administrator sent an email stating the staff will not be able to implement any EBIs pending the outcome. The staff were also reminded that the use of EBI must be appropriate response to the behaviors demonstrated and de-escalation must have failed.


facility_name: Azleway Valley View

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

raw_content: During a heightened monitoring visit to the operation on 08/14/2025, some donuts, with a best if used by date of 08/04/25, located on the counter in the kitchen were observed to have mold on them.

Correction Narrative: On 8/26/25 and 9/8/2025 physical site inspections occurred. During each inspection the refrigerator, freezer and pantry were checked for expired and or spoiled food. Bread on both cottages were also inspected for mold, and none was observed. The written corrections were received during the inspection on 9/8/2025. Staff have been provided a checklist in which food needs to be inspected and or discarded. The package of donuts with a mold spot were discarded.  Administrative staff will conduct a week day walk through including inspection of food items.  Executive Director will conduct at least a twice monthly walk through including inspection of food items.


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

raw_content: Roughhousing between two residents escalated. One resident placed the other in a headlock and transitioned to placing hands around the neck and choking. The caregiver delayed to de-escalate and intervene.

Correction Narrative: On 9/19/2025 the operation provided a corrective action letter. Training was conducted on 9/16/25 and individually on 9/17/2025 for the caregiver who was unable to attend on 9/16/2025. Training included supervision, early intervention, follow-up after any physical altercations including examination of youth, documentation and reporting to on-call. Rules, expectations, and consistency among staff and with all youth were discussed. A record of caregiver signatures who attended the class was provided. On 9/23/2025 the staff training folder was reviewed. Certificates of training were located in the binder for all caregivers required to attend the training.


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

raw_content: One of the facility vans had a protruding wire sticking out of the second seat and a sliding door that came off the hinges when the door was opened.  This was corrected at the initial inspection, but residents were transported in this vehicle for several weeks before the issues were fixed.


raw_content: An employee at the operation was using profanity towards the residents and in the presence of direct care staff.

Correction Narrative: Program Director who was in training at the time, introduced additional structure and expectations to be implemented in the future. Staff completed initial training and orientation including the verbal de-escalation segments of PAPH.  Staff was retrained in Minimum Standards related to discipline.


summary: 748.1101(b)(4)(A)(vi) - Children's rights- To be free from being threatened with the loss of placement or shelter as punishment

raw_content: The residents and staff witnessed a caregiver threatening placements and inappropriate discipline at the operation.

Correction Narrative: Program Director who was in training at the time, introduced additional structure and expectations to be implemented in the future. Staff completed initial training and orientation. Staff was retrained in Minimum Standards related to discipline.


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

raw_content: During a walk-through of the operation, it was observed that conditions of a cabin were not clean. The boy's rooms were observed to be cluttered, the bathroom toilet dispenser was broken off, dirty dishes were observed in the kitchen sink and a liquid was observed on one of the bedroom floors.

Correction Narrative: On 6/3/2025 a physical site inspection was conducted at both cottages for corrections. All bathrooms had functioning toilet paper dispensers. No dirty dishes were observed in the sinks. There was no liquid on the floors.  Resident's rooms were organized and met requirements.


raw_content: A child in care reported seeing a caregiver sleeping while on night duty. The child called out to the caregiver while getting a drink of water and initially received no response until being woken. One caregiver reported observing the same caregiver sleeping on duty when coming on shift. This occurred on two separate occasions. One caregiver also reported observing a separate caregiver sleeping in the office.

Correction Narrative: Management at the operation met with all caregivers and discussed the requirements of 24/7 awake supervision at the operation. Caregivers were required to sign off stating they understood the requirement. Additionally, the operation will be conducting un-announced night inspections at the cottages twice a month. The operation created a form for management to fill out when conducting the visit.


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

raw_content: A preliminary service plan was not provided for the victim child in this case.

Correction Narrative: Chester Amidon provided a correction stating they have retrained the new case manager on the 72-hour time frame for the preliminary plan, which will be monitored by the case manager supervisor for timely completion.


raw_content: During the investigation, I observed the service plans for three children did not include available CAN's results and accurate recommendations.

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

Correction Narrative: On 5/12/25, the operation provided a written plan stating the new case manager has received additional instruction regarding expectations regarding the completion of service plans with thorough inclusion of CAN's results and recommendations.   The administrator will ensure the initial plan is completed in a timely manner and reflected in ChildTrax documentation.


summary: 748.930(b)(2) - Annual Training- Caregivers must have 2 hrs trauma informed care.

raw_content: During the investigation, I observed two staff failed to take Trauma Informed Care training in 2024.

Correction Narrative: On 5/12/25, the operation provided a written plan stating training is being tracked through a new system which will email the worker and supervisor multiple advanced notices of training which is coming due or is past due.  The supervisor will monitor these notices and ensure all annual trainings are completed as required prior to scheduling that staff to work.  This brings this standard back into compliance.


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

raw_content: During the investigation, I observed one child's medication log contained an entry for which no time of administration was recorded.

Correction Narrative: On 5/12/25, the operation provided a written plan stating an HM task is being implemented to address documentation errors which will include a weekly review by the PQI Coordinator or Assistant, who will then report to the administrator, and a plan will be developed to address any errors which arise.  This brings this standard into compliance.


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

raw_content: During the investigation, I observed the medication logs for one child's medication failed to document an administration of this medication on 12/21/24.

Correction Narrative: On 5/12/25, the operation provided a written plan stating an HM task is being implemented to address missed medication through a weekly review by the PQI Coordinator or Assistant, reporting to the administrator, and developing a plan to address each error as it is identified.  This brings this standard back into compliance.


summary: 748.1349(b)(2) - Initial Service Plan- When given to child then child must sign or operation document child's refusal to sign

raw_content: During the investigation, I observed the service plan for one child did not include his signature or documentation of refusal.

Correction Narrative: On 5/12/25, the operation provided a written plan stating the case manager has received additional instruction regarding expectations they acquire a child's signature or a notation of refusal to sign for each child's service plan henceforth.  This will be monitored by the administrator through ensuring the signed service plan is uploaded into ChildTrax.  This brings this standard back into compliance.


summary: 748.1337(b)(1)(D) - Initial Service Plan-Include specific goals and strategies to meet the child's needs, including instructions to caregivers

raw_content: During the investigation, I observed six child service plans lacked specific goals in multiple areas.

Correction Narrative: On 5/12/25, the operation provided a written plan stating the new case manager has received additional instruction regarding expectations regarding the completion of service plans with thorough inclusion of goals, needs, and strategies.   The administrator will ensure the initial plan is completed in a timely manner and reflected in ChildTrax documentation.


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

raw_content: During the investigation, I observed a child's service plan lacking the results of the most recent Psychological Evaluation or attempts to schedule a new one.

Correction Narrative: On 5/12/25, the operation provided a written plan stating the new case manager has received additional instruction regarding expectations regarding the completion of service plans with thorough inclusion of goals, needs, strategies, and psychological evaluation results.   The administrator will ensure the initial plan is completed in a timely manner and reflected in ChildTrax documentation.


summary: 748.1349(a)(2) - Initial Service Plan-Give copy or summary of plan to child's parents

raw_content: During the investigation, I observed a child's service plan failed to record when the plan was provided to the child's parent entity.

Correction Narrative: On 5/12/25, the operation provided a written plan stating the new case manager has received additional instruction regarding expectations regarding expectations they upload the email documenting the provision of the service plan to the parent entity into their system in a timely manner.  The administrator will ensure this email is uploaded into ChildTrax.  This brings this standard back into compliance.


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

raw_content: The medication count for one of the residents did  not match the medication documentation log

Correction Narrative: Two staff will be retrained in dispensation of PRN medications.  Training will include need to record administration of PRN medications given at times other than the medication time of other routine medications.  Medication dispensation of PRN medications will be recorded at the time the PRN medication is taken.


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

raw_content: One child's medication log did not include the reason the medication was prescribed.

Correction Narrative: Corrections made and shared with RCCR on medication form for child.


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

raw_content: During the walk through of the operation it was found that there were no towels at the sinks in the one of  the  bathrooms.


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

raw_content: During the inspection, I observed a medication log for a child included documentation of one medication administration on 9/30/24  that staff confirmed did not occur as the medication did not return with the child from his last visit and the operation was not in posession of the medication at the time of this inspection.

Correction Narrative: During the follow-up, I reviewed records for all three children with medications and observed no issues.  All records and counts were in compliance.


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: During the inspection, I observed the operation last administered a prescription nasal spray on 9/27/24 prior to the child's visit.  The medication was not administered again following that date as it did not return to the operation from the visit.  As of the date of the inspection, the operation was not in posession of this prescription medication and the child has not received an administration since 9/27/24


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 was seriously injured on 9/22/24, and the parent was not notified until 9/23/24, a day after the child was verified safe.

Correction Narrative: On 1/14/25, the operation submitted a written correction plan stating the administrator would take responsibility for ensuring the parent entity is notified in a timely manner.  This brings this standard into compliance.


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

raw_content: During the monitoring inspection, the operation did not provide documents, when requested. Copies of the admissions assessments were provided after the conclusion of the inspection, but discharge summaries were never produced.

Correction Narrative: On 9/23/2024, the administrator advised the operation's plan of correction for deficiency 748.399(a). The administrator will ensure that records are available through Childtrax or subsequent information management system or in the form of hard copies.  Records will be completed in a timely manner and uploaded or available as reproductions.


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

raw_content: During the monitoring inspection, the operation was not able to provide all documents when requested such as discharge summaries for two children.

Correction Narrative: On 9/23/2024, the administrator advised the operation's plan of correction for deficiency 748.1437(1). The administrator will ensure that discharge summaries or documentation include date and circumstances of discharge.  The summary or documentation will be completed in a timely manner and will be uploaded into Childtrax or subsequent information management system to be readily available for monitoring.


raw_content: During a walk through of the operation one bathroom was found not to have hand towels at the sink. Staff corrected this issue at the time of the inspection.

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


raw_content: The investigation revealed that the operation did not inform the permanency specialist/conservator of a child in care's fractured hand. The permanency specialist/conservator remained unaware until the inspector brought it to her attention.

Standard Number / Description: 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.

Correction Narrative: Administrator sent email stating the following:Serious injury/illness will continue to be reported to the managing conservator, DFPS, via the DFPS hotline.  In addition, children placed through SSCCs will be contacted through incident report in the Texas Provider Network or method prescribed by the contract with that particular SSCC or by phoning/emailing the care coordinator or similarly titled staff.


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

raw_content: The investigation revealed that a child in care suffered an injury which was not promptly addressed. The child, having injured his hand, was seen by a doctor who recommended an X-ray. However, the X-ray was not performed until two weeks following this recommendation.

Correction Narrative: Administrator sent email stating the following:Proper medical care will be provided as indicated.  For injury/illness requiring immediate care, treatment will be sought through Urgent Care or Emergency Room.  For non-critical injuries or delayed symptoms, recommendation of primary care physician will be followed.  If non-immediate x-rays are ordered by the primary care physician rather than urgent care or emergency room, they will be acquired as scheduled.  If schedule modifications are required, the primary care physician will be consulted, or they will be taken to urgent care or emergency room prior to the scheduled x-ray.


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

raw_content: During the monitoring inspection, there was one medication record that did not have documentation of the medication (Escitalopram 10mg) administered to the child on the evening of 4/27/2024.

Correction Narrative: The administrator provided plan of corrections which stated staff member received medication administration retraining.  Log was corrected.


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 monitoring inspection, there was rotten fruit observed in the refrigerator.


summary: 748.393(b)(4) - Active child record - Ensure record is locked and kept in a safe location or locations

raw_content: During the ANE Investigation, it was reported the operation staff permitted a child to go into the staff office, close, and lock the door, behind him. At that time, the child had access to child records that are stored in the staff office.

Correction Narrative: The administrator provided plan of corrections which stated the children's active records are stored electronically or locked in the administrative office.  Supplemental records such as CSAs and Medicaid cards will be locked in the cottage office. The cottage office will remain locked when not occupied by a staff member.  Youth will not be permitted in the office unaccompanied by staff.


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 found that the staff member on duty did not intervene when two children began physically fighting. This resulted in a child in care having to intervene in order to stop the altercation. The staff member lacked prudent judgement in not trying to stop the altercation between the two children.

Correction Narrative: Administrator sent email that that the staff members had been retrained.


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

raw_content: During the investigation, it was learned that the caregiver for the children did not try to intervene in anyway when the altercation started including the verbal altercation.

Correction Narrative: Administrator sent email that staff members have been retrained as recently as the end of March. 2024


summary: 748.2601(a) - Personal Restraint Monitor-Qualified caregiver monitors child for signs of physical distress & ensures ample respiration, circulation, well-being

raw_content: During the investigation, it was learned that no one was monitoring the child while he was being restrained.


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

raw_content: During the investigation, it was learned that a post discussion with the child was not held after he was restrained.


summary: 748.2453 - Emergency Behavior Intervention-Only a qualified caregiver may administer emergency behavior intervention, except short personal restraint

raw_content: During the investigation, it was found that a child in care restrained another child in care. The child in care who conducted the restraint does not have the necessary training in restraints.


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

raw_content: The operation failed to comply with the safety plan implemented during the ANE investigation.

Correction Narrative: On 4/2/2024, the Administrator provided corrections via email. The Administrator advised, in the future, safety plans will be provided to the care workers in the cottage. The safety plan related to this investigation is no longer in effect as it was time limited until the original investigation was closed. The youth requiring the additional supervision is currently in the psychiatric hospital, and a 14 day notice had been submitted prior to the hospitalization.


summary: 748.3273(9) - First Aid Kits-Each one must contain tweezers

raw_content: During the monitoring inspection, the first aid kit was missing tweezers.

Category: Safety and Emergency Practices

Correction Narrative: On 1/30/2024, the Administrator, Chester Amidon, advised a new first aid kit supplied with the required items was purchased and placed in the cottage. A picture was provided.


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

raw_content: During the monitoring inspection, one child's medication records was missing the reason medication was prescribed.

Correction Narrative: On 1/30/2024, the Administrator, Chester Amidon, advised medication log from placement the afternoon before lacked reason and was awaiting information from worker. Director of Residential Services was retrained in intake procedures and log completion to include reason.  He was instructed that if the worker is unable to provide reason when interviewed at placement, that intake staff are responsible for researching reason.  Certificate was attached.


raw_content: During the monitoring inspection, a package of spinash that was found rotten, expired, and almost liquified in the refrigerator.

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


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

raw_content: During the monitoring inspection, a bottle of Pine-Sol was observed to be in the common area and accessible to a child in care.


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

raw_content: During the monitoring inspection, a window located next to the front door was observed to have a crack. There was also a toilet in the home that was observed to be dirty and needing to be cleaned.

Correction Narrative: On 1/30/2024, the Administrator, Chester Amidon, advised the small Plexiglas window at entry with a crack in it was replaced. Picture was attached.  The commode in the bathroom, out of use for repair and with the tank lid off, had a gasket replaced to allow for better volume for refuse removal and cleaned. Picture was attached.


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

raw_content: During the investigation inspection, two of the three bathrooms had empty paper towel dispensers and no personal towels or hand dryers for use. This was previously citated at the last inspection completed earlier this month.

Correction Narrative: Administrator put paper towels and all of the bathrooms. They will do checks daily to ensure there are paper towels at all sinks.


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

raw_content: During the investigation inspection, medication records were reviewed, and it was observed that one child's medication record was inaccurate. The record indicated the medication had 26 doses remaining, while the package only contained 25 doses. It was also observed that the balance on the medication record was wrong and there was not a deduction after each dose provided. This was previously cited at the monitoring inspection completed in May of this year.

Correction Narrative: Administrator sent email with the med log corrected and the additional training.


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

raw_content: During the investigation inspection, there was a bowl of food (corn) uncovered and stored in the refrigerator.

Correction Narrative: Administrator removed the food that was uncovered and threw it away. They will ensure that all food is covered.


summary: 748.3393(d) - Toilets-Toilets must be equipped with toilet paper at all times

raw_content: During the walk through of the operation, it is noticed that 2 of the restrooms did not have toilet paper in the bathrooms. This was corrected during the inspection by rolls of toilet paper being added to those bathrooms.


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: Upon reviewing documents, it is noticed that the operation did not have documentation or had conducted a severe weather drill. This was also corrected at the inspection by having a severe weather drill conducted by the operation.


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

raw_content: Upon reviewing fire inspections, it is noticed that their most recent fire drill was done outside of the 6 months on 4/2/2023. This was corrected at the inspection by the operation conducting a fire drill.


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

raw_content: During the walk through of the inspection, it is noticed that the pantry door had a hole and the ledge of it was coming off.

Correction Narrative: The administrator provided photograph to verify the door was replaced and repaired.


summary: 748.3365(c)(1) - Bedding-must provide each child with pillow/bed linens appropriate for temperature including pillowcase, top sheet, fitted or bottom sheet

raw_content: During the walk through of the operation, it is noticed that 2 of the boys bedrooms did not have pillow cases on the pillow. This was corrected at the inspection by one pillow being removed from the room and a pillow case being added to the other pillow.


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

raw_content: Four beds in use had no mattress protectors.

Correction Narrative: Photos sent of the mattresses that were missing protectors.


raw_content: The kids' bathroom on the right side of the facility had mold in the shower floor and doors.  There were soiled walls and baseboards around the large  trash can, and the vents were covered with dust.

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

Correction Narrative: Photos sent of cleaned bathroom areas.


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

raw_content: There were 4 tomatoes with mold in the refrigerator and several packets of snack sandwiches covered in mold.  Also, a large bag of shredded cheese was completely opened in the same drawer.

Correction Narrative: Pictures of the refrigerator cleaned out - no more rotten produce or packages of snack cakes that are not fresh.


raw_content: There was nothing written on a child's medication record for "reason the medication was prescribed".

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

Correction Narrative: Corrected forms were sent and added to the document library.


raw_content: Two of the children's beds (in use) had no pillowcases.

Standard Number / Description: 748.3365(c)(1) - Bedding-must provide each child with pillow/bed linens appropriate for temperature including pillowcase, top sheet, fitted or bottom sheet

Correction Narrative: Pillow pictures taken and sent to my by Chester Amidon.


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

raw_content: A caregiver argued with children in care, and then she commented "at least I have a home to go home to" - which was demeaning to the boys in the facility.

Correction Narrative: Mr. Amidon met with Dominique Ellis to review child right issues and reiterate the trainings that Ms. Ellis has completed.  This review/extra training was put in her employee file. Please see document library.


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

raw_content: During the inspection, I observed a hole in the surround of a shower stall, and the operation did not show a maintenance request on file for the damage.

Correction Narrative: The operation provided a picture via email as documentation of the hole being repaired.  This brings this standard into compliance.


raw_content: During the unannounced after hours inspection, it was observed that a child's medication record and actual medication count did not match. The medication record reflected there were 24 doses remaining while the package only contained 23 doses.

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

Correction Narrative: On 5/30/2023, the Administrator advised that during a staff meeting on 5/24, the PQI Director covered the need to record PRN medications as well as routine medications accurately. Content included the need to verify the count with actual number rather than just subtracting one from prior count.  Content also includes the need to replace a medication rather than discarding if not given.  For example, if a medication is pulled thinking it was a routine medication when it was actually changed to PRN such as this particular medication.


summary: 748.3395(a) - Hand-washing-Hand-washing sinks must be maintained in good repair and kept clean

raw_content: During the inspection, I observed a sink a cottage bathroom with a broken hot water knob preventing its use.  The operation repaired the knob while I was there for the inspection.


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

raw_content: During the inspection, I observed the curtains in one bedroom to be suspended in such a way that the curtains did not adequately cover the window to provide requisite privacy or sufficiently block light for rest.


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

raw_content: During the course of this investigation, evidence indicates that a staff failed to properly supervise children in care, resulting in a resident having inappropriate contact with a minor online and several residents being able to congregate, contact this same minor, and call the police without the staff's awareness.


summary: 748.1385(2) - Service Plan Review-Must identify any new needs and strategies or techniques to meet these needs, including instructions to employees

raw_content: In reviewing the documentation, I observed that the resident's service plan did discuss or assess documented behaviors that resulted in increased supervision levels as documented in the operation's corrective actions to a previous investigation.

Correction Narrative:
On 5/23/23, the operation offered this correction plan via email:

Administrator will insure that service plan reviews include needs, strategies, and instructions including any safety plans or supervision plan changes since the last review.  The administrator or designee will review and sign service plan for appropriate inclusion of behavioral information since last review.

This will bring this standard into compliance.


summary: 748.3111(b) - Smoke Detector-Company licensed by State Fire Marshal or fire inspector must test electronic smoke alarm system annually; documentation required

raw_content: The operation is equipped with an electric smoke detection system, and the operation was not able to produce documentation of annual testing of the system by an approved party.

Correction Narrative: On 1/13/23, the administrator provided a copy of the fire inspection form denoting the system had been tested and passed via email.  The administrator also included a picture of the new smoke detectors for the system which include a testing button on each detector.  This brings the facility into compliance with this standard.


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 inspection, I observed no thermometer in the refrigerator.  The operation replaced the thermometer during the inspection.


raw_content: During the inspection, I observed pillow cases and sheets missing from a number of the children's beds.

Correction Narrative: All beds with residents assigned were fitted with appropriate sheets and pillowcases.


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

raw_content: In three of the four records reviewed, there was either no date for a copy of the service plan being provided to the children, no child's signature, or no documentation that a copy was provided to the child.

Correction Narrative: Chester reviewed the standard with staff and retrained the case management staff to ensure that this doesn't happen again.  See digital storage.


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

raw_content: There were over 5 places found where a staff failed to sign when medicatoins were given.  The timeframe ranged from late 2021 to May of 2022.

Correction Narrative: Pages were reviewed with direct care staff by the administrator.  Staff will be signing a new sheet at the end of each shift to ensure that initials are used for each medication administration.


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

raw_content: There were several medication sheets for two boys that did not state the reason the medications were prescribed.

Correction Narrative: Paperwork was sent by Chester Amidon showing that these issues were reviewed with all staff and stating the importance of all sections on the medication logs.  They will be using more tools to document the issues that require explanations and signatures.


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: The facility did not have any record of severe weather drills.

Correction Narrative: Documentation of the first severe weather drill was sent in, as well as plans to do them no less than every 6 months.


summary: 748.685(c)(1) - Caregiver responsibility - be aware of children's habits, interests, and any special needs including supervision

raw_content: A young man with a history of sexual abuse and a pre-occupation with pornography did not receive adequate supervision.  This resulted in sexually inappropriate behaviors and solicitation of younger kids.

Correction Narrative: Correction was sent-- All staff meeting on 10/20/22 where staff were reminded and retrained regarding individual needs and supervision requirements.  The child who was misusing his phone and the internet is being watched closely and his supervision has increased.


summary: 748.3271 - First Aid Kits-All separate living areas & buildings must have first-aid kit available; first-aid kit must be available for field trips

raw_content: There was one first aid kit in the house, but none in the vehicles to transport the boys.  There should always be one available for the vehicle that is taking the kids on an outing.  There should be a minimum of two at the Valley View Cottage.

Correction Narrative: The administrator sent pictures of the various first aid kits that are now in the vehicles and the cottage.


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

raw_content: The one first aid kit at the operation was missing a thermometer - as required by minimum standards.

Correction Narrative: Chester Amidon sent me pictures of their  new first aid kids and the thermometers that have been added at the facility.


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

raw_content: Two beds did not have protective convers separating the mattress and the sheet.  There was also one pillow case missing.

Correction Narrative: The pictures were sent to me of the pillow with a new pillow case on it.  Entered into digital storage.  Also the mattress protectors.


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

raw_content: In one of the child's records reviewed, the name used in the service plan is not  the child  who the  plan is  being completed for.

Correction Narrative: I received a training certificate for the case manager who was re-trained on Service Plans.  The training took place on 6/15/21/ and 6/16/21. This information was sent via email from Chester Amidon.


summary: 748.1385(1) - Service Plan Review-Must include evaluation of child's progress and effectiveness of strategies and techniques used to meet identified needs

raw_content: In the child's records reviewed, an evaluation of the strategies and techniques used were not included in the Service Plan Review. The information documented in the service plans reviewed is cut and pasted from the previous service plan, with no changes.


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

raw_content: There was a report of a staff testing positive for COVID.  This was reported to the hotline, but there was no documentation available for review during this inspection.

Correction Narrative: A corrective action for the citation issued above was submitted by Chester Amidon, Administrator.  In the future, serious incidents will continue to be documented in the child's electronic file on Childtrax when the incident involves a child.  If the incident is not an incident related to a child such as this one related to a staff with Covid 19, it will be recorded on an incident report form.  Attached is a completed incident report form for the noted incident.


summary: 748.1387 - Service Plan Review-Must comply with notification, participation, implementation, and documentation requirements for an initial service plan

raw_content: The service plan reviewed is not signed by the child or agency supervisor.

Correction Narrative:
I received a plan of correction from Chester Amidon.  It states the following:
Case Manager will submit service plan reviews to agency supervisor for review and signature.  Casemanager will assure that service plan reviews are signed by care worker, residential coordinator, professional level service provider and youth prior to uploading the document in Childtrax.  Casemanager will review all current plans of service and acquire any needed signatures.


facility_name: Journey to Dream - Kyle's Place

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 operations background list was last validated on 5/21/2025.

Correction Narrative: The operation validated the person list and set a reoccurring reminder to alert them every 90 days, so it won't be missed again.


summary: 748.915(b)(4) - Pediatric CPR training documentation must include the trainer's name and qualifications.

raw_content: Two of two files reviewed contained CPR certificates that did not include the trainers name and qualifications.

Category: Training and Professional Development

Correction Narrative: The CPR certificates with the missing information has been corrected. RCCR reviewed the certificates to ensure all are in compliance.


summary: 748.1331(f) - Preliminary Service Plan-Implement and follow the preliminary service plan

raw_content: One of two child files reviewed documented action items in a preliminary service plan that were not followed.

Correction Narrative: The operation is changing the way they complete preliminary service plans to ensure staff are following the time frames documented in the plans.


summary: 748.1501(b)(1) - Dental Care-Written record of each dental examination must include a copy of the examination results

raw_content: Two of two child files reviewed did not include dental results with the dental exam forms.

Category: Child Care

Correction Narrative: The operation updated the child records to include the dental results. RCCR confirmed compliance by reviewing the documentation.


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

raw_content: Operation did not submit EBI information for quarter 3.

Correction Narrative: The operation met compliance by entering the EBI data. Inspector is waiting on systemic corrections and will input once received.