facility_name: CFH-Cummings

summary: Unannounced - 1 finding

raw_content:
Licensed Child Caring Agency Site Visit Report
Residential Care
Licensee: Trillium Family Services Licensing Coordinator:
Executive Director: Kim Scott Aubrey Kelly
Date of site visit: May 11, 2022
Other Regulatory or Accrediting Agencies: Oregon Health Authority
SCOPE: On May 11, 2022, an unannounced site visit was conducted at Children’s Farm Home by ODHS – Licensing and OHA.
Physical Plant Yes No N/A Comments Corrective Action
Completed
413-215-0511(2)(a) &(c) Buildings are X Cummings – Bedrooms 9 and 10 were very messy and
smoke free, clean and in good repair cluttered.
Redwood – Bedrooms 3, 9, 10 and 12 were very messy and
cluttered. Room 14 had graffiti on the walls. There was trash
on the ground outside of the entrance to the unit.
The program shall ensure all buildings are clean and in good
repair.
Interview Summary
Five staff who work across campus were interviewed. Staff reported they are struggling with high acuity clients and a staffing crisis. Staff reported they feel
supported through the staffing crisis by management. CFH previously had several temporary staff on campus. Staff reported CFH did not have any plan of
how to deal with staffing when the temporary staff were not working anymore.
Nine clients were interviewed, across all cottages. Clients reported they know there isn’t enough staff. Bullying was reported to be occurring between clients
on the Cumming unit. Clients reported they don’t feel like all their needs are being met because there is not enough staff. Generally clients reported feeling
safe.
(rev. 07/29/2020)
Follow-up
As of Thursday, May 12, 2022, temporary staff are back at CFH. Based on the circumstances that occurred after the first group of temporary staff left, CFH will
submit a plan to Licensing by June 15, 2022, to address how they will handle the temporary staff leaving at the end of June 2022.
Corrective Actions and Timeframes: Please submit the following to verify compliance.
Within 45 days of receipt of this report Trillium Family Services must submit a letter of verification indicating the agency is in compliance with the
specific rules cited above and describing how compliance will be maintained going forward. Along with the letter of verification, the agency must
submit any and all specific documentation requested in the body of this report. The letter of verification and any additional requested documents can
be emailed directly to (Licensing Coordinator and email address) or sent by regular mail to the following address:
Department of Human Services, Children’s Care Licensing Unit
Attn: Aubrey Kelly
500 Summer St NE (E-94)
Salem, OR 97301
Licensing Coordinator’s Signature: ________________________ Date: _0_5_.3_1_._2_0_2_2_ _________
Manager Review: ______________________________________ Date: _ _5_-_1_9_-_2_0_2_2_ _______
2

program_name: CFH-Cummings

executive_director: Kim Scott Aubrey Kelly

other_regulatory_agencies: Oregon Health Authority SCOPE: On May 11, 2022, an unannounced site visit was conducted at Children's Farm Home by ODHS - Licensing and OHA. Physical Plant Yes No N/A Comments Corrective Action Completed 413-215-0511(2)(a) &(c) Buildings are X Cummings - Bedrooms 9 and 10 were very messy and smoke free, clean and in good repair cluttered. Redwood - Bedrooms 3, 9, 10 and 12 were very messy and cluttered. Room 14 had graffiti on the walls. There was trash on the ground outside of the entrance to the unit. The program shall ensure all buildings are clean and in good repair. Interview Summary Five staff who work across campus were interviewed. Staff reported they are struggling with high acuity clients and a staffing crisis. Staff reported they feel supported through the staffing crisis by management. CFH previously had several temporary staff on campus. Staff reported CFH did not have any plan of how to deal with staffing when the temporary staff were not working anymore. Nine clients were interviewed, across all cottages. Clients reported they know there isn't enough staff. Bullying was reported to be occurring between clients on the Cumming unit. Clients reported they don't feel like all their needs are being met because there is not enough staff. Generally clients reported feeling safe. Follow-up As of Thursday, May 12, 2022, temporary staff are back at CFH. Based on the circumstances that occurred after the first group of temporary staff left, CFH will submit a plan to Licensing by June 15, 2022, to address how they will handle the temporary staff leaving at the end of June 2022.

excerpt:
&(c) Buildings are
smoke free, clean and in good repair Cummings – Bedrooms 9 and 10 were very messy and
cluttered.
Redwood – Bedrooms 3, 9, 10 and 12 were very messy and
cluttered. Room 14 had graffiti on the walls. There was trash
on the ground outside of the entrance to the unit.
The program shall ensure all buildings are clean and in good
repair.


state: OR

facility_name: CFH-Mallett

summary: Unannounced - 2 findings

raw_content:
Licensed Child Caring Agency Site Visit Report
Residential Care
Licensee: Trillium – Children’s Farm Home Licensing Coordinator:
Date of site visit: August 5, 2022 Aubrey Kelly, Jeff Minden
Other Regulatory or Accrediting Agencies: OHA
Observations:
An unannounced site visit was completed by CCLP on August 5, 2022 at Children’s Farm Home (CFH) after receiving a complaint. A tour of the
campus was completed and one client was interviewed. Overall the campus was clean and welcoming. There was a significant odor in the
basement of Mallett, which was caused by water damage.
Interviews:
Client – They have been at CFH for 1.5 months, they came from home. They do not like the food at the program, however does like the ice cream.
Their favorite staff are Hayden and Joe. They get along with the other clients. Another client called them names and yelled at them. The last hold
they were in was 3 days ago. They are allowed to call family. They don’t feel safe and want to move units. Following this site visit, the youth was
moved to a different unit at Children’s Farm Home.
Corrective Actions and Timeframes: Please submit the following to verify compliance.
Within 45 days of receipt of this report Trillium – Children’s Farm Home must submit a letter of verification indicating the agency is in compliance
with the specific rules cited above and describing how compliance will be maintained going forward. Along with the letter of verification, the agency
must submit any and all specific documentation requested in the body of this report. The letter of verification and any additional requested
documents can be emailed directly to Aubrey Kelly at Aubrey.J.Kelly@dhsoha.state.or.us or sent by regular mail to the following address:
Department of Human Services, Children’s Care Licensing Unit
Attn: Aubrey Kelly
500 Summer St NE (E-94)
(rev. 07/29/2020)
Salem, OR 97301
Physical Plant Yes No N/A Comments Corrective Action
Completed
413-215-0046(3)(a) Foster Rights Posted (if X
children in DHS custody)
413-215-0051(1) Sufficient safe space, X
equipment, and office equipment
413-215-0091(12) License is posted in X
common area at each facility
413-215-0001(5)(d), 0516(4(a)(I) & 0521(1) X
Adequate furnishings and personal items
413-215-0511(2)(a) &(c) Buildings are X The basement in Mallett had a very strong odor, there
smoke free, clean and in good repair was a section of carpet and wall that was soaked with
413-215-0511(2)(d) Rooms are free of X water. The program shall ensure no clients are in the
harmful drafts, odors, and excessive basement of Mallett until the odor is gone and the carpet
noise and walls are repaired.
413-215-0511(2)(e) Rooms are adequate in X
size and arrangement
413-215-0511(2)(f) System provides a X
continuous supply of hot and cold water to
taps located throughout the facility
413-215-0511(2)(h) Building is well X
ventilated and room temperature is within a
normal comfort range
413-215-0516(1) All parts of the facility X
ensure the safety of children
Room and Space Requirements Yes No N/A Comments Corrective Action
Bedrooms 413-215-0516(3) Completed
(a) Adequate furnishings and personal items X
(b) Separate from rooms used for dining, X
living, laundry, kitchen, and storage
(c) Outside room with window allowing X
egress from building
(d) Ceiling at least 90 inches X
(e) Minimum 60 SF per bed X
(f) No more than 25 if dorm style X
(g) Permanently wired fixtures X
(h) Window covering X
(i) Beds are 3 feet apart and maintained to X
ensure safety
Room and Space Requirements Yes No N/A Comments Corrective Action
Bathrooms 413-215-0516(4) Completed
(a)(A)&(B) 1:8 ratio for toilets and sinks X
(a)(D) Hot and cold running water, soap, and X
approved hand drying options
(a)(E) 1:10 ratio for shower or bathtub X
(a)(E) Individual privacy X
(a)(F) Window covering X
(a)(G) Permanently wired fixtures X
(a)(H) Adequate ventilation X
(b)&(c) Wooden racks on floors are X
prohibited and impervious shower mats are
disinfected & dried daily
Room and Space Requirements Yes No N/A Comments Corrective Action
Kitchen 413-215-0516(6) Completed
(a) Used exclusively for storage, food X
preparation, dish washing and activities
related to eating
(b) Walls, floors are easily cleanable X
(c) Equipment and utensils are easily X
cleanable, durable, nontoxic, and kept clean
(e) Equipment is easy to clean beneath, X
between and behind
Room and Space Requirements Yes No N/A Comments Corrective Action
413-215-0516 Completed
(2) There is a separate living room or lounge X
area – 15 SF minimum per child
(5) There is a separate dining room with X
capacity for ½ of children in care and 15 SF
per child in care
(7) Laundry is separate from living areas, X
kitchen and dining
(8) Separate storage areas are provided for X
food, kitchen supplies, utensils, clean linens,
soiled linens and clothing, cleaning supplies
and equip, poisons, chemicals, outdoor
recreational and maintenance equipment.
(hazardous materials are properly labeled, in
original container and locked)
(9) Outdoor activity area is protected from X
vehicles and other hazards and of a size and
availability appropriate to the age and needs
of children in care
(11) & 413-215-0076(3)(c)(C)Time out rooms X
have adequate space, heat, light and
ventilation and is not capable of locking
Furnishings and Personal Items Yes No N/A Comments Corrective Action
413-215-0521 Completed
(1) There is a bed with frame, clean mattress X
and pillow and personal storage (dresser,
closet)
(2) Linens are in good repair. There is a X
waterproof mattress cover or mattress.
Linens are appropriate and towels and
washcloths are provided
(3) Bedding is changed weekly or when X
soiled
(4)&(5) Personal hygiene supplies and X
appropriate clothing are provided
Licensing Coordinator’s Signature: ________________________ Date: _8_/3_1_/_2_0_2_2_ __________
8-30-2022
Manager Review: ______________________________________ Date: __________________

agency_name: Trillium Family Services (TFS)

program_name: CFH-Mallett

program_type: (RC) Residential Care Programs

report_type: Unannounced

view_code: RC

facility_type: Residential Care

licensee: Trillium - Children's Farm Home Licensing Coordinator

other_regulatory_agencies: OHA Observations: An unannounced site visit was completed by CCLP on August 5, 2022 at Children's Farm Home (CFH) after receiving a complaint. A tour of the campus was completed and one client was interviewed. Overall the campus was clean and welcoming. There was a significant odor in the basement of Mallett, which was caused by water damage. Interviews: Client - They have been at CFH for 1.5 months, they came from home. They do not like the food at the program, however does like the ice cream. Their favorite staff are Hayden and Joe. They get along with the other clients. Another client called them names and yelled at them. The last hold they were in was 3 days ago. They are allowed to call family. They don't feel safe and want to move units. Following this site visit, the youth was moved to a different unit at Children's Farm Home.

excerpt:
&(c) Buildings are
smoke free, clean and in good repair

excerpt:
Rooms are free of
harmful drafts, odors, and excessive
noise


summary: Unannounced - 2 findings

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Licensee: Trillium Family Services – Children’s Farm Home
Executive Director: Kim Scott
Date of Unannounced: September 8, 2022
Licensing Coordinator: Aubrey Kelly
Other Regulatory or Accrediting Agencies: OHA
Purpose: Per OAR 413-215-0101 (1) (b) Children’s Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Comments
Findings
Further Action
Needed
413-215-0511(2)(a) &(c) Buildings are Yes☐ No The smell and water damage in the basement of Mallett was
smoke free, clean and in good repair
much better.
413-215-0511(2)(d) Rooms are free of Yes☐ No
harmful drafts, odors, and excessive noise
New Findings from Site Visit Comments
None
1
(rev. 200115)
Interview Summary
Client interview: They feel safe here and their favorite staff are Duncan, Evan, Trevor and Big Sam. The food is
good, especially the nachos. They reported some of the food tastes like cat food. They get along with other
clients. When asked what else can be done to keep them safe, they said, “Nothing. It’s not their fault.”
Observations
The Mallett and Redwood cottages were toured. Both cottages were clean and well maintained. There has been
significant work done to keep one suicidal client safe, to include removing their bedroom door, removing the lock
from the bathroom door and allowing the client only to be in rooms with more than one door in and out.
Corrective Actions and Timeframes:
Please submit the following to verify compliance.
Within 45 days of receipt of this report Trillium – Children’s Farm Home must submit a letter of verification indicating the agency is in compliance
with the specific rules cited above and describing how compliance will be maintained going forward. Along with the letter of verification, the agency
must submit any and all specific documentation requested in the body of this report. The letter of verification and any additional requested
documents can be emailed directly to Aubrey.J.Kelly@dhsoha.state.or.us.
Licensing Coordinator’s Signature: ________________________ Date: _9_-_2_6_-2__0_2_2__________
Manager Review: ______________________________________ Date: _9_-_1_9_-2__0_2_2_ ________
(rev. 07/21/2022)

licensee: Trillium Family Services - Children's Farm Home

executive_director: Kim Scott

visit_date: September 8, 2022

licensing_coordinator: Aubrey Kelly

other_regulatory_agencies: OHA

purpose:
Per OAR 413-215-0101 (1) (b) Children's Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Comments
Findings
Further Action
Needed
413-215-0511(2)(a) &(c) Buildings are Yes[ ] No The smell and water damage in the basement of Mallett was
smoke free, clean and in good repair
much better.
413-215-0511(2)(d) Rooms are free of Yes[ ] No
harmful drafts, odors, and excessive noise
New Findings from Site Visit Comments
None
1

Interview Summary
Client interview: They feel safe here and their favorite staff are Duncan, Evan, Trevor and Big Sam. The food is
good, especially the nachos. They reported some of the food tastes like cat food. They get along with other
clients. When asked what else can be done to keep them safe, they said, "Nothing. It's not their fault."
Observations
The Mallett and Redwood cottages were toured. Both cottages were clean and well maintained. There has been
significant work done to keep one suicidal client safe, to include removing their bedroom door, removing the lock
from the bathroom door and allowing the client only to be in rooms with more than one door in and out.

new_findings:
None
1

excerpt:
413-215-0511(2)(d) Rooms are free of Yes[ ] No
harmful drafts, odors, and excessive noise
New Findings from Site Visit Comments
None
1
None
1


facility_name: Sender House Y.A.T.

summary: Unannounced - 3 findings

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Licensee: Trillium Family Services – Sender House
Executive Director: Kim Scott
Board Chairperson: Eric Larsen
Date of Unannounced: November 30, 2022
Licensing Coordinator: Aubrey Kelly
Other Regulatory or Accrediting Agencies: OHA
Purpose: Per OAR 413-215-0101 (1) (b) Children’s Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Comments
2021 License Renewal Site Visit 08-24-2021 Findings
Further Action
Needed
Supplemental Information Provided by Yes☐ No The documents were reviewed.
CCA
Documents as indicated on the form titled
“Renewal Licensing Required Documents”
- Not all Certificates of Occupancy
have been received
- PCC does not have a current
Environmental Health Inspection
- No conflict of interest policy meeting
requirements of licensing rule
Supplemental Information Provided by Yes☐ No Policies and procedures are up to date.
CCA
All required policies and procedures as
identified in the “Umbrella Rules”
1
(rev. 07/21/2022)
Personnel Files 413-215-0061 Yes☐ No Annual performance evaluations were reviewed for three Sender House staff.
(3)(d) Annual performance evaluations
Sender - missing one performance evaluation
Ongoing Training Yes☐ No Prudent Parent training was completed for three Sender House staff.
413-215-0556(4) Designated staff authorized
to apply reasonable and prudent parent
standard are trained in application of the
standard
Sender - Only 2020 Prudent Parent
documented for all staff
Service Planning 413-215-0581(2) Yes☐ No Service plans for three Sender House clients were reviewed and updated quarterly.
(e)(C)&(D) Service plan is reviewed quarterly
and revised when information indicates other
services should be provided
Sender - not reviewed quarterly
Personal Possessions Records 413-215- Yes☐ No Personal possessions records for three Sender House clients were reviewed.
0581(5)
Individual written inventory of all personal
possessions is maintained and updated as
needed
Sender – No documentation of individual
written inventories
New Findings from Site Visit Comments
None
2
Interview Summary
One client, who has been at the program for a year and a half, was interviewed. They like the program, it’s more than they could ask for. The food is good,
clients and staff go grocery one time a week. The clients cook. They feel safe at the program, program staff are friendly and supportive. They like all the staff
an gets along with the other clients. There is nothing they would change about the program.
Observations
The program currently has 4 clients. Each client has their own, large bedroom. The program was very clean.
Corrective Actions and Timeframes:
Please submit the following to verify compliance.
Within 45 days of receipt of this report Trillium – Sender House must submit a letter of verification indicating the agency is in compliance with the
specific rules cited above and describing how compliance will be maintained going forward. Along with the letter of verification, the agency must
submit any and all specific documentation requested in the body of this report. The letter of verification and any additional requested documents can
be emailed directly to Aubrey.J.Kelly@dhsoha.state.or.us.
Licensing Coordinator’s Signature: ________________________ Date: _1_2_-1_9_-_2_0_2_2__________
Manager Review: ______________________________________ Date: _1_2_-_8_-2__0_2_2_ ________
3

program_name: Sender House Y.A.T.

licensee: Trillium Family Services - Sender House

board_chairperson: Eric Larsen

visit_date: November 30, 2022

purpose:
Per OAR 413-215-0101 (1) (b) Children's Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Comments
2021 License Renewal Site Visit 08-24-2021 Findings
Further Action
Needed
Supplemental Information Provided by Yes[ ] No The documents were reviewed.
CCA
Documents as indicated on the form titled
"Renewal Licensing Required Documents"
- Not all Certificates of Occupancy
have been received
- PCC does not have a current
Environmental Health Inspection
- No conflict of interest policy meeting
requirements of licensing rule
Supplemental Information Provided by Yes[ ] No Policies and procedures are up to date.
CCA
All required policies and procedures as
identified in the "Umbrella Rules"
1

Personnel Files 413-215-0061 Yes[ ] No Annual performance evaluations were reviewed for three Sender House staff.
(3)(d) Annual performance evaluations
Sender - missing one performance evaluation
Ongoing Training Yes[ ] No Prudent Parent training was completed for three Sender House staff.
413-215-0556(4) Designated staff authorized
to apply reasonable and prudent parent
standard are trained in application of the
standard
Sender - Only 2020 Prudent Parent
documented for all staff
Service Planning 413-215-0581(2) Yes[ ] No Service plans for three Sender House clients were reviewed and updated quarterly.
(e)(C)&(D) Service plan is reviewed quarterly
and revised when information indicates other
services should be provided
Sender - not reviewed quarterly
Personal Possessions Records 413-215- Yes[ ] No Personal possessions records for three Sender House clients were reviewed.
0581(5)
Individual written inventory of all personal
possessions is maintained and updated as
needed
Sender - No documentation of individual
written inventories
New Findings from Site Visit Comments
None
2
Interview Summary
One client, who has been at the program for a year and a half, was interviewed. They like the program, it's more than they could ask for. The food is good,
clients and staff go grocery one time a week. The clients cook. They feel safe at the program, program staff are friendly and supportive. They like all the staff
an gets along with the other clients. There is nothing they would change about the program.
Observations
The program currently has 4 clients. Each client has their own, large bedroom. The program was very clean.

new_findings:
None
2

excerpt:
413-215-0581(2) Yes[ ] No Service plans for three Sender House clients were reviewed and updated quarterly.
(e)(C)&(D) Service plan is reviewed quarterly
and revised when information indicates other
services should be provided
Sender - not reviewed quarterly
Personal Possessions Records 413-215- Yes[ ] No Personal possessions records for three Sender House clients were reviewed.
0581(5)
Individual written inventory of all personal
possessions is maintained and updated as
needed
Sender - No documentation of individual
written inventories
New Findings from Site Visit Comments
None
2
None
2


state: TX

facility_name: Methodist Children's Home BCC

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

raw_content: During the course of the investigation, it was determined that the caregiver yelled and intimidated a child during verbal redirection.

Category: Individual Standards Evaluated

Standard Risk Level: Medium High

Corrected at Inspection: No

Correction Narrative:
Methodist Children's Home has taken action to address licensing reporting standards compliance. A training in Trust Based Relational Intervention (TBRI), MCH's treatment model, was completed with the home parents assigned to the Harris home on 03/18/2026. The residential supervisor has increased presence in the home to ensure home parents are complying with minimum standards and MCH discipline policy. Case Managers will complete routine check-in with children in the home. Home parents will continue to receive on-going support in individual supervision meetings. In addition, a meeting was held with the home parent listed in the allegation on 03/25/2026 where the following was addressed:
  Minimum standard 748.2307 (8) was reviewed with the home parent and she acknowledged a clear understanding
  The home parent will complete trainings in TBRI Connecting, Empowering, and Correcting Principles with a TBRI Practitioner by April 22, 2026


facility_name: Laurel Ridge Treatment Center

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

raw_content: During an after hours inspection a wall was observed to be peeling, sheet rock was damaged and the base board was cut due to a bed being removed.

Category: Physical Site

Correction Narrative: During an unannounced Inspection the Inspector observed the previous hole in the wall to be patched up.


summary: 748.3105(b) - Fire Inspection-Must comply with local code & all corrections, restrictions, or conditions specified by inspector in fire inspection report

raw_content:
The operation completed its annual fire inspection on time; however, the operation did not pass the inspection.  The operation must address and correct all identified code violations to achieve compliance.

This standard was re-cited due to the fire re-inspection resulting in violations. The operation made corrections following the initial inspection, however, they did not bring the operation into compliance with the respective fire codes.

Correction Narrative:
Fire inspection is pending approval from the gas inspection which required corrections. Approval for extension granted on 4/17/26; new compliance date is 4/30/26.
On 4/28/26, Deborah Toscano provided CCR with the passing fire inspection report.


summary: 748.3397(a) - Bathing-Bath & shower areas must provide for individual privacy

raw_content: During an unannounced monitoring inspection, a shower curtain was observed to not be in place, it was determined children in care had to shower without a curtain in place.

Standard Risk Level: Medium

Correction Narrative: The shower curtains in the operation were all in place during an unannounced inspection.


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

raw_content: During an unannounced monitoring inspection, while assessing the medication for children in care seven out of nine medication counts were found to be incorrect.

Category: Medication

Correction Narrative: The inspector reviwed 25 medications and found 24/25 medications to be counted correctly.


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

raw_content:
During a follow-up inspection a wall was obsevred to have a water leak as well as the brick around the shower was warped due to the leak. Shower 413 was observed to be clogged and no draining adequately. The operation is blocking off the room with the wall damage caused by the water leak and will not be used until corrections are approved.
************************************
This was re-cited during a separate follow up inspection as the bathroom remains inoperable while repairs are being completed.
*************************************
This was re-cited, although the shower is complete and no mold appears to be in the shower. The water pressue is  high, causing the water to pool outside of the shower. Two soaked towels were observed on the floor completly wet. The operation is using an extra long shower curtain for the shower, but the water is still escaping causing a slipping hazard

Standard Risk Level: High

Correction Narrative: During an in person follow up the bathroom repairs were completed and all repairs fixed.


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

raw_content: During an investigation, it was found that on two occasions, a nursing staff mixed up the medications for two children in care. On the first occasion, the children received the incorrect medication for two days; on the second occasion, the children received the incorrect medication on one day. Additionally, on the second occasion, the nursing staff were not aware of the medication error until the children informed them of the error.

Correction Narrative: The Nurses are now provided a quiet place to give out medication to children ensuring they are in a location where they can concentrate on the medications given. Medication re-training was given to all nursing staff on 03/27/2026.


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 an investigation it was determined on multiple occasions nurses on staff administered the incorrect medication dosage giving a child in care a whole pill instead of the half pill the prescription label instructed to.


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

Correction Narrative:
748.151 (3) - Operational Responsibilities: Maintain current, true, accurate and complete records

A serious incident report completed by the administrator reflected X-ray results for a child when the child never received any X-rays, making the report inaccurate.	RN that provided inaccurate information to administrator was terminated 1/22/2026.

DON and Program Director to review of diagnostic testing following injury to ensure accurate reporting as of 4/01/2026.


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

raw_content: Two direct care staff in ratio during the incident did not have a background check under the RTC.

Correction Narrative: Administrator stated the facility has begun to submit new background checks for those who require this, all background checks for those who are within the Lavaca and San Gabriel units where the children are will be submitted.


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

raw_content: Operation staff did not exercise prudent judgment when they allowed for two children previously involved in a verbal altercation remain in proximity of each other; this lead to the children engaging in a physical altercation resulting in severe injuries to one of the children in care.

Correction Narrative: Administrator stated all staff have been spoken to and verbally re-trained on how to handle altercation that would require separating children from harming each other. The staff that allowed the children to remain within close proximity to one another has been terminated.


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

raw_content: While reviewing a medication log for a child in care, it was noted that there was no name or signature of the staff who administered a medication to a child.

Correction Narrative: RN was terminated as of 1/22/2026. Re-education to all RTC nurses on medication administration and documentation process. Reeducation to include attestation to be provided by DON by 3/26/2026.


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 sustained a hand fracture and was not provided medical care until 5 days later.

Correction Narrative: The staff that conducted this error was terminated and the nursing staff were re-trained on how to report children injuries.


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

raw_content: A child in care became injured on 1/15/26 and the operation notified the parent on 1/16/26. The operation sought medical treatment for the child on 1/20/26 and did not notify the parent until 1/21/26.

Correction Narrative: DON will provide reeducation to all RTC nurses on parent notification process. Attestations will be completed with re-education by 3/26/26. The Inspector asked Ms. Roberts about the trainings, she stated all of the staff are now trained on how to call statewide intake.


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

raw_content: A child sustained an injury on 2/15/26. The operation sought medical care on 2/20/26 and did not notify CCR within the 24-hour reporting requirement.

Correction Narrative: LCCA will provide reeducation to all RTC staff on policy PC-83 Residential Servies Child-Care, to include process of reporting patient injuries in the mandated time frames. The Inspector reviewed this information with Tonya Roberts.


facility_name: Nothing Just Happens Inc.

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

raw_content: The Preliminary Service Plan did not address supervision requirements for a child who exhibited high risk behaviors.

Standard Risk Level: Medium Low

Correction Narrative: An email was sent from the administrator regarding investigation # 3152450. The administrator stated that we will continue to review with more diligence our Service Plans to ensure that all requirements are addressed to meet the immediate needs of the child within 72 hours, to include supervision requirements. The documentation can be found in the document library.


raw_content: A child with a history of high-risk behaviors did not have supervision requirements indicated on the plan.

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

Correction Narrative: The operation identified that there was a need to enhance management's oversight of the common application and child' background/needs at placement to ensure this criteria is met. The operation implemented a new policy.


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

Correction Narrative: An unannounced follow-up inspection was conducted in regards to assessment number 247903 due to physical cite citation. Pictures were received from the administrator. Pictures were taken during the inspection and can be found in external file.


summary: 748.3273(6) - First Aid Kits-Each one must contain scissors

raw_content: The first aid kit is missing a thermometer,scissors, and a pair of tweezers.

Category: Safety and Emergency Practices

Corrected at Inspection: Yes


facility_name: Texas Tranquility Estates, Inc.

summary: 748.935(a)(1) - Annual Training Timeline-Each person must complete the required annual training within 12 months from the date of hire

raw_content: 1 of 4 employee records reviewed was missing annual trainings.

Category: Training and Professional Development

Correction Narrative: Operation provided Completed training certificates, noted that they are using computerized system that will alert when trainings are due.


facility_name: Make A Way Residential Treatment Center

raw_content: Children and staff reported a child was upset when staff held a child so birthday cake could be smashed in the childs face.

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

Correction Narrative: Staff confirm staff training and staffings to not engage in touching activities and keep appropriate with residents.


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

raw_content: During an investigation children reported staff use profanity towards them. A staff member admitted to using profanity towards children when directing the children to sit down.

Correction Narrative: Staff confirm having trainings and staffings not to use profanity towards residents. Staff confirm to trainings staff be professional and think before they speak.


facility_name: Fostering Life Youth Ranch, LLC Meraki

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

raw_content: The operation did not make a report to Licensing when police responded to the facility.

Correction Narrative: Per email from the Administrator, all staff have been directed to report to the hotline any time police respond to the facility regardless of who initiated their response.


facility_name: Kaufman County Children's Emergency Shelter

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

raw_content: The operation did not report a serious incident within the timeframe alloted.

Category: Reports and Record Keeping

Correction Narrative: Staff and Administrator was interviewed they confirmed that a training is scheduled to go over the requirements for reporting and how to document.


summary: 748.3891(a)(2) - Trampolines-must have shock-absorbing pads covering the springs, hooks and frame

raw_content: The trampoline pads were torn in multiple areas and the springs were visible.  In addition, the poles on the trampoline were broken and leaning into the middle area of the trampoline.

Category: Recreation Activities

Correction Narrative: A walk through of the operation was completed and the trampoline has been removed from the playground.


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

raw_content: There was a hole on the door to the heater in the boys hallway. The bathroom had floor lining pulling apart from the wall. The outside playground had two ant piles that children had access to.

Correction Narrative: The Administrator indicated that they have scheduled a meeting for the staff on 4/24/26 to go over the new forms that were created regarding ensuring that if maintenance is required, the management is notified. A walkthrough inspection also supported that appropriate repairs were made to the maintenance request.


facility_name: Hill Country Youth Ranch Residential Treatment Center

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

raw_content: During an inspection, it was observed that mold was accumulating in one of the showers.

Correction Narrative: A physical walkthrough was conducted of Stevens I cabin as the Terry cabin is in the process of closing officially on 6/12/25. The operation will be conducting a full-scale renovation to the Terry cabin. Walkthrough of Stevens I cabin showed staff and residents cleaning the cabin to prepare for the move in on 6/12/25 of residents. Maintenance requests have been submitted in the Terry cabin to fix the dripping water in one bathtub and a small hole in an air ventilator by one of the beds. No site of mold was in the Stevens I cabin. Moving forward the Terry cabin will be shut down for remodeling.


facility_name: Sophies House for Children

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

raw_content: The operation did not have an annual evaluation for review.

Category: Emergency Behavior Intervention

Correction Narrative: Operation submitted evaluation. Operation also shared that they will set calendar reminders for the end of the year to get the annual evaluation completed timely.


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

raw_content: One child was missing a TB test.

Category: Child Care

Deficiency Narrative: One child was missing a TB test.

Correction Narrative: Sophie's House staff submitted a copy of the child's TB test that was conducted. Negative results were obtained and provided to RCCR.


summary: 748.1271(8) - Emergency Admission Documentation-Include the results of the suicide screening at admission, if required.

raw_content: It was noted that a child was missing their suicide screening assessment.

Category: Admission, Service Planning, Discharge

Correction Narrative: Operation submitted a suicide screening assessment for the child.


summary: 748.1381(2) - Service Plan Review-If child receiving treatment services for ED, ASD, or PMN, review at least 90 days from date of last service plan

raw_content: One child's service plan review was completed 10 days late.

Correction Narrative: Going forward, the operation plans to maintain a spreadsheet to assist in maintaining timely compliance with service plan reviews.


summary: 748.453(c) - Unauthorized Absence - Annual summary logs should be available to Licensing for review and reproduction, upon request.

raw_content: When requested, the operation was unable to provide an annual summary log of the previous runaways.

Correction Narrative: Operation Administrator submitted a copy of the operation's annual summary log through email. Upon review of the log, it meets the requirements as set by minimum standards.


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

raw_content: Two of the four staff records reviewed did not contain a copy of their educational records/certifications.

Correction Narrative: Operation Administrator submitted a copy of the missing documents from the personnel records. The documents show that the employees meet the qualifications for the position.


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

raw_content: Upon review of documentation, it was found that two of the initial service plans were completed past the 45-day mark.

Correction Narrative: SHC Administrator/Case Manager will make sure all initial service plans are completed within 45 days after admission.


raw_content: Upon review of documentation, it was found that five service plan reviews were completed past the 90-day mark.

Standard Number / Description: 748.1381(2) - Service Plan Review-If child receiving treatment services for ED, ASD, or PMN, review at least 90 days from date of last service plan

Correction Narrative: SHC Administrator/Case Manager will make sure all service plans are completed within 90 days from the date of the last service plan. SHC Administrator/Case Manager will make sure service plans are emailed to the caseworkers within ten days of completion.


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

raw_content: The 2nd quarter EBI report has not been submitted to Child Care Regulation.

Correction Narrative: EBI quarterly report reviewed through CLASS system. Operation reported one personal restraints.


raw_content: One of four child records is missing a documentated TB Test.

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

Correction Narrative:
SHC Administrator will make sure that all youth have their tb vaccinations within 30 days of placement.

Child recieved TB test on 8/23/2022


summary: 748.395(1) - Active child record - All documentation in the record no later than 30 days after occurrence or event

raw_content: Four of the four child records were missing documentation that is past 30 days of being completed.

Standard Risk Level: Low

Correction Narrative: All documents for each youth will be placed in their chart no later than 30 days of an appointment being completed. Any and all documents that are completed for each youth will be placed in their chart immediately (within 30 days of completion).


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

raw_content: Annual Fire Inspection was due May 2022.

Correction Narrative: Operation had a Fire Inspection conducted on 08/18/2022 with the city of Lufkin Fire Department. Ozzie Jarman conducted the inspection and the operation received passing results.


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

Deficiency Narrative: The 2nd quarter EBI report has not been submitted to Child Care Regulation.

Correction Narrative: EBI quarterly report reviewed through CLASS system. Operation reported zero personal restraints.


raw_content: The operation's 1st Quarter EBI report has not been submitted to Licensing.

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

Correction Narrative: The operation submitted the quarterly EBI report through their portal. EBI quarterly report was reviewed in CLASS. Operation reported conducted 2 personal restraints.


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

raw_content: Four of six medication logs for one youth did not document the youth's allergy to amoxicillin.

Correction Narrative: An email was sent to RCCR stating moving forward in order to ensure the medication logs are correctly filled out the administrator and The Administrator and Case Aide will be responsible for checking medication logs for accuracy.


summary: 748.2259(a) - Psychotropic medication documentation-Maintain a daily record of the child's use of psychotropic medication according to requirements in 748.2151

Correction Narrative: An email was sent to RCCR stating moving forward in order to ensure the medication logs are correctly filled out the administrator and The Administrator and Case Aide will be responsible for checking medication logs for accuracy and all psychotropic medication will be checked and ensured the medications are administered daily.


summary: 748.2151(c)(4) - Medication record - must include medication name, strength and dosage

raw_content: Two medication logs did not include dosage instructions.


facility_name: St. Georgia's

raw_content: A review of personal records shows an active employee with a hire date of 10/17/2024 has not completed a TB test to date.

Correction Narrative: On 05/29/2025 the operation provided a follow-up compliance plan by phone. Operation states that the staff member in question had a completed TB test prior to employment which was completed on 02/03/2024. Operation has submitted proof of this TB test. Operation has reviewed all staff files to ensure necessary records are complete and updated. They have also implemented use of software to track required documents by individual staff along with due dates. Automatic alerts and reminders are generated through this case management software.


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

raw_content: Two employees that were terminated on 1/30/2025 remain active on background checks.

Correction Narrative: On 05/29/2025 the operation provided a follow-up compliance plan by phone. Operation states that they have since reviewed their personnel list to ensure their records are up to date. They have also implemented use of software to track required tasks along with due dates. Automatic alerts and reminders are generated through this case management software.


facility_name: Brotherhood Academy

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

raw_content: It was determined that a caregiver did not have a current background check on file with the operation.


facility_name: TRELS Home LLC

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 a Contracts visits to the operation on 9/24/2025, it was observed that a child in care was not administered a prescribed medication for at least 5 days due to the medication not being refilled timely.


facility_name: A Journey of Hope

summary: 748.683(2) - Caregiver Supervision-Provide oversight of caregivers to ensure that assigned duties are performed adequately

raw_content: Caregivers were performing other duties and failed to provided one-on-one supervision for child.

Correction Narrative:
Provided by Email from Administrator on 03/02/2026: Effective immediately, A Journey of Hope will implement corrective measures in addressing the specifics of this standard rule and preventing all related occurrences in the future, will ensure all staff members involved in this isolated incident will be retrained on Appropriate Supervision of Children with emphases on staff to Child Ratio, 1:1 Supervision approach, importance of Sight, Proximity and Earing, interventions during supervision. As a monthly occurrence, during monthly meetings refresher trainings in this and other areas will be conducted.

The Facility Administration will ensure completion and proper documentation of this.


facility_name: Adaptive Mind Services, LLC

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

raw_content: Two staff records evaluated did not contain a statement signed and dated by the employee documenting that the employee has read a copy of the operational policies.

Correction Narrative:
04/09/2026-The CEO submitted the operation's corrective action plan to Licensing via email, indicating the CEO has provided all staff with the required acknowledgement forms to read and sign, confirming that each employee has received and read a copy of the operational policies.

Additionally, the CEO submitted an external document demonstrating a written statement requiring the employee's signature and date to verify that he or she has read the operational policies.

04/17/2026-The CEO submitted the operation's corrective action plan to Licensing via email, the operation provided signed and dated acknowledgement form verifying that staff have received and reviewed a copy of the operational policies.


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

raw_content: An employee's employment check did not include the three most recent employers.

Category: Personnel

Correction Narrative: 04/09/2026-The CEO submitted the operation's corrective action plan to Licensing via email, indicating the CEO will ensure that all required onboarding documentation, including verification of employment with the applicant's three most recent employers, is completed and maintained in each staff member's personnel file.


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

raw_content: An employee only had one reference check completed.

Correction Narrative: 04/09/2026-The CEO submitted the operation's corrective action plan to Licensing via email, indicating the CEO will ensure all necessary onboarding documentation, including reference checks are suitable to work with children, is completed and appropriately filed within staff personnel records.


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

raw_content: One staff file evaluated did not contain completed and signed  the Pre-Employment Affidavit for Applicants for Employment at Certain Child Care Operations form.

Correction Narrative:
04/09/2026-The CEO submitted the operation's corrective action plan to Licensing via email, indicating the CEO will ensure that all onboarding paperwork is fully completed and maintained in each staff member's personnel file in accordance with requirements.

04/17/2026-The CEO submitted the operation's corrective action plan to Licensing via email, the operation provided signed and dated Pre-Employment Affidavit for Applicants for Employment at Certain Child Care Operations Form for staff.


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

raw_content: The first floor toilet does not flush.

Deficiency Narrative: The first floor toilet does not flush.

Correction Narrative:
04/09/2026-The CEO submitted the operation's corrective action plan to Licensing via email, indicating that a plumber was contacted to address all necessary repairs.  It was noted that the toilet is now operable and flushing properly.

Additionally, video documentation was provided demonstrating that the toilet is functioning as required, indicating compliance with applicable standards.


summary: 748.363(13) - Personnel records-Include record of training and training hours.

raw_content:
An employee's personnel record did not contain certificates with date and curriculum for the following trainings: Orientation, Normalcy, Reporting Abuse and Neglect (including Sexual Abuse), Runaway Prevention, Trauma Informed Care, Psychotropic Medication, Administering Psychotropic Medication, Communicable Diseases, Emergency Behavior Intervention, Transportation, Suicide Prevention, Intervention, and Postvention.
Administrator filed evaluated contained expired trainings.

Correction Narrative:
04/09/2026-The CEO submitted the operation's corrective action plan to Licensing via email, indicating the CEO will ensure that all required onboarding documentation, including training and orientation records, is completed and properly maintained in each staff member's personnel file.

Additionally, the CEO has submitted external documentation verifying that the Case Manager's required trainings have been updated for the following courses:
Medical Consent Training, Psychotropic Medication Training, Runaway Prevention Training, Trauma Informed Care, and Normalcy Training.


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

raw_content: The fridge thermometer showed a temperature between 60-70 degrees.

Correction Narrative:
04/09/2026-The CEO submitted the operation's corrective action plan to Licensing via email, indicating that the refrigerator is now functioning properly and maintaining a temperature of 40 degrees or below.

Additionally, the CEO provided photographic documentation of the refrigerator thermometer reflecting a temperature below 40 degrees, demonstrating compliance with Minimum Standards.


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

raw_content: The operation's administrator is not on-site for announced inspections.

Correction Narrative:
04/09/2026-The CEO submitted the operation's corrective action plan to Licensing via email, indicating that the Administrator will be scheduled and present onsite to continue mentoring, provide daily supervision, and fulfill administrative responsibilities to ensure the smooth operation of the facility.

04/17/2026-The CEO submitted the operation's corrective action plan to Licensing via email, documentation outlining the Administrator's work schedule, reflecting eight-hour workdays, Monday through Friday.


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

raw_content: The back concrete stoop of the operation had a decomposing rodent.

Correction Narrative: 04/09/2026-The CEO submitted the operation's corrective action plan to Licensing via email, indicating that the exterior of the operation has been cleaned and cleared of rodent activity, demonstrating compliance with applicable standards.


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

raw_content: The operation's fire inspection is expired.

Correction Narrative:
04/09/2026-The CEO submitted the operation's corrective action plan to Licensing via email, indicating the operation is currently coordinating with the Fire Marshal's Office to schedule the required fire inspection and obtain a new permit.

04/17/2026-The CEO submitted the operation's corrective action plan to Licensing via email, a document from the Harris County Fire Marshal's Office indicating that, upon completion of the inspection and approval, the permit will be valid, and a certificate of inspection will be issued with a start date of 04/14/2026 and an end date of 04/14/2027.  Per the CEO, the fire inspection is scheduled for 04/20/2026.


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

raw_content: No documentation showing how the person meets the minimum age for the job position.

Correction Narrative: 04/09/2026-The CEO submitted the operation's corrective action plan to Licensing via email, the CEO submitted photographic documentation of the Case Manager's driver's license, demonstrating compliance with age requirements based on the date of birth provided.


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

raw_content: Two staff records evaluated did not contain a statement signed and dated by the employee indicating the employee must immediately report any suspected incident of child abuse, neglect, or exploitation.

Correction Narrative:
04/09/2026-The CEO submitted the operation's corrective action plan to Licensing via email, indicating the CEO has provided all staff with the required statement regarding the reporting of suspected abuse, neglect, and exploitation, requiring staff to review the operational policies, sign, date, and maintain documentation in their personnel files.

Additionally, the CEO submitted an external document outlining a written statement requiring staff to immediately report suspected child abuse, neglect, or exploitation, including acknowledgement through signatures and date.

04/17/2026-The CEO submitted the operation's corrective action plan to Licensing via email, the operation provided signed and dated acknowledgement form verifying that staff have received and reviewed a statement regarding the reporting of suspected abuse, neglect, and exploitation.


summary: 748.563(a) - Professional level service provider-meet specific qualifications if operation provides certain amount of treatment services for emotional disorders

raw_content: The operation's identified PLSP does not meet the educational qualifications.

Correction Narrative:
04/09/2026-The CEO submitted the operation's corrective action plan to Licensing via email, indicating the CEO is actively recruiting, interviewing, and hiring a qualified full-time PLSP, with the expectation that the position will be filled within 60 days or less.

Additionally, the current Case Manager will remain an active staff member in a new role within the operation.


facility_name: Boys & Girls Country Of Houston

summary: 748.67 - Transitional living program-Includes a training program that helps children develop competencies in specified areas

raw_content: Operation was not able to provide a list of services for transitional living program.

Category: Definitions and Services


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

raw_content: The operation was unable to provide a calendar/list of daily recreation activities for chilren in care.


summary: 748.1103(c) - Informing child of rights-If a person has a visual or auditory impairment, explain child's rights in a manner that is understandable to that person

raw_content: 4 child files reviewed did not obtain the proper child right's information per minimum standards.

Category: Children's Rights


facility_name: Methodist Childrens Home Boys Ranch

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

raw_content: The Initial Service Plan reviewed did indicate the level of supervision required.

Correction Narrative:
On 1/23/2026, Director, stated that the incorrect plan of service was sent to the Inspector. To correct such an incident from happening in the future, training will be held on 1/26/2026 with the Director for the programs-Boy Ranch and the Boys Ranch Case managers, to review the plan of service expectation.

On 1/23/2026, Senior Director for Clinical and Compliance, sent an email stating that an Administrative Review will be requested.


facility_name: SJRC Texas, Inc.

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

raw_content: Incident Report documentation reveals a child attempted suicide by wrapping pant leg around their neck and trying to hang themself on shower rod. The child was unsuccessful and told staff about the self-harming behavior. The operation completed an incident report on 12/02/2025 and reported to Statewide Intake on 12/03/2025, with the report reflecting just after midnight on 12/4/25; thus, the incident was not reported as soon as the operation was aware of the attempt.

Correction Narrative: The administrator states that an all-staff meeting ocurred following up the incident reporting. Core managers were present at the meeting and were explained about the citation and importance of reporting. Meeting took place on 01/07/2026. Administrator states that now their staff will be reporting incidents as soon as they ocurr to prevent any future deficiencies. Copies of the meeting documents (meeting agenda and sign-in sheet) were received and will be uploaded. Administrator states that they split up the meetings by role and that they review trends such as IR's, staff meetings etc; core manager meetings on Mondays and clinical meetings and shift supervisor meetings on Wednesdays.


summary: 748.3757(b) - Swimming Ratio-when all children in group are at least 4 yrs or older, if four/more children swimming, there must be at least two adults supervising

raw_content: During a swimming activity, staff were found to be out of ratio, resulting in a child in care being injured during the activity, requiring medical care.

Correction Narrative: Staff are being provided with a training that implements the rules and regulations of the staff required during swimming activities. The training will be completed by 8/23/24.


summary: 748.3755 - Lifeguard-Must be located in a position to observe all swimmers and to respond to emergencies

raw_content: During a recreational water activity, outside of the operation, children in care were allowed to participate in a swimming activity with no lifeguard present.

Correction Narrative: Administration staff has implemented new rules regarding swimming activities, the amount of children that can attend, high risk behaviors and the increased amount of supervision required during the water activities. Lifeguard must be present during water activities.


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 2 activities outside of the operation, staff did not bring the necessary emergency medication for children in care, resulting in further medical care needed.

Correction Narrative: Interviews with staff present at the operation reported to having badge access to the medicaitons double locked. In addition, during any outtings, staff must be equipped with the medical bag reuired to carry emergency medicaiton for children in care.


facility_name: HMIH CEDAR CREST, LLC

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

raw_content: Two children engaged in an altercation for several minutes. Staff were present and did not intervene to separate the children to ensure their safety. Both children sustained injuries from this altercation.

Correction Narrative: Two children and two staff were interviewed and report staff intervene appropriately when children are fighting.  Staff were trained on prudent judgment, child's rights, caregiver responsibilities to address appropriate supervision, interventions, and maintaining professional and therapuetic boundaries.


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

raw_content: Through interviews it was determined that several children and one staff reported that another staff member encouraged a child to fight another child who had been bullying and antagonizing other residents.

Correction Narrative: Two children and two staff were interviewed and report no staff encourage children to fight.  Staff were trained on prudent judgment, child's rights, caregiver responsibilities to address staff using prudent judgment and maintaining professional and therapeutic boundaries.


raw_content: A child in care made a suicide attempt in November 2023 by wrapping something around their neck and their face was discolored as a result of this. This was not reported by the operation to Child Care Regulation.

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

Correction Narrative: A discussion with director of risk management took place where it was discussed that nursing leadership had training on 2/20/24 regarding serious incidents and reporting. It was discussed the person with first hand knowldge writes the incident report and the nurse is notified immediately. House supervisoor and/or director of risk management will provide nurses with guidance on if a hotline report needs to be made. Additionally it was discussed there was further training on what constitutes a suicide attempt and the child involved should always be asked if they had intentions of suicide.


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

raw_content: It was determined within this DFPS investigation that children in care were not free from abuse or neglect when staff allowed children to fight each other and staff dragged a child out of their room.


facility_name: Safe Haven Youth Ranch

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

raw_content: An employee was observed to be delinquent in completing the required annual Normalcy Training.

Correction Narrative: A copy of the employees Normalcy Training Certificate was emailed showing that the employee completed the training on 02/10/26.


summary: 748.453(a)(4) - Unauthorized Absence - Annual summary log must include name of caregiver responsible for child at time absence discovered

raw_content: During the review of the investigation, it was found that the unauthorized absence did not contain the name of the caregiver responsible at the time of the absence.

Correction Narrative: Revised the Unauthorized Absence form to include a mandatory field for documenting the name of the caregiver supervising at the time the absence is discovered.


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

raw_content: Two of four children confirmed that staff member made improper comments.

Correction Narrative:
A follow-up inspection was conducted with children in care. Neither made any further outcries of abuse or neglect.
The agency emailed the following corrective action on 03/05/26: The staff member has been scheduled to complete Trust-Based Relational Intervention (TBRI) training on March 6th. This training will reinforce trauma-informed practices, developmentally appropriate interactions, emotional regulation, and relationship-based engagement with youth in care. The purpose of this additional training is to strengthen the staff members understanding of how to communicate in a manner that promotes dignity, connection, and emotional safety.
Ongoing Corrective Action:
To promote consistency and prevent recurrence, Safe Haven Youth Ranch requires ongoing training for all direct care staff as follows:
 Trust-Based Relational Intervention (TBRI)  required quarterly
 Handle With Care (HWC)  required every six months
In addition to formal training requirements, supervisory staff will provide continued active oversight, coaching, and monitoring of staff interactions with youth. Leadership will reinforce expectations related to professionalism, respect, and trauma-informed engagement to ensure all children in care are treated with dignity and emotional safety at all times.


summary: 745.8641 - Requirements during probation

raw_content:
Condition #1-Met
Condition #2-Not met
Condition #3-Not Met
Condition #4-Met
Condition #5-Met
Condition #6-Met

Correction Narrative:
Moving forward, Safe Haven Youth Ranch has implemented monthly compliance meetings to regularly review, track, and document probation conditions and required completion timelines. These meetings will support stronger operational alignment, organization, and efficiency, while ensuring probation requirements are not only met but exceeded. This process will also strengthen program structure and improve overall outcomes. Additionally, Safe Haven Youth Ranch will ensure the following is documented and maintained:
 Serious Incident Report Requirement Training Sign-in Sheet
 Serious Incident Report Requirement Post Test
 Serious Incident Report Requirements Certificate


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

raw_content: A medication log for a child in care indicated a remaining count of 30 pills; however, a physical count revealed only 16 pills.

Correction Narrative:
To address the citation regarding improper documentation of a pill count, refresher training will be conducted prior to January 20, 2026. This training will reinforce the following expectations:
 Staff must carefully review and follow prescription directions as written by the prescribing physician, with specific attention to the prescribed quantity and required physical pill counts.
 Staff must ensure that the documented number of remaining pills accurately matches the actual number of pills present in the prescription at each count.
These corrective actions are intended to strengthen medication management practices and prevent future documentation errors.


summary: 748.1381(2) - Service Plan Review-If child receiving treatment services for ED, ASD, or PMN, review at least 90 days from date of last service plan

raw_content: A Service Plan Review was observed to be completed past 90 days of the Initial Service Plan completion date.

Correction Narrative:
To ensure a child who is receiving treatment services for ED, ASD, or PMN, Safe Haven will ensure that a Service Plan Review is reviewed and completed at least 90 days from date of last service plan:

1.	Case Manager will monitor all upcoming ISP meetings and will ensure an invitation is sent to all parties no later than fourteen (14) days in advance.
2.	Case Manager will ensure written notification of invitation is uploaded into Extended Reach.
3.	At the conclusion of the ISP meeting, Case Manager will ensure the completed ISP is sent to the childs parent(s) for signature and completed within ten (10) days.
4.	Case manager will ensure written notification of completed and signed ISP will be unloaded into Extended Reach within ten (10) days.
5.	An oversight audit will be conducted by LCCA to ensure tasks are completed by the Case Manager in a timely manner.

The Case Manager will be responsible for tracking and scheduling the Service Plan Reviews, ensuring they are completed by the appropriate renewal date.

The noted missing documentation was due to staffing changes within the Safe Haven Clinical Team, which resulted in gaps in proper documentation.  Safe Haven currently has a stable Clinical and Case Management Team in place to support and ensure documentation is conducted within the required timeframes.


summary: 748.1341(b) - Initial Service Plan-Child's record must include documentation of advance notice to parents of planning meeting and any responses from the parents

raw_content: A child's records reviewed did not have documentation that the service plan meeting letter was sent to all parties

Correction Narrative:
To ensure documentation of advance notices to parent(s) of childs initial service planning meeting and any responses from parent(s):

1.	Case Manager will monitor all upcoming ISP meetings and will ensure an invitation is sent to all parties no later than fourteen (14) days in advance.
2.	Case Manager will ensure written notification of invitation is uploaded into Extended Reach.
3.	At the conclusion of the ISP meeting, Case Manager will ensure the completed ISP is sent to the childs parent(s) for signature and completed within ten (10) days.
4.	Case manager will ensure written notification of completed and signed ISP will be unloaded into Extended Reach within ten (10) days.
5.	An oversight audit will be conducted by LCCA to ensure tasks are completed by the Case Manager in a timely manner.

The noted missing documentation was due to staffing changes within the Safe Haven Clinical Team, which resulted in gaps in proper documentation.  Safe Haven currently has a stable Clinical and Case Management Team in place to support and ensure documentation is conducted within the required timeframes


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

raw_content: Admissions Assessments for two children in care were observed to be missing pertinent information.

Correction Narrative:
To ensure Safe Havens responsibility to maintain current, true, accurate and complete records:

1.	Prior to placement, a childs parent(s) will be sent the required documentation and authorizations prior to intake.
2.	Documents and signed authorization will be requested to be sent prior to intake, if applicable.
3.	Upon intake, intake admissions will use an audit tool/checklist to ensure all required documentation and authorization is received from childs parent(s).
4.	If during intake, any items required are missing, intake admissions will make notes of next steps and ensure all items are collected within a timely manner.
5.	Completed checklist will be uploaded into Extended Reach and Case Manager will follow up on any missing items with childs parent(s).
6.	An oversight audit will be conducted by LCCA to ensure tasks are completed by the Case Manager in a timely manner.

Admission Assessments of a childs record will be completed in full.  All Safe Haven Team members responsible for completing admission paperwork will be trained to ensure they understand no fields within the admission assessment should be left blank.  This training will be conducted prior to Tuesday, December 30, 2025.


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

raw_content: There is no documentation showing that the smoke detector was tested in October 2025 in the Brazos House, and none from July through December 2025 in the Llano House.

Correction Narrative:
To ensure battery operated smoke detectors are tested monthly and properly documented:

1.	A monthly calendar with scheduled test dates will be implemented.
2.	Supervisors or a designee will ensure tests are conducted monthly.
3.	Program Manager will ensure test dates calendared are conducted monthly and will audit the Emergency Drill Log prior to the last day of the month.

Safe Haven will ensure testing is conducted in all facilities, even if a youth is not residing in the home during that month.


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: Notification of a Service Plan meeting occurring on 05/15/25 was not sent until 05/07/25.

Correction Narrative:
To ensure a childs initial service plan meeting is attended by the childs parent(s), Safe Haven will ensure the childs parent(s) is notified at least two-weeks in advance by:

1.	Case Manager will monitor all upcoming ISP meetings and will ensure an invitation is sent to all parties no later than fourteen (14) days in advance.
2.	Case Manager will ensure written notification of invitation is uploaded into Extended Reach.
3.	At the conclusion of the ISP meeting, Case Manager will ensure the completed ISP is sent to the childs parent(s) for signature and completed within ten (10) days.
4.	Case manager will ensure written notification of completed and signed ISP will be unloaded into Extended Reach within ten (10) days.
5.	An oversight audit will be conducted by LCCA to ensure tasks are completed by the Case Manager in a timely manner.

The noted missing documentation was due to staffing changes within the Safe Haven Clinical Team, which resulted in gaps in proper documentation.  Safe Haven currently has a stable Clinical and Case Management Team in place to support and ensure documentation is conducted within the required timeframes


raw_content:
Condition #1-Met
Condition #2-Met
Condition #3-Met
Condition #4-Not Met
Condition #5-Met
Condition #6-Met

Standard Number / Description: 745.8641 - Requirements during probation

Correction Narrative: Moving forward, when completing an employee audit and documents requested from the employee are not received within ten (10) days, there will be disciplinary action taken to reinforce the seriousness of maintaining accurate and current personnel records.


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

raw_content: One Child's Right's form was observed to be missing the child's signature.

Correction Narrative:
To ensure a child is informed of their rights, understand the information provided and have an opportunity to ask questions; Safe Haven Youth Ranch will ensure a childs signature is obtained on the Childs Rights form upon intake by ensuring:

1.	A childs signature is obtained upon intake.
2.	If a child refuses to sign the form, Safe Haven Youth Ranch will attempt to obtain said signature within seven (7) days.
3.	If within seven (7) days, child still refuses to sign said form, the word refused, will be written on the form in-lieu of the childs signature.


raw_content:
Condition #1-Not Met
Condition #2-Met
Condition #3-Met
Condition #4-Met
Condition #5-Met
Condition #6-Met

Correction Narrative:
To ensure all probation conditions that have been imposed to ensure the safety and well-being of the children in care, support the operation in maintaining compliance with minimum standards and prevent repeated or ongoing violation; Safe Haven Youth Ranch has revised the Supervision and Observation Template to include and reflect the requested change:
-	In addition to a field to address deficiencies observed during observations, a field has been added to address resolutions.
-	This updated form will be used in future observations


summary: 748.685(a)(1) - Caregiver responsibility - knowing which children they are responsible for

raw_content: A child in care was reported to have been on a one-to-one level of supervision, yet there are multiple incidents where the same child was involved in horseplay with a second child in care. These same incidents were documented and required further investigation.

Correction Narrative: On 12-09-25 The operation submitted a CAP for the deficiency. The operation will complete refresher training with staff. A supervision log will children's LOS and staff responsible for supervision identified. Twice a shift a supervisor will review the LOS log, and any issues will be addressed.


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

raw_content: During the course of this investigation, it was determined that a staff member was utilized inappropriate disciplinary practices by referring to a child using derogatory names.


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

raw_content: Medication errors were not documented for missed dosages of prescription medication for six children in care.

Correction Narrative:
Inspector observed all medication records to be in compliance during investigation/inspection on 07/03/25.
The operation emailed the following corrective action on 08/05/25: Safe Haven Youth Ranch will conduct a thorough review of each child's Medication Logs to ensure full compliance with medication error reports to explain any discrepancies in regard to the administration of medication for a child.

Step 1: Medication Error Discovery
When a medication error is found regarding a prescribed medication, the team member who found the error must contact a health-care professional immediately (unless the youth received the medication at the wrong time or a medication dose was skipped or missed) and follow the health-care professional's recommendations.

When a medication error is found regarding a non-prescribed medication, the team member who found the medication error must take the appropriate and necessary actions as required by the circumstances.

Step 2: Medication Error Documentation
For all medication errors, the following will be documented within 24 hours:
- the time and date of the error;
- the explanation of medication error;
- the time and date of the call(s) to the licensed health-care professional (if applicable);
- the name and title of the health-care professional contacted (if applicable); and
- the health-care professional's medical recommendations for ensuring the youth's safety (if applicable).

Step 3: Regulatory Oversight and Corrective Action
To limit the number of team members involved in the medication administration process, only Supervisors, Managers, and the Program Administrator are trained and approved to dispense medication. Additionally, a QA Medication Technician has been contracted to support with reviewing medication logs as further oversight and a quality assurance effort in the proper administration of medication.

Quality Assurance Process:
A QA Medication Technician has been contracted to support as an additional layer of quality assurance when reviewing medication logs for further oversight in the proper administration of medication. The findings from the medication log review is then shared with the Program Manager and Program Administrator for further follow-up as determined necessary.

Leadership Oversight:
The Director of Regulatory Compliance and Quality Improvement and the LCCA provide oversight by reviewing medication compliance data during monthly quality assurance meetings. They audit logs for accuracy, monitor for patterns of errors, and develop corrective actions accordingly. Any significant medication errors are escalated for immediate review and response in accordance with state regulations and agency policy.

Where Documented:
Safe Haven Youth Ranch maintains all documentation related to All medication administration logs, incident reports, and medication error reports in each child's file within the Extended Reach database.

Responsible Management:
The QA Medication Technician in collaboration with the Program Administrator is primarily responsible for implementing Medication Error Documentation Compliance. This includes overseeing medication log reviews, coordinating training, ensuring timely documentation, and verifying compliance with Minimum Standards. In the event the QA Medication Technician is unavailable, the Program Manager or LCCA will temporarily assume responsibility for these duties to ensure uninterrupted compliance monitoring and accurate documentation.

The Director of Regulatory Compliance and Quality Improvement provides oversight to guarantee consistent adherence, accountability, and regulatory compliance throughout the process.


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: Six children in care missed dosages of prescribed medications on multiple occasions for consecutive days.

Correction Narrative:
Inspector observed all medication records to be in compliance during investigation/inspection on 07/03/25.
The operation emailed the following corrective action on 08/05/25: Immediate Remedial Action:
o	Safe Haven Youth Ranch has transitioned to using Brookshire Brothers Pharmacy #11, Brenham, TX, as our primary local pharmacy to ensure timely access to prescribed medications for all youth in care.
o	This change was implemented to reduce delivery delays and avoid the risk of medication lapses caused by supply shortages or out-of-stock situations at prior providers.
Medication Procurement Procedure Update:
o	If a prescribed medication is unavailable at our primary pharmacy, staff are now required to immediately contact the Program Director/Case Manager and an alternate pharmacy to secure the medication before the current supply is depleted (if applicable).  If a prescribed medication is not covered by medical insurance, but available, the Program Director or Case Manager will secure funding to pay for the required medication.
o	Case Managers and staff trained in distributing medication will maintain a list of two backup pharmacies to expedite the fulfillment of prescriptions.
Staff Training and Accountability:
o	All designated medication administrators have received refresher training on HHSC requirements for medication administration, emphasizing the importance of ensuring uninterrupted medication regimens.
o	Training includes protocols for checking medication supply levels 57 days prior to depletion and initiating refill or alternative pharmacy procedures promptly.
o	Documentation of pharmacy contact efforts will be logged in the youth's medical file.
Ongoing Compliance Monitoring:
o	The Program Director will conduct monthly audits of medication administration records (MARs) to verify compliance with prescribing instructions and timeliness of refills.
o	Any identified delays or lapses will be reviewed, corrective measures implemented, and findings documented in compliance reports for licensing.
Preventive Measures:
By utilizing a local, reliable pharmacy partner and implementing a proactive monitoring process, Safe Haven Youth Ranch will ensure that all medications are administered exactly as prescribed, without lapse, in compliance with HHSC regulations and the child's healthcare plan.


raw_content: While reviewing the child service plan it was discovered in the "Transitioning To Successful Adulthood," several statements indicated the child was a twelve-year-old, which was not true or accurate at the time this plan was completed. This section of the plan was also not current, as the child plan was a review and this section should've been completed at the time of the review as the child was fourteen years old at the time the plan was completed.

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

Correction Narrative: The Program Administrator, LCCA is responsible for reviewing completed ISPs submitted by the TD or designated Casse Manager. The Administrator ensures all service plans reflect current and relevant information across all domains that comply with applicable Minimum Standards. The operation will ensure information in each domain of the service plan is current, true and accurate, and includes a true depiction of the child.


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

raw_content: An employee file was observed to lack documentation related to pre-employment screening.

Correction Narrative:
The following corrective action was received:
1.	File Remediation
o	The affected employee file will be updated by June 11, 2025, with proper documentation of employment verification, including dates of contact and outcomes.
2.	Full HR File Audit
o	A complete review of all active employee files was conducted to verify that documentation of prior employer contact is on file for each staff member. All missing documentation will be obtained and filed appropriately.
3.	Staff Training
o	Personnel will be retrained no later than June 11, 2025, regarding the specific documentation requirements under §748.751(b)(2) and the required contents of pre-employment screening records.
Preventative Measures Implemented
1.	Pre-Employment Verification Form
o	A standardized Pre-Employment Verification Form is now required for all hires. This form captures:
	Date of contact with prior employer(s)
	Name and title of individual contacted
	Summary of verification received
	Intake Staff initials and date
2.	Onboarding Checklist Update
o	The HR onboarding checklist has been revised to include a dedicated section for prior employment verification. The file is not considered complete until this documentation is present.
3.	File Review Sign-Off
o	Before a new hire begins work, the Program Director must now review and sign off on the completed personnel file, confirming all licensing documentation requirements are met.
4.	Quarterly File Audits
o	Beginning July 2025, quarterly audits of 25% of all employee files will be conducted by the Compliance Officer to ensure ongoing adherence to all pre-employment documentation requirements.


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

raw_content: A child admitted on 06/11/2024 did not receive an initial medical visit until 08/14/2024.

Correction Narrative:
The following corrective action was received:
1. Medical Appointment Completed
Although delayed, the child's initial medical exam was conducted on August 14, 2024. Documentation has been uploaded and verified in the child's file.
2. Admission and Medical Audit
A retrospective review was conducted for all children admitted in 20242025 to ensure medical visits occurred within required timeframes.
3. Staff Re-Training
By June 11, 2025, all Intake Coordinators and the Case Managers will receive refresher training on medical care requirements outlined in §748.1223, emphasizing the timeframes for initial medical, dental, and vision appointments.
Preventative Measures Implemented
1. Medical Appointment Tracking Log
A centralized tracking system has been implemented to record admission dates and ensure medical appointments are scheduled and completed within regulatory timeframes. This log is reviewed weekly by the Program Manager.
2. Admission Compliance Checklist
A mandatory checklist has been created to be completed at the time of admission. The checklist includes scheduled medical appointments and required timelines, with supervisory sign-off required within 72 hours of admission.
3. Weekly Oversight Review
Program Manager will conduct weekly compliance checks for all newly admitted youth to ensure that initial medical appointments are scheduled and occur in a timely manner.
4. Accountability and Escalation
If a child's medical appointment is not scheduled within 3 days of admission, an alert will be sent to the Program Director. Delays beyond 7 days will trigger immediate escalation and require written justification.


summary: 748.395(1) - Active child record - All documentation in the record no later than 30 days after occurrence or event

raw_content: Documentation related to the medical records of a child admitted in June 2024 was not observed in the child's file.

Correction Narrative:
The following corrective action was received:
1.File Remediation:
The child's medical documentation has been located and uploaded to the digital and hardcopy file as of June 5, 2025.
2.File Audit:
A full audit of all active child files was conducted to verify that no other medical documents were overdue or missing. 3.Immediate Staff Re-Education:
All Case Managers and Intake staff will be retrained on documentation timelines and requirements by June 11, 2025.
Preventative Measures Implemented
1.Child Medical Documentation Tracking Log
A standardized log is now in use to track all medical documentation timelines and ensure submission and upload occur within the 30-day compliance window.
This log is maintained by the Case Manager and reviewed weekly by the Program Manager.
2. Weekly Compliance Review
Program Manager will conduct weekly file checks to confirm all medical records are accounted for and uploaded.
3. Monthly Internal Audits
The Compliance Officer now audits 20% of all child files monthly for documentation accuracy and timely uploads.
4. Performance Accountability
All Case Managers are required to submit a File Completion Certification Form for every new admission within 30 days.


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: One caregiver was observed to be supervising 7 children in Llanos House.

Category: Child/Caregiver Ratios


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: The allegations are related to a DFPS abuse/neglect investigation.

Correction Narrative: This standard was found to be compliant during a follow-up inspection.


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

raw_content: A staff member choked a child in care as a form of discipline.


raw_content: One of four child's records reviewed had a different child's name listed in file.Additionally, one of the employee records reviewed lacked documentation of a drug tests being taken

Category: Organization and Administration

Correction Narrative:
The following corrective action was received: Prior to this on-site monitoring, Safe Haven had been without a case manager since October 2024. The previous LCCA, who abruptly resigned in November 2024 without ensuring the maintenance of youth records, had assigned a supervisory staff member to oversee records management. However, this staff member also resigned immediately after the LCCA's departure, leaving the responsibility for managing resident records incomplete. As a result, the electronic filing system, Extended Reach, was not consistently updated as the sole records system as originally intended. This led to instances of misfiled youth records, where documents were placed in the incorrect youth's electronic record.
As of February 24, 2025, SHYR hired a new case manager who has begun preservice training, including instruction on the Extended Reach electronic record-keeping system and the record management protocol. This protocol requires all youth records to be updated no later than the 5th of the following month, with compliance monitored by the current LCCA on an ongoing basis.
The correction process for updating each youth's electronic record began on Monday, February 3, 2025, with other program staff assisting. This process will continue with the support of the current LCCA, Treatment Director, Program Managers, Case Manager, and CEO, who will provide training, guidance, and quality assurance. A deadline has been set to ensure that all youth electronic records in Extended Reach are fully updated by April 30, 2025.
Safe Haven will conduct audits of youth electronic records throughout April to ensure consistency and compliance as the record maintenance and uploads are completed.
Additionally, the SHYR Admin Assistant failed to maintain current, true, accurate, and complete records for each employee, as required by the job description. As immediate corrective action, this employee was reprimanded for deficiency on March 12, 2025. Moving forward, the Admin Assistant will conduct monthly audits of each employee's personnel record, with any deficiencies documented in a report shared with the LCCA.
To ensure all employee records are current, true, accurate, and complete, Safe Haven will conduct a full audit of each employee's electronic record beginning Monday, March 17, 2025, until completion, under the direct oversight of the CEO.


summary: 748.361(d) - Personnel records-The system for maintaining all records must be uniform throughout the operation

raw_content: Records were supplied in two formats: electronic and paper. However, the documents in both formats lacked uniformity, which created challenges in processing the information. Additionally, there were several missing documents in both the electronic and paper submissions, further complicating the review and analysis of the records.

Correction Narrative:
The following corrective action was received: SHYR Correction Action Implemented	Prior to this on-site monitoring, Safe Haven had been without a case manager since October 2024. The previous LCCA, who abruptly resigned in November of 2024 without ensuring the maintenance of youth records, had assigned a supervisory staff member to oversee records management. However, this staff member also resigned immediately after the LCCA's departure, leaving the responsibility for managing resident records incomplete. As a result, the electronic filing system, Extended Reach, was not consistently updated as the sole records system as originally intended.
As of February 24, 2025, SHYR has hired a new case manager who has begun preservice training, which includes instruction on the Extended Reach electronic record-keeping system and the record management protocol. This protocol requires all youth records to be updated no later than the 5th of the following month. This process will be monitored by the current LCCA to ensure full compliance each month.
The correction process for updating each youth's electronic record began on Monday, February 3, 2025, with other program staff assisting. This process will continue with the support of the current LCCA, Treatment Director, Program Managers, Case Manager, and CEO, who will provide training, guidance, and quality assurance. A deadline has been set to ensure that all youth electronic records in Extended Reach are fully updated by April 30, 2025.