summary: A resident reported that after a suicide attempt a staff member said, “That is how it be sometimes,” and hit the resident multiple times leading to an altercation. The resident stated that the staff member grabbed her by the throat and left a handprint and scratches on the resident’s face and neck. The complaint was UNFOUNDED by Licensing. The facility was cited 110.12 for late reporting.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 026835
Date of Incident: 12/27/2024
Date Received: 1/14/2025
Facility Name: Elizabeth Mitchell Centers
Facility Number: 157
Incident Type:
Report Description: AV is . Out of home
AO is staff member at Centers for Youth and Families, Unknown name. is currently
in and court ordered to receive residential services at Centers for Youth
and Families. On /24 was brought to for
attempted suicide at Centers. During her initial session with her therapist at the hospital,
shared that after her attempt was interrupted at Centers, a staff member (
cannot remember her name but knows it starts with a describes her as heavy set,
) said "that is how it be sometimes" and proceeded to
hit first multiple times, leading the two to get in altercation. Other girls ran to get
help and by the time other staff came back, said, " beat her repeatedly".
grabbed by throat during this altercation and had handprint and
scratches on her face and neck. She requested to have photo taken of injuries but was
denied by staff. also stated that hit another child ( .
Interim Action Narrative: Staff member suspended pending the facility's investigation.
Narrative: AV is . Out of
home AO is staff member at Centers for Youth and Families, Unknown name. is
currently in and court ordered to receive residential services at Centers
for Youth and Families. On /24 was brought to Methodist Behavioral
Hospital for attempted suicide at Centers. During her initial session with her therapist at the
hospital, shared that after her attempt was interrupted at Centers, a staff member
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

( cannot remember her name but knows it starts with a and describes her as
) said "that is how it be sometimes" and
proceeded to hit first multiple times, leading the two to get in altercation. Other
girls ran to get help and by the time other staff came back, said, " beat her
repeatedly". grabbed by throat during this altercation and had
handprint and scratches on her face and neck. She requested to have photo taken of injuries
but was denied by staff. also stated that hit another child ( ).
Licensing Narrative: 1/14/2025-Licensing received
.
determined that licensing was never made aware of this report through ELS
. Licensing was provided with a copy of the video footage for review and has
requested nursing notes and witness statements from the facility.
, and they reported that they were
not made aware until 1/14/2024. However, after review of information
, it was determined that a staff member at the facility was contacted regarding the
on 1/2/2025, but it was not reported to
licensing. Per facility: This allegation is part of the incident on 12/26/24. The client made
the allegation while in acute care and Centers was not aware of the alleged staff involved
until today when the investigator came for a visit.
, and
could continue working. ,
. 01/16/2025 Licensing Specialist Horton inquired of the facility
witness statements or nursing notes on this case. 1/21/2025, case staffed. Licensing
Specialist will interview some residents. 1/23/2025, licensing interviewed 3 residents
regarding this incident. Program Coordinator spoke with Ms. Barbara and informed her that
the staff member could not participate in any restraints until retrained. Ms. Barbara
informed licensing that staff member would most likely be sent home until she can be
retrained. Licensing requested for an update once a decision was made. Ms. Barbara was
informed of licensing concerns regarding the staff member being disrespectful toward the
residents. Program Coordinator reviewed the nurse's note and observed where an injection
was ordered but there was not a reason why. Program Coordinator requested restraint
packet and witness statements from the staff members present.
.

Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
521 Visit Compliance Report
Licensee: Elizabeth Mitchell Centers
Facility Number: 157
Licensee Address: 6501 W 12TH ST
LITTLE ROCK AR 72204-1511
Licensing Specialist: Arlene Horton
Person In Charge: Barbara McCrory
Record Visit Date: 3/25/2025
Home Visit Date: 3/25/2025
Purpose of Visit: Complaint Visit
Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
521 for ELS Case #026835
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 2

No in-person licensing visit was completed 03/25/2025.
Licensing received a complaint on 01/14/2025 for ELS Case #026835.
This complaint has been unfounded by Licensing.
***** Pursuant to A.C.A. § 9-24-406(e) (3-4): If you believe that the Department’s notice of noncompliance
is in error, you may ask for reconsideration. The request for reconsideration must be in writing and delivered
to the Department by certified mail within twenty (20) business days of receipt of the notice of
noncompliance. The request must specify the parts of the notice that are alleged to be in error, explain why
you believe those parts are in error, and include documentation to support the allegation of error. Once
received the Department shall issue a decision on your request within twenty (20) days after receipt of the
request.
Provider Comments:
CCL Staff Signature : Date: 3/25/2025
Provider Signature : Date: 3/25/2025
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 2


state: AR

facility_name: Centers for Youth and Families - Little Rock

summary: A resident was observed attempting to choke herself with her shirt while in the bathroom.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 026424
Date of Incident: 12/26/2024
Date Received: 12/27/2024
Facility Name: Elizabeth Mitchell Centers
Facility Number: 157
Incident Type: Licensing
Report Description: On 12/27/2024, client
Residential) was observed attempting to choke herself with her shirt while in the bathroom.
Client was on LOS bathroom protocol and staff was present outside the door with the door
ajar. Staff immediately entered the bathroom and removed the clothing item that client was
attempting to use. Client was assessed by nurse, who noted a red mark on client's cheek
and neck. Following this incident, 1:1 ratio was ordered, and client was referred to acute
care. At this time, she has not been accepted for acute care and remains at Centers. The
client is an out-of-state placement from at The Centers and the guardian but has been
notified.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 12/27/2024 Licensing Specialist Horton inquired of the facility when
the resident go to acute care, are they waiting on placement? If yes, will she return after
acute placement? Facility reported documents via email to Licensing. Documents have
been uploaded. The facility reported to Licensing at this time, the resident has not gone to
acute care we (the facility) are still trying to find an acute care that will accept her.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

doc_type: Notice of Incident


summary: Officers responded to the facility for an alarm call. False alarm.

raw_content:
LITTLE ROCK POLICE DEPARTMENT ABBREVIATED INCIDENT REPORT

JUVENILE INFORMATION INCIDENT Report generated: 12/24/2024 7:36 PM

INCIDENT NUMBER UNIT ASSIGNED CALL DATE CALL TIME TYPE OF CALL

2024-173192 2Y61 12/24/2024 16:09:00 ALMBRG

INCIDENT DATE LOCATION OF INCIDENT (ADDRESS / BUSINESS NAME)

12/24/2024 4:09:33 PM

6501 W 12TH ST

OFFENSE

FALSE ALARM

OFFICERS CHECKED THE LOCATION FOR ANY SIGNS OF POSSIBLE BURLARY WITH NEGATIVE RESULTS. FALSE
ALARM.

ENTRY DATE REPORTING OFFICER ORIGINAL APPROVING SUPERVISOR .
12/25/2024 01:34:32 | TUCKER ROBERTSON -[g TUCKER ROBERTSON - Jig MVR in use

LRPD Form 5501-01 Rev. RMS-2019-01-23 Page 1 of 1

doc_type: Police Report


summary: Officers were dispatched to the facility. Officers spoke to staff who stated that there was no emergency and that officers were not needed.

raw_content:
LITTLE ROCK POLICE DEPARTMENT ABBREVIATED INCIDENT REPORT

JUVENILE INFORMATION INCIDENT Report generated: 12/23/2024 12:14 PM

INCIDENT NUMBER UNIT ASSIGNED CALL DATE CALL TIME TYPE OF CALL

2024-172719 1X61 12/23/2024 11:17:00 UNK

INCIDENT DATE LOCATION OF INCIDENT (ADDRESS / BUSINESS NAME) DISTRICT
6425 W 12TH ST

12/23/2024 11:17:13 AM 61

OFFENSE

NON POLICE INCIDENT

OFFICER MCCULLIN CHECKED WITH THE STAFF AND STATED THAT THERE WAS NO EMERGENCY AND THAT LRPD
WAS NOT NEEDED.

ENTRY DATE REPORTING OFFICER ORIGINAL APPROVING SUPERVISOR .
12/23/2024 18:08:08 | JEREMIAH MCCULLIN - JEREMIAH MCCULLIN - J MVR in use

LRPD Form 5501-01 Rev. RMS-2019-01-23 Page 1 of 1


summary: A resident was observed attempting to strangle herself with her shirt while in the bathroom.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 026386
Date of Incident: 12/22/2024
Date Received: 12/26/2024
Facility Name: Elizabeth Mitchell Centers
Facility Number: 157
Incident Type: Licensing
Report Description: On 12/22/2024, client
Residential) was observed attempting to strangle herself with her shirt while in the
bathroom. Client was on LOS 1:1 bathroom protocol and staff was present outside the door
with the door ajar. Staff immediately entered the bathroom and removed the clothing item
that client was attempting to use. Client was assessed by nurse, who noted a red mark on
client's neck. The client is an out-of-state placement from at The Centers. Attempts
have been made to notify the guardian, but have been unsuccessful; we will continue until
contact is made. As always, please do not hesitate to contact me if you need any additional
information.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 12/26/2024 Licensing Specialist Horton inquired of the facility is the
resident still on LOS? Were any other safety precautions added? Please provide nursing
note. Facility provided nursing note via email to Licensing. Document has been uploaded.
Facility reported to Licensing that the resident was placed on 1:1 status when this incident
occurred. Facility reported to Licensing as of today, her 1:1 status is being reduced to LOS
(Line of sight) and SIDA (sleep in day area) because she is more regulated.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: Officers responded to the facility for an alarm call. The nurse at the facility advised officers it was a false alarm.

raw_content:
LITTLE ROCK POLICE DEPARTMENT ABBREVIATED INCIDENT REPORT

JUVENILE INFORMATION INCIDENT Report generated: 12/21/2024 6:48 PM

INCIDENT NUMBER UNIT ASSIGNED CALL DATE CALL TIME TYPE OF CALL

2024-171981 2Y61 12/21/2024 15:39:00 ALMBRG

INCIDENT DATE LOCATION OF INCIDENT (ADDRESS / BUSINESS NAME)

12/21/2024 3:39:06 PM

6501 W 12TH ST

OFFENSE

FALSE ALARM

OFFICERS MADE CONTACT WITH THE NURSE ON DUTY WHO ADVISED THAT IT WAS A FALSE ALARM AND
EVERYTHING WAS SECURE. BWC/MVR IN USE

ENTRY DATE REPORTING OFFICER ORIGINAL APPROVING SUPERVISOR .
12/22/2024 00:44:12 | SYMONE BROWN - SYMONE BROWN - MVR in use

LRPD Form 5501-01 Rev. RMS-2019-01-23 Page 1 of 1


raw_content:
LITTLE ROCK POLICE DEPARTMENT ABBREVIATED INCIDENT REPORT

JUVENILE INFORMATION INCIDENT Report generated: 12/15/2024 7:53 PM

INCIDENT NUMBER UNIT ASSIGNED CALL DATE CALL TIME TYPE OF CALL

2024-169326 2X61 12/15/2024 18:52:00 ALMBRG

INCIDENT DATE LOCATION OF INCIDENT (ADDRESS / BUSINESS NAME)

12/15/2024 6:52:20 PM

6501 W 12TH ST

OFFENSE

NON POLICE INCIDENT

OFFICERS RESPONDED TO THIS LOCATION FOR AN ALARM CALL. OFFICERS OBSERVED THE CALL NOTES AND
WAS ADVISED THE NURSES ONSCENE ADVISED IT WAS A FALSE ALARM.

ENTRY DATE REPORTING OFFICER ORIGINAL APPROVING SUPERVISOR .
12/16/2024 01:50:31 | SYMONE BROWN - SYMONE BROWN - L]MVR in use

LRPD Form 5501-01 Rev. RMS-2019-01-23 Page 1 of 1


summary: Officers responded to the facility in reference to a fire alarm. False alarm.

raw_content:
LITTLE ROCK POLICE DEPARTMENT ABBREVIATED INCIDENT REPORT

JUVENILE INFORMATION INCIDENT Report generated: 12/11/2024 7:46 PM

INCIDENT NUMBER UNIT ASSIGNED CALL DATE CALL TIME TYPE OF CALL

2024-167552 2X61 12/11/2024 16:56:00 ALMBRG

INCIDENT DATE LOCATION OF INCIDENT (ADDRESS / BUSINESS NAME)

12/11/2024 4:56:44 PM

6501 W 12TH ST

OFFENSE

FALSE ALARM

FIRE PANEL

ENTRY DATE REPORTING OFFICER ORIGINAL APPROVING SUPERVISOR .
12/12/2024 01:44:35 | EMANUEL ESTRADA - EMANUEL ESTRADA - J MVR in use

LRPD Form 5501-01 Rev. RMS-2019-01-23 Page 1 of 1


summary: A resident was transported to Arkansas Children’s Hospital after experiencing an allergic reaction from eating a peanut butter cracker.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 026035
Date of Incident: 12/9/2024
Date Received: 12/10/2024
Facility Name: Elizabeth Mitchell Centers
Facility Number: 157
Incident Type: Licensing
Report Description: On 12/9/2024, client
Residential) reported that she had eaten a peanut butter cracker and was having an allergic.
She received 50mg of Benadryl at Centers but continued to complain of an itchy throat. Out
of an abundance of caution, she was transported to ACH for further evaluation. ACH did
not administer additional medication, diagnosed her with and
recommended adding Zyrtec to her medications. The client is an out-of-state placement
from at The Centers and the guardian was notified. As always, please do not hesitate
to contact me if you need any additional information.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 12/11/2024 Licensing Specialist inquired of the facility nurse's note
and discharge summary from ACH. Does the resident have a known peanut butter allergy
and if so, where did the peanut butter cracker come from? Licensing uploaded
documentation provided via email from the facility.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was involved in a physical altercation with peers. Later, staff checked on her and found her lying in bed with sweatpants tied around her neck.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 025986
Date of Incident: 12/8/2024
Date Received: 12/9/2024
Facility Name: Elizabeth Mitchell Centers
Facility Number: 157
Incident Type: Licensing
Report Description: On 12/8/2024, client
PRTF) was involved in a physical altercation with peers. During debriefing with the dorm,
she quietly walked away and went to her bedroom. Staff checked on her and found her
laying in her bed with sweatpants tied around her neck. She appeared unresponsive to
verbal stimuli and staff called for nursing, who arrived within a few seconds. Nursing
contacted the on-call physician and obtained vitals. Out of an abundance of caution, she
was sent to ACH for further evaluation and consideration of transfer to acute care. The
client is a at The Centers and the guardian was notified. As always, please
do not hesitate to contact me if you need any additional information.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 12.09.24 Licensing inquired of the facility camera footage and nurse's
note. Did the resident go to acute care? If so, will she return to the facility? Will there be a
safety plan? Facility provided nurse's note to Licensing via email, and it was uploaded.
12/10/2024 Facility reported to Licensing there is video. Licensing is scheduled to view the
video on 12.11.2024. Facility reported to Licensing that the plan is for the resident to return
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

to the facility when she is discharged from acute. 12/11/2024 Licensing viewed the camera
footage.


summary: Police were dispatched to the facility to assist a medical call.

raw_content:
Report Contains Juvenile Information
INCIDENT NUMBER 2024-161704 JUVENILE INFORMATION Report generated: 11/27/2024 4:55 PM
Redact Before Release
PROPERTY DRUG INFORMATION
P.LOSS P.DES QTY Description (ser#, color, make, model) PROP TAG VALUE TYPE QUANTITY MEASURE
4 43 1.00 NONE NONE + 0 100 0.00
NONE KICKED HOLE ON WALL
TYPE PROPERTY LOSS: (0) Stored (1) None (2) Burned (3) Counterfeited/Forged (4) Damaged/Destroyed/Vandalized (5) Recovered (6) Seized (7) Stolen, etc (8) Unknown
PROPERTY DESCRIPTION: (10) Drugs/Narcotics (21) Negotiable Instruments (32) Structures-Industrial/Manufacture
(11) Drug/Narcotic Equipment (22) Nonnegotiable Instruments (33) Structures-Public/Community
(01) Aircraft (12) Farm Equipment (23) Office-Type Equipment (34) Structures-Storage
(02) Alcohol (13) Firearms (24) Other Motor Vehicles (35) Structures-Other
(03) Automobiles (14) Gambling Equipment (25) Purses/Handbags/Wallets (36) Tools-Power/Hand/Lawnmower
(04) Bicycles (15) Heavy Equipment Construction/ (26) Radios/TVs/VCR (37) Trucks
(05) Buses Industry (27) Recordings-Audio/Visual (38) Vehicle Parts/Accessories
(06) Clothes/Furs (16) Household Good (28) Recreational Vehicles (39) Watercraft
(07) Computer Hardware/ (17) Jewelry/Precious Metal (29) Structures-Single Occupancy (77) Other
Software (18) Livestock (30) Structures-Other Dwellings (88) Pending Inventory (of Property)
(08) Consumable Goods (19) Merchandise (31) Structures-Commercial/Business
(09) Credit Cards/Debit Cards (20) Money
TYPE DRUG MEASUREMENT:
DRUG TYPE: (D) Heroin (H) Other Narcotics (L) Amphetamines/ (O) Other Depressants
Units Weight
(A) Crack Cocaine (E) Marijuana (I) LSD Methamphetamines (P) Other Drugs
(DU) Dosage Unit (GM) Gram (OZ) Ounce
(B) Cocaine (F) Morphine (J) PCP (M) Other Stimulants (U) Unknown Type
(Pills, etc) (KG) Kilogram (LB) Pound
(C) Hashish (G) Opium (K) Other Hallucino. (N) Barbituates (NP) Number of Plants
Capacity
FOR BURGLARIES: Point of Entry: (ML) Milliliter (GL) Gallon
(LT) Liter (FO) Fluid Ounce
Tools Apparently Used:
Page 7 of 9

Report Contains Juvenile Information
INCIDENT NUMBER 2024-161704 JUVENILE INFORMATION Report generated: 11/27/2024 4:55 PM
Redact Before Release
NARRATIVE
ON 11/27/2024, AT APPROXIMATELY 1450 HOURS, OFFICERS RESPONDED TO AN ASSIST MEDICAL CALL AT 6601 W
12TH STREET AT THE CENTER FOR YOUTH AND FAMILY.
OFFICERS MADE CONTACT WITH DIRECTOR ASHLEY BURKS AND J1'S MOTHER, .
REQUESTED THAT J1 BE TRANSPORTED TO RAVENDALE DUE TO J1 DISPLAYING AGGRESSIVE BEHAVIOR AND
EXPERIENCING A MENTAL BREAKDOWN. J1 WAS OBSERVED YELLING AND STRUGGLING TO CONTROL HIS
EMOTIONS.
WHILE ON SCENE, OFFICERS OBSERVED J1 KICKING HIS FOOT BACK, WHICH RESULTED IN A HOLE BEING
CREATED IN THE WALL. J1 CALMED DOWN SHORTLY AFTER AND WAS TAKEN INTO CUSTODY BY MEMS.
BURKS ADVISED THAT SHE DID NOT WANT TO PRESS CHARGES AT THE TIME BUT WAS PROVIDED WITH THE
REPORT NUMBER AND ADVISED THAT SHE COULD PURSUE CHARGES IN THE FUTURE IF SHE CHOSE TO DO SO.
BODY-WORN CAMERAS WERE IN USE.
Page 8 of 9


summary: A resident was transported to Arkansas Children’s Hospital for further evaluation of an allergic reaction that wasn’t subsiding after a dose of Benadryl.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 025641
Date of Incident: 11/19/2024
Date Received: 11/20/2024
Facility Name: Elizabeth Mitchell Centers
Facility Number: 157
Incident Type: Licensing
Report Description: On 11/19/2024, client
was transported to Arkansas Children's Hospital for further evaluation of an allergic
reaction that wasn't subsiding after a does of Benadryl. Centers? staff transported the client
to ACH. Client was diagnosed with an and
prescribed an . After her evaluation, the client
was transported back to EMAC. The client is a private placement at The Centers and the
guardian was notified. As always, please do not hesitate to contact me if you need any
additional information.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 11/21/2024 Licensing Specialist Horton inquired of the facility the
nurse's note and discharge paperwork from ACH and what the resident was allergic to.
11/25/2024 The facility provided documentation via email documentation has been
uploaded.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident became dysregulated and was transferred to acute care.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 025585
Date of Incident: 11/15/2024
Date Received: 11/18/2024
Facility Name: Elizabeth Mitchell Centers
Facility Number: 157
Incident Type: Licensing
Report Description: On 11/15/2024, client
became dysregulated and was transferred to acute care at Pinnacle Pointe. The client is a
at The Centers and the guardian was notified. As always, please do not
hesitate to contact me if you need any additional information.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 11/19/2024 Licensing Specialist Horton inquired of the facility if the
resident will return to the facility after acute care. The facility reported to Licensing the
resident is not expected to return to the facility following her acute care stay.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident became dysregulated during her initial intake and was transferred to acute care.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 025586
Date of Incident: 11/15/2024
Date Received: 11/18/2024
Facility Name: Elizabeth Mitchell Centers
Facility Number: 157
Incident Type: Licensing
Report Description: On 11/15/2024, client
became dysregulated during her initial intake and was transferred to acute care at Pinnacle
Pointe. The client is a private placement at The Centers and the guardian was present at the
time. As always, please do not hesitate to contact me if you need any additional information.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 11/19/2024 Licensing Specialist Horton inquired of the facility if the
resident will be placed at the facility after acute care? The facility reported to Licensing that
they believe that the resident will return to the facility and complete her admission.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was transported to Arkansas Children’s Hospital for evaluation and treatment of a laceration to his left knee sustained while on the playground.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 025414
Date of Incident: 11/11/2024
Date Received: 11/12/2024
Facility Name: Elizabeth Mitchell Centers
Facility Number: 157
Incident Type: Licensing
Report Description: On 11/11/2024,
was transported to Arkansas Children's Hospital for evaluation and treatment of a
laceration to his left knee sustained while on the playground. Centers? staff transported the
client to ACH. X-rays were performed and client was diagnosed
Client was transported back to EMCC at approximately 1700.
Centers? medical personnel will continue to monitor the client. The client is a private
placement at The Centers and the guardian was notified. As always, please do not hesitate
to contact me if you need any additional information.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 11/13/2024 Licensing Specialist Horton inquired of the facility is it
known how the resident got the laceration on the playground? Licensing Specialist Horton
uploaded documentation provided via email.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident reported that a staff member held down another resident and poured water on her face for discipline. The reporting resident also stated that staff members at the facility yell and cuss at the children residing there. The facility was cited 109.1.g for unprofessional conduct.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 025394
Date of Incident: 11/11/2024
Date Received: 11/12/2024
Facility Name: Elizabeth Mitchell Centers
Facility Number: 157
Incident Type: Dual
Report Description: On 11/8/2024, visited EMAC to interview staff
member, At this time, Centers became aware of a
has been suspended pending
completion of the investigation.
Interim Action Narrative: Staff member was suspended pending the investigation.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Licensing Narrative: 11/12/2024 Licensing Specialist Horton inquired of the facility the
name of , resident's name, DOB, and guardianship. Program Coordinator
spoke with t to gather more information regarding this complaint.
informed Program Coordinator that the alleged incident happened in
June 2024 or July 2024. Per , this complaint
visited
the facility on 11/11/2024 and 11/12/2024. Licensing was informed that the staff member
was interviewed and admitted to horseplaying with the resident with water. 11/13/2024
Facility reported to Licensing is the client.
11/25/2024
Facility provided documentation via email to Licensing. Documentation has been uploaded.
12/04/2024 Facility provided documentation to Licensing via email and the documentation
has been uploaded. Licensing Specialist informed Program Manager documentation was
received. 12/19/2024 ICA was lifted 12/04/2024. Licensing reported to the facility staff may
return to normal job duties. 12/20/2024 Licensing Program Manager reported that this
complaint should have been FOUNDED. Licensing Specialist Horton reported update to
the facility and issued a new 521 to reflect the finding.

Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
521 Visit Compliance Report
Licensee: Elizabeth Mitchell Centers
Facility Number: 157
Licensee Address: 6501 W 12TH ST
LITTLE ROCK AR 72204-1511
Licensing Specialist: Arlene Horton
Person In Charge: Barbara McCrory
Record Visit Date: 11/25/2024
Home Visit Date: 11/25/2024
Purpose of Visit: Complaint Visit
Regulations Out of Compliance:
Regulation Number: 100.109.1.g
Regulation Description: Unprofessional conduct in the practice of child welfare activities shall include, but not
limited to the following:
Finding Description:
Action Due Date:
Action Due Description:
Comply Date:
Sub-Regulation Level 1 Description: Engaging in behavior that could be viewed as sexual, dangerous,
exploitative, or physically harmful to children.
Action Due Description:
Regulations Needing Technical Assistance:
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 2

Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
No in-person licensing visit was completed 11/25/2024.
Licensing received a complaint on 11/12/2024 for ELS Case #025394.
This complaint wasFOUNDEDby Licensing.
Facility will be cited 109.1.g, staff member was horseplaying with a resident.
Per facility, the staff member involved will be trained in maintaining appropriate boundaries.
Provider Comments:
CCL Staff Signature : Date: 11/25/2024
Provider Signature : Date: 11/25/2024
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 2

Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
521 Visit Compliance Report
Licensee: Elizabeth Mitchell Centers
Facility Number: 157
Licensee Address: 6501 W 12TH ST
LITTLE ROCK AR 72204-1511
Licensing Specialist: Arlene Horton
Person In Charge: Barbara McCrory
Record Visit Date: 11/25/2024
Home Visit Date: 11/25/2024
Purpose of Visit: Complaint Visit
Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
No in-person licensing visit was completed 11/25/2024.
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 2

Licensing received a complaint on 11/12/2024 for ELS Case #025394.
This complaint wasFOUNDEDby Licensing.
Facility will be cited 109.1.g, staff member was horseplaying with a resident.
Per facility, the staff member involved will be trained in maintaining appropriate boundaries.
Provider Comments:
CCL Staff Signature : Date: 11/25/2024
Provider Signature : Date: 11/25/2024
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 2


summary: A report received stated that a resident was pulled out against medical advice (AMA) from the facility, because he felt he was not safe there. He was seen with bruises on his cheekbone and jaw. The complaint was UNFOUNDED by Licensing.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 025887
Date of Incident: 10/26/2024
Date Received: 12/3/2024
Facility Name: Elizabeth Mitchell Centers
Facility Number: 157
Incident Type: Dual
Report Description: A/V is A/O is unknown staff at Elizabeth Mitchell
Centers for Youth and Families (Little Rock, AR, Pulaski CO). PRFCs are bio mother
and . was at
the facility from 10/22/24 until pulled out AMA on 11/25/24. was removed because he
was felt not safe there. He is back with his outpatient therapist and no further residential
treatment recommended at this time. is not having behavior issues (why initially at
facility). was seen Saturday (10/26/24) at facility and he had a bruise on his
cheekbone and another bruise by his jaw. No picture was taken because visitors are not
allowed to take electronics inside. said his roommate hit him the face and threw a
shoe at him. told staff, but they did not do anything. Another time was
overheard while on the phone telling staff that the roommate continued to hit him and was
going through his stuff. Nothing was done. Staff were overheard to berate a/v after just a
few seconds of being told he had a phone call that he was not getting there fast enough,
threatened to hang up. said he was beat up 2 additional times by other minors in the
facility (assaulted by 3 different minors). He was finally moved to a new area, but the
physical assaults by other minors continued. said staff only responded once to the
assaults and that was when he was screaming because the roommate was trying to rip up
his stuffed animal and hit him with the shoe. was heard reporting the assaults over the
phone and a staff nearby accused him of saying the ?n word?, but a/v denied it and said the
only thing he said was that he would ?throw hands?. Concern he was targeted because he
was white and a majority of the staff is black. therapist at the facility was continually
emailed during this time frame and therapist claimed everything was great. Therapist was
told about reporting that he had bruises up and down his arms, he ?could not feel? his
arms (thought from being hit, a/v not very specific), had glasses broken, etc. due to the
violence by other minors. Staff were hard to reach and they would try to claim not aware of
issues though was heard informing them. Staff would not contact mother about any
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

incidents. facility case manager, Addison Johnson, would not return calls until he
was pulled from facility. had a small bruise on his arm and some bruises on his legs
11/25/24 visible from the peer abuse. is having nightmares and panic attacks from
being in the facility, has to take anxiety medication if the name of facility is mentioned.
Human feces was observed in the shower at the facility 11/25/24. Front desk staff indicated
aware, but it was not addressed. said that was a regular occurrence (human feces not
cleaned up). Concern about feces being left lying around and not cleaned up. was
taken to PCP and diagnosed with under his lip and on his thumb. The
was visible in a picture taken of him when leaving the facility and it spread to his thumb.
10/26/24, indicated having pressure on his chest/chest pains at night, feeling like he
could not breathe. Nighttime staff would just tell him that to go to sleep and would not
help. He was confirmed to not have any physical problems and was believed having panic
attacks. would say he is a ?medium? (something bio father also claims to be) and the
pressure is ?when spirits are trying to communicate with him?. He was finally put on
anxiety medication and antipsychotic after mother complained about the chest pain not
being addressed. He has been diagnosed with
Staff falsified paperwork by claiming the parent and belongings were searched, but
they actually did not.
Interim Action Narrative:

would send via email to Licensing. Guardian reported that she would send documentation
on today. 12/11/2024, Program Coordinator uploaded photos from 12/18/2024
Licensing inquired of the facility all nursing notes regarding this resident. 12/19/2024
Licensing contacted regarding concerns. reported documentation via
email to Licensing and it has been uploaded. 12/20/2024 The facility reported nursing notes
documents via email. Documents were uploaded. 12/23/2024 Licensing Specialist Horton
inquired of the facility when visitation take place where are visits held? Facility reported to
Licensing visitation occurs in different places. Usually, it is in the conference room, the
lobby, or outside if it?s a pretty day. 1/21/2025, case staffed. Licensing Specialist will
complete buildings and grounds of EMAC and interview residents from EMAC and EMCC.
1/23/2025, licensing interviewed 2 residents from each dorm at EMCC. The resident was at
EMCC during his stay. Program Coordinator will request of incident reports involving any
altercations, communication with parent and if a diagnosis of was given.
2/13/2025, per and Licensing Specialist informed. This
complaint was UNFOUNDED by licensing.

Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
521 Visit Compliance Report
Licensee: Elizabeth Mitchell Centers
Facility Number: 157
Licensee Address: 6501 W 12TH ST
LITTLE ROCK AR 72204-1511
Licensing Specialist: Arlene Horton
Person In Charge: Barbara McCrory
Record Visit Date: 12/5/2024
Home Visit Date: 12/5/2024
Purpose of Visit: Subsequent Building and Grounds
Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
Time of Visit: 9:30 am to: 10:30 am
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 2

Census: 27
Licensing received a complaint on 12/3/2024 for ELS Case #025887.
Licensing Specialist Horton completed buildings and grounds visit for EMCC. Licensing was escorted by
staff members Rachel Howard and Brent Ellison.
Rachel with the facility reported to Licensing that EMAC has three residents and a nurse who has Covid.
Licensing inquired when facility became aware of the covid cases. Rachel reported to Licensing that it
occurred over the weekend of 11/30/2024. Licensing Specialist did not visit EMAC due to the covid cases
reported by the facility staff.
EMCC – The grounds of the facility observed were maintained. Licensing walked through and observed the
following dorms: North, South, East, and New Dorm. No residents were present during the walkthrough of the
dorms. Licensing observed the residents’ bedrooms and bathrooms. All bathrooms including the shower areas
were maintained. Licensing observed housekeeping making rounds while walking through the building.
Rachel reported the facility has several Christmas activities planned for the residents.
EMCC building met the minimum licensing standards for buildings and grounds.
Provider Comments:
CCL Staff Signature : Date: 12/5/2024
Provider Signature : Date: 12/5/2024
Rachel Howard
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 2


summary: An officer was dispatched to the facility to assist EMS with a patient.

raw_content:
LITTLE ROCK POLICE DEPARTMENT ABBREVIATED INCIDENT REPORT

JUVENILE INFORMATION INCIDENT Report generated: 10/25/2024 12:20 PM

INCIDENT NUMBER UNIT ASSIGNED CALL DATE CALL TIME TYPE OF CALL

2024-146211 1X70 10/25/2024 10:51:00 ASTMED

INCIDENT DATE LOCATION OF INCIDENT (ADDRESS / BUSINESS NAME)

10/25/2024 10:51:13 AM

6601 W 12TH ST

OFFENSE

NON POLICE INCIDENT

MEMS LOADED THE PATIENT INTO THE AMBLUENCE AND TRANSPORTED HIM TO THE HOSPITAL WITHOUT
INCIDENT.

ENTRY DATE REPORTING OFFICER ORIGINAL APPROVING SUPERVISOR .
10/25/2024 17:18:27 | CLINT GRIFFIN ES CLINT GRIFFIN - MVR in use

LRPD Form 5501-01 Rev. RMS-2019-01-23 Page 1 of 1


summary: Communications advised they received secondhand information that a juvenile was at the listed location. The juvenile was transported back to Methodist Children’s Home.

raw_content:
Report Contains Juvenile Information
INCIDENT NUMBER 2024-145428 JUVENILE INFORMATION Report generated: 10/24/2024 4:23 AM
Redact Before Release
NARRATIVE
COMMUNICATIONS ADVISED THEY RECEIVED SECONDHAND INFORMATION THAT CON1 WAS AT THE LISTED
LOCATION. CON1 WAS NOT REPORTED A RUNAWAY WHEN OFFICERS MADE CONTACT WITH HIM. CON1 WAS
TRANSPORTED BACK TO METHODIST CHILDREN'S HOME. CONTACT WAS MADE WITH MS. MCKENZIE, WHO WORKS
AT THE LOCATION. MS. MCKENZIE TOOK CUSTODY OF CON1. BWC WAS IN USE.
Page 4 of 5


summary: Licensing visited the facility to conduct a buildings and grounds walkthrough. No deficiencies cited.

raw_content:
521 Visit Compliance Report

Licensee: Elizabeth Mitchell Centers

Facility Number: 157

Licensee Address: 6501 W 12TH ST
LITTLE ROCK AR 72204-1511

Licensing Specialist: Arlene Horton
Person In Charge:

Record Visit Date: 10/24/2024
Home Visit Date: 10/24/2024

Purpose of Visit: Subsequent Building and Grounds

Regulations Out of Compliance:

Regulations Needing Technical Assistance:

Regulation Not Applicable:

Regulations Not Correctable:

Narrative:

Time of visit: 9:29 A.M. — 9:44 A.M.

www.arkansas.gov/dhs
Serving more than one million Arkansans each year

» ARK AN BA S
DEPARTMENT OF

Ww HUMAN
=! SERVICES
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437

P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550

. A» h

a

Page 1 of 2

Census: 28
Licensing Specialist Horton was escorted by EMAC staff Rachel Howard for the walkthrough of Dorm 4.

EMAC — Dorm 4, ratio 1:6. No residents were present in Dorm 4 during Licensing’s walkthrough. Licensing
askedRachel when the residents should return to Dorm 4, she advised around 5 p.m. or 5:30 p.m. today.

Walking through Dorm 4, Licensing observed that the flooring is complete, all baseboards are in place, the
dorm has been cleaned from repairs, and the walls were not damaged from the flooring being replaced. The
doors were opened to air the dorm from the smell of paint.

Building is in ratio.

Provider Comments:

CCL Staff Signature : Date: 10/24/2024

Provider Signature : Date: 10/24/2024

www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 2

doc_type: Compliance Report


summary: A resident was transported to Arkansas Children’s Hospital for further evaluation following complaints of pain and bleeding in her vaginal area.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 024966
Date of Incident: 10/24/2024
Date Received: 10/27/2024
Facility Name: Elizabeth Mitchell Centers
Facility Number: 157
Incident Type: Licensing
Report Description: On 10/24/2024, client
PRTF) was transported to Arkansas Children's Hospital for further evaluation following
complaints of pain and bleeding in her vaginal area. Centers? staff transported the client to
ACH. Client was diagnosed . After her evaluation, the client was transported back
to EMCC. The client is a at The Centers and the guardian was notified.
As always, please do not hesitate to contact me if you need any additional information.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 10/29/2024 Licensing Specialist Horton uploaded documentation for
this case. Facility reports that the client was transported to Arkansas Children's Hospital to
be evaluated. The client was diagnosed with
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was transported to Arkansas Children’s Hospital for further evaluation of her blood sugar level.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 024722
Date of Incident: 10/13/2024
Date Received: 10/14/2024
Facility Name: Elizabeth Mitchell Centers
Facility Number: 157
Incident Type: Licensing
Report Description: On 10/13/2024, client )
was transported to Arkansas Children's Hospital for further evaluation of her blood sugar
level/ Centers? staff transported the client to ACH. Client was diagnosed with
After her evaluation, the client was transported back
to EMCC. Centers? medical personnel will continue to monitor the client. The client is a
at The Centers and the guardian was notified. As always, please do not
hesitate to contact me if you need any additional information.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 10/15/2024 Licensing Specialist Horton asked facility for the safety
plan regarding how they are monitoring Documents uploaded.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: Mold was discovered in dorm 4 during a flooring replacement project.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 024513
Date of Incident: 10/3/2024
Date Received: 10/4/2024
Facility Name: Elizabeth Mitchell Centers
Facility Number: 157
Incident Type: Licensing
Report Description: As of 10/1/2024 mold was discovered in dorm 4 at EMAC while
working on replacing the flooring. The flooring company had originally reported this would
be a one-day job for each dorm, so no clients would need to be moved. After the mold was
discovered a restoration company was called and has done testing to determine next steps.
We are requesting the clients from dorm 4 be allowed to sleep in the dining room area until
this is resolved. There will be up to 8 clients needing to be in the dining room. We will make
sure there is appropriate staffing in place. The classrooms will be used after school hours
and they will only be in dining room for sleeping purposes.
Interim Action Narrative: Residents will be moved off the dorm until repairs are completed.
Maltreatment Narrative:
Licensing Narrative: Program Coordinator followed up with facility, requested a written
plan, and inquired about how many residents are on Dorm 4. 10/8/2024, facility reported 8
female residents from Dorm 4 will sleep in the cafeteria. The classrooms will be used after
school hours for the dayroom area. The residents will use the restrooms near the
cafeteria/classrooms area. Residents will use those restrooms to dress/undress as well. For
showers, the residents will use Dorms 1, 2, and 3 as deemed most appropriate. Remediation
and repairs are underway and they anticipate completion during the late part of next week.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

10/9/2024, Licensing inquired about where Dorms 1, 2, and 3 were eating their meals. The
facility reported that the residents are using their dorms or classrooms. 10/14/2024, Program
Coordinator inquried about an update on Dorm 4, 10/15/2024 Facility provided update on
dorm 4. Per facility, progress is going as projected and they anticipate the residents moving
back on the dorm by the end of the week. Facility will keep Licensing updated. 10/21/2024,
Facility reported that Dorm 4 was not ready for a walkthrough due to construction still
going on. The facility anticipates the dorm will be ready by Thursday, 10/24/2024.
10/24/204 Residents returned to Dorm 4. Dorm 4 is complete.


summary: A resident was transported to Arkansas Heart Hospital emergency room for evaluation of right ear pain.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 024461
Date of Incident: 10/1/2024
Date Received: 10/2/2024
Facility Name: Elizabeth Mitchell Centers
Facility Number: 157
Incident Type: Licensing
Report Description: On 10/1/2024, client
PRTF) was transported to Arkansas Heart Hospital ER for evaluation of right ear pain.
Centers? staff transported the client to AHH. Client was diagnosed with After
her evaluation, the client was transported back to EMAC. The client is a private placement
at The Centers and the guardian was notified. As always, please do not hesitate to contact
me if you need any additional information.
Interim Action Narrative: Resident was evaluated at the hospital.
Maltreatment Narrative:
Licensing Narrative: Facility informed Licensing of provider reported incident via email
and provided documentation. 10/3/2024, Licensing reviewed provider reported incident for
licensing concerns.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was transported to Arkansas Heart Hospital emergency room for evaluation of left ear pain.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 024462
Date of Incident: 10/1/2024
Date Received: 10/2/2024
Facility Name: Elizabeth Mitchell Centers
Facility Number: 157
Incident Type: Licensing
Report Description: On 10/1/2024, client ,
Residential) was transported to Arkansas Heart Hospital ER for evaluation of left ear pain.
Centers? staff transported the client to AHH. Client was diagnosed . After
her evaluation, the client was transported back to EMAC. The client is a an
client at The Centers and the guardian was notified. As always, please do not hesitate to
contact me if you need any additional information.
Interim Action Narrative: Reisdent was evaluated at the hospital.
Maltreatment Narrative:
Licensing Narrative: Faciltiy informed Licensing of provider reported incident via email
and provided documentation. 10/3/2024, Licenisng reviewed provider reported incident for
licensing concerns.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was transported to Arkansas Children’s Hospital for further evaluation of her blood sugar level/diabetes.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Case Number: 024382
Date of Incident: 9/29/2024
Date Received: 9/30/2024
Facility Name: Elizabeth Mitchell Centers
Facility Number: 157
Incident Type: Licensing
Report Description: On 9/29/2024, client PRTF)
was transported to Arkansas Children's Hospital for further evaluation of her blood sugar
level/diabetes. Centers? staff transported the client to ACH. Client was diagnosed with
and recommendations were made for changing her
After her evaluation, the client was transported back to EMCC. Centers?
medical personnel will continue to monitor the client. The client is a at
The Centers and the guardian was notified. As always, please do not hesitate to contact me
if you need any additional information.
Interim Action Narrative: Resident was evaluated at ACH.
Maltreatment Narrative:
Licensing Narrative: Licensing reviewed provider reported incident for licensing concerns.
Facility provided documentatoin for this incident.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: Officers were dispatched to the facility in response to someone dialing 911 and screaming for help. A male took the phone, advising everything was fine. Officers attempted to make contact with staff at the location with no answer on call back.

raw_content:
INCIDENT NUMBER 2024-132491 JUVENILE INFORMATION Report generated: 9/27/2024 8:11 PM
NARRATIVE
OFFICERS RESPONDED TO THE LISTED ADDRESS IN REFERENCE TO AN UNKNOWN TROUBLE.
REFUSED COMPLAINANT DIALED 911, SCREAMING FOR HELP AND A MALE TOOK THE PHONE ADVISING
EVERYTHING WAS FINE. OFFICERS ATTEMPTED TO MAKE CONTACT WITH STAFF AT THE LOCATION AND NO
ANSWER ON CALLBACK. NO CRIMINAL OR SUSPICIOUS ACTIVITY WAS OBSERVED AT THE GROUP HOME.
BWC/MVR IN USE.
Page 3 of 4


summary: A resident was transported to Arkansas Children’s Hospital after experiencing seizure-like activity.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Case Number: 024198
Date of Incident: 9/20/2024
Date Received: 9/23/2024
Facility Name: Elizabeth Mitchell Centers
Facility Number: 157
Incident Type: Licensing
Report Description: On 9/20/2024 EMAC client DOB:
(PRTF Client) was on Dorm 2 and began having seizure like activity occur. The nurses
began helping and checking her vitals. was transported to Arkansas
Children's Hospital where she was assessed and discharged back to Centers on the same
day. is from and her guardian was notified of the
incident.
Interim Action Narrative: Resident was assessed by the nurse and evaluated at ACH.
Maltreatment Narrative:
Licensing Narrative: Licensing reviewed provider reported incident for licensing concerns.
Program Coordinator will inquire about a diagnosis and documentation. Facility reported
the resident's diagoness
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Urgent Care after reporting redness and itching to the birth control site in her arm.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Case Number: 024077
Date of Incident: 9/18/2024
Date Received: 9/19/2024
Facility Name: Elizabeth Mitchell Centers
Facility Number: 157
Incident Type: Licensing
Report Description: On 9/18/2024 EMAC client, DOB:
(Residential Client) was sent to Baptist Urgent Care for redness and itching to the birth
control site in her arm. was seen by staff at urgent care and was diagnosed with
returned to the Centers with antibiotics for seven days. is an
client from and her guardian was notified.
Interim Action Narrative: Resident was assessed by the nurse and evaluated at urgent care.
Maltreatment Narrative:
Licensing Narrative: Licensing reviewed provider reported incident for licensing concerns.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was transported to Arkansas Children’s Hospital after experiencing seizure like activity.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Case Number: 024025
Date of Incident: 9/16/2024
Date Received: 9/17/2024
Facility Name: Elizabeth Mitchell Centers
Facility Number: 157
Incident Type: Licensing
Report Description: On 9/16/2024 EMAC client DOB:
(PRTF Client) was in the hallway of EMAC and began having seizure like activity occur.
The nurses began helping and checking her vitals. had two more
apparent seizures after the first one and 911 was called. EMS arrived at the Centers and
transported to Arkansas Childrens Hospital. was admitted into the
hospital and has not been released yet. is from and
her guardian was notified of the incident.
Interim Action Narrative: Resident was assessed by the nurse and transported to ACH.
Maltreatment Narrative:
Licensing Narrative: Licensing reviewed provider reported incident for licensing concerns.
Program Coordinator will inquire if a timeframe has been determined. Facility has not been
a timeframe from ACH on how long the resident will be in their care. 9/18/2024, facility
reported that resident returned on 9/17/2024. The hospital
Discharge summary from hospital was requested.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was transported to Arkansas Children’s Hospital after complaining of back pain following a physical altercation with a peer.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Case Number: 024022
Date of Incident: 9/16/2024
Date Received: 9/17/2024
Facility Name: Elizabeth Mitchell Centers
Facility Number: 157
Incident Type: Licensing
Report Description: On 9/16/2024 EMAC client DOB:
(PRTF Client) was in a physical altercation with another client. After the altercation
was seen by the nurse and complained of pain to her back. The on-call provider
ordered to be transported to Arkansas Childrens Hospital. is
from and her guardian was notified of the incident. was
discharged from ACH and diagnosed . The police were not
called for this incident.
Interim Action Narrative: Resident was assessed by the nurse and evaluated at ACH.
Residents were placed on assault precautions.
Maltreatment Narrative:
Licensing Narrative: Licensing reviewed provider reported incident for licensing concerns.
Program Coordinator inquired abour camera footage and will review on 9/18/2024.
9/18/2024, Program Coordinator reviewed camera footage of provider reported incident.
Facility reported that peers involved were placed on assaultive precautions.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
521 Visit Compliance Report
Licensee: Elizabeth Mitchell Centers
Facility Number: 157
Licensee Address: 6501 W 12TH ST
LITTLE ROCK AR 72204-1511
Licensing Specialist: Kendra Slade
Person In Charge: Paul Hofstad
Record Visit Date: 9/18/2024
Home Visit Date: 9/18/2024
Purpose of Visit: Self Report Visit
Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
Time of visit: 9:00 am to 10:30 am
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 2

Census: 57
Licensing received a provider reported incident on 9/17/2024 for ELS Case #024022.
Program Coordinator discussed and reviewed camera footage with Centers’ staff members. The provider
reported incident took place at EMAC on Dorm 4 in a bedroom. The resident was observed standing by the
staff member. Peers were observed walking around the bedroom, sitting on beds, or standing in the doorway
of the bedroom, ratio 1:4 then 1:6.
Resident was observed standing by the staff member and it appeared that some kind of communication was
going on with her and her peers. When her peers were walking toward the resident, the staff member was
observed guiding the resident behind him. The peers were observed trying to strike the resident with the staff
member blocking the strikes.
The staff member was observed guiding the resident into the bathroom for safety. The peers were observed
trying to get to the bathroom but were unable to due to the staff member blocking the door. The peers were
observed leaving the bedroom. There were two (2) peers that were not involved in the verbal/physical
altercation who remained on the beds.
Per staff, the peers were placed on assaultive precautions.
Program Coordinator was unable to determine how the resident’s back was injured.
Provider Comments:
CCL Staff Signature : Date: 9/20/2024
Provider Signature : Date: 9/20/2024
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 2


summary: A resident was observed biting a staff member during an emergency safety intervention. The staff member reacted by lightly hitting the resident on the face.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 024006
Date of Incident: 9/14/2024
Date Received: 9/16/2024
Facility Name: Elizabeth Mitchell Centers
Facility Number: 157
Incident Type: Dual
Report Description: On Saturday September 14, 2024, client
at EMCC became dysregulated and was placed into an emergency safety
intervention. While in the hold, client bit the staff member on the arm. The
staff reacted and lightly hit the client on the face. The client is PRTF private placement
from Arkansas and the guardian was notified. Hotline call was made and accepted
. The staff involved was suspended immediately after the
incident.
Interim Action Narrative: Facility called the hotline and call was accepted. Staff member
placed on suspension.
Maltreatment Narrative:
It was
reported that this morning 9/14/24 ~0810-0820, was performing a physical restraint
on because she was attacking her. bit on the shoulder, and
reacted by raising her arm over her head and then hitting in the face. The skin was
not broken from the bite, and it was reported that the hit to seemed light but did
make contact. was immediately dismissed from the situation and another staff
member took over the hold while medication was retrieved to help calm down. No
injuries to were reported. was admitted to the center on 8/29/24 and it was
reported that this is the second time she has had to be in hold since arriving.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Licensing Narrative: Licensing reviewed complaint for licensing concerns. Program
Coordinator will request permission from the invesitgator to contact the facility and inquire
about camera footage and the name of the staff member. 9/17/2024, facility reported camera
footage is available and provided the name of the staff member. Licensing will review
camera footage on 9/18/2024. Permission received to contact the facility. The facility
reported there are no witness statements. 9/18/2024, Program Coordinator reviewed camera
footage with and requested nursing note. Progam Coordinator will sit in
on the interview with the AO on 9/19/2024 at the DHS South Office. Facility reported that
staff member involved will receive a written warning and a refresher course in CPI.
9/19/2024, Program Coordinator traveled to DHS South Office and sat in on interivew with
and the AO. 9/25/2024, Investigator informed Licensing that case would
found unbsubstantiated. Per CHRIS, case unsubstantiated. 9/26/2024, followed up with
facility to see if staff member will complete training or received any disciplinary action.
Facility reported that staff member mentioned in this complaint has not been scheduled for
training yet. Licensing requested documentation once training is completed. 10/7/2024,
Program Coordinator inquired about training documentation. 10/9/2024, facility reported
that staff member completed training on last week and will submit documentation.
10/14/2024, followe dup with facility on getting training documentation. 10/15/2024, facility
provided training documentation for the staff member. Case complete.

Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
521 Visit Compliance Report
Licensee: Elizabeth Mitchell Centers
Facility Number: 157
Licensee Address: 6501 W 12TH ST
LITTLE ROCK AR 72204-1511
Licensing Specialist: Kendra Slade
Person In Charge:
Record Visit Date: 9/18/2024
Home Visit Date: 9/18/2024
Purpose of Visit: Complaint Visit
Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
Time of visit: 9:00 am to 10:30 am
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 2

Census: 57
Licensing received a complaint on 9/16/2024 for ELS Case #024006.
Program Coordinator discussed and reviewed camera footage with and Centers’ staff. This
incident took place at EMCC on the East Dorm in the day area. Residents were observed laying down, sitting
down, or watching the television.
Two (2) residents were observed to what appeared to be in a verbal/physical altercation, ratio 2:5. Staff
members were observed attempting to keep the residents from making physical contact with each other. The
male resident was observed attempting to get to the female resident.
The female resident was observed attempting to get around staff to get to the male resident. The female
became physically aggressive with staff and was placed in a restraint. Ratio of restraint 2:1. During the
restraint, other residents were escorted off the dorm and other staff members were observed entering the dorm,
ratio 4:1.
While in the restraint, resident was observed kicking, hitting, and attempting to get out of the restraint. Staff
members were observed on each arm, controlling the resident’s legs, and protecting her head from hitting the
wall. Resident was observed biting a staff member and then laying her head on the staff member's shoulder.
Resident was observed biting the staff member again and the staff member was observed tapping the resident
to let go. Program Coordinator could not determine where exactly the staff member tapped the resident. The
staff member was not observed being aggressive in any form while tapping the resident.
The staff member tapped out of the restraint and the nurse took the staff member’s place in the restraint. The
staff member was observed stating what appeared to say “OH” while rubbing her left shoulder.
Facility reported that staff member has been suspended pending the investigation, she will receive a written
warning and will receive refresher training in CPI.
Licensing is not prepared to leave a finding at this time.
Provider Comments:
CCL Staff Signature : Date: 9/20/2024
Provider Signature : Date: 9/20/2024
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 2

Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
521 Visit Compliance Report
Licensee: Elizabeth Mitchell Centers
Facility Number: 157
Licensee Address: 6501 W 12TH ST
LITTLE ROCK AR 72204-1511
Licensing Specialist: Kendra Slade
Person In Charge: John Hogue
Record Visit Date: 9/25/2024
Home Visit Date: 9/25/2024
Purpose of Visit: Revisit Complaint
Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
No in-person licensing visit was completed on 9/25/2024.
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 2

Licensing received a complaint on 9/16/2024 for ELS Case #024006.
This complaint has beenUNFOUNDEDby Licensing.
Provider Comments:
CCL Staff Signature : Date: 9/25/2024
Provider Signature : Date: 9/25/2024
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 2


summary: A resident was transported for acute care after expressing suicidal ideations.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Case Number: 023746
Date of Incident: 9/5/2024
Date Received: 9/5/2024
Facility Name: Elizabeth Mitchell Centers
Facility Number: 157
Incident Type: Licensing
Report Description: On 9/5/2024 EMAC PRTF client DOB:
began having suicidal ideations and spoke with staff in reference to the thoughts.
was then transported to Rivendale for acute placement. is an client in
guardian was notified of the transfer.
Interim Action Narrative: Resident was transferred to acute care.
Maltreatment Narrative:
Licensing Narrative: Licensing reviewed provider reported incident for licensing concerns.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was transported to Arkansas Children’s Hospital after vomiting and passing out.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Case Number: 023717
Date of Incident: 9/3/2024
Date Received: 9/4/2024
Facility Name: Elizabeth Mitchell Centers
Facility Number: 157
Incident Type: Licensing
Report Description: On September 3, 2024 EMAC client DOB:
(Residential) began vomiting in the bathroom. When she walked out of the
bathroom she fell on the floor and appeared to have passed out. was seen by the
nursing staff and then transported to Arkansas Childrens Hospital to be evaluated.
was discharged from ACH and diagnosed .
was given Bactrim DS medication was transported back to the
Centers. is an client from and her guardian was notified of the
incident.
Interim Action Narrative: Resident was assessed by the nurse and evaluated at ACH.
Maltreatment Narrative:
Licensing Narrative: Licensing reviewed provider reported incident for licensing concerns.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: Mold was discovered in Dorm 1 during the replacement of flooring in the dorm.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Case Number: 023511
Date of Incident: 8/26/2024
Date Received: 8/26/2024
Facility Name: Elizabeth Mitchell Centers
Facility Number: 157
Incident Type: Licensing
Report Description: As of 8/26/24 mold was discovered in dorm 1 at EMAC while working
on replacing the flooring. The flooring company had originally reported this would be a
one-day job for each dorm, so no clients would need to be moved. After the mold was
discovered a restoration company was called and will be doing testing to determine next
steps. We are requesting the clients from dorm 1 be allowed to sleep in the dining room area
until this is resolved. There will be up to 8 clients needing to be in the dining room. We will
make sure there is appropriate staffing in place. The classrooms will be used after school
hours and they will only be in dining room for sleeping purposes.
Interim Action Narrative: Dorm 1 residents will not return to the dorm until issue is
resolved.
Maltreatment Narrative:
Licensing Narrative: During a visit, Program Coordinator was informed of this incident and
staffed with the PRLU Administrator. Facility was encouraged to submit something in
writing regarding their plans. Dorm 1 consists of 8 female residents. Facility's plan has been
temporarily approved by PRLU Administrator. Program Coordinator will follow up with the
facility. 8/28/2024, faciltiy reported they were expecting to received a report regarding a
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

remediation plan and have a contractor on standby depending on what needs to be done
and would keep Licensing updated. Facility also reported that programming had not been
affected. Residents are still attending school, and activities are continuing as scheduled.
They are using classrooms after school hours instead of the common area on the dorm and
they are sleeping in the cafeteria. 8/30/2024, Program Coordinator followed up with facility
on admissions for Dorm 1. Facility reported no admissions for Dorm 1 are being taken at
this time. Program Coordinator requested a written plan on accommodations. 9/5/2024,
Program Coordinator followed up with facility for an update. 9/9/2024, facility reported they
received and approved the estimate for remediation today. The facility is hoping the
complany will will start remediation work tomorrow (9/10/2024) or Wednesday (9/11/2024)
and expect it to take a couple of days. Then, the facility will get EMTEC to do another test
for levels. Assuming that test it good, the sheetrock will be replaced that has to be removed,
and lay the floor. If all goes according to plan, the facility should be moving the girls back in
next week. 9/18/2024, facility reported that they are waiting on the test results to determine
if the atmosphere is mold free. If the facility receives notice that all is clear, they are hoping
to start construction on 9/19/2024 with the hopes of moving the residents back on their
dorm on Tuesday, 9/24/2024.


summary: A resident was transported to Arkansas Children’s Hospital after reporting abdominal pain following a physical altercation with two peers.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Case Number: 023423
Date of Incident: 8/22/2024
Date Received: 8/23/2024
Facility Name: Elizabeth Mitchell Centers
Facility Number: 157
Incident Type: Licensing
Report Description: On Thursday August 22, 2024, EMAC client (PRFT
Placement) was involved in a physical altercation with two other peers. As a result of the
altercation was transported to Arkansas Childrens Hospital for abdominal pain.
was seen by staff at Arkansas Childrens Hospital and x-rays were administered.
The x-rays and was ordered to take Tylenol and Ibuprofen as needed.
The discharge paperwork stated
is in and the guardian was notified.
Interim Action Narrative: Resident was evaluated at ACH and moved to another dorm.
Maltreatment Narrative:
Licensing Narrative: Licensing reviewed provider reported incident for licensing concerns.
Program Coordinator inquired about camera footage and restrictions. Facility reported that
there is camera footage and resident was moved to another dorm. Program Coordinator
requested for camera footage to be saved to be reviewed. 8/26/2024, Program Coordinator
reviewed camera footage. No supervision concerns were observed.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was transported to Arkansas Children’s Hospital after complaining of an itchy throat, swelling of the lips and mouth, and redness and mild swelling to the right hand.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Case Number: 023402
Date of Incident: 8/21/2024
Date Received: 8/22/2024
Facility Name: Elizabeth Mitchell Centers
Facility Number: 157
Incident Type: Licensing
Report Description: On August 21, 2024 client
complained of an itchy throat, swelling of lips, swelling on the inside of her mouth, redness
and mild swelling to the right hand. The on-call provider was notified, and Benadryl was
ordered. The provider also ordered for the client to be transported to Arkansas Childrens
Hospital. The client is from and her guardian was notified.
Interim Action Narrative: Resident was assessed by the nurse and evaluated at ACH.
Maltreatment Narrative:
Licensing Narrative: Licensing reviewed provider reported incident for licensing comcerns.
Program Coordinator inquried if resident was PRTF or residential and the outcome of ACH
visit. Facility reported resident is residential and diagnosed with
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: Multiple deficiencies were noted during the Inspection of Care (IOC) review. The Corrective Action Plan (CAP) was cancelled; All deficiencies were overturned.

raw_content:
August 19, 2024
Centers For Youth and Families, Inc
6501 W 12th St
Little Rock, AR 72204-1511
The Division of Provider Services and Quality Assurance (DPSQA) of the Arkansas Department of Human
Services has contracted with Arkansas Foundation for Medical Care (AFMC) to perform Inspections of Care
(IOC) for Inpatient Psychiatric Services for Under 21. The Medicaid Manual for Inpatient Psychiatric Services
for Under Age 21 was used in the completion of this report.
Observations and any deficiencies noted are listed below for the inspection conducted at the following service
site on the following date:
Centers For Youth and Families, Inc
Provider Medicaid ID:
Onsite Inspection Date: August 15, 2024
Onsite Inspection Time: 8:19 AM
A summary of the inspection and any deficiencies noted are outlined below.
The provider must submit a Corrective Action Plan (CAP) designed to correct any deficiency noted in the
written report of the IOC. Accordingly, you must complete and submit to AFMC a Corrective Action Plan for
each deficiency noted. The Corrective Action Plan must state with specificity the:
(a) Corrective action to be taken.
(b) Person(s) responsible for implementing and maintaining the corrective action; and
(c) Completion date or anticipated completion date for each corrective action.
The CAP must be completed within 30 calendar days of the date of the email notice of the IOC report. Please
follow the link provided in the email notice to submit either a Reconsideration or CAP for the inspection, all via
AccessPoint.
The contractor (AFMC) will:
(a) Review the Corrective Action Plan.
(b) Determine whether the Corrective Action Plan is sufficient to credibly assure future compliance; and
(c) Provide the Corrective Action Plan to the Division of Provider Services and Quality Assurance (DPSQA).
Please see § 160 of the Medicaid Manual for an explanation of your rights to administrative reconsideration and
appeal. Additionally, the imposition of this Corrective Action Plan does not prevent the Department of Human
Services from prescribing additional remedial actions as may be necessary.

Inspection of Care Summary
Facility Tour:
Upon arrival at the facility, AFMC staff was promptly greeted at the entrance by a Centers for Youth and
Families receptionist in the main lobby. AFMC staff signed the visitor log and were immediately taken to a
conference room where they were met by the Regulatory Compliance Officer and the Clinical Service Director.
AFMC staff was given the completed and signed consent form listing approval for access to the AFMC portal.
Facility staff were given the Document Request Form and AFMC staff discussed the requirements for the
Inspection of Care.
A tour of the facility was completed with the Regulatory Compliance Officer, the Clinical Service Director, and
Director of Nursing Consultant. There are two buildings that house the under 21 years of age population. The
first building, Elizabeth Mitchell Adolescent Center (EMAC), houses the older adolescent girls aged 12 to 18
years of age. The second building, Elizabeth Mitchell Children’s Center (EMCC), houses the younger male and
female children aged 5 to 14 years old. Both buildings have four units each that house the clients. Areas toured
included the client units including the clients’ rooms and in room bathrooms and showers, the common areas
that are used for group activities and meals, community bathrooms, outside area, classrooms, and the medication
rooms.
The facility environment was clean, well-organized, and appeared to be in good repair. Staff members were
observed interacting calmly with clients throughout the facility. Staff were able to answer questions regarding
the facility. No issues were noted.
Facility Review – Policies and Procedures:
Upon review of the site’s policies, procedures, and certification requirements, the following deficiencies were
noted:
Regulation Deficiency Statement Reviewer Notes
Medicaid IP Sec. 2: HR records did not indicate that all During the review of personnel records, it was
CFR 42 482.130, direct care personnel are currently noted that not all staff had evidence that they are
483.376 certified in cardiopulmonary currently certified in cardiopulmonary
resuscitation (CPR). resuscitation (CPR).
Medicaid IP Sec. 2: There is no documentation in the HR During the review of personnel records, it was
CFR 42 482.130, records that all direct care personnel noted that not all direct care personnel are trained,
483.376 are trained in facility's Restraint and as well as demonstrate competency, in facility's
Seclusion policy. Restraint and Seclusion policy and appropriate
procedures to be used in Restraint and Seclusion
interventions.
Medicaid IP Sec. 2: HR records did not indicate that all During the review of personnel records, it was
221.804 direct care personnel have ongoing noted that not all direct care personnel have
CFR 42 482.130, education, training, and demonstrated ongoing education, training, and demonstrated
483.376 knowledge of techniques to identify knowledge of techniques to identify staff and
staff and resident behaviors that may resident behaviors, events and environmental
trigger an emergency safety situation factors that may trigger emergency safety
semi-annually. situations on a semi-annual basis.
Medicaid IP Sec. 2: HR records did not indicate training During the review of personnel records, it was
221.804 in the use of nonphysical intervention noted that not all direct care staff are trained in the
CFR 42 482.130, skills, such as de-escalation on an use of nonphysical intervention skills, such as de-
483.376 annual basis. escalation, mediation conflict resolution, active
listening, and verbal and observational methods,
to prevent emergency safety situations on an
annual basis.
Centers For Youth and Families, Inc – Little Rock, AR – IOC Report 2 | P ag e

Personnel Records – Licenses, Certifications, Training:
There was a total of 29 personnel records reviewed, 7 (25%) professional and 21 (25%) paraprofessional.
During the review of the personnel records, the following deficiencies were noted:
Personnel Rule Credential Validated Outcome Reviewer Notes
Record Number
SR017814 Medicaid IP Sec. 2: CPR training Failed No file received.
221.804C
SR017798 Medicaid IP Sec. 2: Restraint and Seclusion Failed No file received.
221.804 Training (CPI)
CFR 42 482.130, 483.376
Personnel Records – Licenses, Certifications, Training Observations:
The provider submitted the letter of resignation for SR017810; therefore, they did not have any training available
for review.
Observations:
AFMC staff reviewed the final document request form with the Regulatory Compliance Officer and the Clinical
Service Director at the completion of the on-site Inspection of Care. The provider signed the acknowledgement
of manual requirements that were made available in the provider’s policy and procedures. AFMC staff explained
that these findings were preliminary and there was still an off-site portion to be completed.
Clinical Summary
As a part of the Quality-of-Care survey of the IOC, an active Fee for Service (FFS) Medicaid client list was
requested, client and/or guardian interviews were conducted, and a clinical record review was completed. The
following is a summary of findings and noted deficiencies.
Client/Guardian Interviews:
There was no active FFS Medicaid clients currently admitted at the time of IOC. Therefore, no client interviews
were conducted.
Program Activity/Service Milieu Observation:
Staff and clients were observed throughout the facility in the educational classroom setting and in organized
group activities. Clients were engaged in schoolwork and activities. Staff were calmly interacting with clients
and providing a therapeutic environment that was conducive for learning and treatment therapies.
Medication Pass:
No active FFS Medicaid clients received medications during a medication pass while AFMC staff was onsite.
Due to the observation of non-Medicaid clients not being complaint with the HIPAA minimal necessary rule, no
medication pass was observed. AFMC RN visited with the facility medication nurse who was able to show
AFMC RN the facility policies and procedures regarding medication administration, narcotic
count/reconciliation/handling, and medication discrepancies.
Facility nurse was able to verbalize the step-by-step process of medication delivery including the demonstration
of the five rights of medication administration, documentation of medication delivery, verification of client
taking medication including mouth/cheek checks, and how clients are educated about each medication. The
facility nurse also verbalized the process utilized when a client refuses medication. Tour of medication room
completed no discrepancies with medication storage, cleanliness of medication room, and knowledge of
medication dispensing found.
Centers For Youth and Families, Inc – Little Rock, AR – IOC Report 3 | P ag e

Clinical Record Review Deficiencies:
There was no active FFS Medicaid clients currently admitted at the time of IOC. Therefore, no clinical records
reviews were conducted.
Corrective Action Plan:
The CAP must be completed within 30 calendar days of the date of the email notice of the IOC reports.
Additionally, any findings that were noted in any Health and Safety Inspection(s), which are governed by
certification rules and requirements, are shared with DPSQA and may result in other remedial actions, by
DPSQA, if warranted.
*For more details on the individual related deficiencies, please log into the portal.
Respectfully,
Inspection of Care Team
InspectionTeam@afmc.org
1020 W. 4TH ST., SUITE 300
LITTLE ROCK, AR 72201 • afmc.org
Centers For Youth and Families, Inc – Little Rock, AR – IOC Report 4 | P ag e

doc_type: IOC Report


summary: Licensing visited the facility to perform a buildings and grounds walkthrough. All areas observed were well maintained and organized.

raw_content:
521 Visit Compliance Report

Licensee: Elizabeth Mitchell Centers

Facility Number: 157

Licensee Address: 6501 W 12TH ST
LITTLE ROCK AR 72204-1511

Licensing Specialist: Kendra Rice
Person In Charge: Paul Hofstad
Record Visit Date: 8/8/2024
Home Visit Date: 8/8/2024

Purpose of Visit: Subsequent Building and Grounds

Regulations Out of Compliance:

Regulations Needing Technical Assistance:

Regulation Not Applicable:

Regulations Not Correctable:

Narrative:

Time of visit: 9:45 am to 10:30 am

www.arkansas.gov/dhs
Serving more than one million Arkansans each year

— ARKANSAS
\ DEPARTMENT OF

‘U7 HUMAN
[al SERVICES
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550

Page 1 of 2

Census: 25

Program Coordinator went to EMAC and rang the doorbell three (3) times before walking over to EMCC. The
receptionist at EMCC called different staff members to assist with completing the visit. Two staff members
entering the lobby area of EMCC reported that EMAC currently had a code (Code Red) going on.

BE Director of Risk Management, and Clinical Manager, came to EMCC and escorted Program
Coordinator through the building. The following areas were observed: lobby, therapy hallway, dining room,
laundry room, dorms, and nurse’s station.

Walking through the therapy hall, Program Coordinator observed the rooms that the facility is considering
using for residential bedrooms. Entering through the doors by the dining room, housekeeping was observed
cleaning the dining room and the area (hallway and bathrooms) around the dining room.

All dorms were having groups during the walkthrough. All areas observed were well maintained and
organized. The following ratios were observed: New Dorm 2:6; East Dorm 2:6, North Dorm 2:6, and South
Dorm 2:7.

Nursef assisted with showing the MAR’s. Upon arrival, NurselJwas preparing medications for the
next med pass. Program Coordinator reviewed the MAR’s for the residents listed below:

Initials DOB

All initialed and up to date.

Provider Comments:

CCL Staff Signature : Date: 8/8/2024

Provider Signature : Date: 8/8/2024

Lae Nepatad

www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 2


summary: A resident was transported to Arkansas Children’s Hospital after hitting her head against a window and wall.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Case Number: 023084
Date of Incident: 8/7/2024
Date Received: 8/8/2024
Facility Name: Elizabeth Mitchell Centers
Facility Number: 157
Incident Type: Licensing
Report Description: On August 7, 2024, EMAC
(Residential Client) client became dysregulated hit her head against the window in dorm 1,
was placed in a hold for safety concerns. Once the hold was released
hit her head on the wall and was placed into another hold. nose began
bleeding, and she was taken to Arkansas Childrens Hospital for evaluation. was
but no further medical attention was needed. The discharge
paperwork stated to administer Ibuprofen and Tylenol as needed. is an
and her guardian was notified of the incident.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 8/8/2024-Licensing reviewed provider reported incident report.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Urgent Care for a hand injury caused by punching a desk and wall after a physical altercation with another resident.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Case Number: 023067
Date of Incident: 8/6/2024
Date Received: 8/7/2024
Facility Name: Elizabeth Mitchell Centers
Facility Number: 157
Incident Type: Licensing
Report Description: On August 6, 2024, EMCC client
(PRTF Client) became dysregulated and became aggressive with staff. was in a
physical altercation with another peer. started punching a desk and wall which
caused his hand to begin bleeding. was then accessed by the nurse and the provider
ordered an Xray for right hand was x-rayed and
was sent to Orthro-Arkansas Urgent Care to be seen and a
is private placement and his guardian was notified.
Interim Action Narrative: Resident was assessed by the nurse and sent for an x-ray.
Maltreatment Narrative:
Licensing Narrative: Program Coordinator reviewed provider reported incident for
licensing concerns, inquired about nurse's note, and requested documentation from Ortho
AR. 8/8/2024, facility provided documentation. Program Coordinator inquired about safety
precautions. 8/9/2024, facility reported both residents were placed on assaultive
precautions.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: Officers responded to the facility for an alarm. False alarm.

raw_content:
LITTLE ROCK POLICE DEPARTMENT ABBREVIATED INCIDENT REPORT

JUVENILE INFORMATION INCIDENT Report generated: 8/4/2024 7:50 PM

INCIDENT NUMBER UNIT ASSIGNED CALL DATE CALL TIME TYPE OF CALL

2024-104934 2X61 08/04/2024 17:50:00 ALMBRG

INCIDENT DATE LOCATION OF INCIDENT (ADDRESS / BUSINESS NAME)

8/4/2024 5:50:57 PM

6501 W 12TH ST

OFFENSE

FALSE ALARM

OFFICERS CHECKED THE AREA. FALSE ALARM

ENTRY DATE REPORTING OFFICER ORIGINAL APPROVING SUPERVISOR .
08/05/2024 00:46:45 | JASMINE JACKSON - J JASMINE JACKSON - [ga MVR in use

LRPD Form 5501-01 Rev. RMS-2019-01-23 Page 1 of 1


summary: Licensing met with Paul Hofstad and Barbara McCrory to discuss adding additional bedrooms to the Elizabeth Mitchell Children Center (EMCC) facility.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
521 Visit Compliance Report
Licensee: Elizabeth Mitchell Centers
Facility Number: 157
Licensee Address: 6501 W 12TH ST
LITTLE ROCK AR 72204-1511
Licensing Specialist: Kendra Rice
Person In Charge: Paul Hofstad
Record Visit Date: 7/30/2024
Home Visit Date: 7/30/2024
Purpose of Visit: Monitor Visit
Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
Time of Visit: 2:00 pm to 3:00 pm
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 2

Census: 37
Program Coordinator met with Paul Hofstad and Barbara McCrory to discuss adding additional bedrooms to
EMCC.
The facility is licensed to have 33 residential beds and would like to be able to offer more services to residents
in need of services. The facility no longer utilizes Destiny House for residential services. Destiny House is
being utilized to house adults in their adult program.
The facility discussed using the old classrooms that were utilized in December 2022 and January 2023 when
EMCC was being repaired. The facility reported cameras being in the classrooms, a toilet and sink. The
residents would utilize the shower down the hall for hygiene.
Facility was informed that a written plan (documentation) should be submitted to Licensing of their plans.
Provider Comments:
CCL Staff Signature : Date: 7/31/2024
Provider Signature : Date: 7/31/2024
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 2


summary: Licensing met with Paul Hofstad and Barbara McCrory to discuss accommodations for the residents at the Elizabeth Mitchell Adolescent Center (EMAC) facility while flooring is being replaced.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
521 Visit Compliance Report
Licensee: Elizabeth Mitchell Centers
Facility Number: 157
Licensee Address: 6501 W 12TH ST
LITTLE ROCK AR 72204-1511
Licensing Specialist: Kendra Rice
Person In Charge:
Record Visit Date: 7/30/2024
Home Visit Date: 7/30/2024
Purpose of Visit: Monitor Visit
Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
Time of Visit: 2:00 pm to 3:00 pm
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 2

Census: 37
Program Coordinator met with Paul Hofstad and Barbara McCrory to discuss accommodation for the residents
at EMAC while flooring is being replaced. The facility does not have an exact timeframe of how long it will
take for the flooring to be replaced or dates.
The facility presented two (2) options:
· For a two (2) day operation, the flooring company would strip the floors on day one (1). The residents’
beds would be placed back into their bedrooms to allow the residents to stay in their dorms. Day two (2), the
flooring and all furnishings will be replaced.
· Have the residents sleep in the classrooms and dining room area while the flooring is being replaced.
During sleeping hours, dining room ratio would be 1:8 and the classrooms ratio would be 1:4.
Facility was informed that a written plan (documentation) should be submitted to Licensing of their plans.
Provider Comments:
CCL Staff Signature : Date: 7/31/2024
Provider Signature : Date: 7/31/2024
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 2


summary: A resident reported right foot pain after kicking the exit door while dysregulated. An x-ray was ordered.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Case Number: 022901
Date of Incident: 7/29/2024
Date Received: 7/30/2024
Facility Name: Elizabeth Mitchell Centers
Facility Number: 157
Incident Type: Licensing
Report Description: On July 29, 2024 EMAC client
(PRTF client) became dysregulated and started kicking the exit door on the dorm with her
right foot. was later seen by a nurse and stated that her foot was hurting but it was
noted that had no bruising and full range of motion of her right foot. The following
morning on July 30, 2024 appeared to be limping and was accessed by the nurse
again. An X-Ray was ordered, and the X-Ray
is and her guardian was notified.
Interim Action Narrative: Resident was assessed by the nurse twice and an x-ray was
completed.
Maltreatment Narrative:
Licensing Narrative: Program Coordinator received an email from the facility regarding
this incident. Provider reported incident reviewed for licensing concerns. Program
Coordinator requested nursing notes for 7/29/2024 and 7/30/2024. 8/1/2024, nursing notes
received and uploaded.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was taken to Urgent Care after a nurse gave her the wrong medication.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Case Number: 022774
Date of Incident: 7/24/2024
Date Received: 7/24/2024
Facility Name: Elizabeth Mitchell Centers
Facility Number: 157
Incident Type: Licensing
Report Description: On 7/22/2024 EMAC client,
went to the nurse's station to get her medication and the nurse grabbed the
wrong medicine cup and gave to the client. The client received Topamax, Seroquel, Claritin,
and Trazadone. The client was monitored by nursing and vital signs were taken after the
medicine was consumed. On 7/23/2024 stated she had a headache and was
dizzy. was taken to Urgent Care to be seen. While at Urgent Care the doctor
stated that the meds will have to wear off. returned to the Centers. is
and the guardian was notified of the incident.
Interim Action Narrative: Resident was evaluated at Urgent Care.
Maltreatment Narrative:
Licensing Narrative: Program Coordinator reviewed provider reported incident for
licensing concerns. Program Coordinator inquired about if nurse was discplined and what
plan will be implemented to prevent this from happening again. 7/29/2024, Program
Coordinator followed up with facility. Three nurses were written up following this incident
and all have received retraining. Program Coordinator requested copy of training roster.
Facility provided the Performance Improvement Plan for the nurses. The nurses will have a
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

meeting on the 7th and all will be given the training. The nurse involved will receive the
training when returning tomorrow, 7/30/2024. 8/1/2024, Program Coordinator inquired
about training documentation for the nurse named in this provider reported incident.
8/2/2024, Program Coordinator requested for facility to send a copy of the roster for the
training scheduled for 8/7/2024. 8/6/2024, Program Coordinator received a phone call from
the facility stating that the nurse involved in this incident resigned. No training
documentation is available for this nurse due to her resigning. 8/9/2024, Program
Coordinator followed up with facility on providing a copy of training roster. Facility
provided copy of training roster and it has been uploaded.


summary: A resident was transported to Arkansas Children’s Hospital after falling and hitting her head while skating.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Case Number: 022801
Date of Incident: 7/24/2024
Date Received: 7/25/2024
Facility Name: Elizabeth Mitchell Centers
Facility Number: 157
Incident Type: Licensing
Report Description: On 7/24/2024 EMAC client was
skating while on an outing, while skating fell and hit her head. began
vomiting and was taken Arkansas Childrens Hospital for evaluation. was seen by
hospital staff and
is an from and . guardian was notified.
was then released back to the Centers.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 7/25/2024- Licensing reviewed for concerns and emailed the facility
to determine the status of the resident today. The facility reports that the resident is doing
better.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: Licensing visited the facility to conduct an annual review of policies. All policies complied with minimum licensing standards.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
521 Visit Compliance Report
Licensee: Elizabeth Mitchell Centers
Facility Number: 157
Licensee Address: 6501 W 12TH ST
LITTLE ROCK AR 72204-1511
Licensing Specialist: Kendra Rice
Person In Charge: Paul Hofstad
Record Visit Date: 7/16/2024
Home Visit Date: 7/16/2024
Purpose of Visit: Special Visit
Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
Time of Visit: 9:45 am to 10:55 am
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 2

Census: 25
Program Coordinator conducted an annual review of policies for EMCC with Barbara McCrory and Paul
Hofstad.
All policies complied with minimum licensing standards.
Provider Comments:
CCL Staff Signature : Date: 7/16/2024
Provider Signature : Date: 7/16/2024
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 2


summary: A resident was sent to Arkansas Children’s Hospital (ACH) due to facial swelling.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Case Number: 022436
Date of Incident: 7/5/2024
Date Received: 7/8/2024
Facility Name: Elizabeth Mitchell Centers
Facility Number: 157
Incident Type: Licensing
Report Description: On July 5, 2024 EMCC client
was sent to Arkansas Children's Hospital due to facial swelling. was seen by staff at
ACH and determined that the swelling was due to a dental infection. was given
antibiotics to take for 7 days. has a dental appointment on July 16, 2024 for a tooth
extraction. is , and the guardian was notified.
Interim Action Narrative: Resident was evaluated at ACH and dental appointment
scheduled for 7/16/2024.
Maltreatment Narrative:
Licensing Narrative: Program Coordinator reviewed provider reported incident for
licensing concerns.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov