Peaceful Meadows DBA

A review of a previous employee's file did not have documentation of having the required 40 hours of experience or observation. This employee was observed to be working alone with the children in care during the last inspection.

Resolution: Corrected: 2026-04-13

A review of the Treatment Director's qualifications revealed that he does not meet professional or educational requirements.

Resolution: Corrected: 2026-04-13

A review of records revealed that a child admitted on 03/18/26 did not have a completed admissions assessment in his file.

Resolution: Corrected: 2026-04-13

A review of a child's immunization record indicated that required immunizations were delinquent.

Resolution: Corrected: 2026-04-13

A review of an employee's pre-employment screening revealed that results of contact with previous employers were not documented.

Resolution: Corrected: 2026-04-13

There is conflicting information regarding the administrator's presence at the operation. The administrator was not present during either inspection, also children in care and some staff have reported having no knowledge of who the administrator is.

Resolution: Corrected: 2026-04-13

Medical and dental visit documentation was observed to be missing caregiver signatures in the designated areas

Resolution: Corrected: 2026-04-14

Documentation related to fire and emergency evacuation drills could not be produced upon request.

Resolution: Corrected: 2026-04-13

A review of an employee's pre-employment screening revealed that contact with at least two references was not documented.

Resolution: Corrected: 2026-04-13

There is conflicting information regarding the administrator's presence at the operation. The administrator was not present during either inspection, also children in care and some staff have reported having no knowledge of who the administrator is.

Resolution: Corrected: 2026-04-13

A review of the Treatment Director's qualifications revealed that he does not meet professional or educational requirements.

Resolution: Corrected: 2026-04-13

A review of an employee's pre-employment screening revealed that results of contact with previous employers were not documented.

Resolution: Corrected: 2026-04-13

Medical and dental visit documentation was observed to be missing caregiver signatures in the designated areas

Resolution: Corrected: 2026-04-14

Documentation related to fire and emergency evacuation drills could not be produced upon request.

Resolution: Corrected: 2026-04-13

A review of an employee's pre-employment screening revealed that contact with at least two references was not documented.

Resolution: Corrected: 2026-04-13

A review of records revealed that a child admitted on 03/18/26 did not have a completed admissions assessment in his file.

Resolution: Corrected: 2026-04-13

A review of a child's immunization record indicated that required immunizations were delinquent.

Resolution: Corrected: 2026-04-13

A review of a previous employee's file did not have documentation of having the required 40 hours of experience or observation. This employee was observed to be working alone with the children in care during the last inspection.

Resolution: Corrected: 2026-04-13

A review of a child's immunization record indicated that required immunizations were delinquent.

Resolution: Corrected: 2026-04-13

There is conflicting information regarding the administrator's presence at the operation. The administrator was not present during either inspection, also children in care and some staff have reported having no knowledge of who the administrator is.

Resolution: Corrected: 2026-04-13

Medical and dental visit documentation was observed to be missing caregiver signatures in the designated areas

Resolution: Corrected: 2026-04-14

A review of an employee's pre-employment screening revealed that contact with at least two references was not documented.

Resolution: Corrected: 2026-04-13

Documentation related to fire and emergency evacuation drills could not be produced upon request.

Resolution: Corrected: 2026-04-13

A review of the Treatment Director's qualifications revealed that he does not meet professional or educational requirements.

Resolution: Corrected: 2026-04-13

A review of an employee's pre-employment screening revealed that results of contact with previous employers were not documented.

Resolution: Corrected: 2026-04-13

A review of records revealed that a child admitted on 03/18/26 did not have a completed admissions assessment in his file.

Resolution: Corrected: 2026-04-13

A review of a previous employee's file did not have documentation of having the required 40 hours of experience or observation. This employee was observed to be working alone with the children in care during the last inspection.

Resolution: Corrected: 2026-04-13

Medical and dental visit documentation was observed to be missing caregiver signatures in the designated areas

Resolution: Corrected: 2026-04-14

Documentation related to fire and emergency evacuation drills could not be produced upon request.

Resolution: Corrected: 2026-04-13

There is conflicting information regarding the administrator's presence at the operation. The administrator was not present during either inspection, also children in care and some staff have reported having no knowledge of who the administrator is.

Resolution: Corrected: 2026-04-13

A review of the Treatment Director's qualifications revealed that he does not meet professional or educational requirements.

Resolution: Corrected: 2026-04-13

A review of an employee's pre-employment screening revealed that contact with at least two references was not documented.

Resolution: Corrected: 2026-04-13

A review of an employee's pre-employment screening revealed that results of contact with previous employers were not documented.

Resolution: Corrected: 2026-04-13

A review of records revealed that a child admitted on 03/18/26 did not have a completed admissions assessment in his file.

Resolution: Corrected: 2026-04-13

A review of a child's immunization record indicated that required immunizations were delinquent.

Resolution: Corrected: 2026-04-13

A review of the Treatment Director's qualifications revealed that he does not meet professional or educational requirements.

Resolution: Corrected: 2026-04-13

A review of a previous employee's file did not have documentation of having the required 40 hours of experience or observation. This employee was observed to be working alone with the children in care during the last inspection.

Resolution: Corrected: 2026-04-13

Medical and dental visit documentation was observed to be missing caregiver signatures in the designated areas

Resolution: Corrected: 2026-04-14

A review of an employee's pre-employment screening revealed that results of contact with previous employers were not documented.

Resolution: Corrected: 2026-04-13

There is conflicting information regarding the administrator's presence at the operation. The administrator was not present during either inspection, also children in care and some staff have reported having no knowledge of who the administrator is.

Resolution: Corrected: 2026-04-13

A review of records revealed that a child admitted on 03/18/26 did not have a completed admissions assessment in his file.

Resolution: Corrected: 2026-04-13

A review of a child's immunization record indicated that required immunizations were delinquent.

Resolution: Corrected: 2026-04-13

Documentation related to fire and emergency evacuation drills could not be produced upon request.

Resolution: Corrected: 2026-04-13

A review of an employee's pre-employment screening revealed that contact with at least two references was not documented.

Resolution: Corrected: 2026-04-13

A review of the Treatment Director's qualifications revealed that he does not meet professional or educational requirements.

Resolution: Corrected: 2026-04-13

A review of an employee's pre-employment screening revealed that results of contact with previous employers were not documented.

Resolution: Corrected: 2026-04-13

A review of records revealed that a child admitted on 03/18/26 did not have a completed admissions assessment in his file.

Resolution: Corrected: 2026-04-13

Documentation related to fire and emergency evacuation drills could not be produced upon request.

Resolution: Corrected: 2026-04-13

A review of an employee's pre-employment screening revealed that contact with at least two references was not documented.

Resolution: Corrected: 2026-04-13

A review of a previous employee's file did not have documentation of having the required 40 hours of experience or observation. This employee was observed to be working alone with the children in care during the last inspection.

Resolution: Corrected: 2026-04-13

A review of a child's immunization record indicated that required immunizations were delinquent.

Resolution: Corrected: 2026-04-13

Medical and dental visit documentation was observed to be missing caregiver signatures in the designated areas

Resolution: Corrected: 2026-04-14

There is conflicting information regarding the administrator's presence at the operation. The administrator was not present during either inspection, also children in care and some staff have reported having no knowledge of who the administrator is.

Resolution: Corrected: 2026-04-13

A review of records revealed that a child admitted on 03/18/26 did not have a completed admissions assessment in his file.

Resolution: Corrected: 2026-04-13

Documentation related to fire and emergency evacuation drills could not be produced upon request.

Resolution: Corrected: 2026-04-13

A review of a previous employee's file did not have documentation of having the required 40 hours of experience or observation. This employee was observed to be working alone with the children in care during the last inspection.

Resolution: Corrected: 2026-04-13

Medical and dental visit documentation was observed to be missing caregiver signatures in the designated areas

Resolution: Corrected: 2026-04-14

A review of an employee's pre-employment screening revealed that results of contact with previous employers were not documented.

Resolution: Corrected: 2026-04-13

A review of the Treatment Director's qualifications revealed that he does not meet professional or educational requirements.

Resolution: Corrected: 2026-04-13

A review of a child's immunization record indicated that required immunizations were delinquent.

Resolution: Corrected: 2026-04-13

There is conflicting information regarding the administrator's presence at the operation. The administrator was not present during either inspection, also children in care and some staff have reported having no knowledge of who the administrator is.

Resolution: Corrected: 2026-04-13

A review of an employee's pre-employment screening revealed that contact with at least two references was not documented.

Resolution: Corrected: 2026-04-13

A review of a previous employee's file did not have documentation of having the required 40 hours of experience or observation. This employee was observed to be working alone with the children in care during the last inspection.

Resolution: Corrected: 2026-04-13

It was observed that an employee hired on 12/08/25 completed the pre-employment affidavit on 12/09/25, after the date of hire.

Resolution: Corrected: 2026-01-13

It was observed that the Preliminary Service Plans for children in care were completed beyond the 72-hour requirement and lacked required information.

Resolution: Corrected: 2026-01-13

The operation's Treatment Director reported coming to the facility once per week for eight hours and work the remaining hours remotely.

Resolution: Corrected: 2026-01-13

There was no running water observed at the facility.

Resolution: Corrected: 2026-01-13

Personnel records for an individual whose employment status recently became inactive were not available for review.

Resolution: Corrected: 2026-01-13

It was observed that the permit holder/owner signed admissions assessments for a child in care.

Resolution: Corrected: 2026-01-16

Background checks results were not observed in two staff files that were reviewed.

Resolution: Corrected: 2026-01-16

A review of the children's files showed that immunization records were not present for either child.

Resolution: Corrected: 2026-01-13

It was observed that a background check remains active for an individual who is no longer employed at the operation.

Resolution: Corrected: 2026-01-13

A review of records showed that employees began employment before background check results were received.

Resolution: Corrected: 2026-01-13

The operation was unable to produce a personnel record for an active employee.

Resolution: Corrected: 2026-01-13

The employee census provided included an individual who is no longer affiliated with the operation. Additionally, the hire dates listed on the census were inconsistent with the hire dates documented in the employee files that were reviewed.

Resolution: Corrected: 2026-01-13

A review of records showed that Preliminary Service Plans were not developed or signed by a Treatment Director or PLSP, as required.

Resolution: Corrected: 2026-01-13

The operation failed to provide notification regarding the resignation of the designated administrator effective 12/17/25 and the subsequent hiring of a new designated administrator on 12/30/25.

Resolution: Corrected: 2026-01-13

Pre-employment screenings were not documented in the employee files that were reviewed.

Resolution: Corrected: 2026-01-13

It was observed that an admission assessment was not completed for a child in care admitted into care on 12/30/25.

Resolution: Corrected: 2026-01-13

Personnel records for an individual whose employment status recently became inactive were not available for review.

Resolution: Corrected: 2026-01-13

The employee census provided included an individual who is no longer affiliated with the operation. Additionally, the hire dates listed on the census were inconsistent with the hire dates documented in the employee files that were reviewed.

Resolution: Corrected: 2026-01-13

The operation's Treatment Director reported coming to the facility once per week for eight hours and work the remaining hours remotely.

Resolution: Corrected: 2026-01-13

It was observed that a background check remains active for an individual who is no longer employed at the operation.

Resolution: Corrected: 2026-01-13

Personnel records for an individual whose employment status recently became inactive were not available for review.

Resolution: Corrected: 2026-01-13

Pre-employment screenings were not documented in the employee files that were reviewed.

Resolution: Corrected: 2026-01-13

It was observed that an admission assessment was not completed for a child in care admitted into care on 12/30/25.

Resolution: Corrected: 2026-01-13

It was observed that an employee hired on 12/08/25 completed the pre-employment affidavit on 12/09/25, after the date of hire.

Resolution: Corrected: 2026-01-13

A review of records showed that employees began employment before background check results were received.

Resolution: Corrected: 2026-01-13

The operation was unable to produce a personnel record for an active employee.

Resolution: Corrected: 2026-01-13

It was observed that the Preliminary Service Plans for children in care were completed beyond the 72-hour requirement and lacked required information.

Resolution: Corrected: 2026-01-13

The employee census provided included an individual who is no longer affiliated with the operation. Additionally, the hire dates listed on the census were inconsistent with the hire dates documented in the employee files that were reviewed.

Resolution: Corrected: 2026-01-13

Background checks results were not observed in two staff files that were reviewed.

Resolution: Corrected: 2026-01-16

A review of records showed that Preliminary Service Plans were not developed or signed by a Treatment Director or PLSP, as required.

Resolution: Corrected: 2026-01-13

The operation failed to provide notification regarding the resignation of the designated administrator effective 12/17/25 and the subsequent hiring of a new designated administrator on 12/30/25.

Resolution: Corrected: 2026-01-13

There was no running water observed at the facility.

Resolution: Corrected: 2026-01-13

It was observed that the permit holder/owner signed admissions assessments for a child in care.

Resolution: Corrected: 2026-01-16

A review of the children's files showed that immunization records were not present for either child.

Resolution: Corrected: 2026-01-13

A review of records showed that employees began employment before background check results were received.

Resolution: Corrected: 2026-01-13

There was no running water observed at the facility.

Resolution: Corrected: 2026-01-13

It was observed that the Preliminary Service Plans for children in care were completed beyond the 72-hour requirement and lacked required information.

Resolution: Corrected: 2026-01-13

A review of records showed that Preliminary Service Plans were not developed or signed by a Treatment Director or PLSP, as required.

Resolution: Corrected: 2026-01-13

It was observed that an employee hired on 12/08/25 completed the pre-employment affidavit on 12/09/25, after the date of hire.

Resolution: Corrected: 2026-01-13

The operation's Treatment Director reported coming to the facility once per week for eight hours and work the remaining hours remotely.

Resolution: Corrected: 2026-01-13

Background checks results were not observed in two staff files that were reviewed.

Resolution: Corrected: 2026-01-16

Pre-employment screenings were not documented in the employee files that were reviewed.

Resolution: Corrected: 2026-01-13

Personnel records for an individual whose employment status recently became inactive were not available for review.

Resolution: Corrected: 2026-01-13

The operation was unable to produce a personnel record for an active employee.

Resolution: Corrected: 2026-01-13

The operation failed to provide notification regarding the resignation of the designated administrator effective 12/17/25 and the subsequent hiring of a new designated administrator on 12/30/25.

Resolution: Corrected: 2026-01-13

It was observed that a background check remains active for an individual who is no longer employed at the operation.

Resolution: Corrected: 2026-01-13

The employee census provided included an individual who is no longer affiliated with the operation. Additionally, the hire dates listed on the census were inconsistent with the hire dates documented in the employee files that were reviewed.

Resolution: Corrected: 2026-01-13

It was observed that an admission assessment was not completed for a child in care admitted into care on 12/30/25.

Resolution: Corrected: 2026-01-13

It was observed that the permit holder/owner signed admissions assessments for a child in care.

Resolution: Corrected: 2026-01-16

A review of the children's files showed that immunization records were not present for either child.

Resolution: Corrected: 2026-01-13

It was observed that an admission assessment was not completed for a child in care admitted into care on 12/30/25.

Resolution: Corrected: 2026-01-13

Background checks results were not observed in two staff files that were reviewed.

Resolution: Corrected: 2026-01-16

It was observed that the Preliminary Service Plans for children in care were completed beyond the 72-hour requirement and lacked required information.

Resolution: Corrected: 2026-01-13

It was observed that the permit holder/owner signed admissions assessments for a child in care.

Resolution: Corrected: 2026-01-16

Personnel records for an individual whose employment status recently became inactive were not available for review.

Resolution: Corrected: 2026-01-13

A review of records showed that employees began employment before background check results were received.

Resolution: Corrected: 2026-01-13

A review of records showed that Preliminary Service Plans were not developed or signed by a Treatment Director or PLSP, as required.

Resolution: Corrected: 2026-01-13

A review of the children's files showed that immunization records were not present for either child.

Resolution: Corrected: 2026-01-13

It was observed that a background check remains active for an individual who is no longer employed at the operation.

Resolution: Corrected: 2026-01-13

It was observed that an employee hired on 12/08/25 completed the pre-employment affidavit on 12/09/25, after the date of hire.

Resolution: Corrected: 2026-01-13

The operation's Treatment Director reported coming to the facility once per week for eight hours and work the remaining hours remotely.

Resolution: Corrected: 2026-01-13

Pre-employment screenings were not documented in the employee files that were reviewed.

Resolution: Corrected: 2026-01-13

The employee census provided included an individual who is no longer affiliated with the operation. Additionally, the hire dates listed on the census were inconsistent with the hire dates documented in the employee files that were reviewed.

Resolution: Corrected: 2026-01-13

There was no running water observed at the facility.

Resolution: Corrected: 2026-01-13

The operation was unable to produce a personnel record for an active employee.

Resolution: Corrected: 2026-01-13

The operation failed to provide notification regarding the resignation of the designated administrator effective 12/17/25 and the subsequent hiring of a new designated administrator on 12/30/25.

Resolution: Corrected: 2026-01-13

The operation's Treatment Director reported coming to the facility once per week for eight hours and work the remaining hours remotely.

Resolution: Corrected: 2026-01-13

It was observed that the Preliminary Service Plans for children in care were completed beyond the 72-hour requirement and lacked required information.

Resolution: Corrected: 2026-01-13

The operation was unable to produce a personnel record for an active employee.

Resolution: Corrected: 2026-01-13

Pre-employment screenings were not documented in the employee files that were reviewed.

Resolution: Corrected: 2026-01-13

It was observed that a background check remains active for an individual who is no longer employed at the operation.

Resolution: Corrected: 2026-01-13

It was observed that an admission assessment was not completed for a child in care admitted into care on 12/30/25.

Resolution: Corrected: 2026-01-13

A review of records showed that Preliminary Service Plans were not developed or signed by a Treatment Director or PLSP, as required.

Resolution: Corrected: 2026-01-13

A review of records showed that employees began employment before background check results were received.

Resolution: Corrected: 2026-01-13

The employee census provided included an individual who is no longer affiliated with the operation. Additionally, the hire dates listed on the census were inconsistent with the hire dates documented in the employee files that were reviewed.

Resolution: Corrected: 2026-01-13

It was observed that an employee hired on 12/08/25 completed the pre-employment affidavit on 12/09/25, after the date of hire.

Resolution: Corrected: 2026-01-13

The operation failed to provide notification regarding the resignation of the designated administrator effective 12/17/25 and the subsequent hiring of a new designated administrator on 12/30/25.

Resolution: Corrected: 2026-01-13

Background checks results were not observed in two staff files that were reviewed.

Resolution: Corrected: 2026-01-16

There was no running water observed at the facility.

Resolution: Corrected: 2026-01-13

It was observed that the permit holder/owner signed admissions assessments for a child in care.

Resolution: Corrected: 2026-01-16

Personnel records for an individual whose employment status recently became inactive were not available for review.

Resolution: Corrected: 2026-01-13

A review of the children's files showed that immunization records were not present for either child.

Resolution: Corrected: 2026-01-13

The operation failed to provide notification regarding the resignation of the designated administrator effective 12/17/25 and the subsequent hiring of a new designated administrator on 12/30/25.

Resolution: Corrected: 2026-01-13

Pre-employment screenings were not documented in the employee files that were reviewed.

Resolution: Corrected: 2026-01-13

It was observed that the permit holder/owner signed admissions assessments for a child in care.

Resolution: Corrected: 2026-01-16

A review of records showed that employees began employment before background check results were received.

Resolution: Corrected: 2026-01-13

It was observed that an admission assessment was not completed for a child in care admitted into care on 12/30/25.

Resolution: Corrected: 2026-01-13

There was no running water observed at the facility.

Resolution: Corrected: 2026-01-13

The employee census provided included an individual who is no longer affiliated with the operation. Additionally, the hire dates listed on the census were inconsistent with the hire dates documented in the employee files that were reviewed.

Resolution: Corrected: 2026-01-13

The operation was unable to produce a personnel record for an active employee.

Resolution: Corrected: 2026-01-13

It was observed that the Preliminary Service Plans for children in care were completed beyond the 72-hour requirement and lacked required information.

Resolution: Corrected: 2026-01-13

A review of records showed that Preliminary Service Plans were not developed or signed by a Treatment Director or PLSP, as required.

Resolution: Corrected: 2026-01-13

Background checks results were not observed in two staff files that were reviewed.

Resolution: Corrected: 2026-01-16

A review of the children's files showed that immunization records were not present for either child.

Resolution: Corrected: 2026-01-13

It was observed that an employee hired on 12/08/25 completed the pre-employment affidavit on 12/09/25, after the date of hire.

Resolution: Corrected: 2026-01-13

It was observed that a background check remains active for an individual who is no longer employed at the operation.

Resolution: Corrected: 2026-01-13

Personnel records for an individual whose employment status recently became inactive were not available for review.

Resolution: Corrected: 2026-01-13

The operation's Treatment Director reported coming to the facility once per week for eight hours and work the remaining hours remotely.

Resolution: Corrected: 2026-01-13

It was observed that an employee hired on 12/08/25 completed the pre-employment affidavit on 12/09/25, after the date of hire.

Resolution: Corrected: 2026-01-13

Pre-employment screenings were not documented in the employee files that were reviewed.

Resolution: Corrected: 2026-01-13

It was observed that the permit holder/owner signed admissions assessments for a child in care.

Resolution: Corrected: 2026-01-16

Background checks results were not observed in two staff files that were reviewed.

Resolution: Corrected: 2026-01-16

A review of records showed that employees began employment before background check results were received.

Resolution: Corrected: 2026-01-13

It was observed that a background check remains active for an individual who is no longer employed at the operation.

Resolution: Corrected: 2026-01-13

There was no running water observed at the facility.

Resolution: Corrected: 2026-01-13

A review of records showed that Preliminary Service Plans were not developed or signed by a Treatment Director or PLSP, as required.

Resolution: Corrected: 2026-01-13

The operation was unable to produce a personnel record for an active employee.

Resolution: Corrected: 2026-01-13

A review of the children's files showed that immunization records were not present for either child.

Resolution: Corrected: 2026-01-13

It was observed that an admission assessment was not completed for a child in care admitted into care on 12/30/25.

Resolution: Corrected: 2026-01-13

It was observed that the Preliminary Service Plans for children in care were completed beyond the 72-hour requirement and lacked required information.

Resolution: Corrected: 2026-01-13

The operation's Treatment Director reported coming to the facility once per week for eight hours and work the remaining hours remotely.

Resolution: Corrected: 2026-01-13

The operation failed to provide notification regarding the resignation of the designated administrator effective 12/17/25 and the subsequent hiring of a new designated administrator on 12/30/25.

Resolution: Corrected: 2026-01-13

Personnel records for an individual whose employment status recently became inactive were not available for review.

Resolution: Corrected: 2026-01-13

It was observed that the permit holder/owner signed admissions assessments for a child in care.

Resolution: Corrected: 2026-01-16

Background checks results were not observed in two staff files that were reviewed.

Resolution: Corrected: 2026-01-16

Pre-employment screenings were not documented in the employee files that were reviewed.

Resolution: Corrected: 2026-01-13

The operation's Treatment Director reported coming to the facility once per week for eight hours and work the remaining hours remotely.

Resolution: Corrected: 2026-01-13

It was observed that the Preliminary Service Plans for children in care were completed beyond the 72-hour requirement and lacked required information.

Resolution: Corrected: 2026-01-13

It was observed that a background check remains active for an individual who is no longer employed at the operation.

Resolution: Corrected: 2026-01-13

A review of records showed that Preliminary Service Plans were not developed or signed by a Treatment Director or PLSP, as required.

Resolution: Corrected: 2026-01-13

It was observed that an employee hired on 12/08/25 completed the pre-employment affidavit on 12/09/25, after the date of hire.

Resolution: Corrected: 2026-01-13

A review of records showed that employees began employment before background check results were received.

Resolution: Corrected: 2026-01-13

The employee census provided included an individual who is no longer affiliated with the operation. Additionally, the hire dates listed on the census were inconsistent with the hire dates documented in the employee files that were reviewed.

Resolution: Corrected: 2026-01-13

The operation failed to provide notification regarding the resignation of the designated administrator effective 12/17/25 and the subsequent hiring of a new designated administrator on 12/30/25.

Resolution: Corrected: 2026-01-13

Personnel records for an individual whose employment status recently became inactive were not available for review.

Resolution: Corrected: 2026-01-13

There was no running water observed at the facility.

Resolution: Corrected: 2026-01-13

The operation was unable to produce a personnel record for an active employee.

Resolution: Corrected: 2026-01-13

A review of the children's files showed that immunization records were not present for either child.

Resolution: Corrected: 2026-01-13

It was observed that an admission assessment was not completed for a child in care admitted into care on 12/30/25.

Resolution: Corrected: 2026-01-13

It was observed that the Preliminary Service Plans for children in care were completed beyond the 72-hour requirement and lacked required information.

Resolution: Corrected: 2026-01-13

A review of records showed that employees began employment before background check results were received.

Resolution: Corrected: 2026-01-13

Pre-employment screenings were not documented in the employee files that were reviewed.

Resolution: Corrected: 2026-01-13

The employee census provided included an individual who is no longer affiliated with the operation. Additionally, the hire dates listed on the census were inconsistent with the hire dates documented in the employee files that were reviewed.

Resolution: Corrected: 2026-01-13

It was observed that an employee hired on 12/08/25 completed the pre-employment affidavit on 12/09/25, after the date of hire.

Resolution: Corrected: 2026-01-13

Background checks results were not observed in two staff files that were reviewed.

Resolution: Corrected: 2026-01-16

Personnel records for an individual whose employment status recently became inactive were not available for review.

Resolution: Corrected: 2026-01-13

The operation failed to provide notification regarding the resignation of the designated administrator effective 12/17/25 and the subsequent hiring of a new designated administrator on 12/30/25.

Resolution: Corrected: 2026-01-13

A review of the children's files showed that immunization records were not present for either child.

Resolution: Corrected: 2026-01-13

There was no running water observed at the facility.

Resolution: Corrected: 2026-01-13

The operation was unable to produce a personnel record for an active employee.

Resolution: Corrected: 2026-01-13

It was observed that an admission assessment was not completed for a child in care admitted into care on 12/30/25.

Resolution: Corrected: 2026-01-13

The operation's Treatment Director reported coming to the facility once per week for eight hours and work the remaining hours remotely.

Resolution: Corrected: 2026-01-13

It was observed that a background check remains active for an individual who is no longer employed at the operation.

Resolution: Corrected: 2026-01-13

It was observed that the permit holder/owner signed admissions assessments for a child in care.

Resolution: Corrected: 2026-01-16

A review of records showed that Preliminary Service Plans were not developed or signed by a Treatment Director or PLSP, as required.

Resolution: Corrected: 2026-01-13

The employee census provided included an individual who is no longer affiliated with the operation. Additionally, the hire dates listed on the census were inconsistent with the hire dates documented in the employee files that were reviewed.

Resolution: Corrected: 2026-01-13

The operation was unable to produce a personnel record for an active employee.

Resolution: Corrected: 2026-01-13

It was observed that the Preliminary Service Plans for children in care were completed beyond the 72-hour requirement and lacked required information.

Resolution: Corrected: 2026-01-13

The operation failed to provide notification regarding the resignation of the designated administrator effective 12/17/25 and the subsequent hiring of a new designated administrator on 12/30/25.

Resolution: Corrected: 2026-01-13

It was observed that the permit holder/owner signed admissions assessments for a child in care.

Resolution: Corrected: 2026-01-16

The operation's Treatment Director reported coming to the facility once per week for eight hours and work the remaining hours remotely.

Resolution: Corrected: 2026-01-13

Background checks results were not observed in two staff files that were reviewed.

Resolution: Corrected: 2026-01-16

It was observed that an admission assessment was not completed for a child in care admitted into care on 12/30/25.

Resolution: Corrected: 2026-01-13

It was observed that a background check remains active for an individual who is no longer employed at the operation.

Resolution: Corrected: 2026-01-13

A review of records showed that Preliminary Service Plans were not developed or signed by a Treatment Director or PLSP, as required.

Resolution: Corrected: 2026-01-13

It was observed that an employee hired on 12/08/25 completed the pre-employment affidavit on 12/09/25, after the date of hire.

Resolution: Corrected: 2026-01-13

A review of records showed that employees began employment before background check results were received.

Resolution: Corrected: 2026-01-13

The employee census provided included an individual who is no longer affiliated with the operation. Additionally, the hire dates listed on the census were inconsistent with the hire dates documented in the employee files that were reviewed.

Resolution: Corrected: 2026-01-13

Pre-employment screenings were not documented in the employee files that were reviewed.

Resolution: Corrected: 2026-01-13

There was no running water observed at the facility.

Resolution: Corrected: 2026-01-13

A review of the children's files showed that immunization records were not present for either child.

Resolution: Corrected: 2026-01-13

Personnel records for an individual whose employment status recently became inactive were not available for review.

Resolution: Corrected: 2026-01-13

There was no running water observed at the facility.

Resolution: Corrected: 2026-01-13

Pre-employment screenings were not documented in the employee files that were reviewed.

Resolution: Corrected: 2026-01-13

The operation failed to provide notification regarding the resignation of the designated administrator effective 12/17/25 and the subsequent hiring of a new designated administrator on 12/30/25.

Resolution: Corrected: 2026-01-13

It was observed that the permit holder/owner signed admissions assessments for a child in care.

Resolution: Corrected: 2026-01-16

The operation's Treatment Director reported coming to the facility once per week for eight hours and work the remaining hours remotely.

Resolution: Corrected: 2026-01-13

Background checks results were not observed in two staff files that were reviewed.

Resolution: Corrected: 2026-01-16

It was observed that an admission assessment was not completed for a child in care admitted into care on 12/30/25.

Resolution: Corrected: 2026-01-13

It was observed that a background check remains active for an individual who is no longer employed at the operation.

Resolution: Corrected: 2026-01-13

A review of records showed that Preliminary Service Plans were not developed or signed by a Treatment Director or PLSP, as required.

Resolution: Corrected: 2026-01-13

It was observed that an employee hired on 12/08/25 completed the pre-employment affidavit on 12/09/25, after the date of hire.

Resolution: Corrected: 2026-01-13

It was observed that the Preliminary Service Plans for children in care were completed beyond the 72-hour requirement and lacked required information.

Resolution: Corrected: 2026-01-13

The operation was unable to produce a personnel record for an active employee.

Resolution: Corrected: 2026-01-13

A review of records showed that employees began employment before background check results were received.

Resolution: Corrected: 2026-01-13

The employee census provided included an individual who is no longer affiliated with the operation. Additionally, the hire dates listed on the census were inconsistent with the hire dates documented in the employee files that were reviewed.

Resolution: Corrected: 2026-01-13

A review of the children's files showed that immunization records were not present for either child.

Resolution: Corrected: 2026-01-13

Personnel records for an individual whose employment status recently became inactive were not available for review.

Resolution: Corrected: 2026-01-13

Background checks results were not observed in two staff files that were reviewed.

Resolution: Corrected: 2026-01-16

The operation was unable to produce a personnel record for an active employee.

Resolution: Corrected: 2026-01-13

The employee census provided included an individual who is no longer affiliated with the operation. Additionally, the hire dates listed on the census were inconsistent with the hire dates documented in the employee files that were reviewed.

Resolution: Corrected: 2026-01-13

The operation's Treatment Director reported coming to the facility once per week for eight hours and work the remaining hours remotely.

Resolution: Corrected: 2026-01-13

Pre-employment screenings were not documented in the employee files that were reviewed.

Resolution: Corrected: 2026-01-13

The operation failed to provide notification regarding the resignation of the designated administrator effective 12/17/25 and the subsequent hiring of a new designated administrator on 12/30/25.

Resolution: Corrected: 2026-01-13

A review of records showed that Preliminary Service Plans were not developed or signed by a Treatment Director or PLSP, as required.

Resolution: Corrected: 2026-01-13

It was observed that a background check remains active for an individual who is no longer employed at the operation.

Resolution: Corrected: 2026-01-13

A review of records showed that employees began employment before background check results were received.

Resolution: Corrected: 2026-01-13

It was observed that an admission assessment was not completed for a child in care admitted into care on 12/30/25.

Resolution: Corrected: 2026-01-13

A review of the children's files showed that immunization records were not present for either child.

Resolution: Corrected: 2026-01-13

It was observed that the permit holder/owner signed admissions assessments for a child in care.

Resolution: Corrected: 2026-01-16

Personnel records for an individual whose employment status recently became inactive were not available for review.

Resolution: Corrected: 2026-01-13

There was no running water observed at the facility.

Resolution: Corrected: 2026-01-13

It was observed that an employee hired on 12/08/25 completed the pre-employment affidavit on 12/09/25, after the date of hire.

Resolution: Corrected: 2026-01-13

It was observed that the Preliminary Service Plans for children in care were completed beyond the 72-hour requirement and lacked required information.

Resolution: Corrected: 2026-01-13

It was observed that an employee hired on 12/08/25 completed the pre-employment affidavit on 12/09/25, after the date of hire.

Resolution: Corrected: 2026-01-13

It was observed that the permit holder/owner signed admissions assessments for a child in care.

Resolution: Corrected: 2026-01-16

There was no running water observed at the facility.

Resolution: Corrected: 2026-01-13

A review of the children's files showed that immunization records were not present for either child.

Resolution: Corrected: 2026-01-13

It was observed that a background check remains active for an individual who is no longer employed at the operation.

Resolution: Corrected: 2026-01-13

It was observed that the Preliminary Service Plans for children in care were completed beyond the 72-hour requirement and lacked required information.

Resolution: Corrected: 2026-01-13

The operation failed to provide notification regarding the resignation of the designated administrator effective 12/17/25 and the subsequent hiring of a new designated administrator on 12/30/25.

Resolution: Corrected: 2026-01-13

It was observed that an admission assessment was not completed for a child in care admitted into care on 12/30/25.

Resolution: Corrected: 2026-01-13

The employee census provided included an individual who is no longer affiliated with the operation. Additionally, the hire dates listed on the census were inconsistent with the hire dates documented in the employee files that were reviewed.

Resolution: Corrected: 2026-01-13

Personnel records for an individual whose employment status recently became inactive were not available for review.

Resolution: Corrected: 2026-01-13

The operation's Treatment Director reported coming to the facility once per week for eight hours and work the remaining hours remotely.

Resolution: Corrected: 2026-01-13

Pre-employment screenings were not documented in the employee files that were reviewed.

Resolution: Corrected: 2026-01-13

The operation was unable to produce a personnel record for an active employee.

Resolution: Corrected: 2026-01-13

A review of records showed that employees began employment before background check results were received.

Resolution: Corrected: 2026-01-13

A review of records showed that Preliminary Service Plans were not developed or signed by a Treatment Director or PLSP, as required.

Resolution: Corrected: 2026-01-13

Background checks results were not observed in two staff files that were reviewed.

Resolution: Corrected: 2026-01-16

The operation failed to provide notification regarding the resignation of the designated administrator effective 12/17/25 and the subsequent hiring of a new designated administrator on 12/30/25.

Resolution: Corrected: 2026-01-13

The operation's Treatment Director reported coming to the facility once per week for eight hours and work the remaining hours remotely.

Resolution: Corrected: 2026-01-13

It was observed that an admission assessment was not completed for a child in care admitted into care on 12/30/25.

Resolution: Corrected: 2026-01-13

A review of records showed that Preliminary Service Plans were not developed or signed by a Treatment Director or PLSP, as required.

Resolution: Corrected: 2026-01-13

It was observed that an employee hired on 12/08/25 completed the pre-employment affidavit on 12/09/25, after the date of hire.

Resolution: Corrected: 2026-01-13

A review of records showed that employees began employment before background check results were received.

Resolution: Corrected: 2026-01-13

It was observed that the Preliminary Service Plans for children in care were completed beyond the 72-hour requirement and lacked required information.

Resolution: Corrected: 2026-01-13

A review of the children's files showed that immunization records were not present for either child.

Resolution: Corrected: 2026-01-13

The operation was unable to produce a personnel record for an active employee.

Resolution: Corrected: 2026-01-13

Background checks results were not observed in two staff files that were reviewed.

Resolution: Corrected: 2026-01-16

It was observed that the permit holder/owner signed admissions assessments for a child in care.

Resolution: Corrected: 2026-01-16

There was no running water observed at the facility.

Resolution: Corrected: 2026-01-13

Pre-employment screenings were not documented in the employee files that were reviewed.

Resolution: Corrected: 2026-01-13

It was observed that a background check remains active for an individual who is no longer employed at the operation.

Resolution: Corrected: 2026-01-13