Her Heart Can

The staff that was lacking documentation in the file showing the caregiver had the necessary skills is still lacking .

Resolution: Corrected: 2025-10-06

A drive was allowed to transport at least one youth in care with an expired drivers license.

Resolution: Corrected at inspection

In the last seven weeks, the documentation reflects the treatment director not being full time.

Resolution: Corrected: 2025-10-06

The staff file reviewed during the last inspection still does not have the documentation of the pre-employment affidavit on file. An additional staff file reviewed during today's inspection also did not have documentation of the pre-employment affidavit.

Resolution: Corrected at inspection

During the walk through of the operation, an infants crib did not have a tight fitting sheet. A bottle was also observed in the crib.

Resolution: Corrected: 2025-09-30

During the review of files at the inspection, the files were not complete. This was demonstrated the management staffing finding documents, printing, and placing the documents in the files.

Resolution: Corrected: 2025-10-06

During the walk through of the operation, an infants crib did not have a tight fitting sheet. A bottle was also observed in the crib.

Resolution: Corrected: 2025-09-30

During the review of files at the inspection, the files were not complete. This was demonstrated the management staffing finding documents, printing, and placing the documents in the files.

Resolution: Corrected: 2025-10-06

In the last seven weeks, the documentation reflects the treatment director not being full time.

Resolution: Corrected: 2025-10-06

The staff that was lacking documentation in the file showing the caregiver had the necessary skills is still lacking .

Resolution: Corrected: 2025-10-06

During the review of files at the inspection, the files were not complete. This was demonstrated the management staffing finding documents, printing, and placing the documents in the files.

Resolution: Corrected: 2025-10-06

The staff that was lacking documentation in the file showing the caregiver had the necessary skills is still lacking .

Resolution: Corrected: 2025-10-06

During the walk through of the operation, an infants crib did not have a tight fitting sheet. A bottle was also observed in the crib.

Resolution: Corrected: 2025-09-30

In the last seven weeks, the documentation reflects the treatment director not being full time.

Resolution: Corrected: 2025-10-06

A drive was allowed to transport at least one youth in care with an expired drivers license.

Resolution: Corrected at inspection

During the review of files at the inspection, the files were not complete. This was demonstrated the management staffing finding documents, printing, and placing the documents in the files.

Resolution: Corrected: 2025-10-06

A drive was allowed to transport at least one youth in care with an expired drivers license.

Resolution: Corrected at inspection

The staff file reviewed during the last inspection still does not have the documentation of the pre-employment affidavit on file. An additional staff file reviewed during today's inspection also did not have documentation of the pre-employment affidavit.

Resolution: Corrected at inspection

The staff that was lacking documentation in the file showing the caregiver had the necessary skills is still lacking .

Resolution: Corrected: 2025-10-06

The staff file reviewed during the last inspection still does not have the documentation of the pre-employment affidavit on file. An additional staff file reviewed during today's inspection also did not have documentation of the pre-employment affidavit.

Resolution: Corrected at inspection

In the last seven weeks, the documentation reflects the treatment director not being full time.

Resolution: Corrected: 2025-10-06

During the walk through of the operation, an infants crib did not have a tight fitting sheet. A bottle was also observed in the crib.

Resolution: Corrected: 2025-09-30

The staff file reviewed during the last inspection still does not have the documentation of the pre-employment affidavit on file. An additional staff file reviewed during today's inspection also did not have documentation of the pre-employment affidavit.

Resolution: Corrected at inspection

A drive was allowed to transport at least one youth in care with an expired drivers license.

Resolution: Corrected at inspection

During the time of the incident, there were 1 staff and six children. The operation also had a baby in the home at the time as well. The operation has a treatment director and has children in care that requires treatment services.

Resolution: Corrected at inspection

During the incident, staff did not intervene appropriately which led to children being injured at the facility.

Resolution: Corrected: 2025-09-23

During the time of the incident, there were 1 staff and six children. The operation also had a baby in the home at the time as well. The operation has a treatment director and has children in care that requires treatment services.

Resolution: Corrected at inspection

During the incident, staff did not intervene appropriately which led to children being injured at the facility.

Resolution: Corrected: 2025-09-23

During the incident, staff did not intervene appropriately which led to children being injured at the facility.

Resolution: Corrected: 2025-09-23

During the time of the incident, there were 1 staff and six children. The operation also had a baby in the home at the time as well. The operation has a treatment director and has children in care that requires treatment services.

Resolution: Corrected at inspection

During the incident, staff did not intervene appropriately which led to children being injured at the facility.

Resolution: Corrected: 2025-09-23

During the time of the incident, there were 1 staff and six children. The operation also had a baby in the home at the time as well. The operation has a treatment director and has children in care that requires treatment services.

Resolution: Corrected at inspection

One of two caregiver's file reviewed did not have documentation showing the pre-emoloymeent screening assessment.

Resolution: Corrected: 2025-08-18

One of two caregiver's file did not the results of the drug testing.

Resolution: Corrected: 2025-08-18

There has not been a full-time administrator at the operation two of four weeks based on timecards reviewed.

Resolution: Corrected: 2025-09-22

One of two caregiver files reviewed did not have documentation showing the caregiver had the necessary skills.

Resolution: Corrected: 2025-08-18

One of two caregiver files reviewed did not have an affidavit on file.

Resolution: Corrected: 2025-08-18

The administrators' timecards reviewed did not include accurate information reflected.

Resolution: Corrected: 2025-09-22

One of two caregiver files reviewed did not have documentation of the pre-employment affidavit on file.

Resolution: Corrected: 2025-08-18

One of two caregiver files reviewed did not have an affidavit on file.

Resolution: Corrected: 2025-08-18

One of two caregiver's file reviewed did not have documentation showing the pre-emoloymeent screening assessment.

Resolution: Corrected: 2025-08-18

There has not been a full-time administrator at the operation two of four weeks based on timecards reviewed.

Resolution: Corrected: 2025-09-22

One of two caregiver files reviewed did not have documentation of the pre-employment affidavit on file.

Resolution: Corrected: 2025-08-18

One of two caregiver files reviewed did not have documentation of the pre-employment affidavit on file.

Resolution: Corrected: 2025-08-18

One of two caregiver files reviewed did not have documentation showing the caregiver had the necessary skills.

Resolution: Corrected: 2025-08-18

The administrators' timecards reviewed did not include accurate information reflected.

Resolution: Corrected: 2025-09-22

One of two caregiver's file did not the results of the drug testing.

Resolution: Corrected: 2025-08-18

One of two caregiver's file reviewed did not have documentation showing the pre-emoloymeent screening assessment.

Resolution: Corrected: 2025-08-18

One of two caregiver files reviewed did not have an affidavit on file.

Resolution: Corrected: 2025-08-18

There has not been a full-time administrator at the operation two of four weeks based on timecards reviewed.

Resolution: Corrected: 2025-09-22

One of two caregiver's file reviewed did not have documentation showing the pre-emoloymeent screening assessment.

Resolution: Corrected: 2025-08-18

One of two caregiver files reviewed did not have an affidavit on file.

Resolution: Corrected: 2025-08-18

One of two caregiver's file did not the results of the drug testing.

Resolution: Corrected: 2025-08-18

The administrators' timecards reviewed did not include accurate information reflected.

Resolution: Corrected: 2025-09-22

One of two caregiver files reviewed did not have documentation showing the caregiver had the necessary skills.

Resolution: Corrected: 2025-08-18

There has not been a full-time administrator at the operation two of four weeks based on timecards reviewed.

Resolution: Corrected: 2025-09-22

One of two caregiver files reviewed did not have documentation of the pre-employment affidavit on file.

Resolution: Corrected: 2025-08-18

One of two caregiver files reviewed did not have documentation showing the caregiver had the necessary skills.

Resolution: Corrected: 2025-08-18

One of two caregiver's file did not the results of the drug testing.

Resolution: Corrected: 2025-08-18

The administrators' timecards reviewed did not include accurate information reflected.

Resolution: Corrected: 2025-09-22

The operation failed to notify RCCR of the unauthorized absence of two youth in care.

Resolution: Corrected: 2025-07-14

There has not been a full time administrator at the operation for the last two of four weeks.

Resolution: Corrected: 2025-07-21

The operation failed to notify RCCR of the unauthorized absence of two youth in care.

Resolution: Corrected: 2025-07-14

The operation failed to notify RCCR of the unauthorized absence of two youth in care.

Resolution: Corrected: 2025-07-14

There has not been a full time administrator at the operation for the last two of four weeks.

Resolution: Corrected: 2025-07-21

The operation failed to notify RCCR of the unauthorized absence of two youth in care.

Resolution: Corrected: 2025-07-14

There has not been a full time administrator at the operation for the last two of four weeks.

Resolution: Corrected: 2025-07-21

There has not been a full time administrator at the operation for the last two of four weeks.

Resolution: Corrected: 2025-07-21

The operation was not able to provide verifiable proof that the administrator is working full time at the operation.

Resolution: Corrected: 2025-06-26

The operation was not able to provide verifiable proof that the administrator is working full time at the operation.

Resolution: Corrected: 2025-06-26

The operation was not able to provide verifiable proof that the administrator is working full time at the operation.

Resolution: Corrected: 2025-06-26

The operation was not able to provide verifiable proof that the administrator is working full time at the operation.

Resolution: Corrected: 2025-06-26

The PLSP file reviewed did not have documentation showing they meet the qualifications requirements.

Resolution: Corrected: 2025-05-19

In the two staff file reviewed both had only one of the previous employers contacted to verify employment.

Resolution: Corrected: 2025-04-21

One of the staff file reviewed during the inspection did not include the required two references.

Resolution: Corrected: 2025-04-21

The named treatment director does not have documentation on file showing they meet the specific educational/professional qualifications.

Resolution: Corrected: 2025-05-19

Based on the weekly schedule and timecards, the LCCA is not a full-time employee of the operation.

Resolution: Corrected: 2025-05-19

Based on the weekly schedule and timecards, the LCCA is not a full-time employee of the operation.

Resolution: Corrected: 2025-05-19

One of the staff file reviewed during the inspection did not include the required two references.

Resolution: Corrected: 2025-04-21

In the two staff file reviewed both had only one of the previous employers contacted to verify employment.

Resolution: Corrected: 2025-04-21

The named treatment director does not have documentation on file showing they meet the specific educational/professional qualifications.

Resolution: Corrected: 2025-05-19

One of the staff file reviewed during the inspection did not include the required two references.

Resolution: Corrected: 2025-04-21

In the two staff file reviewed both had only one of the previous employers contacted to verify employment.

Resolution: Corrected: 2025-04-21

Based on the weekly schedule and timecards, the LCCA is not a full-time employee of the operation.

Resolution: Corrected: 2025-05-19

The named treatment director does not have documentation on file showing they meet the specific educational/professional qualifications.

Resolution: Corrected: 2025-05-19

The PLSP file reviewed did not have documentation showing they meet the qualifications requirements.

Resolution: Corrected: 2025-05-19

One of the staff file reviewed during the inspection did not include the required two references.

Resolution: Corrected: 2025-04-21

In the two staff file reviewed both had only one of the previous employers contacted to verify employment.

Resolution: Corrected: 2025-04-21

Based on the weekly schedule and timecards, the LCCA is not a full-time employee of the operation.

Resolution: Corrected: 2025-05-19

The named treatment director does not have documentation on file showing they meet the specific educational/professional qualifications.

Resolution: Corrected: 2025-05-19

The PLSP file reviewed did not have documentation showing they meet the qualifications requirements.

Resolution: Corrected: 2025-05-19

The PLSP file reviewed did not have documentation showing they meet the qualifications requirements.

Resolution: Corrected: 2025-05-19

During Walkthrough of the operation, it was discovered that the menu was not completely filled out and substitutions were not offered (Standard 1703 b).

Resolution: Corrected at inspection

During Walkthrough of the operation, it was discovered that the menu was not completely filled out and substitutions were not offered (Standard 1703 b).

Resolution: Corrected at inspection

During Walkthrough of the operation, it was discovered that the menu was not completely filled out and substitutions were not offered (Standard 1703 b).

Resolution: Corrected at inspection

During Walkthrough of the operation, it was discovered that the menu was not completely filled out and substitutions were not offered (Standard 1703 b).

Resolution: Corrected at inspection

A child in care was arrested from school. This was not reported.

Resolution: Corrected: 2025-05-16

There are 3 runaway reports on the unauthorized absence log that indicate children were away from the operation more than 6 hours. The reports were not received timely and or documentation of the unauthorize absence log is incomplete.

Resolution: Corrected: 2025-05-16

There are 3 runaway reports on the unauthorized absence log that indicate children were away from the operation more than 6 hours. The reports were not received timely and or documentation of the unauthorize absence log is incomplete.

Resolution: Corrected: 2025-05-16

There are 3 runaway reports on the unauthorized absence log that indicate children were away from the operation more than 6 hours. The reports were not received timely and or documentation of the unauthorize absence log is incomplete.

Resolution: Corrected: 2025-05-16

A child in care was arrested from school. This was not reported.

Resolution: Corrected: 2025-05-16

A child in care was arrested from school. This was not reported.

Resolution: Corrected: 2025-05-16

There are 3 runaway reports on the unauthorized absence log that indicate children were away from the operation more than 6 hours. The reports were not received timely and or documentation of the unauthorize absence log is incomplete.

Resolution: Corrected: 2025-05-16

A child in care was arrested from school. This was not reported.

Resolution: Corrected: 2025-05-16

In one of two staff records reviewed, dates are missing from training documentation, unable to verify if pretraining was completed within 90 days of beginning job duties.

Resolution: Corrected: 2025-03-11

A caregiver is showing active in the operation people list, the caregiver has not been employed with the operation for twenty days.

Resolution: Corrected: 2025-03-07

One of two staff records reviewed, did not detail how the staff was qualified for their role at the operation.

Resolution: Corrected: 2025-03-11

The unauthorized absence log did not include the time the absence was discovered by the staff on two of two occasions, the hotline report number for one of two occasions nor information on the length of time the youth was missing or if the youth returned on two of two occasions.

Resolution: Corrected: 2025-03-11

During the outside walk through, sharp items and sharp glass was observed on the ground, near the barn.

Resolution: Corrected: 2025-03-11

During the outside walk through, sharp items and sharp glass was observed on the ground, near the barn.

Resolution: Corrected: 2025-03-11

In one of two staff records reviewed, dates are missing from training documentation, unable to verify if pretraining was completed within 90 days of beginning job duties.

Resolution: Corrected: 2025-03-11

A caregiver is showing active in the operation people list, the caregiver has not been employed with the operation for twenty days.

Resolution: Corrected: 2025-03-07

One of two staff records reviewed, did not detail how the staff was qualified for their role at the operation.

Resolution: Corrected: 2025-03-11

The unauthorized absence log did not include the time the absence was discovered by the staff on two of two occasions, the hotline report number for one of two occasions nor information on the length of time the youth was missing or if the youth returned on two of two occasions.

Resolution: Corrected: 2025-03-11

During the outside walk through, sharp items and sharp glass was observed on the ground, near the barn.

Resolution: Corrected: 2025-03-11

In one of two staff records reviewed, dates are missing from training documentation, unable to verify if pretraining was completed within 90 days of beginning job duties.

Resolution: Corrected: 2025-03-11

A caregiver is showing active in the operation people list, the caregiver has not been employed with the operation for twenty days.

Resolution: Corrected: 2025-03-07

One of two staff records reviewed, did not detail how the staff was qualified for their role at the operation.

Resolution: Corrected: 2025-03-11

The unauthorized absence log did not include the time the absence was discovered by the staff on two of two occasions, the hotline report number for one of two occasions nor information on the length of time the youth was missing or if the youth returned on two of two occasions.

Resolution: Corrected: 2025-03-11

A caregiver is showing active in the operation people list, the caregiver has not been employed with the operation for twenty days.

Resolution: Corrected: 2025-03-07

The unauthorized absence log did not include the time the absence was discovered by the staff on two of two occasions, the hotline report number for one of two occasions nor information on the length of time the youth was missing or if the youth returned on two of two occasions.

Resolution: Corrected: 2025-03-11

One of two staff records reviewed, did not detail how the staff was qualified for their role at the operation.

Resolution: Corrected: 2025-03-11

During the outside walk through, sharp items and sharp glass was observed on the ground, near the barn.

Resolution: Corrected: 2025-03-11

In one of two staff records reviewed, dates are missing from training documentation, unable to verify if pretraining was completed within 90 days of beginning job duties.

Resolution: Corrected: 2025-03-11

A serious incident report was not completed for a medical event that occured at the operation.

Resolution: Corrected at inspection

During today inspection, the well house was in need of maintenance.

Resolution: Corrected: 2025-02-17

The operation has allowed two individuals access to children in care without received the eligibility notification.

Resolution: Corrected at inspection

At the time of the inspection, the operation did not have insurance for the vehicle being used to transport the children in care.

Resolution: Corrected: 2025-02-17

The operation has admitted a child in care that does not meet the operation's admission policy.

Resolution: Corrected: 2025-02-18

The operation has admitted a child in care that does not meet the operation's admission policy.

Resolution: Corrected: 2025-02-18

A serious incident report was not completed for a medical event that occured at the operation.

Resolution: Corrected at inspection

During today inspection, the well house was in need of maintenance.

Resolution: Corrected: 2025-02-17

The operation has admitted a child in care that does not meet the operation's admission policy.

Resolution: Corrected: 2025-02-18

The operation has allowed two individuals access to children in care without received the eligibility notification.

Resolution: Corrected at inspection

At the time of the inspection, the operation did not have insurance for the vehicle being used to transport the children in care.

Resolution: Corrected: 2025-02-17

The operation has admitted a child in care that does not meet the operation's admission policy.

Resolution: Corrected: 2025-02-18

During today inspection, the well house was in need of maintenance.

Resolution: Corrected: 2025-02-17

A serious incident report was not completed for a medical event that occured at the operation.

Resolution: Corrected at inspection

The operation has allowed two individuals access to children in care without received the eligibility notification.

Resolution: Corrected at inspection

At the time of the inspection, the operation did not have insurance for the vehicle being used to transport the children in care.

Resolution: Corrected: 2025-02-17

A serious incident report was not completed for a medical event that occured at the operation.

Resolution: Corrected at inspection

At the time of the inspection, the operation did not have insurance for the vehicle being used to transport the children in care.

Resolution: Corrected: 2025-02-17

The operation has allowed two individuals access to children in care without received the eligibility notification.

Resolution: Corrected at inspection

During today inspection, the well house was in need of maintenance.

Resolution: Corrected: 2025-02-17

During today inspection, several items were in need of maintenance.

Resolution: Corrected: 2025-01-20

During today inspection, several items were in need of maintenance.

Resolution: Corrected: 2025-01-20

During today inspection, several items were in need of maintenance.

Resolution: Corrected: 2025-01-20

During today inspection, several items were in need of maintenance.

Resolution: Corrected: 2025-01-20

Several policies violated the requirements of 748.303 and 748.313. Further there were no policies for record storage in regards to SIRs.

Resolution: Corrected: 2024-10-22

One bathroom sink had a crack in the bowl that was leaking in the under cabinet.

Resolution: Corrected: 2024-10-22

The tobacco policy did not address smoking in the vehicle.

Resolution: Corrected: 2024-10-22

Operation is getting licensed for girls only, and biological girls that are currently pregnant, policies did not state this. The application indicates children ages 14-17 are admitted, however the policy states ages 7-17.

Resolution: Corrected: 2024-10-22

The policy did not address any of the standards regarding children under the age of 10.

Resolution: Corrected: 2024-10-22

The diagram did not include the designated location in the case of fire. The diagrams were fixed during the inspection.

Resolution: Corrected at inspection

The water quality test was not done for the private water supply.

Resolution: Corrected: 2024-10-22

There was no policy that included this information.

Resolution: Corrected: 2024-10-22

Conflict of interest policies did not meet the requirements of 748.107(1) and (2).

Resolution: Corrected: 2024-10-22

There was a smoke detector outside of one of the bedroom.

Resolution: Corrected: 2024-10-22

A trailer was observed in the back yard with nails sticking up that could become hazardous to youth in care.

Resolution: Corrected: 2024-10-21

The written EBI policies did not meet standard 748.2801(2)(A), 748.2901(a)(2) or (B), 748.113(a)(v), (viii), (ix) or (6).

Resolution: Corrected: 2024-10-22

Bedroom #4 did not have direct access to a bathroom without having to cross activity spaces.

Resolution: Corrected: 2024-10-21

The suicide postvention written plan did not include the required items in 748.125(g)(B)(i) (I-VI).

Resolution: Corrected: 2024-10-21

Several policies violated the requirements of 748.303 and 748.313. Further there were no policies for record storage in regards to SIRs.

Resolution: Corrected: 2024-10-22

The policy did not address any of the standards regarding children under the age of 10.

Resolution: Corrected: 2024-10-22

The tobacco policy did not address smoking in the vehicle.

Resolution: Corrected: 2024-10-22

The water quality test was not done for the private water supply.

Resolution: Corrected: 2024-10-22

The written EBI policies did not meet standard 748.2801(2)(A), 748.2901(a)(2) or (B), 748.113(a)(v), (viii), (ix) or (6).

Resolution: Corrected: 2024-10-22

There was a smoke detector outside of one of the bedroom.

Resolution: Corrected: 2024-10-22

A trailer was observed in the back yard with nails sticking up that could become hazardous to youth in care.

Resolution: Corrected: 2024-10-21

One bathroom sink had a crack in the bowl that was leaking in the under cabinet.

Resolution: Corrected: 2024-10-22

Conflict of interest policies did not meet the requirements of 748.107(1) and (2).

Resolution: Corrected: 2024-10-22

The diagram did not include the designated location in the case of fire. The diagrams were fixed during the inspection.

Resolution: Corrected at inspection

The tobacco policy did not address smoking in the vehicle.

Resolution: Corrected: 2024-10-22

Operation is getting licensed for girls only, and biological girls that are currently pregnant, policies did not state this. The application indicates children ages 14-17 are admitted, however the policy states ages 7-17.

Resolution: Corrected: 2024-10-22

Bedroom #4 did not have direct access to a bathroom without having to cross activity spaces.

Resolution: Corrected: 2024-10-21

One bathroom sink had a crack in the bowl that was leaking in the under cabinet.

Resolution: Corrected: 2024-10-22

A trailer was observed in the back yard with nails sticking up that could become hazardous to youth in care.

Resolution: Corrected: 2024-10-21

Several policies violated the requirements of 748.303 and 748.313. Further there were no policies for record storage in regards to SIRs.

Resolution: Corrected: 2024-10-22

The water quality test was not done for the private water supply.

Resolution: Corrected: 2024-10-22

The diagram did not include the designated location in the case of fire. The diagrams were fixed during the inspection.

Resolution: Corrected at inspection

There was a smoke detector outside of one of the bedroom.

Resolution: Corrected: 2024-10-22

Bedroom #4 did not have direct access to a bathroom without having to cross activity spaces.

Resolution: Corrected: 2024-10-21

There was no policy that included this information.

Resolution: Corrected: 2024-10-22

Conflict of interest policies did not meet the requirements of 748.107(1) and (2).

Resolution: Corrected: 2024-10-22

The written EBI policies did not meet standard 748.2801(2)(A), 748.2901(a)(2) or (B), 748.113(a)(v), (viii), (ix) or (6).

Resolution: Corrected: 2024-10-22

The suicide postvention written plan did not include the required items in 748.125(g)(B)(i) (I-VI).

Resolution: Corrected: 2024-10-21

The policy did not address any of the standards regarding children under the age of 10.

Resolution: Corrected: 2024-10-22

Operation is getting licensed for girls only, and biological girls that are currently pregnant, policies did not state this. The application indicates children ages 14-17 are admitted, however the policy states ages 7-17.

Resolution: Corrected: 2024-10-22

There was no policy that included this information.

Resolution: Corrected: 2024-10-22

Several policies violated the requirements of 748.303 and 748.313. Further there were no policies for record storage in regards to SIRs.

Resolution: Corrected: 2024-10-22

The suicide postvention written plan did not include the required items in 748.125(g)(B)(i) (I-VI).

Resolution: Corrected: 2024-10-21

The policy did not address any of the standards regarding children under the age of 10.

Resolution: Corrected: 2024-10-22

The tobacco policy did not address smoking in the vehicle.

Resolution: Corrected: 2024-10-22

The water quality test was not done for the private water supply.

Resolution: Corrected: 2024-10-22

The written EBI policies did not meet standard 748.2801(2)(A), 748.2901(a)(2) or (B), 748.113(a)(v), (viii), (ix) or (6).

Resolution: Corrected: 2024-10-22

There was a smoke detector outside of one of the bedroom.

Resolution: Corrected: 2024-10-22

A trailer was observed in the back yard with nails sticking up that could become hazardous to youth in care.

Resolution: Corrected: 2024-10-21

One bathroom sink had a crack in the bowl that was leaking in the under cabinet.

Resolution: Corrected: 2024-10-22

Conflict of interest policies did not meet the requirements of 748.107(1) and (2).

Resolution: Corrected: 2024-10-22

The diagram did not include the designated location in the case of fire. The diagrams were fixed during the inspection.

Resolution: Corrected at inspection

Bedroom #4 did not have direct access to a bathroom without having to cross activity spaces.

Resolution: Corrected: 2024-10-21

Operation is getting licensed for girls only, and biological girls that are currently pregnant, policies did not state this. The application indicates children ages 14-17 are admitted, however the policy states ages 7-17.

Resolution: Corrected: 2024-10-22

There was no policy that included this information.

Resolution: Corrected: 2024-10-22

The suicide postvention written plan did not include the required items in 748.125(g)(B)(i) (I-VI).

Resolution: Corrected: 2024-10-21