Tshepang Center Residential Treatment Center, LLC

Based on video observed, there was no documentation indicating the type of restraint administered nor the accurate length of time for the restraint.

Resolution: Corrected: 2025-12-22

Based on the video observed, staff was seen pushing child towards the wall and grabbing him by the neck.

Resolution: Corrected: 2025-12-22

Based on the video observed, there was no de-escalation methods used prior to restraint.

Resolution: Corrected: 2025-12-22

There was no post discussion documentation available for review.

Resolution: Corrected: 2025-12-22

Based on the video observed, there was no de-escalation methods used prior to restraint.

Resolution: Corrected: 2025-12-22

Based on the video observed, staff was seen pushing child towards the wall and grabbing him by the neck.

Resolution: Corrected: 2025-12-22

Based on video observed, there was no documentation indicating the type of restraint administered nor the accurate length of time for the restraint.

Resolution: Corrected: 2025-12-22

There was no post discussion documentation available for review.

Resolution: Corrected: 2025-12-22

Based on the video observed, there was no de-escalation methods used prior to restraint.

Resolution: Corrected: 2025-12-22

Based on the video observed, staff was seen pushing child towards the wall and grabbing him by the neck.

Resolution: Corrected: 2025-12-22

There was no post discussion documentation available for review.

Resolution: Corrected: 2025-12-22

Based on video observed, there was no documentation indicating the type of restraint administered nor the accurate length of time for the restraint.

Resolution: Corrected: 2025-12-22

Two children confirmed that they experienced mistreatment by staff during their time in care.

Resolution: Corrected: 2025-12-23

Two children confirmed that they experienced mistreatment by staff during their time in care.

Resolution: Corrected: 2025-12-23

Two children confirmed that they experienced mistreatment by staff during their time in care.

Resolution: Corrected: 2025-12-23

Two children confirmed that they experienced mistreatment by staff during their time in care.

Resolution: Corrected: 2025-12-23

Children in care confirmed three staff have been observed sleep during overnight awake staff duties.

Resolution: Corrected: 2025-03-14

Children in care confirmed three staff have been observed sleep during overnight awake staff duties.

Resolution: Corrected: 2025-03-14

Children in care confirmed three staff have been observed sleep during overnight awake staff duties.

Resolution: Corrected: 2025-03-14

Children in care confirmed three staff have been observed sleep during overnight awake staff duties.

Resolution: Corrected: 2025-03-14

The case was reported to statewide Intake but the staff did not place the Report number therein. Thus Law Enforcement called in the case and the Op made a subsequent Report anew, this time with a report number.

Resolution: Corrected: 2025-03-05

The case was reported to statewide Intake but the staff did not place the Report number therein. Thus Law Enforcement called in the case and the Op made a subsequent Report anew, this time with a report number.

Resolution: Corrected: 2025-03-05

The case was reported to statewide Intake but the staff did not place the Report number therein. Thus Law Enforcement called in the case and the Op made a subsequent Report anew, this time with a report number.

Resolution: Corrected: 2025-03-05

The case was reported to statewide Intake but the staff did not place the Report number therein. Thus Law Enforcement called in the case and the Op made a subsequent Report anew, this time with a report number.

Resolution: Corrected: 2025-03-05

A caregiver interfered with a child's call to the Ombudsman's office by not interrupting the call and preventing privacy.

Resolution: Corrected: 2025-01-03

A caregiver interfered with a child's call to the Ombudsman's office by not interrupting the call and preventing privacy.

Resolution: Corrected: 2025-01-03

A caregiver interfered with a child's call to the Ombudsman's office by not interrupting the call and preventing privacy.

Resolution: Corrected: 2025-01-03

A caregiver interfered with a child's call to the Ombudsman's office by not interrupting the call and preventing privacy.

Resolution: Corrected: 2025-01-03

During the inspection it was found that the child's parent was not given two weeks advance notice of a service plan meeting.

Resolution: Corrected: 2024-10-29

During the inspection it was found that a child's service plan did not have signatures of service planning team members.

Resolution: Corrected: 2024-10-29

During the inspection it was found that a child's service plan did not have signatures of service planning team members.

Resolution: Corrected: 2024-10-29

During the inspection it was found that a child's service plan did not have signatures of service planning team members.

Resolution: Corrected: 2024-10-29

During the inspection it was found that the child's parent was not given two weeks advance notice of a service plan meeting.

Resolution: Corrected: 2024-10-29

During the inspection it was found that a child's service plan did not have signatures of service planning team members.

Resolution: Corrected: 2024-10-29

During the inspection it was found that the child's parent was not given two weeks advance notice of a service plan meeting.

Resolution: Corrected: 2024-10-29

During the inspection it was found that the child's parent was not given two weeks advance notice of a service plan meeting.

Resolution: Corrected: 2024-10-29

Staff member stated to have placed child in a head lock and according to officer that arrested child, child had visible marks on neck at the time of their arrest.

Resolution: Corrected: 2024-10-23

Staff member stated to have placed child in a head lock and according to officer that arrested child, child had visible marks on neck at the time of their arrest.

Resolution: Corrected: 2024-10-23

Staff member stated to have placed child in a head lock and according to officer that arrested child, child had visible marks on neck at the time of their arrest.

Resolution: Corrected: 2024-10-23

Staff member stated to have placed child in a head lock and according to officer that arrested child, child had visible marks on neck at the time of their arrest.

Resolution: Corrected: 2024-10-23

At one point in time the operation did not have personal storage space for children in care. During the inspection on 7/11/24 the operation was observed to have 3 drawer plastic bins in each room.

Resolution: Corrected at inspection

At one point in time the operation did not have personal storage space for children in care. During the inspection on 7/11/24 the operation was observed to have 3 drawer plastic bins in each room.

Resolution: Corrected at inspection

At one point in time the operation did not have personal storage space for children in care. During the inspection on 7/11/24 the operation was observed to have 3 drawer plastic bins in each room.

Resolution: Corrected at inspection

At one point in time the operation did not have personal storage space for children in care. During the inspection on 7/11/24 the operation was observed to have 3 drawer plastic bins in each room.

Resolution: Corrected at inspection

Children in care were able to smoke on the operations property while being left unsupervised.

Resolution: Corrected: 2024-07-26

Children in care were able to smoke on the operations property while being left unsupervised.

Resolution: Corrected: 2024-07-26

Children in care were able to smoke on the operations property while being left unsupervised.

Resolution: Corrected: 2024-07-26

Children in care were able to smoke on the operations property while being left unsupervised.

Resolution: Corrected: 2024-07-26

During the inspection it was noted that the fire inspection had expired. The operation has had a new inspection however they do not have the results.

Resolution: Corrected: 2023-12-22

During the inspection it was noted that the fire inspection had expired. The operation has had a new inspection however they do not have the results.

Resolution: Corrected: 2023-12-22

During the inspection it was noted that the fire inspection had expired. The operation has had a new inspection however they do not have the results.

Resolution: Corrected: 2023-12-22

During the inspection it was noted that the fire inspection had expired. The operation has had a new inspection however they do not have the results.

Resolution: Corrected: 2023-12-22

During a review of the policies that the operation submitted there was not and fiscal plan or documentation to reserve funds or available credit for to at least equal cost for three months. Furthermore, there was no estimated 12-month budget of income or expense.

Resolution: Corrected: 2023-10-13

During the inspection of the first aid kit there were a few items missing. There was not a thermometer, tweezers, or waterproof gloves.

Resolution: Corrected: 2023-10-13

During a review of the policies, it was determined that the policy manual identifies the CEO as a controlling person but does identify all board as a controlling person...

Resolution: Corrected: 2023-10-13

During a review of the child's service plan, it was found that the plan did not include the following: cultural identity needs and plans, instructions to the caregiver about the child's trauma history or triggers, nor does it include methods of responding that increase trust, help them feel safe, and adapt to their environment. The service plan also does not include a mock safety plan or caregiver inclusion. Finally, the plan does not have all treatment services provided.

Resolution: Corrected: 2023-10-13

Out of three personnel files reviewed all three files did not have a documentation of a driver's records check that is required. This was corrected at inspection as all driver's records were ran.

Resolution: Corrected at inspection

During a review of the service plan it does not identfy the normalcy decision maker in the team.

Resolution: Corrected: 2023-10-13

During a review of the policies, it was determined that the policy manual identifies the CEO as a controlling person but does identify all board as a controlling person...

Resolution: Corrected: 2023-10-13

During a review of the policies that the operation submitted there was not and fiscal plan or documentation to reserve funds or available credit for to at least equal cost for three months. Furthermore, there was no estimated 12-month budget of income or expense.

Resolution: Corrected: 2023-10-13

During a review of the service plan it does not identfy the normalcy decision maker in the team.

Resolution: Corrected: 2023-10-13

During a review of the child's service plan, it was found that the plan did not include the following: cultural identity needs and plans, instructions to the caregiver about the child's trauma history or triggers, nor does it include methods of responding that increase trust, help them feel safe, and adapt to their environment. The service plan also does not include a mock safety plan or caregiver inclusion. Finally, the plan does not have all treatment services provided.

Resolution: Corrected: 2023-10-13

During a review of the service plan it does not identfy the normalcy decision maker in the team.

Resolution: Corrected: 2023-10-13

During a review of the child's service plan, it was found that the plan did not include the following: cultural identity needs and plans, instructions to the caregiver about the child's trauma history or triggers, nor does it include methods of responding that increase trust, help them feel safe, and adapt to their environment. The service plan also does not include a mock safety plan or caregiver inclusion. Finally, the plan does not have all treatment services provided.

Resolution: Corrected: 2023-10-13

Out of three personnel files reviewed all three files did not have a documentation of a driver's records check that is required. This was corrected at inspection as all driver's records were ran.

Resolution: Corrected at inspection

During a review of the policies, it was determined that the policy manual identifies the CEO as a controlling person but does identify all board as a controlling person...

Resolution: Corrected: 2023-10-13

During the inspection of the first aid kit there were a few items missing. There was not a thermometer, tweezers, or waterproof gloves.

Resolution: Corrected: 2023-10-13

During a review of the policies that the operation submitted there was not and fiscal plan or documentation to reserve funds or available credit for to at least equal cost for three months. Furthermore, there was no estimated 12-month budget of income or expense.

Resolution: Corrected: 2023-10-13

During the inspection of the first aid kit there were a few items missing. There was not a thermometer, tweezers, or waterproof gloves.

Resolution: Corrected: 2023-10-13

Out of three personnel files reviewed all three files did not have a documentation of a driver's records check that is required. This was corrected at inspection as all driver's records were ran.

Resolution: Corrected at inspection

During a review of the policies, it was determined that the policy manual identifies the CEO as a controlling person but does identify all board as a controlling person...

Resolution: Corrected: 2023-10-13

During a review of the policies that the operation submitted there was not and fiscal plan or documentation to reserve funds or available credit for to at least equal cost for three months. Furthermore, there was no estimated 12-month budget of income or expense.

Resolution: Corrected: 2023-10-13

During a review of the service plan it does not identfy the normalcy decision maker in the team.

Resolution: Corrected: 2023-10-13

During a review of the child's service plan, it was found that the plan did not include the following: cultural identity needs and plans, instructions to the caregiver about the child's trauma history or triggers, nor does it include methods of responding that increase trust, help them feel safe, and adapt to their environment. The service plan also does not include a mock safety plan or caregiver inclusion. Finally, the plan does not have all treatment services provided.

Resolution: Corrected: 2023-10-13

During the inspection of the first aid kit there were a few items missing. There was not a thermometer, tweezers, or waterproof gloves.

Resolution: Corrected: 2023-10-13

Out of three personnel files reviewed all three files did not have a documentation of a driver's records check that is required. This was corrected at inspection as all driver's records were ran.

Resolution: Corrected at inspection