Brownstone Residential Care

One out of three youth files reviewed did not contain a debriefing following a youth's return from unauthorized absences.

Resolution: Corrected: 2024-10-02

One of three employee files reviewed did not contain verification the employee had a refresher EBI training in about 9 months.

Resolution: Corrected: 2024-10-02

During the walkthrough at the operation, it was observed the medication lock box was not double locked and access was available to youth in care.

Resolution: Corrected at inspection

One out of three youth files reviewed did not contain a debriefing following a youth's return from unauthorized absences.

Resolution: Corrected: 2024-10-02

One of three employee files reviewed did not contain verification the employee had a refresher EBI training in about 9 months.

Resolution: Corrected: 2024-10-02

One of three employee files reviewed did not contain verification the employee had a refresher EBI training in about 9 months.

Resolution: Corrected: 2024-10-02

During the walkthrough at the operation, it was observed the medication lock box was not double locked and access was available to youth in care.

Resolution: Corrected at inspection

One out of three youth files reviewed did not contain a debriefing following a youth's return from unauthorized absences.

Resolution: Corrected: 2024-10-02

One out of three youth files reviewed did not contain a debriefing following a youth's return from unauthorized absences.

Resolution: Corrected: 2024-10-02

During the walkthrough at the operation, it was observed the medication lock box was not double locked and access was available to youth in care.

Resolution: Corrected at inspection

One of three employee files reviewed did not contain verification the employee had a refresher EBI training in about 9 months.

Resolution: Corrected: 2024-10-02

During the walkthrough at the operation, it was observed the medication lock box was not double locked and access was available to youth in care.

Resolution: Corrected at inspection

During the course of the investigation, it was discerned staff transported a child in a vehicle with a handgun present as well as another staff reportedly storing a handgun in their vehicle on site.

Resolution: Corrected at inspection

During the inspection, it was discovered staff and children expressed concern that an employee transported children and served as a caregiver while under the influence of alcohol and administration failed to respond in a timely and appropriate manner. The facility is no longer in operation, mitigating risk in this standard.

Resolution: Corrected at inspection

A caregiver was photographed smoking while transporting youth in care in a vehicle.

Resolution: Corrected: 2024-09-20

During the inspection, it was determined a staff member had inappropriate sexual relations with children in care; staff was neglectful in supervision resulting in a child gaining access to, and being arrested for the possession of, staff's firearm; and staff being neglectful in supervision by leaving children in care alone and unsupervised at the facility while providing a child keys which access medications, supplies, and other prohibited areas. The facility is no longer in operation, mitigating risk in this standard.

Resolution: Corrected at inspection

During the investigation, it was discerned the owner of the operation questioned children following investigation issues, promised them bribes to present well, instructed staff to alter or omit documentation to prevent or reduce investigations, and failed to respond appropriately to allegations by staff and children. The facility is no longer in operation, mitigating risk in this standard.

Resolution: Corrected at inspection

During the investigation, it was discovered a child with sexual aggression history was placed with a roommate who had sexual victimization history, violating the aggressor child's service plan. The facility is no longer in operation, mitigating risk in this standard.

Resolution: Corrected at inspection

During the investigation, it was discerned the owner of the operation questioned children following investigation issues, promised them bribes to present well, instructed staff to alter or omit documentation to prevent or reduce investigations, and failed to respond appropriately to allegations by staff and children. The facility is no longer in operation, mitigating risk in this standard.

Resolution: Corrected at inspection

During the inspection, it was discovered staff and children expressed concern that an employee transported children and served as a caregiver while under the influence of alcohol and administration failed to respond in a timely and appropriate manner. The facility is no longer in operation, mitigating risk in this standard.

Resolution: Corrected at inspection

During the investigation, it was discovered a child with sexual aggression history was placed with a roommate who had sexual victimization history, violating the aggressor child's service plan. The facility is no longer in operation, mitigating risk in this standard.

Resolution: Corrected at inspection

During the inspection, it was determined a staff member had inappropriate sexual relations with children in care; staff was neglectful in supervision resulting in a child gaining access to, and being arrested for the possession of, staff's firearm; and staff being neglectful in supervision by leaving children in care alone and unsupervised at the facility while providing a child keys which access medications, supplies, and other prohibited areas. The facility is no longer in operation, mitigating risk in this standard.

Resolution: Corrected at inspection

During the investigation, it was discerned the owner of the operation questioned children following investigation issues, promised them bribes to present well, instructed staff to alter or omit documentation to prevent or reduce investigations, and failed to respond appropriately to allegations by staff and children. The facility is no longer in operation, mitigating risk in this standard.

Resolution: Corrected at inspection

During the inspection, it was determined a staff member had inappropriate sexual relations with children in care; staff was neglectful in supervision resulting in a child gaining access to, and being arrested for the possession of, staff's firearm; and staff being neglectful in supervision by leaving children in care alone and unsupervised at the facility while providing a child keys which access medications, supplies, and other prohibited areas. The facility is no longer in operation, mitigating risk in this standard.

Resolution: Corrected at inspection

During the investigation, it was discovered a child with sexual aggression history was placed with a roommate who had sexual victimization history, violating the aggressor child's service plan. The facility is no longer in operation, mitigating risk in this standard.

Resolution: Corrected at inspection

During the inspection, it was discovered staff and children expressed concern that an employee transported children and served as a caregiver while under the influence of alcohol and administration failed to respond in a timely and appropriate manner. The facility is no longer in operation, mitigating risk in this standard.

Resolution: Corrected at inspection

During the course of the investigation, it was discerned staff transported a child in a vehicle with a handgun present as well as another staff reportedly storing a handgun in their vehicle on site.

Resolution: Corrected at inspection

A caregiver was photographed smoking while transporting youth in care in a vehicle.

Resolution: Corrected: 2024-09-20

During the investigation, it was discerned the owner of the operation questioned children following investigation issues, promised them bribes to present well, instructed staff to alter or omit documentation to prevent or reduce investigations, and failed to respond appropriately to allegations by staff and children. The facility is no longer in operation, mitigating risk in this standard.

Resolution: Corrected at inspection

During the inspection, it was discovered staff and children expressed concern that an employee transported children and served as a caregiver while under the influence of alcohol and administration failed to respond in a timely and appropriate manner. The facility is no longer in operation, mitigating risk in this standard.

Resolution: Corrected at inspection

A caregiver was photographed smoking while transporting youth in care in a vehicle.

Resolution: Corrected: 2024-09-20

A caregiver was photographed smoking while transporting youth in care in a vehicle.

Resolution: Corrected: 2024-09-20

During the course of the investigation, it was discerned staff transported a child in a vehicle with a handgun present as well as another staff reportedly storing a handgun in their vehicle on site.

Resolution: Corrected at inspection

During the course of the investigation, it was discerned staff transported a child in a vehicle with a handgun present as well as another staff reportedly storing a handgun in their vehicle on site.

Resolution: Corrected at inspection

During the inspection, it was determined a staff member had inappropriate sexual relations with children in care; staff was neglectful in supervision resulting in a child gaining access to, and being arrested for the possession of, staff's firearm; and staff being neglectful in supervision by leaving children in care alone and unsupervised at the facility while providing a child keys which access medications, supplies, and other prohibited areas. The facility is no longer in operation, mitigating risk in this standard.

Resolution: Corrected at inspection

During the investigation, it was discovered a child with sexual aggression history was placed with a roommate who had sexual victimization history, violating the aggressor child's service plan. The facility is no longer in operation, mitigating risk in this standard.

Resolution: Corrected at inspection

The operation was not in ratio during awake hours.

Resolution: Corrected: 2024-10-04

The operation was not in ratio during awake hours.

Resolution: Corrected: 2024-10-04

The operation was not in ratio during awake hours.

Resolution: Corrected: 2024-10-04

The operation was not in ratio during awake hours.

Resolution: Corrected: 2024-10-04

One out of two employee files reviewed did not contain documentation to show employment history was verified.

Resolution: Corrected: 2024-07-29

One out of two employee files reviewed did not contain documentation to show employment history was verified.

Resolution: Corrected: 2024-07-29

One out of two employee files reviewed did not contain documentation to show employment history was verified.

Resolution: Corrected: 2024-07-29

One out of two employee files reviewed did not contain documentation to show employment history was verified.

Resolution: Corrected: 2024-07-29

The administration/owner did not use prudent judgment when requiring the child to get back to the operation and not offering to get the child a ride back to the operation when the child made him aware that he could not get a ride.

Resolution: Corrected: 2024-07-03

The administration/owner did not use prudent judgment when requiring the child to get back to the operation and not offering to get the child a ride back to the operation when the child made him aware that he could not get a ride.

Resolution: Corrected: 2024-07-03

The administration/owner did not use prudent judgment when requiring the child to get back to the operation and not offering to get the child a ride back to the operation when the child made him aware that he could not get a ride.

Resolution: Corrected: 2024-07-03

The administration/owner did not use prudent judgment when requiring the child to get back to the operation and not offering to get the child a ride back to the operation when the child made him aware that he could not get a ride.

Resolution: Corrected: 2024-07-03

Children in care were assisting staff and intervening with another child in care having a manic episode.

Resolution: Corrected: 2024-06-07

Children in care were assisting staff and intervening with another child in care having a manic episode.

Resolution: Corrected: 2024-06-07

Children in care were assisting staff and intervening with another child in care having a manic episode.

Resolution: Corrected: 2024-06-07

Children in care were assisting staff and intervening with another child in care having a manic episode.

Resolution: Corrected: 2024-06-07

Four out of four first aid kits observed during the inspection was missing adhesive tape, thermometers, tweezers, and disposable gloves.

Resolution: Corrected at inspection

During the inspection, the operation was observed to not be clean evidenced by a urine smell in two of the bedrooms and old food on the floor behind the stove.

Resolution: Corrected at inspection

Three out of three employee files reviewed did not contain reference checks.

Resolution: Corrected: 2024-04-10

During the inspection, the operation was observed to not be clean evidenced by a urine smell in two of the bedrooms and old food on the floor behind the stove.

Resolution: Corrected at inspection

Four out of four first aid kits observed during the inspection was missing adhesive tape, thermometers, tweezers, and disposable gloves.

Resolution: Corrected at inspection

Three out of three employee files reviewed did not contain reference checks.

Resolution: Corrected: 2024-04-10

Three out of three employee files reviewed did not contain reference checks.

Resolution: Corrected: 2024-04-10

Four out of four first aid kits observed during the inspection was missing adhesive tape, thermometers, tweezers, and disposable gloves.

Resolution: Corrected at inspection

During the inspection, the operation was observed to not be clean evidenced by a urine smell in two of the bedrooms and old food on the floor behind the stove.

Resolution: Corrected at inspection

Three out of three employee files reviewed did not contain reference checks.

Resolution: Corrected: 2024-04-10

Four out of four first aid kits observed during the inspection was missing adhesive tape, thermometers, tweezers, and disposable gloves.

Resolution: Corrected at inspection

During the inspection, the operation was observed to not be clean evidenced by a urine smell in two of the bedrooms and old food on the floor behind the stove.

Resolution: Corrected at inspection

A cleaning product was observed during the inspection accessible to youth in care under an unlocked bathroom sink.

Resolution: Corrected at inspection

Two medications reviewed for one youth in care was documented with the wrong ending count.

Resolution: Corrected: 2024-01-11

The serious incident reports reviewed did not detail interventions made following the incidents.

Resolution: Corrected: 2024-01-11

One out of three youth files reviewed had a dental appointment dated longer than the required maintenance of 6 months.

Resolution: Corrected: 2024-01-11

One of three youth files reviewed did not include an immunization record or reasoning explaining for the lack of it.

Resolution: Corrected: 2024-01-11

A cleaning product was observed during the inspection accessible to youth in care under an unlocked bathroom sink.

Resolution: Corrected at inspection

The serious incident reports reviewed did not detail interventions made following the incidents.

Resolution: Corrected: 2024-01-11

One out of three youth files reviewed had a dental appointment dated longer than the required maintenance of 6 months.

Resolution: Corrected: 2024-01-11

One out of three youth files reviewed had a dental appointment dated longer than the required maintenance of 6 months.

Resolution: Corrected: 2024-01-11

A cleaning product was observed during the inspection accessible to youth in care under an unlocked bathroom sink.

Resolution: Corrected at inspection

Two medications reviewed for one youth in care was documented with the wrong ending count.

Resolution: Corrected: 2024-01-11

One of three youth files reviewed did not include an immunization record or reasoning explaining for the lack of it.

Resolution: Corrected: 2024-01-11

The serious incident reports reviewed did not detail interventions made following the incidents.

Resolution: Corrected: 2024-01-11

The serious incident reports reviewed did not detail interventions made following the incidents.

Resolution: Corrected: 2024-01-11

One of three youth files reviewed did not include an immunization record or reasoning explaining for the lack of it.

Resolution: Corrected: 2024-01-11

Two medications reviewed for one youth in care was documented with the wrong ending count.

Resolution: Corrected: 2024-01-11

One of three youth files reviewed did not include an immunization record or reasoning explaining for the lack of it.

Resolution: Corrected: 2024-01-11

Two medications reviewed for one youth in care was documented with the wrong ending count.

Resolution: Corrected: 2024-01-11

One out of three youth files reviewed had a dental appointment dated longer than the required maintenance of 6 months.

Resolution: Corrected: 2024-01-11

A cleaning product was observed during the inspection accessible to youth in care under an unlocked bathroom sink.

Resolution: Corrected at inspection

The operation has been without an administrator for more than 120 days.

Resolution: Corrected: 2024-01-10

The operation has been without an administrator for more than 120 days.

Resolution: Corrected: 2024-01-10

The operation has been without an administrator for more than 120 days.

Resolution: Corrected: 2024-01-10

The operation has been without an administrator for more than 120 days.

Resolution: Corrected: 2024-01-10

Operation staff laid on top of a child in care to gain control during a restraint.

Resolution: Corrected: 2024-03-15

Operation staff laid on top of a child in care to gain control during a restraint.

Resolution: Corrected: 2024-03-15

Operation staff laid on top of a child in care to gain control during a restraint.

Resolution: Corrected: 2024-03-15

Operation staff laid on top of a child in care to gain control during a restraint.

Resolution: Corrected: 2024-03-15

The operation has not had an administrator for more than 90 days.

Resolution: Corrected: 2023-12-10

Two out of three employee files reviewed only contained verification for 8 hours completed for EBI training instead of the required 16 hours.

Resolution: Corrected: 2023-11-29

The operation has not had an administrator for more than 90 days.

Resolution: Corrected: 2023-12-10

The operation has not had an administrator for more than 90 days.

Resolution: Corrected: 2023-12-10

The operation has not had an administrator for more than 90 days.

Resolution: Corrected: 2023-12-10

Two out of three employee files reviewed only contained verification for 8 hours completed for EBI training instead of the required 16 hours.

Resolution: Corrected: 2023-11-29

Two out of three employee files reviewed only contained verification for 8 hours completed for EBI training instead of the required 16 hours.

Resolution: Corrected: 2023-11-29

Two out of three employee files reviewed only contained verification for 8 hours completed for EBI training instead of the required 16 hours.

Resolution: Corrected: 2023-11-29

Records requested from the operation on 11/21/2023 were not received until 12/20/2023.

Resolution: Corrected: 2024-01-12

Operation provided an inaccurate copy of a child's service plan.

Resolution: Corrected: 2024-01-12

Service Plan completed for a child in care on 08/12/2023 indicates that the child should not be placed in a bedroom with any other children. This child was instead placed in a room with two roommates.

Resolution: Corrected: 2024-01-12

Records requested from the operation on 11/21/2023 were not received until 12/20/2023.

Resolution: Corrected: 2024-01-12

Service Plan completed for a child in care on 08/12/2023 indicates that the child should not be placed in a bedroom with any other children. This child was instead placed in a room with two roommates.

Resolution: Corrected: 2024-01-12

Operation provided an inaccurate copy of a child's service plan.

Resolution: Corrected: 2024-01-12

Service Plan completed for a child in care on 08/12/2023 indicates that the child should not be placed in a bedroom with any other children. This child was instead placed in a room with two roommates.

Resolution: Corrected: 2024-01-12

Operation provided an inaccurate copy of a child's service plan.

Resolution: Corrected: 2024-01-12

Records requested from the operation on 11/21/2023 were not received until 12/20/2023.

Resolution: Corrected: 2024-01-12

Service Plan completed for a child in care on 08/12/2023 indicates that the child should not be placed in a bedroom with any other children. This child was instead placed in a room with two roommates.

Resolution: Corrected: 2024-01-12

Operation provided an inaccurate copy of a child's service plan.

Resolution: Corrected: 2024-01-12

Records requested from the operation on 11/21/2023 were not received until 12/20/2023.

Resolution: Corrected: 2024-01-12

During walk through, it was observed that substance controll medication was not double lock.

Resolution: Corrected at inspection

During walk through, it was observed that the childrens bathroom was unequipt with handsoap and tissue.

Resolution: Corrected at inspection

During walk through, it was observed that substance controll medication was not double lock.

Resolution: Corrected at inspection

During walk through, it was observed that the childrens bathroom was unequipt with handsoap and tissue.

Resolution: Corrected at inspection

During walk through, it was observed that the childrens bathroom was unequipt with handsoap and tissue.

Resolution: Corrected at inspection

During walk through, it was observed that the childrens bathroom was unequipt with handsoap and tissue.

Resolution: Corrected at inspection

During walk through, it was observed that substance controll medication was not double lock.

Resolution: Corrected at inspection

During walk through, it was observed that substance controll medication was not double lock.

Resolution: Corrected at inspection

The operation has not had an administrator for more than 60 days.

Resolution: Corrected: 2023-11-10

The operation has not had an administrator for more than 60 days.

Resolution: Corrected: 2023-11-10

The operation has not had an administrator for more than 60 days.

Resolution: Corrected: 2023-11-10

The operation has not had an administrator for more than 60 days.

Resolution: Corrected: 2023-11-10

The staff list provided still included 4 previous employees.

Resolution: Corrected: 2023-10-20

The staff list provided still included 4 previous employees.

Resolution: Corrected: 2023-10-20

The staff list provided still included 4 previous employees.

Resolution: Corrected: 2023-10-20

The staff list provided still included 4 previous employees.

Resolution: Corrected: 2023-10-20

An attempt was made by CCI to do an on-site inspection and no one was there.

Resolution: Corrected: 2023-10-13

An attempt was made by CCI to do an on-site inspection and no one was there.

Resolution: Corrected: 2023-10-13

An attempt was made by CCI to do an on-site inspection and no one was there.

Resolution: Corrected: 2023-10-13

An attempt was made by CCI to do an on-site inspection and no one was there.

Resolution: Corrected: 2023-10-13

It was observed that there were two originally packaged packs of fish in the sink in water thawing. The staff removed the packages of fish and begin to prepare dinner.

Resolution: Corrected at inspection

Records were requested at the start of the inspection licensing did not have access by the conclusion of the inspection.

Resolution: Corrected: 2023-10-17

It was observed that there were two originally packaged packs of fish in the sink in water thawing. The staff removed the packages of fish and begin to prepare dinner.

Resolution: Corrected at inspection

It was observed that there were two originally packaged packs of fish in the sink in water thawing. The staff removed the packages of fish and begin to prepare dinner.

Resolution: Corrected at inspection

Records were requested at the start of the inspection licensing did not have access by the conclusion of the inspection.

Resolution: Corrected: 2023-10-17

Records were requested at the start of the inspection licensing did not have access by the conclusion of the inspection.

Resolution: Corrected: 2023-10-17

Records were requested at the start of the inspection licensing did not have access by the conclusion of the inspection.

Resolution: Corrected: 2023-10-17

It was observed that there were two originally packaged packs of fish in the sink in water thawing. The staff removed the packages of fish and begin to prepare dinner.

Resolution: Corrected at inspection

2 same medications log for the month of September 2023 for 1 child med log was reviewed. One of the med logs stated that Fluticasone Propio 50 MG was administered for the 1st of September 2023 at 7:15am and initialed by one staff while the second medication log for the month of September 2023 for same child stated that same medication was administered on the 1st of September at 7am and initialed by another staff.

Resolution: Corrected: 2024-04-15

CCI Investigator requested for medication logs for all children for 2023 but the operation was not able to provide the records upon request.

Resolution: Corrected: 2024-04-15

CCI Investigator requested for medication logs for all children for 2023 but the operation was not able to provide the records upon request.

Resolution: Corrected: 2024-04-15

2 same medications log for the month of September 2023 for 1 child med log was reviewed. One of the med logs stated that Fluticasone Propio 50 MG was administered for the 1st of September 2023 at 7:15am and initialed by one staff while the second medication log for the month of September 2023 for same child stated that same medication was administered on the 1st of September at 7am and initialed by another staff.

Resolution: Corrected: 2024-04-15

2 same medications log for the month of September 2023 for 1 child med log was reviewed. One of the med logs stated that Fluticasone Propio 50 MG was administered for the 1st of September 2023 at 7:15am and initialed by one staff while the second medication log for the month of September 2023 for same child stated that same medication was administered on the 1st of September at 7am and initialed by another staff.

Resolution: Corrected: 2024-04-15

CCI Investigator requested for medication logs for all children for 2023 but the operation was not able to provide the records upon request.

Resolution: Corrected: 2024-04-15

2 same medications log for the month of September 2023 for 1 child med log was reviewed. One of the med logs stated that Fluticasone Propio 50 MG was administered for the 1st of September 2023 at 7:15am and initialed by one staff while the second medication log for the month of September 2023 for same child stated that same medication was administered on the 1st of September at 7am and initialed by another staff.

Resolution: Corrected: 2024-04-15

CCI Investigator requested for medication logs for all children for 2023 but the operation was not able to provide the records upon request.

Resolution: Corrected: 2024-04-15

The unauthorized absence incident is documented to have occurred on 9/12/23 at 3:45pm, but the children's parent was not notified until 9/13/23 at 8:37pm.

Resolution: Corrected: 2023-11-14

The unauthorized absence incident is documented to have occurred on 9/12/23 at 3:45pm, but the children's parent was not notified until 9/13/23 at 8:37pm.

Resolution: Corrected: 2023-11-14

The unauthorized absence incident is documented to have occurred on 9/12/23 at 3:45pm, but the children's parent was not notified until 9/13/23 at 8:37pm.

Resolution: Corrected: 2023-11-14

The unauthorized absence incident is documented to have occurred on 9/12/23 at 3:45pm, but the children's parent was not notified until 9/13/23 at 8:37pm.

Resolution: Corrected: 2023-11-14

One out of three employee files reviewed did not include a signed and notarized Affidavit for Employment.

Resolution: Corrected: 2023-08-23

Three out of three youth files reviewed were missing several documents in the files that the operation provided separately.

Resolution: Corrected: 2023-08-23

One out of three employee files reviewed did not include a signed and notarized Affidavit for Employment.

Resolution: Corrected: 2023-08-23

One out of three employee files reviewed did not include a signed and notarized Affidavit for Employment.

Resolution: Corrected: 2023-08-23

Three out of three youth files reviewed were missing several documents in the files that the operation provided separately.

Resolution: Corrected: 2023-08-23

Three out of three youth files reviewed were missing several documents in the files that the operation provided separately.

Resolution: Corrected: 2023-08-23

One out of three employee files reviewed did not include a signed and notarized Affidavit for Employment.

Resolution: Corrected: 2023-08-23

Three out of three youth files reviewed were missing several documents in the files that the operation provided separately.

Resolution: Corrected: 2023-08-23

A staff member admitted to calling a child in care a "crackhead".

Resolution: Corrected: 2023-08-23

A staff member admitted to calling a child in care a "crackhead".

Resolution: Corrected: 2023-08-23

A staff member admitted to calling a child in care a "crackhead".

Resolution: Corrected: 2023-08-23

A staff member admitted to calling a child in care a "crackhead".

Resolution: Corrected: 2023-08-23

Two out of two first aid kits did not contain a guide, tweezers, gloves, scissors, tape, or gauze pads. One out of two first aid kits did not contain a thermometer.

Resolution: Corrected: 2023-05-08

One out of two employee records reviewed indicated the TB skin test was completed more than 30 days after hire.

Resolution: Corrected: 2023-05-08

The operation's Treatment Director's personnel file was not provided as requested.

Resolution: Corrected: 2023-05-08

Cleaning supplies were observed to be stored in two accessible areas for youth in care.

Resolution: Corrected at inspection

Twelve fire drills conducted by the operation were indicated to have lasted significantly longer than three minutes.

Resolution: Corrected: 2023-05-08

One out of two employee files reviewed did not contain a signed affidavit for employment, indication of date of hire, or verification of completed TB skin test.

Resolution: Corrected: 2023-05-08

Two out of two serious incident reports reviewed did not include the interventions made by staff or the resolution to the incident.

Resolution: Corrected: 2023-05-08

Cleaning supplies were observed to be stored in two accessible areas for youth in care.

Resolution: Corrected at inspection

One out of two employee files reviewed did not contain a signed affidavit for employment, indication of date of hire, or verification of completed TB skin test.

Resolution: Corrected: 2023-05-08

Cleaning supplies were observed to be stored in two accessible areas for youth in care.

Resolution: Corrected at inspection

Two out of two first aid kits did not contain a guide, tweezers, gloves, scissors, tape, or gauze pads. One out of two first aid kits did not contain a thermometer.

Resolution: Corrected: 2023-05-08

One out of two employee records reviewed indicated the TB skin test was completed more than 30 days after hire.

Resolution: Corrected: 2023-05-08

One out of two employee records reviewed indicated the TB skin test was completed more than 30 days after hire.

Resolution: Corrected: 2023-05-08

Two out of two serious incident reports reviewed did not include the interventions made by staff or the resolution to the incident.

Resolution: Corrected: 2023-05-08

Two out of two first aid kits did not contain a guide, tweezers, gloves, scissors, tape, or gauze pads. One out of two first aid kits did not contain a thermometer.

Resolution: Corrected: 2023-05-08

Twelve fire drills conducted by the operation were indicated to have lasted significantly longer than three minutes.

Resolution: Corrected: 2023-05-08

One out of two employee files reviewed did not contain a signed affidavit for employment, indication of date of hire, or verification of completed TB skin test.

Resolution: Corrected: 2023-05-08

The operation's Treatment Director's personnel file was not provided as requested.

Resolution: Corrected: 2023-05-08

Cleaning supplies were observed to be stored in two accessible areas for youth in care.

Resolution: Corrected at inspection

One out of two employee records reviewed indicated the TB skin test was completed more than 30 days after hire.

Resolution: Corrected: 2023-05-08

Two out of two serious incident reports reviewed did not include the interventions made by staff or the resolution to the incident.

Resolution: Corrected: 2023-05-08

Two out of two first aid kits did not contain a guide, tweezers, gloves, scissors, tape, or gauze pads. One out of two first aid kits did not contain a thermometer.

Resolution: Corrected: 2023-05-08

Twelve fire drills conducted by the operation were indicated to have lasted significantly longer than three minutes.

Resolution: Corrected: 2023-05-08

One out of two employee files reviewed did not contain a signed affidavit for employment, indication of date of hire, or verification of completed TB skin test.

Resolution: Corrected: 2023-05-08

The operation's Treatment Director's personnel file was not provided as requested.

Resolution: Corrected: 2023-05-08

Two out of two serious incident reports reviewed did not include the interventions made by staff or the resolution to the incident.

Resolution: Corrected: 2023-05-08

Twelve fire drills conducted by the operation were indicated to have lasted significantly longer than three minutes.

Resolution: Corrected: 2023-05-08

The operation's Treatment Director's personnel file was not provided as requested.

Resolution: Corrected: 2023-05-08

Staff members were observed not being in the proper caregiver/child ratio. Two staff were interviewed and confirmed they were out of ratio for a short period of time.

Resolution: Corrected: 2023-03-28

Staff members were observed not being in the proper caregiver/child ratio. Two staff were interviewed and confirmed they were out of ratio for a short period of time.

Resolution: Corrected: 2023-03-28

Staff members were observed not being in the proper caregiver/child ratio. Two staff were interviewed and confirmed they were out of ratio for a short period of time.

Resolution: Corrected: 2023-03-28

Staff members were observed not being in the proper caregiver/child ratio. Two staff were interviewed and confirmed they were out of ratio for a short period of time.

Resolution: Corrected: 2023-03-28

Not all requested child documents were provided or provided within the specified timeframe.

Resolution: Corrected: 2023-03-14

Not all requested child documents were provided or provided within the specified timeframe.

Resolution: Corrected: 2023-03-14

Not all requested child documents were provided or provided within the specified timeframe.

Resolution: Corrected: 2023-03-14

Not all requested child documents were provided or provided within the specified timeframe.

Resolution: Corrected: 2023-03-14

A medication label was said to have had the wrong quantity printed compared to the medication log reviewed, but the operation failed to get the label corrected.

Resolution: Corrected: 2023-02-17

Two discharged youth's medications were stored in the same box with current youth's medications.

Resolution: Corrected at inspection

There is not always administrative staff present at the operation during normal business hours to assist with administrative duties such as allowing Licensing to conduct an inspection.

Resolution: Corrected: 2023-02-17

All active records were not in the files reviewed timely.

Resolution: Corrected: 2023-02-17

A medication label was said to have had the wrong quantity printed compared to the medication log reviewed, but the operation failed to get the label corrected.

Resolution: Corrected: 2023-02-17

There is not always administrative staff present at the operation during normal business hours to assist with administrative duties such as allowing Licensing to conduct an inspection.

Resolution: Corrected: 2023-02-17

All active records were not in the files reviewed timely.

Resolution: Corrected: 2023-02-17

Two discharged youth's medications were stored in the same box with current youth's medications.

Resolution: Corrected at inspection

A medication label was said to have had the wrong quantity printed compared to the medication log reviewed, but the operation failed to get the label corrected.

Resolution: Corrected: 2023-02-17

Two discharged youth's medications were stored in the same box with current youth's medications.

Resolution: Corrected at inspection

There is not always administrative staff present at the operation during normal business hours to assist with administrative duties such as allowing Licensing to conduct an inspection.

Resolution: Corrected: 2023-02-17

All active records were not in the files reviewed timely.

Resolution: Corrected: 2023-02-17

A medication label was said to have had the wrong quantity printed compared to the medication log reviewed, but the operation failed to get the label corrected.

Resolution: Corrected: 2023-02-17

Two discharged youth's medications were stored in the same box with current youth's medications.

Resolution: Corrected at inspection

There is not always administrative staff present at the operation during normal business hours to assist with administrative duties such as allowing Licensing to conduct an inspection.

Resolution: Corrected: 2023-02-17

All active records were not in the files reviewed timely.

Resolution: Corrected: 2023-02-17

The unauthorized absence log was not available upon request.

Resolution: Corrected: 2023-01-10

The unauthorized absence log was not available upon request.

Resolution: Corrected: 2023-01-10

The unauthorized absence log was not available upon request.

Resolution: Corrected: 2023-01-10

The unauthorized absence log was not available upon request.

Resolution: Corrected: 2023-01-10

The serious incident report did not have the names of the children involved in the incident.

Resolution: Corrected: 2023-02-13

The serious incident report did not have the names of the children involved in the incident.

Resolution: Corrected: 2023-02-13

The serious incident report did not have the names of the children involved in the incident.

Resolution: Corrected: 2023-02-13

The serious incident report did not have the names of the children involved in the incident.

Resolution: Corrected: 2023-02-13

The unauthorized absence log was not available upon request.

Resolution: Corrected: 2022-12-21

During the inspection, observed a window to be broken in a bedroom. Window was taped with Plexiglas glass for temporary repairs. Observed a part of a bedroom door frame to have been detached from the wall.

Resolution: Corrected: 2022-12-21

Three out of four child records reviewed did not contain the known allergies on the exterior of the child's file.

Resolution: Corrected: 2022-12-21

During my inspection, it was observed in each bathroom to not have personal towels to dry hands. In one bathroom, there was no handwashing soap.

Resolution: Corrected: 2022-12-21

During my inspection, it was observed in each bathroom to not have personal towels to dry hands. In one bathroom, there was no handwashing soap.

Resolution: Corrected: 2022-12-21

During the inspection, observed a window to be broken in a bedroom. Window was taped with Plexiglas glass for temporary repairs. Observed a part of a bedroom door frame to have been detached from the wall.

Resolution: Corrected: 2022-12-21

The unauthorized absence log was not available upon request.

Resolution: Corrected: 2022-12-21

During my inspection, it was observed in each bathroom to not have personal towels to dry hands. In one bathroom, there was no handwashing soap.

Resolution: Corrected: 2022-12-21

The unauthorized absence log was not available upon request.

Resolution: Corrected: 2022-12-21

During the inspection, observed a window to be broken in a bedroom. Window was taped with Plexiglas glass for temporary repairs. Observed a part of a bedroom door frame to have been detached from the wall.

Resolution: Corrected: 2022-12-21

During the inspection, observed a window to be broken in a bedroom. Window was taped with Plexiglas glass for temporary repairs. Observed a part of a bedroom door frame to have been detached from the wall.

Resolution: Corrected: 2022-12-21

Three out of four child records reviewed did not contain the known allergies on the exterior of the child's file.

Resolution: Corrected: 2022-12-21

Three out of four child records reviewed did not contain the known allergies on the exterior of the child's file.

Resolution: Corrected: 2022-12-21

The unauthorized absence log was not available upon request.

Resolution: Corrected: 2022-12-21

During my inspection, it was observed in each bathroom to not have personal towels to dry hands. In one bathroom, there was no handwashing soap.

Resolution: Corrected: 2022-12-21

Three out of four child records reviewed did not contain the known allergies on the exterior of the child's file.

Resolution: Corrected: 2022-12-21

Two out of three medication records reviewed did not list all medications, strength, dosage, and frequencies prescribed.

Resolution: Corrected: 2022-08-10

Two window blinds were observed to be damaged.

Resolution: Corrected: 2022-08-10

Some active child records were not available to be reviewed due to not being at the operation at the time of inspection.

Resolution: Corrected: 2022-08-10

A youth did not obtain follow up treatment in the recommended timeframe as recommended by a healthcare professional.

Resolution: Corrected: 2022-08-10

Two out of three employee files reviewed did not contain a signed affidavit for employment.

Resolution: Corrected: 2022-08-10

Two out of two first aid kits were observed to be missing scissors, gloves, cotton balls, adhesive tape, tweezers, thermometers, adhesive bandages, and the first aid guide.

Resolution: Corrected at inspection

Two out of three employee files reviewed did not have an identifiable date of employment for the employee.

Resolution: Corrected: 2022-08-10

One out of three youth records reviewed did not contain an immunization record or documentation to verify attempts to obtain were made.

Resolution: Corrected: 2022-08-10

Two window blinds were observed to be damaged.

Resolution: Corrected: 2022-08-10

Two out of three employee files reviewed did not have an identifiable date of employment for the employee.

Resolution: Corrected: 2022-08-10

Two out of three medication records reviewed did not list all medications, strength, dosage, and frequencies prescribed.

Resolution: Corrected: 2022-08-10

A youth did not obtain follow up treatment in the recommended timeframe as recommended by a healthcare professional.

Resolution: Corrected: 2022-08-10

Some active child records were not available to be reviewed due to not being at the operation at the time of inspection.

Resolution: Corrected: 2022-08-10

One out of three youth records reviewed did not contain an immunization record or documentation to verify attempts to obtain were made.

Resolution: Corrected: 2022-08-10

Two out of three employee files reviewed did not contain a signed affidavit for employment.

Resolution: Corrected: 2022-08-10

Two window blinds were observed to be damaged.

Resolution: Corrected: 2022-08-10

Two out of two first aid kits were observed to be missing scissors, gloves, cotton balls, adhesive tape, tweezers, thermometers, adhesive bandages, and the first aid guide.

Resolution: Corrected at inspection

Two out of three employee files reviewed did not have an identifiable date of employment for the employee.

Resolution: Corrected: 2022-08-10

Two out of three medication records reviewed did not list all medications, strength, dosage, and frequencies prescribed.

Resolution: Corrected: 2022-08-10

A youth did not obtain follow up treatment in the recommended timeframe as recommended by a healthcare professional.

Resolution: Corrected: 2022-08-10

Some active child records were not available to be reviewed due to not being at the operation at the time of inspection.

Resolution: Corrected: 2022-08-10

One out of three youth records reviewed did not contain an immunization record or documentation to verify attempts to obtain were made.

Resolution: Corrected: 2022-08-10

Two out of three employee files reviewed did not contain a signed affidavit for employment.

Resolution: Corrected: 2022-08-10

Two out of two first aid kits were observed to be missing scissors, gloves, cotton balls, adhesive tape, tweezers, thermometers, adhesive bandages, and the first aid guide.

Resolution: Corrected at inspection

Two out of three medication records reviewed did not list all medications, strength, dosage, and frequencies prescribed.

Resolution: Corrected: 2022-08-10

Some active child records were not available to be reviewed due to not being at the operation at the time of inspection.

Resolution: Corrected: 2022-08-10

A youth did not obtain follow up treatment in the recommended timeframe as recommended by a healthcare professional.

Resolution: Corrected: 2022-08-10

Two out of three employee files reviewed did not have an identifiable date of employment for the employee.

Resolution: Corrected: 2022-08-10

One out of three youth records reviewed did not contain an immunization record or documentation to verify attempts to obtain were made.

Resolution: Corrected: 2022-08-10

Two out of two first aid kits were observed to be missing scissors, gloves, cotton balls, adhesive tape, tweezers, thermometers, adhesive bandages, and the first aid guide.

Resolution: Corrected at inspection

Two window blinds were observed to be damaged.

Resolution: Corrected: 2022-08-10

Two out of three employee files reviewed did not contain a signed affidavit for employment.

Resolution: Corrected: 2022-08-10

One out of three youth files reviewed did not contain the PLSP's signature on the admission assessment.

Resolution: Corrected: 2022-06-16

One out of three youth files reviewed did not contain documentation to indicate immunization records were attempted to be obtained.

Resolution: Corrected: 2022-06-16

Two out of three youth orientation did not include process for making complaints to outside agencies.

Resolution: Corrected: 2022-06-16

One out of one employee file reviewed did not contain a signed Employee Affidavit.

Resolution: Corrected: 2022-06-16

One out of three youth files reviewed did not contain documentation to indicate immunization records were attempted to be obtained.

Resolution: Corrected: 2022-06-16

Two out of three youth orientation did not include process for making complaints to outside agencies.

Resolution: Corrected: 2022-06-16

One out of three youth files reviewed did not contain the PLSP's signature on the admission assessment.

Resolution: Corrected: 2022-06-16

One out of one employee file reviewed did not contain a signed Employee Affidavit.

Resolution: Corrected: 2022-06-16

One out of three youth files reviewed did not contain documentation to indicate immunization records were attempted to be obtained.

Resolution: Corrected: 2022-06-16

Two out of three youth orientation did not include process for making complaints to outside agencies.

Resolution: Corrected: 2022-06-16

One out of one employee file reviewed did not contain a signed Employee Affidavit.

Resolution: Corrected: 2022-06-16

One out of three youth files reviewed did not contain the PLSP's signature on the admission assessment.

Resolution: Corrected: 2022-06-16

Two out of three youth orientation did not include process for making complaints to outside agencies.

Resolution: Corrected: 2022-06-16

One out of three youth files reviewed did not contain documentation to indicate immunization records were attempted to be obtained.

Resolution: Corrected: 2022-06-16

One out of three youth files reviewed did not contain the PLSP's signature on the admission assessment.

Resolution: Corrected: 2022-06-16

One out of one employee file reviewed did not contain a signed Employee Affidavit.

Resolution: Corrected: 2022-06-16

Two staff members with pending background checks were supervising children in care.

Resolution: Corrected: 2022-06-15

Two staff members with pending background checks were supervising children in care.

Resolution: Corrected: 2022-06-15

Two staff members with pending background checks were supervising children in care.

Resolution: Corrected: 2022-06-15

Two staff members with pending background checks were supervising children in care.

Resolution: Corrected: 2022-06-15

One of three staff records read was observed to be missing date of pre-service training.

Resolution: Corrected: 2022-05-18

One of three child records read did not have a signature of professional level service provider not a date.

Resolution: Corrected: 2022-05-18

Fence on backyard was exposed with barbb wire and other boards were observed to be warped. Some boards in the backyard fence were missing. There broken chairs both in the front and back yards. Standing water was observed on the trash can lid in the backyard of facility. Standing water was observed in two buckets in the backyard yard. Grass in both front and back yards was failed to be maintained.

Resolution: Corrected: 2022-05-18

A hole was observed in the wall of the dining room of facility. A broken cabinet door was observed in the wet bar area. Door of 2nd restroom was observed to be cracked. Carpet in storage room was observed to be soaking wet. Outlet covering in the living area was observed to be exposed. Cracks were observed in a couple of the walls along with the floor in the dining area appearing to be slanting.

Resolution: Corrected: 2022-05-18

Smoke detector was observed to have a beeping sound indicating that battery was low or needs to be replaced.

Resolution: Corrected: 2022-05-18

One current employee did not have an active background check.

Resolution: Corrected: 2022-05-11

Staff records were not available to be reviewed immediately at operation.

Resolution: Corrected at inspection

Smoke detector was observed to have a beeping sound indicating that battery was low or needs to be replaced.

Resolution: Corrected: 2022-05-18

One of three child records read did not have a signature of professional level service provider not a date.

Resolution: Corrected: 2022-05-18

Smoke detector was observed to have a beeping sound indicating that battery was low or needs to be replaced.

Resolution: Corrected: 2022-05-18

A hole was observed in the wall of the dining room of facility. A broken cabinet door was observed in the wet bar area. Door of 2nd restroom was observed to be cracked. Carpet in storage room was observed to be soaking wet. Outlet covering in the living area was observed to be exposed. Cracks were observed in a couple of the walls along with the floor in the dining area appearing to be slanting.

Resolution: Corrected: 2022-05-18

Fence on backyard was exposed with barbb wire and other boards were observed to be warped. Some boards in the backyard fence were missing. There broken chairs both in the front and back yards. Standing water was observed on the trash can lid in the backyard of facility. Standing water was observed in two buckets in the backyard yard. Grass in both front and back yards was failed to be maintained.

Resolution: Corrected: 2022-05-18

One current employee did not have an active background check.

Resolution: Corrected: 2022-05-11

One of three staff records read was observed to be missing date of pre-service training.

Resolution: Corrected: 2022-05-18

Staff records were not available to be reviewed immediately at operation.

Resolution: Corrected at inspection

A hole was observed in the wall of the dining room of facility. A broken cabinet door was observed in the wet bar area. Door of 2nd restroom was observed to be cracked. Carpet in storage room was observed to be soaking wet. Outlet covering in the living area was observed to be exposed. Cracks were observed in a couple of the walls along with the floor in the dining area appearing to be slanting.

Resolution: Corrected: 2022-05-18

Staff records were not available to be reviewed immediately at operation.

Resolution: Corrected at inspection

One of three child records read did not have a signature of professional level service provider not a date.

Resolution: Corrected: 2022-05-18

One current employee did not have an active background check.

Resolution: Corrected: 2022-05-11

Fence on backyard was exposed with barbb wire and other boards were observed to be warped. Some boards in the backyard fence were missing. There broken chairs both in the front and back yards. Standing water was observed on the trash can lid in the backyard of facility. Standing water was observed in two buckets in the backyard yard. Grass in both front and back yards was failed to be maintained.

Resolution: Corrected: 2022-05-18

One of three staff records read was observed to be missing date of pre-service training.

Resolution: Corrected: 2022-05-18

A hole was observed in the wall of the dining room of facility. A broken cabinet door was observed in the wet bar area. Door of 2nd restroom was observed to be cracked. Carpet in storage room was observed to be soaking wet. Outlet covering in the living area was observed to be exposed. Cracks were observed in a couple of the walls along with the floor in the dining area appearing to be slanting.

Resolution: Corrected: 2022-05-18

Staff records were not available to be reviewed immediately at operation.

Resolution: Corrected at inspection

One of three child records read did not have a signature of professional level service provider not a date.

Resolution: Corrected: 2022-05-18

One current employee did not have an active background check.

Resolution: Corrected: 2022-05-11

Fence on backyard was exposed with barbb wire and other boards were observed to be warped. Some boards in the backyard fence were missing. There broken chairs both in the front and back yards. Standing water was observed on the trash can lid in the backyard of facility. Standing water was observed in two buckets in the backyard yard. Grass in both front and back yards was failed to be maintained.

Resolution: Corrected: 2022-05-18

One of three staff records read was observed to be missing date of pre-service training.

Resolution: Corrected: 2022-05-18

Smoke detector was observed to have a beeping sound indicating that battery was low or needs to be replaced.

Resolution: Corrected: 2022-05-18

Three doors off the hinges were observed leaning against a wall in a storage room easily accessible to youth in care inside a youth bedroom.

Resolution: Corrected: 2022-04-15

Multiple broken furniture were observed in the front yard of the operation.

Resolution: Corrected: 2022-04-15

Multiple broken furniture were observed in the front yard of the operation.

Resolution: Corrected: 2022-04-15

Multiple broken furniture were observed in the front yard of the operation.

Resolution: Corrected: 2022-04-15

Three doors off the hinges were observed leaning against a wall in a storage room easily accessible to youth in care inside a youth bedroom.

Resolution: Corrected: 2022-04-15

Multiple broken furniture were observed in the front yard of the operation.

Resolution: Corrected: 2022-04-15

Three doors off the hinges were observed leaning against a wall in a storage room easily accessible to youth in care inside a youth bedroom.

Resolution: Corrected: 2022-04-15

Three doors off the hinges were observed leaning against a wall in a storage room easily accessible to youth in care inside a youth bedroom.

Resolution: Corrected: 2022-04-15

Two out of three child files reviewed did not have in a clearly visible place to indicate if the child had any known allergies or chronic conditions.

Resolution: Corrected: 2022-02-16

One out of three child files reviewed did not contain a discharge summary with all required components per the minimum standards.

Resolution: Corrected: 2022-02-16

Three out of three medication records reviewed did not contain the dosage documented on the medication record.

Resolution: Corrected: 2022-02-16

Three out of three child medication logs reviewed did not document the exact time administered.

Resolution: Corrected: 2022-02-16

Two out of three child files reviewed did not contain a preliminary service plan.

Resolution: Corrected: 2022-02-16

The operation's administrator does not work full time hours at the operation.

Resolution: Corrected: 2022-02-10

The operation's administrator does not work full time hours at the operation.

Resolution: Corrected: 2022-02-10

One out of three child files reviewed did not contain a discharge summary with all required components per the minimum standards.

Resolution: Corrected: 2022-02-16

Three out of three medication records reviewed did not contain the dosage documented on the medication record.

Resolution: Corrected: 2022-02-16

One out of three child files reviewed did not contain a discharge summary with all required components per the minimum standards.

Resolution: Corrected: 2022-02-16

Three out of three child medication logs reviewed did not document the exact time administered.

Resolution: Corrected: 2022-02-16

Three out of three child medication logs reviewed did not document the exact time administered.

Resolution: Corrected: 2022-02-16

One out of three child files reviewed did not contain a discharge summary with all required components per the minimum standards.

Resolution: Corrected: 2022-02-16

Two out of three child files reviewed did not contain a preliminary service plan.

Resolution: Corrected: 2022-02-16

Two out of three child files reviewed did not have in a clearly visible place to indicate if the child had any known allergies or chronic conditions.

Resolution: Corrected: 2022-02-16

Three out of three medication records reviewed did not contain the dosage documented on the medication record.

Resolution: Corrected: 2022-02-16

Three out of three child medication logs reviewed did not document the exact time administered.

Resolution: Corrected: 2022-02-16

The operation's administrator does not work full time hours at the operation.

Resolution: Corrected: 2022-02-10

Three out of three medication records reviewed did not contain the dosage documented on the medication record.

Resolution: Corrected: 2022-02-16

Two out of three child files reviewed did not have in a clearly visible place to indicate if the child had any known allergies or chronic conditions.

Resolution: Corrected: 2022-02-16

Two out of three child files reviewed did not contain a preliminary service plan.

Resolution: Corrected: 2022-02-16

The operation's administrator does not work full time hours at the operation.

Resolution: Corrected: 2022-02-10

Two out of three child files reviewed did not contain a preliminary service plan.

Resolution: Corrected: 2022-02-16

Two out of three child files reviewed did not have in a clearly visible place to indicate if the child had any known allergies or chronic conditions.

Resolution: Corrected: 2022-02-16

During the walk-through an operation of holes were observed in the children in care bedroom walls, 30 gallon trash can filled with water in the backyard, missing boards on the fence outdoors, and mold in a closet in children bedroom,

Resolution: Corrected: 2022-02-14

During the walk-through an operation of holes were observed in the children in care bedroom walls, 30 gallon trash can filled with water in the backyard, missing boards on the fence outdoors, and mold in a closet in children bedroom,

Resolution: Corrected: 2022-02-14

During the walk-through an operation of holes were observed in the children in care bedroom walls, 30 gallon trash can filled with water in the backyard, missing boards on the fence outdoors, and mold in a closet in children bedroom,

Resolution: Corrected: 2022-02-14

During the walk-through an operation of holes were observed in the children in care bedroom walls, 30 gallon trash can filled with water in the backyard, missing boards on the fence outdoors, and mold in a closet in children bedroom,

Resolution: Corrected: 2022-02-14

One out of three staff files reviewed did not contain documentation of a TB skin test being completed.

Resolution: Corrected: 2022-01-03

During the walkthrough, two wood plank boards were observed lying on the floor exposed in one of the common areas.

Resolution: Corrected at inspection

Two out of two youth files reviewed did not have a second means of identification for the youth in care such as a client number.

Resolution: Corrected: 2022-01-03

One out of one serious incident report reviewed was not fully completed to contain all required information.

Resolution: Corrected: 2022-01-03

Two out of two youth files reviewed did not have the youth's known allergies or medical conditions documented in a clearly visible place within the file.

Resolution: Corrected: 2022-01-03

Two out of two youth files reviewed did not have a second means of identification for the youth in care such as a client number.

Resolution: Corrected: 2022-01-03

During the walkthrough, two wood plank boards were observed lying on the floor exposed in one of the common areas.

Resolution: Corrected at inspection

Two out of two youth files reviewed did not have a second means of identification for the youth in care such as a client number.

Resolution: Corrected: 2022-01-03

One out of one serious incident report reviewed was not fully completed to contain all required information.

Resolution: Corrected: 2022-01-03

Two out of two youth files reviewed did not have the youth's known allergies or medical conditions documented in a clearly visible place within the file.

Resolution: Corrected: 2022-01-03

One out of one serious incident report reviewed was not fully completed to contain all required information.

Resolution: Corrected: 2022-01-03

During the walkthrough, two wood plank boards were observed lying on the floor exposed in one of the common areas.

Resolution: Corrected at inspection

One out of three staff files reviewed did not contain documentation of a TB skin test being completed.

Resolution: Corrected: 2022-01-03

Two out of two youth files reviewed did not have a second means of identification for the youth in care such as a client number.

Resolution: Corrected: 2022-01-03

Two out of two youth files reviewed did not have the youth's known allergies or medical conditions documented in a clearly visible place within the file.

Resolution: Corrected: 2022-01-03

Two out of two youth files reviewed did not have the youth's known allergies or medical conditions documented in a clearly visible place within the file.

Resolution: Corrected: 2022-01-03

One out of one serious incident report reviewed was not fully completed to contain all required information.

Resolution: Corrected: 2022-01-03

During the walkthrough, two wood plank boards were observed lying on the floor exposed in one of the common areas.

Resolution: Corrected at inspection

One out of three staff files reviewed did not contain documentation of a TB skin test being completed.

Resolution: Corrected: 2022-01-03

One out of three staff files reviewed did not contain documentation of a TB skin test being completed.

Resolution: Corrected: 2022-01-03

There is no verification of licensure for the treatment director in the file.

Resolution: Corrected: 2021-12-06

Three employee files reviewed did not contain verification of the required pre-service training regarding communicable diseases.

Resolution: Corrected: 2021-12-06

Three employee records reviewed did not contain verification of orientation completed.

Resolution: Corrected: 2021-12-06

Three employee files reviewed did not contain verification of the required pre-service training regarding location and proper use of the fire extinguisher and first aid equipment.

Resolution: Corrected: 2021-12-06

Two out of three employee files reviewed did not contain verification of the required pre-service training regarding normalcy.

Resolution: Corrected: 2021-12-06

Three employee files reviewed did not contain verification of the required pre-service training regarding emergency procedures.

Resolution: Corrected: 2021-12-06

Two out of three employee records reviewed did not contain verification of the employee's educational qualifications.

Resolution: Corrected: 2021-12-06

Two out of three employee records reviewed did not contain an acknowledgement signed of the operational policies.

Resolution: Corrected: 2021-12-06

Three employee records reviewed did not contain verification of pre-employment drug tests completed.

Resolution: Corrected: 2021-11-23

One out of three employee files reviewed did not contain an Affidavit for Employment.

Resolution: Corrected: 2021-12-06

Three staff files reviewed did not contain verification of pre-service training regarding the needs of children.

Resolution: Corrected: 2021-12-06

Two out of three employee records reviewed did not contain an acknowledgement signed of reporting abuse/neglect.

Resolution: Corrected: 2021-12-06

One out of three employee records reviewed did not contain documentation of a current TB test to meet the requirements.

Resolution: Corrected: 2021-12-06

One out of three employee files reviewed did not contain an Affidavit for Employment.

Resolution: Corrected: 2021-12-06

Two out of three employee records reviewed did not contain verification of the employee's educational qualifications.

Resolution: Corrected: 2021-12-06

Two out of three employee files reviewed did not contain verification of the required pre-service training regarding normalcy.

Resolution: Corrected: 2021-12-06

One out of three employee records reviewed did not contain documentation of a current TB test to meet the requirements.

Resolution: Corrected: 2021-12-06

Three employee files reviewed did not contain verification of the required pre-service training regarding location and proper use of the fire extinguisher and first aid equipment.

Resolution: Corrected: 2021-12-06

Three employee records reviewed did not contain verification of pre-employment drug tests completed.

Resolution: Corrected: 2021-11-23

Three employee records reviewed did not contain verification of orientation completed.

Resolution: Corrected: 2021-12-06

There is no verification of licensure for the treatment director in the file.

Resolution: Corrected: 2021-12-06

Three staff files reviewed did not contain verification of pre-service training regarding the needs of children.

Resolution: Corrected: 2021-12-06

Two out of three employee records reviewed did not contain an acknowledgement signed of the operational policies.

Resolution: Corrected: 2021-12-06

Three employee files reviewed did not contain verification of the required pre-service training regarding communicable diseases.

Resolution: Corrected: 2021-12-06

Three employee files reviewed did not contain verification of the required pre-service training regarding emergency procedures.

Resolution: Corrected: 2021-12-06

Two out of three employee records reviewed did not contain an acknowledgement signed of reporting abuse/neglect.

Resolution: Corrected: 2021-12-06

Two out of three employee records reviewed did not contain verification of the employee's educational qualifications.

Resolution: Corrected: 2021-12-06

Two out of three employee files reviewed did not contain verification of the required pre-service training regarding normalcy.

Resolution: Corrected: 2021-12-06

One out of three employee records reviewed did not contain documentation of a current TB test to meet the requirements.

Resolution: Corrected: 2021-12-06

Three employee files reviewed did not contain verification of the required pre-service training regarding location and proper use of the fire extinguisher and first aid equipment.

Resolution: Corrected: 2021-12-06

Three employee records reviewed did not contain verification of pre-employment drug tests completed.

Resolution: Corrected: 2021-11-23

Three employee records reviewed did not contain verification of orientation completed.

Resolution: Corrected: 2021-12-06

There is no verification of licensure for the treatment director in the file.

Resolution: Corrected: 2021-12-06

One out of three employee files reviewed did not contain an Affidavit for Employment.

Resolution: Corrected: 2021-12-06

Three staff files reviewed did not contain verification of pre-service training regarding the needs of children.

Resolution: Corrected: 2021-12-06

Two out of three employee records reviewed did not contain an acknowledgement signed of the operational policies.

Resolution: Corrected: 2021-12-06

Three employee files reviewed did not contain verification of the required pre-service training regarding communicable diseases.

Resolution: Corrected: 2021-12-06

Three employee files reviewed did not contain verification of the required pre-service training regarding emergency procedures.

Resolution: Corrected: 2021-12-06

Two out of three employee records reviewed did not contain an acknowledgement signed of reporting abuse/neglect.

Resolution: Corrected: 2021-12-06

Two out of three employee records reviewed did not contain an acknowledgement signed of the operational policies.

Resolution: Corrected: 2021-12-06

Three employee records reviewed did not contain verification of orientation completed.

Resolution: Corrected: 2021-12-06

Three employee files reviewed did not contain verification of the required pre-service training regarding location and proper use of the fire extinguisher and first aid equipment.

Resolution: Corrected: 2021-12-06

Two out of three employee records reviewed did not contain verification of the employee's educational qualifications.

Resolution: Corrected: 2021-12-06

Three employee files reviewed did not contain verification of the required pre-service training regarding communicable diseases.

Resolution: Corrected: 2021-12-06

Three staff files reviewed did not contain verification of pre-service training regarding the needs of children.

Resolution: Corrected: 2021-12-06

Two out of three employee files reviewed did not contain verification of the required pre-service training regarding normalcy.

Resolution: Corrected: 2021-12-06

Three employee records reviewed did not contain verification of pre-employment drug tests completed.

Resolution: Corrected: 2021-11-23

There is no verification of licensure for the treatment director in the file.

Resolution: Corrected: 2021-12-06

One out of three employee records reviewed did not contain documentation of a current TB test to meet the requirements.

Resolution: Corrected: 2021-12-06

Three employee files reviewed did not contain verification of the required pre-service training regarding emergency procedures.

Resolution: Corrected: 2021-12-06

One out of three employee files reviewed did not contain an Affidavit for Employment.

Resolution: Corrected: 2021-12-06

Two out of three employee records reviewed did not contain an acknowledgement signed of reporting abuse/neglect.

Resolution: Corrected: 2021-12-06

Missing a general daily schedule for children.

Resolution: Corrected: 2021-09-03

No thermometer in freezers.

Resolution: Corrected: 2021-09-03

No policy about fiscal requirements.

Resolution: Corrected: 2021-09-03

In staff file missing a place for staff evaluations.

Resolution: Corrected: 2021-09-03

In staff file missing a place for TB test.

Resolution: Corrected: 2021-09-03

There is no abuse neglect policy.

Resolution: Corrected: 2021-09-03

In staff file missing a place for a statement that staff has read the operations policies.

Resolution: Corrected: 2021-09-03

Policy does not indicate the area designated inside of the house to take shelter.

Resolution: Corrected: 2021-09-03

In admission assessment missing a spot for the phone number and address of the conservator.

Resolution: Corrected: 2021-09-03

Missing from policy.

Resolution: Corrected: 2021-09-03

Missing how to make outside complaints.

Resolution: Corrected: 2021-09-03

No thermometer in refrigerator.

Resolution: Corrected: 2021-09-03

Loose wooden boards and a broken pipe were observed lying around in the backyard.

Resolution: Corrected: 2021-09-03

Missing from policy.

Resolution: Corrected: 2021-09-03

Missing entire policy

Resolution: Corrected: 2021-09-03

Missing a log for unauthorized absences.

Resolution: Corrected: 2021-09-03

Missing policy.

Resolution: Corrected: 2021-09-03

Missing from policy.

Resolution: Corrected: 2021-09-03

In staff file missing a place for how they meet the age requirement.

Resolution: Corrected: 2021-09-03

The shed in the backyard is not in good repair or structurally sound.

Resolution: Corrected: 2021-09-03

Missing from policy.

Resolution: Corrected: 2021-09-03

In staff file missing a place for the job description.

Resolution: Corrected: 2021-09-03

Missing a place for medications child is taking.

Resolution: Corrected: 2021-09-03

In staff file missing a place for certifications such as high school diploma.

Resolution: Corrected: 2021-09-03

Missing a log for unauthorized absences.

Resolution: Corrected: 2021-09-03

There is no abuse neglect policy.

Resolution: Corrected: 2021-09-03

In staff file missing a place for certifications such as high school diploma.

Resolution: Corrected: 2021-09-03

No policy about fiscal requirements.

Resolution: Corrected: 2021-09-03

Policy does not indicate the area designated inside of the house to take shelter.

Resolution: Corrected: 2021-09-03

Missing entire policy

Resolution: Corrected: 2021-09-03

Missing how to make outside complaints.

Resolution: Corrected: 2021-09-03

Missing from policy.

Resolution: Corrected: 2021-09-03

No thermometer in refrigerator.

Resolution: Corrected: 2021-09-03

In staff file missing a place for a statement that staff has read the operations policies.

Resolution: Corrected: 2021-09-03

In staff file missing a place for how they meet the age requirement.

Resolution: Corrected: 2021-09-03

Missing how to make outside complaints.

Resolution: Corrected: 2021-09-03

Missing from policy.

Resolution: Corrected: 2021-09-03

Missing from policy.

Resolution: Corrected: 2021-09-03

Missing from policy.

Resolution: Corrected: 2021-09-03

No policy about fiscal requirements.

Resolution: Corrected: 2021-09-03

Missing entire policy

Resolution: Corrected: 2021-09-03

No thermometer in freezers.

Resolution: Corrected: 2021-09-03

In staff file missing a place for staff evaluations.

Resolution: Corrected: 2021-09-03

Policy does not indicate the area designated inside of the house to take shelter.

Resolution: Corrected: 2021-09-03

In staff file missing a place for the job description.

Resolution: Corrected: 2021-09-03

Missing a place for medications child is taking.

Resolution: Corrected: 2021-09-03

In staff file missing a place for TB test.

Resolution: Corrected: 2021-09-03

Missing policy.

Resolution: Corrected: 2021-09-03

Missing a log for unauthorized absences.

Resolution: Corrected: 2021-09-03

The shed in the backyard is not in good repair or structurally sound.

Resolution: Corrected: 2021-09-03

In staff file missing a place for a statement that staff has read the operations policies.

Resolution: Corrected: 2021-09-03

Missing from policy.

Resolution: Corrected: 2021-09-03

Missing from policy.

Resolution: Corrected: 2021-09-03

No policy about fiscal requirements.

Resolution: Corrected: 2021-09-03

Missing entire policy

Resolution: Corrected: 2021-09-03

Missing from policy.

Resolution: Corrected: 2021-09-03

In staff file missing a place for certifications such as high school diploma.

Resolution: Corrected: 2021-09-03

Missing a general daily schedule for children.

Resolution: Corrected: 2021-09-03

There is no abuse neglect policy.

Resolution: Corrected: 2021-09-03

Missing from policy.

Resolution: Corrected: 2021-09-03

Loose wooden boards and a broken pipe were observed lying around in the backyard.

Resolution: Corrected: 2021-09-03

In admission assessment missing a spot for the phone number and address of the conservator.

Resolution: Corrected: 2021-09-03

No thermometer in refrigerator.

Resolution: Corrected: 2021-09-03

In staff file missing a place for how they meet the age requirement.

Resolution: Corrected: 2021-09-03

Missing how to make outside complaints.

Resolution: Corrected: 2021-09-03

No thermometer in refrigerator.

Resolution: Corrected: 2021-09-03

In admission assessment missing a spot for the phone number and address of the conservator.

Resolution: Corrected: 2021-09-03

Loose wooden boards and a broken pipe were observed lying around in the backyard.

Resolution: Corrected: 2021-09-03

Missing from policy.

Resolution: Corrected: 2021-09-03

There is no abuse neglect policy.

Resolution: Corrected: 2021-09-03

Missing a general daily schedule for children.

Resolution: Corrected: 2021-09-03

In staff file missing a place for a statement that staff has read the operations policies.

Resolution: Corrected: 2021-09-03

In staff file missing a place for certifications such as high school diploma.

Resolution: Corrected: 2021-09-03

The shed in the backyard is not in good repair or structurally sound.

Resolution: Corrected: 2021-09-03

Missing a log for unauthorized absences.

Resolution: Corrected: 2021-09-03

Missing policy.

Resolution: Corrected: 2021-09-03

In staff file missing a place for TB test.

Resolution: Corrected: 2021-09-03

Missing a place for medications child is taking.

Resolution: Corrected: 2021-09-03

In staff file missing a place for the job description.

Resolution: Corrected: 2021-09-03

Policy does not indicate the area designated inside of the house to take shelter.

Resolution: Corrected: 2021-09-03

In staff file missing a place for staff evaluations.

Resolution: Corrected: 2021-09-03

No thermometer in freezers.

Resolution: Corrected: 2021-09-03

Missing policy.

Resolution: Corrected: 2021-09-03

The shed in the backyard is not in good repair or structurally sound.

Resolution: Corrected: 2021-09-03

In staff file missing a place for how they meet the age requirement.

Resolution: Corrected: 2021-09-03

In admission assessment missing a spot for the phone number and address of the conservator.

Resolution: Corrected: 2021-09-03

Loose wooden boards and a broken pipe were observed lying around in the backyard.

Resolution: Corrected: 2021-09-03

Missing a place for medications child is taking.

Resolution: Corrected: 2021-09-03

No thermometer in freezers.

Resolution: Corrected: 2021-09-03

In staff file missing a place for staff evaluations.

Resolution: Corrected: 2021-09-03

In staff file missing a place for TB test.

Resolution: Corrected: 2021-09-03

Missing from policy.

Resolution: Corrected: 2021-09-03

Missing from policy.

Resolution: Corrected: 2021-09-03

In staff file missing a place for the job description.

Resolution: Corrected: 2021-09-03

Missing from policy.

Resolution: Corrected: 2021-09-03

Missing a general daily schedule for children.

Resolution: Corrected: 2021-09-03