Shamar Hope Haven Residential Treatment Center

The child service plan reviewed included another child's name that was placed at operation approximately 11 months prior. Additionally, the child's date of birth was inaccurate.

Resolution: Corrected: 2026-03-11

The child medication log reviewed was observed prefilled of the amount given approximately 7 hours before evening administration.

Resolution: Corrected: 2026-03-11

The child service plan reviewed included another child's name that was placed at operation approximately 11 months prior. Additionally, the child's date of birth was inaccurate.

Resolution: Corrected: 2026-03-11

The log provided did not include the intake report number, age, and gender of the child's unauthorized absence.

Resolution: Corrected: 2026-03-11

The log provided did not include the intake report number, age, and gender of the child's unauthorized absence.

Resolution: Corrected: 2026-03-11

The child medication log reviewed was observed prefilled of the amount given approximately 7 hours before evening administration.

Resolution: Corrected: 2026-03-11

The child service plan reviewed included another child's name that was placed at operation approximately 11 months prior. Additionally, the child's date of birth was inaccurate.

Resolution: Corrected: 2026-03-11

The log provided did not include the intake report number, age, and gender of the child's unauthorized absence.

Resolution: Corrected: 2026-03-11

The child medication log reviewed was observed prefilled of the amount given approximately 7 hours before evening administration.

Resolution: Corrected: 2026-03-11

According to child discharge paperwork from the hospital on 11-8-25, the discharged doctor recommended child to follow up with his primary care physician in the next 48 hours after discharge but that follow up was not done.

Resolution: Corrected: 2025-12-19

A child in care sustained injury under his left eyes during physical altercation with another resident.

Resolution: Corrected: 2025-12-19

According to child discharge paperwork from the hospital on 11-8-25, the discharged doctor recommended child to follow up with his primary care physician in the next 48 hours after discharge but that follow up was not done.

Resolution: Corrected: 2025-12-19

According to child discharge paperwork from the hospital on 11-8-25, the discharged doctor recommended child to follow up with his primary care physician in the next 48 hours after discharge but that follow up was not done.

Resolution: Corrected: 2025-12-19

A child in care sustained injury under his left eyes during physical altercation with another resident.

Resolution: Corrected: 2025-12-19

A child in care sustained injury under his left eyes during physical altercation with another resident.

Resolution: Corrected: 2025-12-19

A child in care sustained injury under his left eyes during physical altercation with another resident.

Resolution: Corrected: 2025-12-19

According to child discharge paperwork from the hospital on 11-8-25, the discharged doctor recommended child to follow up with his primary care physician in the next 48 hours after discharge but that follow up was not done.

Resolution: Corrected: 2025-12-19

A child previously placed at the facility was discharged with his personal belongings such as clothes and shoes in a trash bag. Multiple staff interviewed confirmed child was discharged with his belongings in trash bag.

Resolution: Corrected: 2025-11-06

A child previously placed at the facility was discharged with his personal belongings such as clothes and shoes in a trash bag. Multiple staff interviewed confirmed child was discharged with his belongings in trash bag.

Resolution: Corrected: 2025-11-06

A child previously placed at the facility was discharged with his personal belongings such as clothes and shoes in a trash bag. Multiple staff interviewed confirmed child was discharged with his belongings in trash bag.

Resolution: Corrected: 2025-11-06

A child previously placed at the facility was discharged with his personal belongings such as clothes and shoes in a trash bag. Multiple staff interviewed confirmed child was discharged with his belongings in trash bag.

Resolution: Corrected: 2025-11-06

The summary log did not include the gender and age of the child on an unauthorized absence. The log provided also did not include the return time for the child.

Resolution: Corrected: 2025-10-08

The operation did not provide requested documents in a timely manner after multiple attempts.

Resolution: Corrected: 2025-10-08

The summary log did not include the gender and age of the child on an unauthorized absence. The log provided also did not include the return time for the child.

Resolution: Corrected: 2025-10-08

The operation did not provide requested documents in a timely manner after multiple attempts.

Resolution: Corrected: 2025-10-08

The summary log did not include the gender and age of the child on an unauthorized absence. The log provided also did not include the return time for the child.

Resolution: Corrected: 2025-10-08

The operation did not provide requested documents in a timely manner after multiple attempts.

Resolution: Corrected: 2025-10-08

The operation did not provide requested documents in a timely manner after multiple attempts.

Resolution: Corrected: 2025-10-08

The summary log did not include the gender and age of the child on an unauthorized absence. The log provided also did not include the return time for the child.

Resolution: Corrected: 2025-10-08

Multiple children in care stated that staff cuss at them.

Resolution: Corrected: 2025-07-30

Multiple children in care stated that staff cuss at them.

Resolution: Corrected: 2025-07-30

Multiple children in care stated that staff cuss at them.

Resolution: Corrected: 2025-07-30

Multiple children in care stated that staff cuss at them.

Resolution: Corrected: 2025-07-30

Two children in care disclosed a staff member threatened residents.

Resolution: Corrected: 2025-07-11

Two children in care disclosed a staff member threatened residents.

Resolution: Corrected: 2025-07-11

Two children in care disclosed a staff member threatened residents.

Resolution: Corrected: 2025-07-11

Two children in care disclosed a staff member threatened residents.

Resolution: Corrected: 2025-07-11

During the review of 2 children files, multiple dates of birth and multiple date of placements were observed in the children files.

Resolution: Corrected at inspection

During the review of 2 children files, multiple dates of birth and multiple date of placements were observed in the children files.

Resolution: Corrected at inspection

During the review of 2 children files, multiple dates of birth and multiple date of placements were observed in the children files.

Resolution: Corrected at inspection

During the review of 2 children files, multiple dates of birth and multiple date of placements were observed in the children files.

Resolution: Corrected at inspection

During the walkthrough of the facility, one cereal box was observed to be left open on top of the kitchen counter.

Resolution: Corrected: 2025-02-19

During the review of a childs file, wrong date of placement was observed in 3 serious incident reports for 2-13-25, 2-10-25 and 2-7-25.

Resolution: Corrected: 2025-02-21

During the walkthrough of the facility, one cereal box was observed to be left open on top of the kitchen counter.

Resolution: Corrected: 2025-02-19

During the review of a childs file, wrong date of placement was observed in 3 serious incident reports for 2-13-25, 2-10-25 and 2-7-25.

Resolution: Corrected: 2025-02-21

During the walkthrough of the facility, one cereal box was observed to be left open on top of the kitchen counter.

Resolution: Corrected: 2025-02-19

During the review of a childs file, wrong date of placement was observed in 3 serious incident reports for 2-13-25, 2-10-25 and 2-7-25.

Resolution: Corrected: 2025-02-21

During the walkthrough of the facility, one cereal box was observed to be left open on top of the kitchen counter.

Resolution: Corrected: 2025-02-19

During the review of a childs file, wrong date of placement was observed in 3 serious incident reports for 2-13-25, 2-10-25 and 2-7-25.

Resolution: Corrected: 2025-02-21

One open energy drink was found inside the fridge during the walkthrough of the kitchen

Resolution: Corrected at inspection

One open energy drink was found inside the fridge during the walkthrough of the kitchen

Resolution: Corrected at inspection

One open energy drink was found inside the fridge during the walkthrough of the kitchen

Resolution: Corrected at inspection

One open energy drink was found inside the fridge during the walkthrough of the kitchen

Resolution: Corrected at inspection

Child was admitted on 12-13-24 and 72 hours preliminary service plan was completed 12-17-24.

Resolution: Corrected at inspection

During the review of staff file, multiple dates of hire was noticed. Date of hire in staff list says 9-22-24 while date of hire inside the staff file says 9-16-24. Also, during the review of one childs file, multiple dates of admissions were identified. The date of admission in the childs file cover says 5-13-24 while the date of admission in the childrens list says 5-10-24.

Resolution: Corrected at inspection

During the review of staff file, multiple dates of hire was noticed. Date of hire in staff list says 9-22-24 while date of hire inside the staff file says 9-16-24. Also, during the review of one childs file, multiple dates of admissions were identified. The date of admission in the childs file cover says 5-13-24 while the date of admission in the childrens list says 5-10-24.

Resolution: Corrected at inspection

During the review of staff file, multiple dates of hire was noticed. Date of hire in staff list says 9-22-24 while date of hire inside the staff file says 9-16-24. Also, during the review of one childs file, multiple dates of admissions were identified. The date of admission in the childs file cover says 5-13-24 while the date of admission in the childrens list says 5-10-24.

Resolution: Corrected at inspection

Child was admitted on 12-13-24 and 72 hours preliminary service plan was completed 12-17-24.

Resolution: Corrected at inspection

Child was admitted on 12-13-24 and 72 hours preliminary service plan was completed 12-17-24.

Resolution: Corrected at inspection

During the review of staff file, multiple dates of hire was noticed. Date of hire in staff list says 9-22-24 while date of hire inside the staff file says 9-16-24. Also, during the review of one childs file, multiple dates of admissions were identified. The date of admission in the childs file cover says 5-13-24 while the date of admission in the childrens list says 5-10-24.

Resolution: Corrected at inspection

Child was admitted on 12-13-24 and 72 hours preliminary service plan was completed 12-17-24.

Resolution: Corrected at inspection

During the walkthrough of the facility, leaking sewer pipe was observed by the front of the building close to the back gate. Feces, flies and waste water were observed in the area of the leak. Damaged floor tiles were also observed inside children restroom upstairs. Some part of the building roof was observed covered with plastic due to missing shingles.

Resolution: Corrected: 2024-11-27

During the walkthrough of the facility, leaking sewer pipe was observed by the front of the building close to the back gate. Feces, flies and waste water were observed in the area of the leak. Damaged floor tiles were also observed inside children restroom upstairs. Some part of the building roof was observed covered with plastic due to missing shingles.

Resolution: Corrected: 2024-11-27

During the walkthrough of the facility, leaking sewer pipe was observed by the front of the building close to the back gate. Feces, flies and waste water were observed in the area of the leak. Damaged floor tiles were also observed inside children restroom upstairs. Some part of the building roof was observed covered with plastic due to missing shingles.

Resolution: Corrected: 2024-11-27

During the walkthrough of the facility, leaking sewer pipe was observed by the front of the building close to the back gate. Feces, flies and waste water were observed in the area of the leak. Damaged floor tiles were also observed inside children restroom upstairs. Some part of the building roof was observed covered with plastic due to missing shingles.

Resolution: Corrected: 2024-11-27

During the review of one discharged childs file, no discharge summary was noticed inside the file and child was discharged on 7-3-24

Resolution: Corrected: 2024-10-14

During the review of one discharged childs file, no discharge summary was noticed inside the file and child was discharged on 7-3-24

Resolution: Corrected: 2024-10-14

During the review of one discharged childs file, no discharge summary was noticed inside the file and child was discharged on 7-3-24

Resolution: Corrected: 2024-10-14

During the review of one discharged childs file, no discharge summary was noticed inside the file and child was discharged on 7-3-24

Resolution: Corrected: 2024-10-14

During the review of the operations record today, it was noted that the last fire inspection was conducted on 5-10-23 which expired on 5-10-24.

Resolution: Corrected: 2024-10-08

During the review of the operations record today, it was noted that the last fire inspection was conducted on 5-10-23 which expired on 5-10-24.

Resolution: Corrected: 2024-10-08

During the review of the operations record today, it was noted that the last fire inspection was conducted on 5-10-23 which expired on 5-10-24.

Resolution: Corrected: 2024-10-08

During the review of the operations record today, it was noted that the last fire inspection was conducted on 5-10-23 which expired on 5-10-24.

Resolution: Corrected: 2024-10-08

It was observed during the review of staff file that the Annual Normalcy training was last taken by staff on 6-29-22

Resolution: Corrected: 2024-08-05

During the review of one staff file, It was noted that the last annual Truama training was taken on 6-29-22.

Resolution: Corrected: 2024-08-05

During the review of staff file, it was observd that annual psychotropic medication training was last taken on 6-29-22

Resolution: Corrected: 2024-08-05

During the review of one staff file, no information regarding annual perfomance evaluation was observed in the file.

Resolution: Corrected: 2024-08-05

During the review of staff file, it was noted that the last time the EBI annual training was last taken on 4-10-23.

Resolution: Corrected: 2024-08-05

During the walkthrough today, 1 childs pillow in side 3 was missing case and also 2 childrens pillow in side 4 was missing cases. Staff was informed about it and she corrected the concern.

Resolution: Corrected at inspection

During the review of one staff file, It was noted that the last annual Truama training was taken on 6-29-22.

Resolution: Corrected: 2024-08-05

During the walkthrough today, 1 childs pillow in side 3 was missing case and also 2 childrens pillow in side 4 was missing cases. Staff was informed about it and she corrected the concern.

Resolution: Corrected at inspection

During the review of staff file, it was noted that the last time the EBI annual training was last taken on 4-10-23.

Resolution: Corrected: 2024-08-05

During the review of staff file, it was observd that annual psychotropic medication training was last taken on 6-29-22

Resolution: Corrected: 2024-08-05

It was observed during the review of staff file that the Annual Normalcy training was last taken by staff on 6-29-22

Resolution: Corrected: 2024-08-05

During the review of one staff file, It was noted that the last annual Truama training was taken on 6-29-22.

Resolution: Corrected: 2024-08-05

During the review of one staff file, no information regarding annual perfomance evaluation was observed in the file.

Resolution: Corrected: 2024-08-05

During the walkthrough today, 1 childs pillow in side 3 was missing case and also 2 childrens pillow in side 4 was missing cases. Staff was informed about it and she corrected the concern.

Resolution: Corrected at inspection

During the review of staff file, it was observd that annual psychotropic medication training was last taken on 6-29-22

Resolution: Corrected: 2024-08-05

During the review of staff file, it was noted that the last time the EBI annual training was last taken on 4-10-23.

Resolution: Corrected: 2024-08-05

During the review of one staff file, no information regarding annual perfomance evaluation was observed in the file.

Resolution: Corrected: 2024-08-05

During the review of one staff file, It was noted that the last annual Truama training was taken on 6-29-22.

Resolution: Corrected: 2024-08-05

It was observed during the review of staff file that the Annual Normalcy training was last taken by staff on 6-29-22

Resolution: Corrected: 2024-08-05

During the review of one staff file, no information regarding annual perfomance evaluation was observed in the file.

Resolution: Corrected: 2024-08-05

During the review of staff file, it was observd that annual psychotropic medication training was last taken on 6-29-22

Resolution: Corrected: 2024-08-05

During the walkthrough today, 1 childs pillow in side 3 was missing case and also 2 childrens pillow in side 4 was missing cases. Staff was informed about it and she corrected the concern.

Resolution: Corrected at inspection

During the review of staff file, it was noted that the last time the EBI annual training was last taken on 4-10-23.

Resolution: Corrected: 2024-08-05

It was observed during the review of staff file that the Annual Normalcy training was last taken by staff on 6-29-22

Resolution: Corrected: 2024-08-05

2 different dates of hire was observed during the review of one staff file. The date of hire on the employee orientation checklist says 1-25-25 while the date of hire on the staff list for the staff says 2-9-24. This was corrected at inspection.

Resolution: Corrected at inspection

During the walkthrough of the facility, open ceiling was observed in staff restroom downstairs and operation staff was notified about this issue months ago and the hole has not been closed. Missing and damaged floor tiles were noticed inside the children room and common area upstairs. Damaged sheet rock wall was observed by the stairs. Also, rotten window wood frame was observed in the children room and stair area.

Resolution: Corrected: 2024-07-19

During the walkthrough of the facility upstairs, we observed a child sleeping on a damaged bed. The mattress of the bed appears to be damaged and not looking comfortable for the child.

Resolution: Corrected: 2024-07-17

2 different dates of hire was observed during the review of one staff file. The date of hire on the employee orientation checklist says 1-25-25 while the date of hire on the staff list for the staff says 2-9-24. This was corrected at inspection.

Resolution: Corrected at inspection

During the walkthrough of the facility, open ceiling was observed in staff restroom downstairs and operation staff was notified about this issue months ago and the hole has not been closed. Missing and damaged floor tiles were noticed inside the children room and common area upstairs. Damaged sheet rock wall was observed by the stairs. Also, rotten window wood frame was observed in the children room and stair area.

Resolution: Corrected: 2024-07-19

During the walkthrough of the facility, open ceiling was observed in staff restroom downstairs and operation staff was notified about this issue months ago and the hole has not been closed. Missing and damaged floor tiles were noticed inside the children room and common area upstairs. Damaged sheet rock wall was observed by the stairs. Also, rotten window wood frame was observed in the children room and stair area.

Resolution: Corrected: 2024-07-19

2 different dates of hire was observed during the review of one staff file. The date of hire on the employee orientation checklist says 1-25-25 while the date of hire on the staff list for the staff says 2-9-24. This was corrected at inspection.

Resolution: Corrected at inspection

During the walkthrough of the facility upstairs, we observed a child sleeping on a damaged bed. The mattress of the bed appears to be damaged and not looking comfortable for the child.

Resolution: Corrected: 2024-07-17

During the walkthrough of the facility, open ceiling was observed in staff restroom downstairs and operation staff was notified about this issue months ago and the hole has not been closed. Missing and damaged floor tiles were noticed inside the children room and common area upstairs. Damaged sheet rock wall was observed by the stairs. Also, rotten window wood frame was observed in the children room and stair area.

Resolution: Corrected: 2024-07-19

2 different dates of hire was observed during the review of one staff file. The date of hire on the employee orientation checklist says 1-25-25 while the date of hire on the staff list for the staff says 2-9-24. This was corrected at inspection.

Resolution: Corrected at inspection

During the walkthrough of the facility upstairs, we observed a child sleeping on a damaged bed. The mattress of the bed appears to be damaged and not looking comfortable for the child.

Resolution: Corrected: 2024-07-17

During the walkthrough of the facility upstairs, we observed a child sleeping on a damaged bed. The mattress of the bed appears to be damaged and not looking comfortable for the child.

Resolution: Corrected: 2024-07-17

A staff member entered a child's room during sleeping hours and engaged in physical contact. Although conflicting statements were provided regarding the nature of the contact, a prudent caregiver would not allow themselves to be in a situation where physical contact with a child, alone in a bedroom, after sleeping hours could be misconstrued.

Resolution: Corrected: 2024-08-30

A staff member entered a child's room during sleeping hours and engaged in physical contact. Although conflicting statements were provided regarding the nature of the contact, a prudent caregiver would not allow themselves to be in a situation where physical contact with a child, alone in a bedroom, after sleeping hours could be misconstrued.

Resolution: Corrected: 2024-08-30

A staff member entered a child's room during sleeping hours and engaged in physical contact. Although conflicting statements were provided regarding the nature of the contact, a prudent caregiver would not allow themselves to be in a situation where physical contact with a child, alone in a bedroom, after sleeping hours could be misconstrued.

Resolution: Corrected: 2024-08-30

A staff member entered a child's room during sleeping hours and engaged in physical contact. Although conflicting statements were provided regarding the nature of the contact, a prudent caregiver would not allow themselves to be in a situation where physical contact with a child, alone in a bedroom, after sleeping hours could be misconstrued.

Resolution: Corrected: 2024-08-30

During the walkthrough of the facility today, several physical site issues were identified such as damaged wall in the children room and common area, Damaged ceiling in staff restroom and peeling paints inside the children rooms.

Resolution: Corrected: 2024-05-31

During the review of children medication record, one childs medication log for CYCLOBENZAPINE 5MG was observed without the name of the prescribing physician

Resolution: Corrected: 2024-05-31

During the review of staff files, 1 direct care staff did not have current psychotropic medication training. Staff last training was on 10-7-22.

Resolution: Corrected: 2024-06-04

During the review of children medication record, multiple children medication record for May 27th PM medication and May 28th AM medication was missing and all the children were at school during the inspection.

Resolution: Corrected: 2024-05-31

During the review of one childs file, it was discovered that the child initial service plan has not been completed by the operation. Child was admitted on 4-2-24.

Resolution: Corrected: 2024-05-31

During the walkthrough of the facility today, several physical site issues were identified such as damaged wall in the children room and common area, Damaged ceiling in staff restroom and peeling paints inside the children rooms.

Resolution: Corrected: 2024-05-31

During the review of children medication record, one childs medication log for CYCLOBENZAPINE 5MG was observed without the name of the prescribing physician

Resolution: Corrected: 2024-05-31

During the walkthrough of the facility today, several physical site issues were identified such as damaged wall in the children room and common area, Damaged ceiling in staff restroom and peeling paints inside the children rooms.

Resolution: Corrected: 2024-05-31

During the review of staff files, 1 direct care staff did not have current psychotropic medication training. Staff last training was on 10-7-22.

Resolution: Corrected: 2024-06-04

During the review of one childs file, it was discovered that the child initial service plan has not been completed by the operation. Child was admitted on 4-2-24.

Resolution: Corrected: 2024-05-31

During the review of children medication record, multiple children medication record for May 27th PM medication and May 28th AM medication was missing and all the children were at school during the inspection.

Resolution: Corrected: 2024-05-31

During the review of children medication record, one childs medication log for CYCLOBENZAPINE 5MG was observed without the name of the prescribing physician

Resolution: Corrected: 2024-05-31

During the review of staff files, 1 direct care staff did not have current psychotropic medication training. Staff last training was on 10-7-22.

Resolution: Corrected: 2024-06-04

During the review of one childs file, it was discovered that the child initial service plan has not been completed by the operation. Child was admitted on 4-2-24.

Resolution: Corrected: 2024-05-31

During the review of children medication record, multiple children medication record for May 27th PM medication and May 28th AM medication was missing and all the children were at school during the inspection.

Resolution: Corrected: 2024-05-31

During the review of one childs file, it was discovered that the child initial service plan has not been completed by the operation. Child was admitted on 4-2-24.

Resolution: Corrected: 2024-05-31

During the review of children medication record, one childs medication log for CYCLOBENZAPINE 5MG was observed without the name of the prescribing physician

Resolution: Corrected: 2024-05-31

During the walkthrough of the facility today, several physical site issues were identified such as damaged wall in the children room and common area, Damaged ceiling in staff restroom and peeling paints inside the children rooms.

Resolution: Corrected: 2024-05-31

During the review of staff files, 1 direct care staff did not have current psychotropic medication training. Staff last training was on 10-7-22.

Resolution: Corrected: 2024-06-04

During the review of children medication record, multiple children medication record for May 27th PM medication and May 28th AM medication was missing and all the children were at school during the inspection.

Resolution: Corrected: 2024-05-31

During the review of 1 childs file today, different date of placement was observed. The child date of placement in the childrens list and youth intake documentation sheet says 1-25-24 while the date of placement in his preliminary service plan says 1-26-24. The error was corrected by treatment director.

Resolution: Corrected at inspection

During the review of 1 childs file today, different date of placement was observed. The child date of placement in the childrens list and youth intake documentation sheet says 1-25-24 while the date of placement in his preliminary service plan says 1-26-24. The error was corrected by treatment director.

Resolution: Corrected at inspection

During the review of 1 childs file today, different date of placement was observed. The child date of placement in the childrens list and youth intake documentation sheet says 1-25-24 while the date of placement in his preliminary service plan says 1-26-24. The error was corrected by treatment director.

Resolution: Corrected at inspection

During the review of 1 childs file today, different date of placement was observed. The child date of placement in the childrens list and youth intake documentation sheet says 1-25-24 while the date of placement in his preliminary service plan says 1-26-24. The error was corrected by treatment director.

Resolution: Corrected at inspection

The log does not contain information on if LE or Licensing was contacted. It also doesn't contain age, gender, or the name of the caregiver responsible for child at the time of AWOL.

Resolution: Corrected: 2024-03-22

The log does not contain information on if LE or Licensing was contacted. It also doesn't contain age, gender, or the name of the caregiver responsible for child at the time of AWOL.

Resolution: Corrected: 2024-03-22

The log does not contain information on if LE or Licensing was contacted. It also doesn't contain age, gender, or the name of the caregiver responsible for child at the time of AWOL.

Resolution: Corrected: 2024-03-22

The log does not contain information on if LE or Licensing was contacted. It also doesn't contain age, gender, or the name of the caregiver responsible for child at the time of AWOL.

Resolution: Corrected: 2024-03-22

Staff failed to intervene timely during the time 2 children were engaged in physical altercation at the facility and one of them sustained bloody nose and required medical attention. EMS was called and victim child was provided medical care.

Resolution: Corrected: 2023-11-20

Staff failed to intervene timely during the time 2 children were engaged in physical altercation at the facility and one of them sustained bloody nose and required medical attention. EMS was called and victim child was provided medical care.

Resolution: Corrected: 2023-11-20

Staff failed to intervene timely during the time 2 children were engaged in physical altercation at the facility and one of them sustained bloody nose and required medical attention. EMS was called and victim child was provided medical care.

Resolution: Corrected: 2023-11-20

Staff failed to intervene timely during the time 2 children were engaged in physical altercation at the facility and one of them sustained bloody nose and required medical attention. EMS was called and victim child was provided medical care.

Resolution: Corrected: 2023-11-20

During walkthrough inspection, a pair of scissors was observed in childrens bathroom. Scissors were removed by staff upon request.

Resolution: Corrected: 2023-09-12

During walkthrough inspection, a pair of scissors was observed in childrens bathroom. Scissors were removed by staff upon request.

Resolution: Corrected: 2023-09-12

During walkthrough inspection, a pair of scissors was observed in childrens bathroom. Scissors were removed by staff upon request.

Resolution: Corrected: 2023-09-12

During walkthrough inspection, a pair of scissors was observed in childrens bathroom. Scissors were removed by staff upon request.

Resolution: Corrected: 2023-09-12

Upon inspection of facility, it was noted that medication is being stored in a separate container without label instructions. Currently the separate containers have only child's name and am/pm for the weeks medication. It is noted that medication is stored in two separate locations.

Resolution: Corrected: 2023-09-01

Upon inspection of facility, it was noted that medication is being stored in a separate container without label instructions. Currently the separate containers have only child's name and am/pm for the weeks medication. It is noted that medication is stored in two separate locations.

Resolution: Corrected: 2023-09-01

Upon inspection of facility, it was noted that medication is being stored in a separate container without label instructions. Currently the separate containers have only child's name and am/pm for the weeks medication. It is noted that medication is stored in two separate locations.

Resolution: Corrected: 2023-09-01

Upon inspection of facility, it was noted that medication is being stored in a separate container without label instructions. Currently the separate containers have only child's name and am/pm for the weeks medication. It is noted that medication is stored in two separate locations.

Resolution: Corrected: 2023-09-01

Staff was not able to intervene as the children gained access to a chemical due to staff driving. One staff and two residents confirmed hand sanitizer was kept in the van and the sanitizer came from the van.

Resolution: Corrected: 2023-09-27

Children gained access to a bottle of hand sanitizer and were able to ingest it.

Resolution: Corrected: 2023-09-27

Children gained access to a bottle of hand sanitizer and were able to ingest it.

Resolution: Corrected: 2023-09-27

Staff was not able to intervene as the children gained access to a chemical due to staff driving. One staff and two residents confirmed hand sanitizer was kept in the van and the sanitizer came from the van.

Resolution: Corrected: 2023-09-27

Children gained access to a bottle of hand sanitizer and were able to ingest it.

Resolution: Corrected: 2023-09-27

Staff was not able to intervene as the children gained access to a chemical due to staff driving. One staff and two residents confirmed hand sanitizer was kept in the van and the sanitizer came from the van.

Resolution: Corrected: 2023-09-27

Children gained access to a bottle of hand sanitizer and were able to ingest it.

Resolution: Corrected: 2023-09-27

Staff was not able to intervene as the children gained access to a chemical due to staff driving. One staff and two residents confirmed hand sanitizer was kept in the van and the sanitizer came from the van.

Resolution: Corrected: 2023-09-27

Staff used profanity while supervising kids at the facility.

Resolution: Corrected: 2023-07-19

Staff used profanity while supervising kids at the facility.

Resolution: Corrected: 2023-07-19

Staff used profanity while supervising kids at the facility.

Resolution: Corrected: 2023-07-19

Staff used profanity while supervising kids at the facility.

Resolution: Corrected: 2023-07-19

During todays inspection, it was observed that the operation fire inspection expired on March 26th, 2023. The operation paid for the fire inspection today April 26th, 2023 and they are hoping the inspection will be completed by next week.

Resolution: Corrected: 2023-05-10

During todays inspection, it was observed that the operation fire inspection expired on March 26th, 2023. The operation paid for the fire inspection today April 26th, 2023 and they are hoping the inspection will be completed by next week.

Resolution: Corrected: 2023-05-10

During todays inspection, it was observed that the operation fire inspection expired on March 26th, 2023. The operation paid for the fire inspection today April 26th, 2023 and they are hoping the inspection will be completed by next week.

Resolution: Corrected: 2023-05-10

During todays inspection, it was observed that the operation fire inspection expired on March 26th, 2023. The operation paid for the fire inspection today April 26th, 2023 and they are hoping the inspection will be completed by next week.

Resolution: Corrected: 2023-05-10

The operation was not able to provide inspector with evidence that 2 week's notice was sent to DFPS caseworker. The operation is given till 4:30pm tomorrow 3-28-23 to send HM Inspector evidence confirming that the 2 weeks prior notice was sent to DFPS caseworker. By 4:30pm on 3-28-23, the operation was still not able to provide Inspector with evidence that the 2 weeks prior notice was sent to DFPS Caseworker.

Resolution: Corrected: 2023-04-04

The operation was not able to provide inspector with evidence that 2 week's notice was sent to DFPS caseworker. The operation is given till 4:30pm tomorrow 3-28-23 to send HM Inspector evidence confirming that the 2 weeks prior notice was sent to DFPS caseworker. By 4:30pm on 3-28-23, the operation was still not able to provide Inspector with evidence that the 2 weeks prior notice was sent to DFPS Caseworker.

Resolution: Corrected: 2023-04-04

The operation was not able to provide inspector with evidence that 2 week's notice was sent to DFPS caseworker. The operation is given till 4:30pm tomorrow 3-28-23 to send HM Inspector evidence confirming that the 2 weeks prior notice was sent to DFPS caseworker. By 4:30pm on 3-28-23, the operation was still not able to provide Inspector with evidence that the 2 weeks prior notice was sent to DFPS Caseworker.

Resolution: Corrected: 2023-04-04

The operation was not able to provide inspector with evidence that 2 week's notice was sent to DFPS caseworker. The operation is given till 4:30pm tomorrow 3-28-23 to send HM Inspector evidence confirming that the 2 weeks prior notice was sent to DFPS caseworker. By 4:30pm on 3-28-23, the operation was still not able to provide Inspector with evidence that the 2 weeks prior notice was sent to DFPS Caseworker.

Resolution: Corrected: 2023-04-04

During a review conducted on January 31, 2023, it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan(s); and (2) 12 months had elapsed since the effective date of the plan. As you know, the heightened monitoring plans for your operation included a specific ?planned end date? at the 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring?. As a direct result of the administrator?s failure to ensure timely compliance with heightened monitoring plans, your operation is now unable to successfully move to post-plan monitoring. Furthermore, your operation?s ?planned end date? must now be revised, and the period of heightened monitoring must be extended. Further details of the failure of your operation?s administrator to ensure compliance include the following: - Operation was unable to meet compliance with Medium-High or High weighted licensing citations, including having an open investigation(s). Finding: 748.535(2) ? The licensed administrator must ensure the operation complies with current heightened monitoring plans.

Resolution: Corrected: 2023-02-01

During a review conducted on January 31, 2023, it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan(s); and (2) 12 months had elapsed since the effective date of the plan. As you know, the heightened monitoring plans for your operation included a specific ?planned end date? at the 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring?. As a direct result of the administrator?s failure to ensure timely compliance with heightened monitoring plans, your operation is now unable to successfully move to post-plan monitoring. Furthermore, your operation?s ?planned end date? must now be revised, and the period of heightened monitoring must be extended. Further details of the failure of your operation?s administrator to ensure compliance include the following: - Operation was unable to meet compliance with Medium-High or High weighted licensing citations, including having an open investigation(s). Finding: 748.535(2) ? The licensed administrator must ensure the operation complies with current heightened monitoring plans.

Resolution: Corrected: 2023-02-01

During a review conducted on January 31, 2023, it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan(s); and (2) 12 months had elapsed since the effective date of the plan. As you know, the heightened monitoring plans for your operation included a specific ?planned end date? at the 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring?. As a direct result of the administrator?s failure to ensure timely compliance with heightened monitoring plans, your operation is now unable to successfully move to post-plan monitoring. Furthermore, your operation?s ?planned end date? must now be revised, and the period of heightened monitoring must be extended. Further details of the failure of your operation?s administrator to ensure compliance include the following: - Operation was unable to meet compliance with Medium-High or High weighted licensing citations, including having an open investigation(s). Finding: 748.535(2) ? The licensed administrator must ensure the operation complies with current heightened monitoring plans.

Resolution: Corrected: 2023-02-01

During a review conducted on January 31, 2023, it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan(s); and (2) 12 months had elapsed since the effective date of the plan. As you know, the heightened monitoring plans for your operation included a specific ?planned end date? at the 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring?. As a direct result of the administrator?s failure to ensure timely compliance with heightened monitoring plans, your operation is now unable to successfully move to post-plan monitoring. Furthermore, your operation?s ?planned end date? must now be revised, and the period of heightened monitoring must be extended. Further details of the failure of your operation?s administrator to ensure compliance include the following: - Operation was unable to meet compliance with Medium-High or High weighted licensing citations, including having an open investigation(s). Finding: 748.535(2) ? The licensed administrator must ensure the operation complies with current heightened monitoring plans.

Resolution: Corrected: 2023-02-01

During the course of the investigation staff were not present when children walked out of the front door and were gone for 3 hrs. Staff could not remember they were when children went AWOL.

Resolution: Corrected: 2022-12-29

During the course of the investigation staff were not present when children walked out of the front door and were gone for 3 hrs. Staff could not remember they were when children went AWOL.

Resolution: Corrected: 2022-12-29

During the course of the investigation staff were not present when children walked out of the front door and were gone for 3 hrs. Staff could not remember they were when children went AWOL.

Resolution: Corrected: 2022-12-29

During the course of the investigation staff were not present when children walked out of the front door and were gone for 3 hrs. Staff could not remember they were when children went AWOL.

Resolution: Corrected: 2022-12-29

During a review conducted on July 29, 2022, it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan(s); and (2) 12 months had elapsed since the effective date of the plan. As you know, the heightened monitoring plans for your operation included a specific ?planned end date? at the 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring?. As a direct result of the administrator?s failure to ensure timely compliance with heightened monitoring plans, your operation is now unable to successfully move to post-plan monitoring. Furthermore, your operation?s ?planned end date? must now be revised, and the period of heightened monitoring must be extended. Further details of the failure of your operation?s administrator to ensure compliance include the following: - Your operation received a High-weighted citation in a pattern/trend category on June 6, 2022. Specifically, the operation was cited for 748.3301(a)(1) ? Living Space and Physical Environment. - Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring; and - Operation was unable to meet compliance with Medium-High or High weighted licensing citations. Finding: 748.535(2) ? The licensed administrator must ensure the operation complies with current heightened monitoring plans.

Resolution: Corrected: 2022-07-30

During a review conducted on July 29, 2022, it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan(s); and (2) 12 months had elapsed since the effective date of the plan. As you know, the heightened monitoring plans for your operation included a specific ?planned end date? at the 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring?. As a direct result of the administrator?s failure to ensure timely compliance with heightened monitoring plans, your operation is now unable to successfully move to post-plan monitoring. Furthermore, your operation?s ?planned end date? must now be revised, and the period of heightened monitoring must be extended. Further details of the failure of your operation?s administrator to ensure compliance include the following: - Your operation received a High-weighted citation in a pattern/trend category on June 6, 2022. Specifically, the operation was cited for 748.3301(a)(1) ? Living Space and Physical Environment. - Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring; and - Operation was unable to meet compliance with Medium-High or High weighted licensing citations. Finding: 748.535(2) ? The licensed administrator must ensure the operation complies with current heightened monitoring plans.

Resolution: Corrected: 2022-07-30

During a review conducted on July 29, 2022, it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan(s); and (2) 12 months had elapsed since the effective date of the plan. As you know, the heightened monitoring plans for your operation included a specific ?planned end date? at the 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring?. As a direct result of the administrator?s failure to ensure timely compliance with heightened monitoring plans, your operation is now unable to successfully move to post-plan monitoring. Furthermore, your operation?s ?planned end date? must now be revised, and the period of heightened monitoring must be extended. Further details of the failure of your operation?s administrator to ensure compliance include the following: - Your operation received a High-weighted citation in a pattern/trend category on June 6, 2022. Specifically, the operation was cited for 748.3301(a)(1) ? Living Space and Physical Environment. - Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring; and - Operation was unable to meet compliance with Medium-High or High weighted licensing citations. Finding: 748.535(2) ? The licensed administrator must ensure the operation complies with current heightened monitoring plans.

Resolution: Corrected: 2022-07-30

During a review conducted on July 29, 2022, it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan(s); and (2) 12 months had elapsed since the effective date of the plan. As you know, the heightened monitoring plans for your operation included a specific ?planned end date? at the 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring?. As a direct result of the administrator?s failure to ensure timely compliance with heightened monitoring plans, your operation is now unable to successfully move to post-plan monitoring. Furthermore, your operation?s ?planned end date? must now be revised, and the period of heightened monitoring must be extended. Further details of the failure of your operation?s administrator to ensure compliance include the following: - Your operation received a High-weighted citation in a pattern/trend category on June 6, 2022. Specifically, the operation was cited for 748.3301(a)(1) ? Living Space and Physical Environment. - Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring; and - Operation was unable to meet compliance with Medium-High or High weighted licensing citations. Finding: 748.535(2) ? The licensed administrator must ensure the operation complies with current heightened monitoring plans.

Resolution: Corrected: 2022-07-30

Inspector observed open electrical switch outlet on the kitchen wall and also exposed kitchen vent cable which was not properly secured. However, the issues were corrected at inspection.

Resolution: Corrected at inspection

Inspector observed open electrical switch outlet on the kitchen wall and also exposed kitchen vent cable which was not properly secured. However, the issues were corrected at inspection.

Resolution: Corrected at inspection

Inspector observed open electrical switch outlet on the kitchen wall and also exposed kitchen vent cable which was not properly secured. However, the issues were corrected at inspection.

Resolution: Corrected at inspection

Inspector observed open electrical switch outlet on the kitchen wall and also exposed kitchen vent cable which was not properly secured. However, the issues were corrected at inspection.

Resolution: Corrected at inspection

A child was restrained but the incident was not appropriately documented on the EBI Report.

Resolution: Corrected: 2022-04-15

A child was restrained but the incident was not appropriately documented on the EBI Report.

Resolution: Corrected: 2022-04-15

A child was restrained but the incident was not appropriately documented on the EBI Report.

Resolution: Corrected: 2022-04-15

A child was restrained but the incident was not appropriately documented on the EBI Report.

Resolution: Corrected: 2022-04-15

During the walkthrough of the facility, Inspector observed a hole on the wall in the childrens room upstairs.

Resolution: Corrected: 2022-02-09

During the walkthrough of the facility, Inspector observed a hole on the wall in the childrens room upstairs.

Resolution: Corrected: 2022-02-09

During the walkthrough of the facility, Inspector observed a hole on the wall in the childrens room upstairs.

Resolution: Corrected: 2022-02-09

During the walkthrough of the facility, Inspector observed a hole on the wall in the childrens room upstairs.

Resolution: Corrected: 2022-02-09

The operation allowed a contracted group therapist to work in the presence of children before receiving a cleared background check determination.

Resolution: Corrected: 2022-02-03

The van has only 8 operable seat belts out of a total of 14 seats.

Resolution: Corrected: 2022-02-08

The van has only 8 operable seat belts out of a total of 14 seats.

Resolution: Corrected: 2022-02-08

The operation allowed a contracted group therapist to work in the presence of children before receiving a cleared background check determination.

Resolution: Corrected: 2022-02-03

The operation allowed a contracted group therapist to work in the presence of children before receiving a cleared background check determination.

Resolution: Corrected: 2022-02-03

The van has only 8 operable seat belts out of a total of 14 seats.

Resolution: Corrected: 2022-02-08

The operation allowed a contracted group therapist to work in the presence of children before receiving a cleared background check determination.

Resolution: Corrected: 2022-02-03

The van has only 8 operable seat belts out of a total of 14 seats.

Resolution: Corrected: 2022-02-08

It was observed during the review of a childs file that the 72 hours preliminary service plan was missing. The child was admitted on 12-3-21 and was confirmed by the Administrator that the preliminary service plan has not been completed.

Resolution: Corrected: 2021-12-28

It was observed during the review of a childs file that the 72 hours preliminary service plan was missing. The child was admitted on 12-3-21 and was confirmed by the Administrator that the preliminary service plan has not been completed.

Resolution: Corrected: 2021-12-28

It was observed during the review of a childs file that the 72 hours preliminary service plan was missing. The child was admitted on 12-3-21 and was confirmed by the Administrator that the preliminary service plan has not been completed.

Resolution: Corrected: 2021-12-28

It was observed during the review of a childs file that the 72 hours preliminary service plan was missing. The child was admitted on 12-3-21 and was confirmed by the Administrator that the preliminary service plan has not been completed.

Resolution: Corrected: 2021-12-28

The van used to transport children had ripped seats, where the metal frame was showing and rear vent covers. The check engine, air bag, and tire pressure maintenance lights were illuminated and the A/C was not working. The Registration and Inspection documents for the van were also expired.

Resolution: Corrected: 2021-12-28

The van used to transport children had ripped seats, where the metal frame was showing and rear vent covers. The check engine, air bag, and tire pressure maintenance lights were illuminated and the A/C was not working. The Registration and Inspection documents for the van were also expired.

Resolution: Corrected: 2021-12-28

The van used to transport children had ripped seats, where the metal frame was showing and rear vent covers. The check engine, air bag, and tire pressure maintenance lights were illuminated and the A/C was not working. The Registration and Inspection documents for the van were also expired.

Resolution: Corrected: 2021-12-28

The van used to transport children had ripped seats, where the metal frame was showing and rear vent covers. The check engine, air bag, and tire pressure maintenance lights were illuminated and the A/C was not working. The Registration and Inspection documents for the van were also expired.

Resolution: Corrected: 2021-12-28

During the walkthrough at the operation, mold was observed in the children restroom bathtub, stained ceiling in staff restroom from water leak, open electrical outlets in unit 4 area and peeling paint was observed in the wall.

Resolution: Corrected: 2021-10-29

During the walkthrough at the operation, mold was observed in the children restroom bathtub, stained ceiling in staff restroom from water leak, open electrical outlets in unit 4 area and peeling paint was observed in the wall.

Resolution: Corrected: 2021-10-29

During the walkthrough at the operation, mold was observed in the children restroom bathtub, stained ceiling in staff restroom from water leak, open electrical outlets in unit 4 area and peeling paint was observed in the wall.

Resolution: Corrected: 2021-10-29

During the walkthrough at the operation, mold was observed in the children restroom bathtub, stained ceiling in staff restroom from water leak, open electrical outlets in unit 4 area and peeling paint was observed in the wall.

Resolution: Corrected: 2021-10-29

It was observed that a child in care did not have a matress protector on their bed.

Resolution: Corrected: 2021-10-08

It was observed that a child in care did not have a matress protector on their bed.

Resolution: Corrected: 2021-10-08

It was observed that a child in care did not have a matress protector on their bed.

Resolution: Corrected: 2021-10-08

It was observed that a child in care did not have a matress protector on their bed.

Resolution: Corrected: 2021-10-08

Based on the observation of the investigation, two staff did not have their 8 hours of training with their initial 90 days.

Resolution: Corrected: 2021-10-06

According to the investigation, a child was placed in a supine position for more than 1 minute.

Resolution: Corrected: 2021-10-01

According to the investigation, a new staff was left alone with children in care

Resolution: Corrected: 2022-02-22

According to the investigation, staff member was age 20 caring for children 13 years and older.

Resolution: Corrected: 2021-10-06

According to the investigation, a child was placed in a supine position for more than 1 minute.

Resolution: Corrected: 2021-10-01

According to the investigation, a new staff was left alone with children in care

Resolution: Corrected: 2022-02-22

According to the investigation, staff member was age 20 caring for children 13 years and older.

Resolution: Corrected: 2021-10-06

According to the investigation, a child was placed in a supine position for more than 1 minute.

Resolution: Corrected: 2021-10-01

According to the investigation, a new staff was left alone with children in care

Resolution: Corrected: 2022-02-22

Based on the observation of the investigation, two staff did not have their 8 hours of training with their initial 90 days.

Resolution: Corrected: 2021-10-06

According to the investigation, staff member was age 20 caring for children 13 years and older.

Resolution: Corrected: 2021-10-06

Based on the observation of the investigation, two staff did not have their 8 hours of training with their initial 90 days.

Resolution: Corrected: 2021-10-06

According to the investigation, a new staff was left alone with children in care

Resolution: Corrected: 2022-02-22

Based on the observation of the investigation, two staff did not have their 8 hours of training with their initial 90 days.

Resolution: Corrected: 2021-10-06

According to the investigation, a child was placed in a supine position for more than 1 minute.

Resolution: Corrected: 2021-10-01

According to the investigation, staff member was age 20 caring for children 13 years and older.

Resolution: Corrected: 2021-10-06

Side 3 restroom was observed without a shower curtain during the walkthrough

Resolution: Corrected at inspection

It was observed during the walkthrough that there was no hand washing soap in side 3 restroom.

Resolution: Corrected at inspection

Side 3 restroom was observed without a shower curtain during the walkthrough

Resolution: Corrected at inspection

It was observed during the walkthrough that there was no hand washing soap in side 3 restroom.

Resolution: Corrected at inspection

Side 3 restroom was observed without a shower curtain during the walkthrough

Resolution: Corrected at inspection

Side 3 restroom was observed without a shower curtain during the walkthrough

Resolution: Corrected at inspection

It was observed during the walkthrough that there was no hand washing soap in side 3 restroom.

Resolution: Corrected at inspection

It was observed during the walkthrough that there was no hand washing soap in side 3 restroom.

Resolution: Corrected at inspection

Work orders are not formatted to accurately reflect the time, dates and person creating work.

Resolution: Corrected: 2021-03-10