Adiee, LLC

The child file reviewed did not include an updated service plan for review.

Resolution: Corrected: 2026-01-31

The child file reviewed did not include an updated service plan for review.

Resolution: Corrected: 2026-01-31

The child file reviewed did not include an updated service plan for review.

Resolution: Corrected: 2026-01-31

The child file reviewed did not include an updated service plan for review.

Resolution: Corrected: 2026-01-31

During the walkthrough of the facility, several windows upstairs were noticed without any curtains, blinds or shades.

Resolution: Corrected: 2025-10-27

During the walkthrough of the facility, several windows upstairs were noticed without any curtains, blinds or shades.

Resolution: Corrected: 2025-10-27

During the walkthrough of the facility, several windows upstairs were noticed without any curtains, blinds or shades.

Resolution: Corrected: 2025-10-27

During the walkthrough of the facility, several windows upstairs were noticed without any curtains, blinds or shades.

Resolution: Corrected: 2025-10-27

During a review conducted on October 2, 2025, 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 again. Further details of the failure of your operation?s administrator to ensure compliance include the following: - Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring, 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: 2025-10-03

During a review conducted on October 2, 2025, 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 again. Further details of the failure of your operation?s administrator to ensure compliance include the following: - Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring, 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: 2025-10-03

During a review conducted on October 2, 2025, 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 again. Further details of the failure of your operation?s administrator to ensure compliance include the following: - Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring, 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: 2025-10-03

During a review conducted on October 2, 2025, 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 again. Further details of the failure of your operation?s administrator to ensure compliance include the following: - Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring, 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: 2025-10-03

During an investigation review, a child stated they were not provided snacks for a few weeks and photographs reviewed showed limited amounts of food in the pantry and refrigerator.

Resolution: Corrected: 2025-11-27

A staff member belittled a child in care when expressing to them that they do not deserve respect and should stay in a child's place.

Resolution: Corrected: 2025-11-27

A staff member belittled a child in care when expressing to them that they do not deserve respect and should stay in a child's place.

Resolution: Corrected: 2025-11-27

A staff member belittled a child in care when expressing to them that they do not deserve respect and should stay in a child's place.

Resolution: Corrected: 2025-11-27

A staff member belittled a child in care when expressing to them that they do not deserve respect and should stay in a child's place.

Resolution: Corrected: 2025-11-27

During an investigation review, a child stated they were not provided snacks for a few weeks and photographs reviewed showed limited amounts of food in the pantry and refrigerator.

Resolution: Corrected: 2025-11-27

During an investigation review, a child stated they were not provided snacks for a few weeks and photographs reviewed showed limited amounts of food in the pantry and refrigerator.

Resolution: Corrected: 2025-11-27

During an investigation review, a child stated they were not provided snacks for a few weeks and photographs reviewed showed limited amounts of food in the pantry and refrigerator.

Resolution: Corrected: 2025-11-27

Children in care were reported to have left the operation at 12:24 pm. Parents (CPS workers) were not notified until 7:43 pm and 7:51 pm, which is after the 6 hour requirement.

Resolution: Corrected: 2025-11-28

Children in care were reported to have left the operation at 12:24 pm. Parents (CPS workers) were not notified until 7:43 pm and 7:51 pm, which is after the 6 hour requirement.

Resolution: Corrected: 2025-11-28

Children in care were reported to have left the operation at 12:24 pm. Parents (CPS workers) were not notified until 7:43 pm and 7:51 pm, which is after the 6 hour requirement.

Resolution: Corrected: 2025-11-28

Children in care were reported to have left the operation at 12:24 pm. Parents (CPS workers) were not notified until 7:43 pm and 7:51 pm, which is after the 6 hour requirement.

Resolution: Corrected: 2025-11-28

The child's file reviewed did not include the service plan update that was scheduled for June 11th.

Resolution: Corrected: 2025-09-24

A serious incident report reviewed did not include the age of the child involved or interventions made during or after the incident.

Resolution: Corrected: 2025-09-24

Multiple employees were observed in CLASS that are no longer employed at the operation.

Resolution: Corrected: 2025-09-24

The policy reviewed did not include the required components for child orientation regarding emergency behavior interventions.

Resolution: Corrected: 2025-09-24

The policy reviewed did not include the required components for child orientation regarding emergency behavior interventions.

Resolution: Corrected: 2025-09-24

Multiple employees were observed in CLASS that are no longer employed at the operation.

Resolution: Corrected: 2025-09-24

A serious incident report reviewed did not include the age of the child involved or interventions made during or after the incident.

Resolution: Corrected: 2025-09-24

The policy reviewed did not include the required components for child orientation regarding emergency behavior interventions.

Resolution: Corrected: 2025-09-24

The child's file reviewed did not include the service plan update that was scheduled for June 11th.

Resolution: Corrected: 2025-09-24

Multiple employees were observed in CLASS that are no longer employed at the operation.

Resolution: Corrected: 2025-09-24

The policy reviewed did not include the required components for child orientation regarding emergency behavior interventions.

Resolution: Corrected: 2025-09-24

The child's file reviewed did not include the service plan update that was scheduled for June 11th.

Resolution: Corrected: 2025-09-24

A serious incident report reviewed did not include the age of the child involved or interventions made during or after the incident.

Resolution: Corrected: 2025-09-24

Multiple employees were observed in CLASS that are no longer employed at the operation.

Resolution: Corrected: 2025-09-24

The child's file reviewed did not include the service plan update that was scheduled for June 11th.

Resolution: Corrected: 2025-09-24

A serious incident report reviewed did not include the age of the child involved or interventions made during or after the incident.

Resolution: Corrected: 2025-09-24

A child's file reviewed did not have an admission assessment for the child's re-admission; the child was previously admitted to the operation in Aug. 2024 and re-admitted on Jan. 4, 2025.

Resolution: Corrected: 2025-09-19

A child's file reviewed did not have an admission assessment for the child's re-admission; the child was previously admitted to the operation in Aug. 2024 and re-admitted on Jan. 4, 2025.

Resolution: Corrected: 2025-09-19

A child's file reviewed did not have an admission assessment for the child's re-admission; the child was previously admitted to the operation in Aug. 2024 and re-admitted on Jan. 4, 2025.

Resolution: Corrected: 2025-09-19

A child's file reviewed did not have an admission assessment for the child's re-admission; the child was previously admitted to the operation in Aug. 2024 and re-admitted on Jan. 4, 2025.

Resolution: Corrected: 2025-09-19

A video recording indicates that a staff member provoked a child by using verbal commands and hand gestures in a manner that challenged the child to fight.

Resolution: Corrected: 2025-09-17

A video recording was provided of a staff member using inappropriate language towards a child in care.

Resolution: Corrected: 2025-09-17

A video recording indicates that a staff member provoked a child by using verbal commands and hand gestures in a manner that challenged the child to fight.

Resolution: Corrected: 2025-09-17

A video recording was provided of a staff member using inappropriate language towards a child in care.

Resolution: Corrected: 2025-09-17

A video recording was provided of a staff member using inappropriate language towards a child in care.

Resolution: Corrected: 2025-09-17

A video recording indicates that a staff member provoked a child by using verbal commands and hand gestures in a manner that challenged the child to fight.

Resolution: Corrected: 2025-09-17

A video recording was provided of a staff member using inappropriate language towards a child in care.

Resolution: Corrected: 2025-09-17

A video recording indicates that a staff member provoked a child by using verbal commands and hand gestures in a manner that challenged the child to fight.

Resolution: Corrected: 2025-09-17

The two service plans obtained for the investigation were not signed by the youth nor was their refusal to sign documented.

Resolution: Corrected: 2025-09-24

The two service plans obtained for the investigation were not signed by the youth nor was their refusal to sign documented.

Resolution: Corrected: 2025-09-24

The two service plans obtained for the investigation were not signed by the youth nor was their refusal to sign documented.

Resolution: Corrected: 2025-09-24

The two service plans obtained for the investigation were not signed by the youth nor was their refusal to sign documented.

Resolution: Corrected: 2025-09-24

The childs medication reviewed did not indicate the accurate count of the remaining pills.

Resolution: Corrected: 2025-07-01

The childs medication reviewed did not indicate the accurate count of the remaining pills.

Resolution: Corrected: 2025-07-01

The childs medication reviewed did not indicate the accurate count of the remaining pills.

Resolution: Corrected: 2025-07-01

The childs medication reviewed did not indicate the accurate count of the remaining pills.

Resolution: Corrected: 2025-07-01

A video recording indicated a staff member cursing at a child in care.

Resolution: Corrected: 2025-08-21

A video recording indicated a staff member yelling at a child in care.

Resolution: Corrected: 2025-08-21

A video recording indicated a staff member cursing at a child in care.

Resolution: Corrected: 2025-08-21

A video recording indicated a staff member yelling at a child in care.

Resolution: Corrected: 2025-08-21

A video recording indicated a staff member yelling at a child in care.

Resolution: Corrected: 2025-08-21

A video recording indicated a staff member cursing at a child in care.

Resolution: Corrected: 2025-08-21

A video recording indicated a staff member yelling at a child in care.

Resolution: Corrected: 2025-08-21

A video recording indicated a staff member cursing at a child in care.

Resolution: Corrected: 2025-08-21

AWOL log provided was for 1 child. Missing age, gender, and date of admission.

Resolution: Corrected: 2025-07-21

Discharge plan provided is missing several details including circumstances of discharge.

Resolution: Corrected: 2025-07-21

Incident report received regarding AWOL was missing departure and return times.

Resolution: Corrected: 2025-07-21

AWOL log provided was for 1 child. Missing age, gender, and date of admission.

Resolution: Corrected: 2025-07-21

Incident report received regarding AWOL was missing departure and return times.

Resolution: Corrected: 2025-07-21

AWOL log provided was for 1 child. Missing age, gender, and date of admission.

Resolution: Corrected: 2025-07-21

Incident report received regarding AWOL was missing departure and return times.

Resolution: Corrected: 2025-07-21

Incident report received regarding AWOL was missing departure and return times.

Resolution: Corrected: 2025-07-21

Discharge plan provided is missing several details including circumstances of discharge.

Resolution: Corrected: 2025-07-21

Discharge plan provided is missing several details including circumstances of discharge.

Resolution: Corrected: 2025-07-21

AWOL log provided was for 1 child. Missing age, gender, and date of admission.

Resolution: Corrected: 2025-07-21

Discharge plan provided is missing several details including circumstances of discharge.

Resolution: Corrected: 2025-07-21

A service plan for a child in care identified as receiving treatment services did not contain two professionals on the service planning team.

Resolution: Corrected: 2025-06-19

A service plan for a child in care identified as receiving treatment services did not contain two professionals on the service planning team.

Resolution: Corrected: 2025-06-19

A service plan for a child in care identified as receiving treatment services did not contain two professionals on the service planning team.

Resolution: Corrected: 2025-06-19

A service plan for a child in care identified as receiving treatment services did not contain two professionals on the service planning team.

Resolution: Corrected: 2025-06-19

During a review conducted on March 31, 2025, 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 again. 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: 2025-04-01

During a review conducted on March 31, 2025, 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 again. 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: 2025-04-01

During a review conducted on March 31, 2025, 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 again. 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: 2025-04-01

During a review conducted on March 31, 2025, 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 again. 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: 2025-04-01

The operation did not report two children in care's unauthorized absences to their CVS workers within the required time frame by minimum standards.

Resolution: Corrected: 2025-02-26

The operation did not report two children in care's unauthorized absences to their CVS workers within the required time frame by minimum standards.

Resolution: Corrected: 2025-02-26

The operation did not report two children in care's unauthorized absences to their CVS workers within the required time frame by minimum standards.

Resolution: Corrected: 2025-02-26

The operation did not report two children in care's unauthorized absences to their CVS workers within the required time frame by minimum standards.

Resolution: Corrected: 2025-02-26

During the investigation, it was learned that the operation failed to notify the conservator of the child timely. Notification was not made about the incident until the following day.

Resolution: Corrected: 2025-02-10

During the investigation, it was learned that the operation failed to notify the conservator of the child timely. Notification was not made about the incident until the following day.

Resolution: Corrected: 2025-02-10

During the investigation, it was learned that the operation failed to notify the conservator of the child timely. Notification was not made about the incident until the following day.

Resolution: Corrected: 2025-02-10

During the investigation, it was learned that the operation failed to notify the conservator of the child timely. Notification was not made about the incident until the following day.

Resolution: Corrected: 2025-02-10

There was no documentation indicating that a debriefing took place with all of the required components according to the minimum standards.

Resolution: Corrected: 2025-01-21

The operation reports they were unaware staff was required to complete an annual suicide prevention training.

Resolution: Corrected: 2024-12-26

There was no documentation indicating that a debriefing took place with all of the required components according to the minimum standards.

Resolution: Corrected: 2025-01-21

There was no documentation indicating that a debriefing took place with all of the required components according to the minimum standards.

Resolution: Corrected: 2025-01-21

There was no documentation indicating that a debriefing took place with all of the required components according to the minimum standards.

Resolution: Corrected: 2025-01-21

The operation reports they were unaware staff was required to complete an annual suicide prevention training.

Resolution: Corrected: 2024-12-26

The operation reports they were unaware staff was required to complete an annual suicide prevention training.

Resolution: Corrected: 2024-12-26

The operation reports they were unaware staff was required to complete an annual suicide prevention training.

Resolution: Corrected: 2024-12-26

During a review conducted on September 30, 2024, 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 again. 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: 2024-10-01

During a review conducted on September 30, 2024, 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 again. 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: 2024-10-01

During a review conducted on September 30, 2024, 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 again. 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: 2024-10-01

During a review conducted on September 30, 2024, 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 again. 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: 2024-10-01

During a review of incident reports and runaway incident reports, on multiple records the documentation was incomplete.

Resolution: Corrected: 2024-09-03

During a review of incident reports and runaway incident reports, on multiple records the documentation was incomplete.

Resolution: Corrected: 2024-09-03

During a review of incident reports and runaway incident reports, on multiple records the documentation was incomplete.

Resolution: Corrected: 2024-09-03

During a review of incident reports and runaway incident reports, on multiple records the documentation was incomplete.

Resolution: Corrected: 2024-09-03

The operation failed to employ a licensed administrator within the 120-day allotted timeframe.

Resolution: Corrected: 2024-09-12

The operation failed to employ a licensed administrator within the 120-day allotted timeframe.

Resolution: Corrected: 2024-09-12

The operation failed to employ a licensed administrator within the 120-day allotted timeframe.

Resolution: Corrected: 2024-09-12

The operation failed to employ a licensed administrator within the 120-day allotted timeframe.

Resolution: Corrected: 2024-09-12

The operation failed to employ a licensed administrator within the 90-day allotted timeframe.

Resolution: Corrected: 2024-08-11

The operation failed to employ a licensed administrator within the 90-day allotted timeframe.

Resolution: Corrected: 2024-08-11

The operation failed to employ a licensed administrator within the 90-day allotted timeframe.

Resolution: Corrected: 2024-08-11

The operation failed to employ a licensed administrator within the 90-day allotted timeframe.

Resolution: Corrected: 2024-08-11

The operation was not able the triggered reviews and stated they are not required to complete triggered reviews.

Resolution: Corrected: 2024-08-16

The operation was not able the triggered reviews and stated they are not required to complete triggered reviews.

Resolution: Corrected: 2024-08-16

The operation was not able the triggered reviews and stated they are not required to complete triggered reviews.

Resolution: Corrected: 2024-08-16

The operation was not able the triggered reviews and stated they are not required to complete triggered reviews.

Resolution: Corrected: 2024-08-16

The operation failed to employ a licensed administrator within the 60-day allotted timeframe.

Resolution: Corrected: 2024-07-12

The operation failed to employ a licensed administrator within the 60-day allotted timeframe.

Resolution: Corrected: 2024-07-12

The operation failed to employ a licensed administrator within the 60-day allotted timeframe.

Resolution: Corrected: 2024-07-12

The operation failed to employ a licensed administrator within the 60-day allotted timeframe.

Resolution: Corrected: 2024-07-12

There was an indication that containment was required in the serious incident report, but the operation did not complete a restraint report.

Resolution: Corrected: 2024-06-21

The caregiver did not have any type of discussion after the incident with the child.

Resolution: Corrected: 2024-06-21

There was an indication that containment was required in the serious incident report, but the operation did not complete a restraint report.

Resolution: Corrected: 2024-06-21

The caregiver did not have any type of discussion after the incident with the child.

Resolution: Corrected: 2024-06-21

The caregiver did not have any type of discussion after the incident with the child.

Resolution: Corrected: 2024-06-21

There was an indication that containment was required in the serious incident report, but the operation did not complete a restraint report.

Resolution: Corrected: 2024-06-21

The caregiver did not have any type of discussion after the incident with the child.

Resolution: Corrected: 2024-06-21

There was an indication that containment was required in the serious incident report, but the operation did not complete a restraint report.

Resolution: Corrected: 2024-06-21

The operation staff confirmed they do not conduct triggered reviews following 3 unauthorized absences within a 60-day timeframe.

Resolution: Corrected: 2024-06-21

The operation failed to report the serious incident after the children AWOL

Resolution: Corrected: 2024-06-21

Operation staff confirmed that they do not debrief the children following serious incidents.

Resolution: Corrected: 2024-06-21

Operation staff confirmed that they do not debrief the children following serious incidents.

Resolution: Corrected: 2024-06-21

Operation staff confirmed that they do not debrief the children following serious incidents.

Resolution: Corrected: 2024-06-21

The operation failed to report the serious incident after the children AWOL

Resolution: Corrected: 2024-06-21

The operation staff confirmed they do not conduct triggered reviews following 3 unauthorized absences within a 60-day timeframe.

Resolution: Corrected: 2024-06-21

The operation staff confirmed they do not conduct triggered reviews following 3 unauthorized absences within a 60-day timeframe.

Resolution: Corrected: 2024-06-21

The operation failed to report the serious incident after the children AWOL

Resolution: Corrected: 2024-06-21

Operation staff confirmed that they do not debrief the children following serious incidents.

Resolution: Corrected: 2024-06-21

The operation staff confirmed they do not conduct triggered reviews following 3 unauthorized absences within a 60-day timeframe.

Resolution: Corrected: 2024-06-21

The operation failed to report the serious incident after the children AWOL

Resolution: Corrected: 2024-06-21

During the inspection, it was found that there is no incident report regarding the unauthorized absence that took place on March 14, 2024

Resolution: Corrected: 2024-04-23

During the inspection, it was found that there is no incident report regarding the unauthorized absence that took place on March 14, 2024

Resolution: Corrected: 2024-04-23

During the inspection, it was found that there is no incident report regarding the unauthorized absence that took place on March 14, 2024

Resolution: Corrected: 2024-04-23

During the inspection, it was found that there is no incident report regarding the unauthorized absence that took place on March 14, 2024

Resolution: Corrected: 2024-04-23

During the inspection, it was observed that the AWOL annual summary log did not display the proper information.

Resolution: Corrected: 2024-04-19

During the inspection, it was observed that the AWOL annual summary log did not display the proper information.

Resolution: Corrected: 2024-04-19

During the inspection, it was observed that the AWOL annual summary log did not display the proper information.

Resolution: Corrected: 2024-04-19

During the inspection, it was observed that the AWOL annual summary log did not display the proper information.

Resolution: Corrected: 2024-04-19

During a review conducted on March 26, 2024, 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 again. 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: 2024-03-27

During a review conducted on March 26, 2024, 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 again. 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: 2024-03-27

During a review conducted on March 26, 2024, 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 again. 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: 2024-03-27

During a review conducted on March 26, 2024, 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 again. 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: 2024-03-27

The medication logs for two children could not be provided.

Resolution: Corrected: 2024-04-26

The medication logs for two children could not be provided.

Resolution: Corrected: 2024-04-26

The medication logs for two children could not be provided.

Resolution: Corrected: 2024-04-26

The medication logs for two children could not be provided.

Resolution: Corrected: 2024-04-26

During the review of the incident report, it was noted that there was no report for March 12, 2024.

Resolution: Corrected: 2024-04-23

During the review of the summary log it was noted that the incident that occurred on 03/14/24 involving a child jumping from the second floor window and leaving unbeknownst staff was not recorded on the log.

Resolution: Corrected: 2024-04-23

During the review of the summary log it was noted that the incident that occurred on 03/14/24 involving a child jumping from the second floor window and leaving unbeknownst staff was not recorded on the log.

Resolution: Corrected: 2024-04-23

During the review of the incident report, it was noted that there was no report for March 12, 2024.

Resolution: Corrected: 2024-04-23

During the review of the summary log it was noted that the incident that occurred on 03/14/24 involving a child jumping from the second floor window and leaving unbeknownst staff was not recorded on the log.

Resolution: Corrected: 2024-04-23

During the review of the incident report, it was noted that there was no report for March 12, 2024.

Resolution: Corrected: 2024-04-23

During the review of the summary log it was noted that the incident that occurred on 03/14/24 involving a child jumping from the second floor window and leaving unbeknownst staff was not recorded on the log.

Resolution: Corrected: 2024-04-23

During the review of the incident report, it was noted that there was no report for March 12, 2024.

Resolution: Corrected: 2024-04-23

During the course of the inspection, it was determined that the adminstrator does not maintain full time hours.

Resolution: Corrected: 2024-03-15

During the course of the inspection, it was determined that the adminstrator does not maintain full time hours.

Resolution: Corrected: 2024-03-15

During the course of the inspection, it was determined that the adminstrator does not maintain full time hours.

Resolution: Corrected: 2024-03-15

During the course of the inspection, it was determined that the adminstrator does not maintain full time hours.

Resolution: Corrected: 2024-03-15

During a Heightened Monitoring Inspection, it was found that an incident of three children running away from the operation was not reported to licensing until 9 hours after the incident occured.

Resolution: Corrected: 2023-12-29

During a Heightened Monitoring Inspection, it was found that an incident of three children running away from the operation was not reported to licensing until 9 hours after the incident occured.

Resolution: Corrected: 2023-12-29

During a Heightened Monitoring Inspection, it was found that an incident of three children running away from the operation was not reported to licensing until 9 hours after the incident occured.

Resolution: Corrected: 2023-12-29

During a Heightened Monitoring Inspection, it was found that an incident of three children running away from the operation was not reported to licensing until 9 hours after the incident occured.

Resolution: Corrected: 2023-12-29

The victim child and several children who witnessed the restraint indicated that the staff used more physical force than required while conducting the restraint.

Resolution: Corrected: 2024-02-16

The victim child and several children who witnessed the restraint indicated that the staff used more physical force than required while conducting the restraint.

Resolution: Corrected: 2024-02-16

The victim child and several children who witnessed the restraint indicated that the staff used more physical force than required while conducting the restraint.

Resolution: Corrected: 2024-02-16

The victim child and several children who witnessed the restraint indicated that the staff used more physical force than required while conducting the restraint.

Resolution: Corrected: 2024-02-16

Medication logs reviewed did not have an accurate count, in addition the medication that was administered last night was not fully documented as the staff did not sign the log for the 7pm dose on 10/24/23 as required per the minimum standards.

Resolution: Corrected: 2023-11-01

There is no medication error protocol or documentation regarding children who have missed a dose of medication.

Resolution: Corrected: 2023-11-01

Medication logs reviewed did not have an accurate count, in addition the medication that was administered last night was not fully documented as the staff did not sign the log for the 7pm dose on 10/24/23 as required per the minimum standards.

Resolution: Corrected: 2023-11-01

There is no medication error protocol or documentation regarding children who have missed a dose of medication.

Resolution: Corrected: 2023-11-01

There is no medication error protocol or documentation regarding children who have missed a dose of medication.

Resolution: Corrected: 2023-11-01

Medication logs reviewed did not have an accurate count, in addition the medication that was administered last night was not fully documented as the staff did not sign the log for the 7pm dose on 10/24/23 as required per the minimum standards.

Resolution: Corrected: 2023-11-01

There is no medication error protocol or documentation regarding children who have missed a dose of medication.

Resolution: Corrected: 2023-11-01

Medication logs reviewed did not have an accurate count, in addition the medication that was administered last night was not fully documented as the staff did not sign the log for the 7pm dose on 10/24/23 as required per the minimum standards.

Resolution: Corrected: 2023-11-01

Children in care are running out of medication and miss doses of medication until the operation is able to get a refill.

Resolution: Corrected: 2023-12-09

Children in care are running out of medication and miss doses of medication until the operation is able to get a refill.

Resolution: Corrected: 2023-12-09

Children in care are running out of medication and miss doses of medication until the operation is able to get a refill.

Resolution: Corrected: 2023-12-09

Children in care are running out of medication and miss doses of medication until the operation is able to get a refill.

Resolution: Corrected: 2023-12-09

During a review conducted on September 25, 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: - Your operation received a Medium-High weighted citation in a pattern/trend category on March 31, 2023. Specifically, the operation was cited for 748.3353(c)- Monitoring Devices. The operation met compliance April 13, 2023. - 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: 2023-09-26

During a review conducted on September 25, 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: - Your operation received a Medium-High weighted citation in a pattern/trend category on March 31, 2023. Specifically, the operation was cited for 748.3353(c)- Monitoring Devices. The operation met compliance April 13, 2023. - 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: 2023-09-26

During a review conducted on September 25, 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: - Your operation received a Medium-High weighted citation in a pattern/trend category on March 31, 2023. Specifically, the operation was cited for 748.3353(c)- Monitoring Devices. The operation met compliance April 13, 2023. - 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: 2023-09-26

During a review conducted on September 25, 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: - Your operation received a Medium-High weighted citation in a pattern/trend category on March 31, 2023. Specifically, the operation was cited for 748.3353(c)- Monitoring Devices. The operation met compliance April 13, 2023. - 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: 2023-09-26

During the investigation it was found that a caregiver failed to exercise prudent judgement in the presence of children when the caregiver failed to actively search for children in the vicinity from which they had gone missing and when the caregiver transported children in the trunk of a vehicle.

Resolution: Corrected: 2023-10-11

During the investigation, multiple children were not allowed to back inside the facility following a short period of unauthorized absence.

Resolution: Corrected: 2023-10-06

During the investigation it was found that six children and one caregiver went on an outing in a vehicle that had five seatbealts.

Resolution: Corrected: 2023-10-11

A caregiver neglectfully supervised multiple children in care when she transported them in the trunk of a vehicle.

Resolution: Corrected: 2023-10-06

The operation failed to follow their own policy when they transported children without the use of seatbelts and when they failed to report several children's unauthorized absences from the facility within the timeframes required by their policy.

Resolution: Corrected: 2023-10-11

During the investigation it was found that a child's (with a history of unauthorized absences) preliminary service plan failed to address their supervision needs.

Resolution: Corrected: 2023-10-11

During the investigation it was found that a child's (with a history of unauthorized absences) preliminary service plan failed to address their supervision needs.

Resolution: Corrected: 2023-10-11

During the investigation it was found that a caregiver failed to exercise prudent judgement in the presence of children when the caregiver failed to actively search for children in the vicinity from which they had gone missing and when the caregiver transported children in the trunk of a vehicle.

Resolution: Corrected: 2023-10-11

During the investigation it was found that a child's (with a history of unauthorized absences) preliminary service plan failed to address their supervision needs.

Resolution: Corrected: 2023-10-11

During the investigation it was found that six children and one caregiver went on an outing in a vehicle that had five seatbealts.

Resolution: Corrected: 2023-10-11

A caregiver neglectfully supervised multiple children in care when she transported them in the trunk of a vehicle.

Resolution: Corrected: 2023-10-06

During the investigation, multiple children were not allowed to back inside the facility following a short period of unauthorized absence.

Resolution: Corrected: 2023-10-06

The operation failed to follow their own policy when they transported children without the use of seatbelts and when they failed to report several children's unauthorized absences from the facility within the timeframes required by their policy.

Resolution: Corrected: 2023-10-11

During the investigation it was found that a caregiver failed to exercise prudent judgement in the presence of children when the caregiver failed to actively search for children in the vicinity from which they had gone missing and when the caregiver transported children in the trunk of a vehicle.

Resolution: Corrected: 2023-10-11

During the investigation it was found that a child's (with a history of unauthorized absences) preliminary service plan failed to address their supervision needs.

Resolution: Corrected: 2023-10-11

During the investigation it was found that six children and one caregiver went on an outing in a vehicle that had five seatbealts.

Resolution: Corrected: 2023-10-11

A caregiver neglectfully supervised multiple children in care when she transported them in the trunk of a vehicle.

Resolution: Corrected: 2023-10-06

During the investigation, multiple children were not allowed to back inside the facility following a short period of unauthorized absence.

Resolution: Corrected: 2023-10-06

The operation failed to follow their own policy when they transported children without the use of seatbelts and when they failed to report several children's unauthorized absences from the facility within the timeframes required by their policy.

Resolution: Corrected: 2023-10-11

The operation failed to follow their own policy when they transported children without the use of seatbelts and when they failed to report several children's unauthorized absences from the facility within the timeframes required by their policy.

Resolution: Corrected: 2023-10-11

During the investigation, multiple children were not allowed to back inside the facility following a short period of unauthorized absence.

Resolution: Corrected: 2023-10-06

During the investigation it was found that a caregiver failed to exercise prudent judgement in the presence of children when the caregiver failed to actively search for children in the vicinity from which they had gone missing and when the caregiver transported children in the trunk of a vehicle.

Resolution: Corrected: 2023-10-11

A caregiver neglectfully supervised multiple children in care when she transported them in the trunk of a vehicle.

Resolution: Corrected: 2023-10-06

During the investigation it was found that six children and one caregiver went on an outing in a vehicle that had five seatbealts.

Resolution: Corrected: 2023-10-11

A child in care was able to access the operation's camera system to review the previous altercation he had with another resident. This caused him to re-escalate and try to fight a second time.

Resolution: Corrected: 2023-04-07

A child in care was able to access the operation's camera system to review the previous altercation he had with another resident. This caused him to re-escalate and try to fight a second time.

Resolution: Corrected: 2023-04-07

A child in care was able to access the operation's camera system to review the previous altercation he had with another resident. This caused him to re-escalate and try to fight a second time.

Resolution: Corrected: 2023-04-07

A child in care was able to access the operation's camera system to review the previous altercation he had with another resident. This caused him to re-escalate and try to fight a second time.

Resolution: Corrected: 2023-04-07

It was observed that the needle of the fire extinguisher on the second floor of the facility was not in the green zone.

Resolution: Corrected: 2023-01-12

It was observed that the needle of the fire extinguisher on the second floor of the facility was not in the green zone.

Resolution: Corrected: 2023-01-12

It was observed that the needle of the fire extinguisher on the second floor of the facility was not in the green zone.

Resolution: Corrected: 2023-01-12

It was observed that the needle of the fire extinguisher on the second floor of the facility was not in the green zone.

Resolution: Corrected: 2023-01-12

Discharge summary was not completed for child who was discharged on 06/26/2022.

Resolution: Corrected: 2023-01-26

Discharge summary was not completed for child who was discharged on 06/26/2022.

Resolution: Corrected: 2023-01-26

Discharge summary was not completed for child who was discharged on 06/26/2022.

Resolution: Corrected: 2023-01-26

Discharge summary was not completed for child who was discharged on 06/26/2022.

Resolution: Corrected: 2023-01-26

It was observed before todays HM inspection that the facility did not have Passed fire inspection. However, the facility was able to provide me with a copy of a recent Fire Inspection which is marked as Pass by Rosenberg Fire Department during my Inspection today.

Resolution: Corrected at inspection

During audit of medication sheet today, it was observed that a child on medication has not been able to take his sertraline HCL 50mg medication since 11-2-22 and also has not taking his Sertraline HCL 100mg medication since 11-6-22 because the child is out of medication. Sertraline HCL 100 mg was taken last on 11-5-22 and Sertraline HCL 50mg was taken last on 11-1-22. However, the facility was able to get a refill of the medications from the pharmacy during my inspection.

Resolution: Corrected at inspection

It was observed before todays HM inspection that the facility did not have Passed fire inspection. However, the facility was able to provide me with a copy of a recent Fire Inspection which is marked as Pass by Rosenberg Fire Department during my Inspection today.

Resolution: Corrected at inspection

It was observed before todays HM inspection that the facility did not have Passed fire inspection. However, the facility was able to provide me with a copy of a recent Fire Inspection which is marked as Pass by Rosenberg Fire Department during my Inspection today.

Resolution: Corrected at inspection

During audit of medication sheet today, it was observed that a child on medication has not been able to take his sertraline HCL 50mg medication since 11-2-22 and also has not taking his Sertraline HCL 100mg medication since 11-6-22 because the child is out of medication. Sertraline HCL 100 mg was taken last on 11-5-22 and Sertraline HCL 50mg was taken last on 11-1-22. However, the facility was able to get a refill of the medications from the pharmacy during my inspection.

Resolution: Corrected at inspection

It was observed before todays HM inspection that the facility did not have Passed fire inspection. However, the facility was able to provide me with a copy of a recent Fire Inspection which is marked as Pass by Rosenberg Fire Department during my Inspection today.

Resolution: Corrected at inspection

During audit of medication sheet today, it was observed that a child on medication has not been able to take his sertraline HCL 50mg medication since 11-2-22 and also has not taking his Sertraline HCL 100mg medication since 11-6-22 because the child is out of medication. Sertraline HCL 100 mg was taken last on 11-5-22 and Sertraline HCL 50mg was taken last on 11-1-22. However, the facility was able to get a refill of the medications from the pharmacy during my inspection.

Resolution: Corrected at inspection

During audit of medication sheet today, it was observed that a child on medication has not been able to take his sertraline HCL 50mg medication since 11-2-22 and also has not taking his Sertraline HCL 100mg medication since 11-6-22 because the child is out of medication. Sertraline HCL 100 mg was taken last on 11-5-22 and Sertraline HCL 50mg was taken last on 11-1-22. However, the facility was able to get a refill of the medications from the pharmacy during my inspection.

Resolution: Corrected at inspection

There was no discharge summary in the inactive child file.

Resolution: Corrected: 2022-09-15

A child in care did not take his medication as prescribed for his morning dose of medication.

Resolution: Corrected: 2022-09-09

The operation did not have an annual summary log available for review and reproduction upon request.

Resolution: Corrected: 2022-09-15

The operation did not have an annual summary log available for review and reproduction upon request.

Resolution: Corrected: 2022-09-15

The operation did not have an annual summary log available for review and reproduction upon request.

Resolution: Corrected: 2022-09-15

There was no discharge summary in the inactive child file.

Resolution: Corrected: 2022-09-15

The operation did not have an annual summary log available for review and reproduction upon request.

Resolution: Corrected: 2022-09-15

A child in care did not take his medication as prescribed for his morning dose of medication.

Resolution: Corrected: 2022-09-09

There was no discharge summary in the inactive child file.

Resolution: Corrected: 2022-09-15

A child in care did not take his medication as prescribed for his morning dose of medication.

Resolution: Corrected: 2022-09-09

A child in care did not take his medication as prescribed for his morning dose of medication.

Resolution: Corrected: 2022-09-09

There was no discharge summary in the inactive child file.

Resolution: Corrected: 2022-09-15

The operation did not have an annual summary log.

Resolution: Corrected: 2022-10-05

The operation did not have an annual summary log.

Resolution: Corrected: 2022-10-05

The operation did not have an annual summary log.

Resolution: Corrected: 2022-10-05

The operation did not have an annual summary log.

Resolution: Corrected: 2022-10-05

One staff member who supervises children in care did not have an active background check with the operation.

Resolution: Corrected: 2022-06-24

One staff member who supervises children in care did not have an active background check with the operation.

Resolution: Corrected: 2022-06-24

One staff member who supervises children in care did not have an active background check with the operation.

Resolution: Corrected: 2022-06-24

One staff member who supervises children in care did not have an active background check with the operation.

Resolution: Corrected: 2022-06-24

All of the staff records evaluated were missing communicable diseases training.

Resolution: Corrected: 2022-05-25

Both of the staff records evaluated did not have a document showing the results of their TB screening in their records.

Resolution: Corrected at inspection

One of the two employee records evaluated did not have first-aid / cpr documentation

Resolution: Corrected: 2022-05-25

Both of the staff records evaluated were missing the emergency procedures in the pre-service curriculum.

Resolution: Corrected: 2022-05-25

One child in care has been at the operation for longer than 90 days.

Resolution: Corrected: 2022-05-10

Both of the staff records evaluated did not address the topics appropriate to the needs of the children in care in their pre-service curriculum.

Resolution: Corrected: 2022-05-25

One of the children records evaluated had an inaccurate count.

Resolution: Corrected at inspection

Both of the staff records evaluated were missing the second half of psychotropic medication training that must be instructor led.

Resolution: Corrected: 2022-05-25

Both employee records evaluated did not address the characteristics of children in the orientation.

Resolution: Corrected: 2022-05-25

Both of the employee records evaluated did not contain training regarding the fire extinguishers nor first aid equipment.

Resolution: Corrected: 2022-05-25

One of the two employee records evaluated did not have first-aid / cpr documentation

Resolution: Corrected: 2022-05-25

One child in care has been at the operation for longer than 90 days.

Resolution: Corrected: 2022-05-10

All of the staff records evaluated were missing communicable diseases training.

Resolution: Corrected: 2022-05-25

Both employee records evaluated did not address the characteristics of children in the orientation.

Resolution: Corrected: 2022-05-25

Both of the employee records evaluated did not contain training regarding the fire extinguishers nor first aid equipment.

Resolution: Corrected: 2022-05-25

One of the children records evaluated had an inaccurate count.

Resolution: Corrected at inspection

Both of the staff records evaluated were missing the emergency procedures in the pre-service curriculum.

Resolution: Corrected: 2022-05-25

Both of the staff records evaluated were missing the emergency procedures in the pre-service curriculum.

Resolution: Corrected: 2022-05-25

One of the children records evaluated had an inaccurate count.

Resolution: Corrected at inspection

Both of the staff records evaluated were missing the second half of psychotropic medication training that must be instructor led.

Resolution: Corrected: 2022-05-25

Both of the staff records evaluated did not have a document showing the results of their TB screening in their records.

Resolution: Corrected at inspection

Both of the staff records evaluated did not have a document showing the results of their TB screening in their records.

Resolution: Corrected at inspection

Both of the staff records evaluated did not address the topics appropriate to the needs of the children in care in their pre-service curriculum.

Resolution: Corrected: 2022-05-25

One of the two employee records evaluated did not have first-aid / cpr documentation

Resolution: Corrected: 2022-05-25

Both of the staff records evaluated were missing the emergency procedures in the pre-service curriculum.

Resolution: Corrected: 2022-05-25

Both employee records evaluated did not address the characteristics of children in the orientation.

Resolution: Corrected: 2022-05-25

All of the staff records evaluated were missing communicable diseases training.

Resolution: Corrected: 2022-05-25

One child in care has been at the operation for longer than 90 days.

Resolution: Corrected: 2022-05-10

Both of the staff records evaluated were missing the second half of psychotropic medication training that must be instructor led.

Resolution: Corrected: 2022-05-25

One child in care has been at the operation for longer than 90 days.

Resolution: Corrected: 2022-05-10

Both of the employee records evaluated did not contain training regarding the fire extinguishers nor first aid equipment.

Resolution: Corrected: 2022-05-25

Both employee records evaluated did not address the characteristics of children in the orientation.

Resolution: Corrected: 2022-05-25

All of the staff records evaluated were missing communicable diseases training.

Resolution: Corrected: 2022-05-25

One of the two employee records evaluated did not have first-aid / cpr documentation

Resolution: Corrected: 2022-05-25

One of the children records evaluated had an inaccurate count.

Resolution: Corrected at inspection

Both of the staff records evaluated were missing the second half of psychotropic medication training that must be instructor led.

Resolution: Corrected: 2022-05-25

Both of the staff records evaluated did not address the topics appropriate to the needs of the children in care in their pre-service curriculum.

Resolution: Corrected: 2022-05-25

Both of the employee records evaluated did not contain training regarding the fire extinguishers nor first aid equipment.

Resolution: Corrected: 2022-05-25

Both of the staff records evaluated did not have a document showing the results of their TB screening in their records.

Resolution: Corrected at inspection

Both of the staff records evaluated did not address the topics appropriate to the needs of the children in care in their pre-service curriculum.

Resolution: Corrected: 2022-05-25

There was no restraint documentation provided.

Resolution: Corrected: 2022-07-06

There was no restraint documentation provided.

Resolution: Corrected: 2022-07-06

There was no restraint documentation provided.

Resolution: Corrected: 2022-07-06

There was no restraint documentation provided.

Resolution: Corrected: 2022-07-06

The operation failed to provide Initial service plan documents for two children previously in their care.

Resolution: Corrected: 2022-06-17

The operation failed to provide a written serious incident report.

Resolution: Corrected: 2022-06-17

The operation failed to provide a written serious incident report.

Resolution: Corrected: 2022-06-17

The operation failed to provide Initial service plan documents for two children previously in their care.

Resolution: Corrected: 2022-06-17

The operation failed to provide Initial service plan documents for two children previously in their care.

Resolution: Corrected: 2022-06-17

The operation failed to provide a written serious incident report.

Resolution: Corrected: 2022-06-17

The operation failed to provide Initial service plan documents for two children previously in their care.

Resolution: Corrected: 2022-06-17

The operation failed to provide a written serious incident report.

Resolution: Corrected: 2022-06-17

The operation did not report that a resident was arrested.

Resolution: Corrected: 2022-06-20

The operation did not report that a resident was arrested.

Resolution: Corrected: 2022-06-20

The operation did not report that a resident was arrested.

Resolution: Corrected: 2022-06-20

The operation did not report that a resident was arrested.

Resolution: Corrected: 2022-06-20

Two fire extinguishers were observed to be expired as of February '22 and one lacked an inspection tag.

Resolution: Corrected: 2022-04-15

Two fire extinguishers were observed to be expired as of February '22 and one lacked an inspection tag.

Resolution: Corrected: 2022-04-15

Two fire extinguishers were observed to be expired as of February '22 and one lacked an inspection tag.

Resolution: Corrected: 2022-04-15

Two fire extinguishers were observed to be expired as of February '22 and one lacked an inspection tag.

Resolution: Corrected: 2022-04-15

The medical exam for a child in care was conducted -- days after admission.

Resolution: Corrected: 2022-04-11

A child in care was not provided two different medications for multiple days.

Resolution: Corrected: 2022-04-11

The initial service plan required for a child in care was not completed within the 45 days.

Resolution: Corrected: 2022-05-11

The initial service plan required for a child in care was not completed within the 45 days.

Resolution: Corrected: 2022-05-11

A child in care was not provided two different medications for multiple days.

Resolution: Corrected: 2022-04-11

A child in care was not provided two different medications for multiple days.

Resolution: Corrected: 2022-04-11

The medical exam for a child in care was conducted -- days after admission.

Resolution: Corrected: 2022-04-11

The medical exam for a child in care was conducted -- days after admission.

Resolution: Corrected: 2022-04-11

The initial service plan required for a child in care was not completed within the 45 days.

Resolution: Corrected: 2022-05-11

A child in care was not provided two different medications for multiple days.

Resolution: Corrected: 2022-04-11

The medical exam for a child in care was conducted -- days after admission.

Resolution: Corrected: 2022-04-11

The initial service plan required for a child in care was not completed within the 45 days.

Resolution: Corrected: 2022-05-11

Two child files reviewed did not contain a preliminary service plan in their file. One child file reviewed did not have an initial service plan in their file.

Resolution: Corrected: 2022-02-22

One staff file reviewed did not contain a signed statement stating he will immediately report suspected child abuse, neglect, or exploitation. One staff file reviewed did not have a job description.

Resolution: Corrected at inspection

Two child files reviewed did not contain a preliminary service plan in their file. One child file reviewed did not have an initial service plan in their file.

Resolution: Corrected: 2022-02-22

One staff file reviewed did not contain a signed statement stating he will immediately report suspected child abuse, neglect, or exploitation. One staff file reviewed did not have a job description.

Resolution: Corrected at inspection

Two child files reviewed did not contain a preliminary service plan in their file. One child file reviewed did not have an initial service plan in their file.

Resolution: Corrected: 2022-02-22

Two child files reviewed did not contain a preliminary service plan in their file. One child file reviewed did not have an initial service plan in their file.

Resolution: Corrected: 2022-02-22

One staff file reviewed did not contain a signed statement stating he will immediately report suspected child abuse, neglect, or exploitation. One staff file reviewed did not have a job description.

Resolution: Corrected at inspection

One staff file reviewed did not contain a signed statement stating he will immediately report suspected child abuse, neglect, or exploitation. One staff file reviewed did not have a job description.

Resolution: Corrected at inspection

One child's service plan reviewed contained inaccurate information in several areas.

Resolution: Corrected: 2022-03-16

One child's service plan reviewed contained inaccurate information in several areas.

Resolution: Corrected: 2022-03-16

One child's service plan reviewed contained inaccurate information in several areas.

Resolution: Corrected: 2022-03-16

One child's service plan reviewed contained inaccurate information in several areas.

Resolution: Corrected: 2022-03-16

Two children in care restrained two other children in care.

Resolution: Corrected: 2022-04-08

A child's movements were restricted after refusing to go to bed.

Resolution: Corrected: 2022-04-08

A child's movements were restricted by a staff holding him across the chest from behind, and then staff using their hands to hold him against the wall.

Resolution: Corrected: 2022-04-08

Children and staff witnessed a staff use their body weight to restrict a child's movements.

Resolution: Corrected: 2022-04-08

A staff was downstairs of the facility while all of the children were upstairs awake and a fight ensued.

Resolution: Corrected: 2022-04-08

A staff was downstairs of the facility while all of the children were upstairs awake and a fight ensued.

Resolution: Corrected: 2022-04-08

A child's movements were restricted after refusing to go to bed.

Resolution: Corrected: 2022-04-08

Two children in care restrained two other children in care.

Resolution: Corrected: 2022-04-08

Children and staff witnessed a staff use their body weight to restrict a child's movements.

Resolution: Corrected: 2022-04-08

A child's movements were restricted by a staff holding him across the chest from behind, and then staff using their hands to hold him against the wall.

Resolution: Corrected: 2022-04-08

A staff was downstairs of the facility while all of the children were upstairs awake and a fight ensued.

Resolution: Corrected: 2022-04-08

A child's movements were restricted after refusing to go to bed.

Resolution: Corrected: 2022-04-08

A staff was downstairs of the facility while all of the children were upstairs awake and a fight ensued.

Resolution: Corrected: 2022-04-08

A child's movements were restricted by a staff holding him across the chest from behind, and then staff using their hands to hold him against the wall.

Resolution: Corrected: 2022-04-08

Children and staff witnessed a staff use their body weight to restrict a child's movements.

Resolution: Corrected: 2022-04-08

Two children in care restrained two other children in care.

Resolution: Corrected: 2022-04-08

Two children in care restrained two other children in care.

Resolution: Corrected: 2022-04-08

Children and staff witnessed a staff use their body weight to restrict a child's movements.

Resolution: Corrected: 2022-04-08

A child's movements were restricted by a staff holding him across the chest from behind, and then staff using their hands to hold him against the wall.

Resolution: Corrected: 2022-04-08

A child's movements were restricted after refusing to go to bed.

Resolution: Corrected: 2022-04-08

The first aid kits observed did not contain scissors.

Resolution: Corrected: 2021-10-15

None of the first aid kits observed contained a thermometer.

Resolution: Corrected: 2021-10-15

All the children records reviewed did not contain a preliminary service plan.

Resolution: Corrected: 2021-10-15

One out of four youth files reviewed did not contain an acknowledgement signed by the youth of their rights.

Resolution: Corrected: 2021-10-15

All the children records had orientation documents that did not address the education program.

Resolution: Corrected: 2021-10-15

Three out of four youth files reviewed did not contain paperwork explaining the youth's reason for placement extension.

Resolution: Corrected: 2021-10-15

One out of two serious incident reports reviewed did not indicate which staff were involved in the incident.

Resolution: Corrected: 2021-10-15

One out of four youth files reviewed did not contain documentation to indicate the youth had received an orientation.

Resolution: Corrected: 2021-10-15

one out of the four children records reviewed did not contain their admission assessments.

Resolution: Corrected: 2021-10-15

Two children in care have been in placement past their maximum 90 day mark and without the proper extension paperwork.

Resolution: Corrected: 2021-10-15

None of the first aid kits observed contained cotton balls.

Resolution: Corrected: 2021-10-15

All of the children records reviewed had orientation documents that did not address trips away from the operation.

Resolution: Corrected: 2021-10-15

All the children records had orientation documents that did not address the education program.

Resolution: Corrected: 2021-10-15

One out of four youth files reviewed did not contain documentation to indicate the youth had received an orientation.

Resolution: Corrected: 2021-10-15

One out of two serious incident reports reviewed did not indicate which staff were involved in the incident.

Resolution: Corrected: 2021-10-15

Three out of four youth files reviewed did not contain paperwork explaining the youth's reason for placement extension.

Resolution: Corrected: 2021-10-15

All the children records reviewed did not contain a preliminary service plan.

Resolution: Corrected: 2021-10-15

The first aid kits observed did not contain scissors.

Resolution: Corrected: 2021-10-15

None of the first aid kits observed contained cotton balls.

Resolution: Corrected: 2021-10-15

All of the children records reviewed had orientation documents that did not address trips away from the operation.

Resolution: Corrected: 2021-10-15

one out of the four children records reviewed did not contain their admission assessments.

Resolution: Corrected: 2021-10-15

None of the first aid kits observed contained a thermometer.

Resolution: Corrected: 2021-10-15

One out of four youth files reviewed did not contain an acknowledgement signed by the youth of their rights.

Resolution: Corrected: 2021-10-15

All the children records had orientation documents that did not address the education program.

Resolution: Corrected: 2021-10-15

Two children in care have been in placement past their maximum 90 day mark and without the proper extension paperwork.

Resolution: Corrected: 2021-10-15

None of the first aid kits observed contained a thermometer.

Resolution: Corrected: 2021-10-15

The first aid kits observed did not contain scissors.

Resolution: Corrected: 2021-10-15

None of the first aid kits observed contained cotton balls.

Resolution: Corrected: 2021-10-15

All of the children records reviewed had orientation documents that did not address trips away from the operation.

Resolution: Corrected: 2021-10-15

one out of the four children records reviewed did not contain their admission assessments.

Resolution: Corrected: 2021-10-15

One out of four youth files reviewed did not contain documentation to indicate the youth had received an orientation.

Resolution: Corrected: 2021-10-15

One out of two serious incident reports reviewed did not indicate which staff were involved in the incident.

Resolution: Corrected: 2021-10-15

Three out of four youth files reviewed did not contain paperwork explaining the youth's reason for placement extension.

Resolution: Corrected: 2021-10-15

All the children records reviewed did not contain a preliminary service plan.

Resolution: Corrected: 2021-10-15

Three out of four youth files reviewed did not contain paperwork explaining the youth's reason for placement extension.

Resolution: Corrected: 2021-10-15

None of the first aid kits observed contained cotton balls.

Resolution: Corrected: 2021-10-15

One out of two serious incident reports reviewed did not indicate which staff were involved in the incident.

Resolution: Corrected: 2021-10-15

None of the first aid kits observed contained a thermometer.

Resolution: Corrected: 2021-10-15

All the children records had orientation documents that did not address the education program.

Resolution: Corrected: 2021-10-15

One out of four youth files reviewed did not contain documentation to indicate the youth had received an orientation.

Resolution: Corrected: 2021-10-15

All the children records reviewed did not contain a preliminary service plan.

Resolution: Corrected: 2021-10-15

Two children in care have been in placement past their maximum 90 day mark and without the proper extension paperwork.

Resolution: Corrected: 2021-10-15

one out of the four children records reviewed did not contain their admission assessments.

Resolution: Corrected: 2021-10-15

All of the children records reviewed had orientation documents that did not address trips away from the operation.

Resolution: Corrected: 2021-10-15

The first aid kits observed did not contain scissors.

Resolution: Corrected: 2021-10-15

One out of four youth files reviewed did not contain an acknowledgement signed by the youth of their rights.

Resolution: Corrected: 2021-10-15

One out of four youth files reviewed did not contain an acknowledgement signed by the youth of their rights.

Resolution: Corrected: 2021-10-15

Two children in care have been in placement past their maximum 90 day mark and without the proper extension paperwork.

Resolution: Corrected: 2021-10-15

three children's medication logs were observed with count errors.

Resolution: Corrected: 2021-08-16

three children's medication logs were observed with count errors.

Resolution: Corrected: 2021-08-16

three children's medication logs were observed with count errors.

Resolution: Corrected: 2021-08-16

three children's medication logs were observed with count errors.

Resolution: Corrected: 2021-08-16

The operation hired a new administrator and failed to notify licensing. They have had a new administrator since 07/06/2021.

Resolution: Corrected: 2021-07-30

During the inspection food was observed on the counter uncovered waiting to be eaten by children. Flies were also present in the kitchen.

Resolution: Corrected at inspection

The operation hired a new administrator and failed to notify licensing. They have had a new administrator since 07/06/2021.

Resolution: Corrected: 2021-07-30

The operation hired a new administrator and failed to notify licensing. They have had a new administrator since 07/06/2021.

Resolution: Corrected: 2021-07-30

During the inspection food was observed on the counter uncovered waiting to be eaten by children. Flies were also present in the kitchen.

Resolution: Corrected at inspection

During the inspection food was observed on the counter uncovered waiting to be eaten by children. Flies were also present in the kitchen.

Resolution: Corrected at inspection

The operation hired a new administrator and failed to notify licensing. They have had a new administrator since 07/06/2021.

Resolution: Corrected: 2021-07-30

During the inspection food was observed on the counter uncovered waiting to be eaten by children. Flies were also present in the kitchen.

Resolution: Corrected at inspection

During the walk through there were 6 mattresses that did not have protectors on them. Pictures were taken.

Resolution: Corrected: 2021-06-02

During the walk through there were 6 mattresses that did not have protectors on them. Pictures were taken.

Resolution: Corrected: 2021-06-02

During the walk through there were 6 mattresses that did not have protectors on them. Pictures were taken.

Resolution: Corrected: 2021-06-02

During the walk through there were 6 mattresses that did not have protectors on them. Pictures were taken.

Resolution: Corrected: 2021-06-02

Five children's medication logs were observed with count errors.

Resolution: Corrected: 2021-08-06

Five children's medication logs were observed with count errors.

Resolution: Corrected: 2021-08-06

Five children's medication logs were observed with count errors.

Resolution: Corrected: 2021-08-06

Five children's medication logs were observed with count errors.

Resolution: Corrected: 2021-08-06

Records were not provided timely.

Resolution: Corrected: 2021-04-16

The incident occurred on February 17, 2021 but was not reported until 2/23/2021.

Resolution: Corrected: 2021-04-16

All collateral children interviewed stating they saw the victim enter the other victims room. The staff member stated he was there but did not see it happen.

Resolution: Corrected: 2021-03-09