Trinity Guidance Residential Treatment Center

While reviewing records at the facility a serious incident report was received by staff detailing an incident on 3/11/2026 that a child did not receive his AM medication as prescribed by a physician due to the pharmacy not being able to fill the prescription timely.

Resolution: Corrected: 2026-04-13

While reviewing serious incidents related to the investigation, it was noted that pertinent information was missing from the report such as time, date, person making the report, and the name of child.

Resolution: Corrected: 2026-04-13

While reviewing records at the facility a serious incident report was received by staff detailing an incident on 3/11/2026 that a child did not receive his AM medication as prescribed by a physician due to the pharmacy not being able to fill the prescription timely.

Resolution: Corrected: 2026-04-13

While reviewing serious incidents related to the investigation, it was noted that pertinent information was missing from the report such as time, date, person making the report, and the name of child.

Resolution: Corrected: 2026-04-13

While reviewing the medication log it was noted the name and signature of the person who administered the medication was not present on the log.

Resolution: Corrected: 2026-04-13

While reviewing records at the facility a serious incident report was received by staff detailing an incident on 3/11/2026 that a child did not receive his AM medication as prescribed by a physician due to the pharmacy not being able to fill the prescription timely.

Resolution: Corrected: 2026-04-13

While reviewing serious incidents related to the investigation, it was noted that pertinent information was missing from the report such as time, date, person making the report, and the name of child.

Resolution: Corrected: 2026-04-13

While reviewing the medication log it was noted the name and signature of the person who administered the medication was not present on the log.

Resolution: Corrected: 2026-04-13

While reviewing the medication log it was noted the name and signature of the person who administered the medication was not present on the log.

Resolution: Corrected: 2026-04-13

The operation is not approved to provide treatment services for autism spectrum disorder, however during an investigation it was found that treatment services for autism spectrum disorder are being provided.

Resolution: Corrected: 2026-04-07

The operation is not approved to provide treatment services for autism spectrum disorder, however during an investigation it was found that treatment services for autism spectrum disorder are being provided.

Resolution: Corrected: 2026-04-07

The operation is not approved to provide treatment services for autism spectrum disorder, however during an investigation it was found that treatment services for autism spectrum disorder are being provided.

Resolution: Corrected: 2026-04-07

The operation is not approved to provide treatment services for autism spectrum disorder, however during an investigation it was found that treatment services for autism spectrum disorder are being provided.

Resolution: Corrected: 2026-04-07

Case workers of the victim were not notified in a timely manner of medical treatment received by children.

Resolution: Corrected: 2026-04-16

A review of the intake, serious incident report, and the medical records indicated that Licensing was notified outside the 24-hour time frame.

Resolution: Corrected: 2026-04-14

A review of the intake, serious incident report, and the medical records indicated that Licensing was notified outside the 24-hour time frame.

Resolution: Corrected: 2026-04-14

Case workers of the victim were not notified in a timely manner of medical treatment received by children.

Resolution: Corrected: 2026-04-16

The medication log reviewed did not have a name and signature of the person who administered the medication.

Resolution: Corrected: 2026-03-31

The medication log reviewed and staff interviewed confirmed a medication was not administered to a child as prescribed.

Resolution: Corrected: 2026-03-31

A staff member did not have a completed background check prior to working at the operation.

Resolution: Corrected: 2026-02-13

A staff member did not have a completed background check prior to working at the operation.

Resolution: Corrected: 2026-02-13

A staff member did not have a completed background check prior to working at the operation.

Resolution: Corrected: 2026-02-13

A staff member did not have a completed background check prior to working at the operation.

Resolution: Corrected: 2026-02-13

A staff member did not have a completed background check prior to working at the operation.

Resolution: Corrected: 2026-02-13

A staff member did not have a completed background check prior to working at the operation.

Resolution: Corrected: 2026-02-13

A staff member did not have a completed background check prior to working at the operation.

Resolution: Corrected: 2026-02-13

A staff member did not have a completed background check prior to working at the operation.

Resolution: Corrected: 2026-02-13

A staff member did not have a completed background check prior to working at the operation.

Resolution: Corrected: 2026-02-13

A medication record for a child in care is not accurately updated to advised if a medication was taken, missed or refused, however the remaining amount reflect as if one medication was taken.

Resolution: Corrected: 2025-09-19

A medication record for a child in care is not accurately updated to advised if a medication was taken, missed or refused, however the remaining amount reflect as if one medication was taken.

Resolution: Corrected: 2025-09-19

A medication record for a child in care is not accurately updated to advised if a medication was taken, missed or refused, however the remaining amount reflect as if one medication was taken.

Resolution: Corrected: 2025-09-19

A medication record for a child in care is not accurately updated to advised if a medication was taken, missed or refused, however the remaining amount reflect as if one medication was taken.

Resolution: Corrected: 2025-09-19

A medication record for a child in care is not accurately updated to advised if a medication was taken, missed or refused, however the remaining amount reflect as if one medication was taken.

Resolution: Corrected: 2025-09-19

A medication record for a child in care is not accurately updated to advised if a medication was taken, missed or refused, however the remaining amount reflect as if one medication was taken.

Resolution: Corrected: 2025-09-19

A medication record for a child in care is not accurately updated to advised if a medication was taken, missed or refused, however the remaining amount reflect as if one medication was taken.

Resolution: Corrected: 2025-09-19

A medication record for a child in care is not accurately updated to advised if a medication was taken, missed or refused, however the remaining amount reflect as if one medication was taken.

Resolution: Corrected: 2025-09-19

A medication record for a child in care is not accurately updated to advised if a medication was taken, missed or refused, however the remaining amount reflect as if one medication was taken.

Resolution: Corrected: 2025-09-19

A medication record for a child in care is not accurately updated to advised if a medication was taken, missed or refused, however the remaining amount reflect as if one medication was taken.

Resolution: Corrected: 2025-09-19

Three fire extinguishers observed at the operations were last serviced in July of 2024.

Resolution: Corrected: 2025-08-27

Three fire extinguishers observed at the operations were last serviced in July of 2024.

Resolution: Corrected: 2025-08-27

Three fire extinguishers observed at the operations were last serviced in July of 2024.

Resolution: Corrected: 2025-08-27

Three fire extinguishers observed at the operations were last serviced in July of 2024.

Resolution: Corrected: 2025-08-27

Three fire extinguishers observed at the operations were last serviced in July of 2024.

Resolution: Corrected: 2025-08-27

Three fire extinguishers observed at the operations were last serviced in July of 2024.

Resolution: Corrected: 2025-08-27

Three fire extinguishers observed at the operations were last serviced in July of 2024.

Resolution: Corrected: 2025-08-27

Three fire extinguishers observed at the operations were last serviced in July of 2024.

Resolution: Corrected: 2025-08-27

Three fire extinguishers observed at the operations were last serviced in July of 2024.

Resolution: Corrected: 2025-08-27

It was determined that staff lacked prudent judgement by allowing a child in care to spend the day and nights at a sister RTC, which was not the child's permanent placement and there was no documentation in place allowing this.

Resolution: Corrected: 2025-08-15

It was determined that a child in care was spending the day and night at another placement and was being transferred by placement staff.

Resolution: Corrected: 2025-08-15

It was determined that a child in care was spending the day and night at another placement and was being transferred by placement staff.

Resolution: Corrected: 2025-08-15

It was determined that staff lacked prudent judgement by allowing a child in care to spend the day and nights at a sister RTC, which was not the child's permanent placement and there was no documentation in place allowing this.

Resolution: Corrected: 2025-08-15

It was determined that a child in care was spending the day and night at another placement and was being transferred by placement staff.

Resolution: Corrected: 2025-08-15

It was determined that a child in care was spending the day and night at another placement and was being transferred by placement staff.

Resolution: Corrected: 2025-08-15

It was determined that staff lacked prudent judgement by allowing a child in care to spend the day and nights at a sister RTC, which was not the child's permanent placement and there was no documentation in place allowing this.

Resolution: Corrected: 2025-08-15

It was determined that staff lacked prudent judgement by allowing a child in care to spend the day and nights at a sister RTC, which was not the child's permanent placement and there was no documentation in place allowing this.

Resolution: Corrected: 2025-08-15

It was determined that a child in care was spending the day and night at another placement and was being transferred by placement staff.

Resolution: Corrected: 2025-08-15

It was determined that a child in care was spending the day and night at another placement and was being transferred by placement staff.

Resolution: Corrected: 2025-08-15

It was determined that staff lacked prudent judgement by allowing a child in care to spend the day and nights at a sister RTC, which was not the child's permanent placement and there was no documentation in place allowing this.

Resolution: Corrected: 2025-08-15

It was determined that a child in care was spending the day and night at another placement and was being transferred by placement staff.

Resolution: Corrected: 2025-08-15

It was determined that staff lacked prudent judgement by allowing a child in care to spend the day and nights at a sister RTC, which was not the child's permanent placement and there was no documentation in place allowing this.

Resolution: Corrected: 2025-08-15

It was determined that staff lacked prudent judgement by allowing a child in care to spend the day and nights at a sister RTC, which was not the child's permanent placement and there was no documentation in place allowing this.

Resolution: Corrected: 2025-08-15

It was determined that staff lacked prudent judgement by allowing a child in care to spend the day and nights at a sister RTC, which was not the child's permanent placement and there was no documentation in place allowing this.

Resolution: Corrected: 2025-08-15

It was determined that staff lacked prudent judgement by allowing a child in care to spend the day and nights at a sister RTC, which was not the child's permanent placement and there was no documentation in place allowing this.

Resolution: Corrected: 2025-08-15

It was determined that a child in care was spending the day and night at another placement and was being transferred by placement staff.

Resolution: Corrected: 2025-08-15

It was determined that a child in care was spending the day and night at another placement and was being transferred by placement staff.

Resolution: Corrected: 2025-08-15

It was determined that a child in care was spending the day and night at another placement and was being transferred by placement staff.

Resolution: Corrected: 2025-08-15

It was determined that staff lacked prudent judgement by allowing a child in care to spend the day and nights at a sister RTC, which was not the child's permanent placement and there was no documentation in place allowing this.

Resolution: Corrected: 2025-08-15

It was determined that a child in care was spending the day and night at another placement and was being transferred by placement staff.

Resolution: Corrected: 2025-08-15

It was determined that staff lacked prudent judgement by allowing a child in care to spend the day and nights at a sister RTC, which was not the child's permanent placement and there was no documentation in place allowing this.

Resolution: Corrected: 2025-08-15

A staff member reported they were not informed a child in care was not to drink soda after being discharged from the hospital and therefore allowed the child to drink soda. This resulted in the child returning to the hospital.

Resolution: Corrected: 2025-09-02

A staff member reported they were not informed a child in care was not to drink soda after being discharged from the hospital and therefore allowed the child to drink soda. This resulted in the child returning to the hospital.

Resolution: Corrected: 2025-09-02

A staff member reported they were not informed a child in care was not to drink soda after being discharged from the hospital and therefore allowed the child to drink soda. This resulted in the child returning to the hospital.

Resolution: Corrected: 2025-09-02

A staff member reported they were not informed a child in care was not to drink soda after being discharged from the hospital and therefore allowed the child to drink soda. This resulted in the child returning to the hospital.

Resolution: Corrected: 2025-09-02

A staff member reported they were not informed a child in care was not to drink soda after being discharged from the hospital and therefore allowed the child to drink soda. This resulted in the child returning to the hospital.

Resolution: Corrected: 2025-09-02

A staff member reported they were not informed a child in care was not to drink soda after being discharged from the hospital and therefore allowed the child to drink soda. This resulted in the child returning to the hospital.

Resolution: Corrected: 2025-09-02

A staff member reported they were not informed a child in care was not to drink soda after being discharged from the hospital and therefore allowed the child to drink soda. This resulted in the child returning to the hospital.

Resolution: Corrected: 2025-09-02

A staff member reported they were not informed a child in care was not to drink soda after being discharged from the hospital and therefore allowed the child to drink soda. This resulted in the child returning to the hospital.

Resolution: Corrected: 2025-09-02

A staff member reported they were not informed a child in care was not to drink soda after being discharged from the hospital and therefore allowed the child to drink soda. This resulted in the child returning to the hospital.

Resolution: Corrected: 2025-09-02

A staff member reported they were not informed a child in care was not to drink soda after being discharged from the hospital and therefore allowed the child to drink soda. This resulted in the child returning to the hospital.

Resolution: Corrected: 2025-09-02

A staff member reported they were not informed a child in care was not to drink soda after being discharged from the hospital and therefore allowed the child to drink soda. This resulted in the child returning to the hospital.

Resolution: Corrected: 2025-09-02

There are several staff personnel with active background checks that no long work for the operation.

Resolution: Corrected: 2025-01-31

There are several staff personnel with active background checks that no long work for the operation.

Resolution: Corrected: 2025-01-31

There are several staff personnel with active background checks that no long work for the operation.

Resolution: Corrected: 2025-01-31

There are several staff personnel with active background checks that no long work for the operation.

Resolution: Corrected: 2025-01-31

There are several staff personnel with active background checks that no long work for the operation.

Resolution: Corrected: 2025-01-31

There are several staff personnel with active background checks that no long work for the operation.

Resolution: Corrected: 2025-01-31

There are several staff personnel with active background checks that no long work for the operation.

Resolution: Corrected: 2025-01-31

There are several staff personnel with active background checks that no long work for the operation.

Resolution: Corrected: 2025-01-31

There are several staff personnel with active background checks that no long work for the operation.

Resolution: Corrected: 2025-01-31

There are several staff personnel with active background checks that no long work for the operation.

Resolution: Corrected: 2025-01-31

Multiple person interviewed advised of children being restrained with their hand behind their backs.

Resolution: Corrected: 2025-02-14

Child was able to just out of window due to lack of supervision.

Resolution: Corrected: 2025-02-14

Multiple person interviewed advised of children being restrained with their hand behind their backs.

Resolution: Corrected: 2025-02-14

Child was able to just out of window due to lack of supervision.

Resolution: Corrected: 2025-02-14

Multiple person interviewed advised of children being restrained with their hand behind their backs.

Resolution: Corrected: 2025-02-14

Child was able to just out of window due to lack of supervision.

Resolution: Corrected: 2025-02-14

Child was able to just out of window due to lack of supervision.

Resolution: Corrected: 2025-02-14

Multiple person interviewed advised of children being restrained with their hand behind their backs.

Resolution: Corrected: 2025-02-14

Child was able to just out of window due to lack of supervision.

Resolution: Corrected: 2025-02-14

Multiple person interviewed advised of children being restrained with their hand behind their backs.

Resolution: Corrected: 2025-02-14

Child was able to just out of window due to lack of supervision.

Resolution: Corrected: 2025-02-14

Multiple person interviewed advised of children being restrained with their hand behind their backs.

Resolution: Corrected: 2025-02-14

Child was able to just out of window due to lack of supervision.

Resolution: Corrected: 2025-02-14

Multiple person interviewed advised of children being restrained with their hand behind their backs.

Resolution: Corrected: 2025-02-14

Child was able to just out of window due to lack of supervision.

Resolution: Corrected: 2025-02-14

Multiple person interviewed advised of children being restrained with their hand behind their backs.

Resolution: Corrected: 2025-02-14

Child was able to just out of window due to lack of supervision.

Resolution: Corrected: 2025-02-14

Multiple person interviewed advised of children being restrained with their hand behind their backs.

Resolution: Corrected: 2025-02-14

Child was able to just out of window due to lack of supervision.

Resolution: Corrected: 2025-02-14

Multiple person interviewed advised of children being restrained with their hand behind their backs.

Resolution: Corrected: 2025-02-14

Child was able to just out of window due to lack of supervision.

Resolution: Corrected: 2025-02-14

Multiple person interviewed advised of children being restrained with their hand behind their backs.

Resolution: Corrected: 2025-02-14

It was determined that the operation failed to report a child arrest. An intake (78855200) was received from law enforcement and not the operation to report a child arrest.

Resolution: Corrected: 2024-05-20

It was determined that the operation failed to report a child arrest. An intake (78855200) was received from law enforcement and not the operation to report a child arrest.

Resolution: Corrected: 2024-05-20

It was determined that the operation failed to report a child arrest. An intake (78855200) was received from law enforcement and not the operation to report a child arrest.

Resolution: Corrected: 2024-05-20

It was determined that the operation failed to report a child arrest. An intake (78855200) was received from law enforcement and not the operation to report a child arrest.

Resolution: Corrected: 2024-05-20

It was determined that the operation failed to report a child arrest. An intake (78855200) was received from law enforcement and not the operation to report a child arrest.

Resolution: Corrected: 2024-05-20

It was determined that the operation failed to report a child arrest. An intake (78855200) was received from law enforcement and not the operation to report a child arrest.

Resolution: Corrected: 2024-05-20

It was determined that the operation failed to report a child arrest. An intake (78855200) was received from law enforcement and not the operation to report a child arrest.

Resolution: Corrected: 2024-05-20

It was determined that the operation failed to report a child arrest. An intake (78855200) was received from law enforcement and not the operation to report a child arrest.

Resolution: Corrected: 2024-05-20

It was determined that the operation failed to report a child arrest. An intake (78855200) was received from law enforcement and not the operation to report a child arrest.

Resolution: Corrected: 2024-05-20

It was determined that the operation failed to report a child arrest. An intake (78855200) was received from law enforcement and not the operation to report a child arrest.

Resolution: Corrected: 2024-05-20

It was determined that the operation failed to report a child arrest. An intake (78855200) was received from law enforcement and not the operation to report a child arrest.

Resolution: Corrected: 2024-05-20

It was found in two out of two staff records did not have the date of employment.

Resolution: Corrected: 2023-04-21

It was found in two out of two staff records reviewed there was no documentation of high school diploma or GED.

Resolution: Corrected: 2023-04-21

It was found in one of the two staff records reviewed that there was no documentation of preservice training.

Resolution: Corrected: 2023-04-21

It was found that the last time the operation validated background checks was in January 2023.

Resolution: Corrected: 2023-04-21

It was found that the operation did not have a written plan that included both indoor and outdoor activities per day.

Resolution: Corrected: 2023-04-21

It was found in two out of two staff files that were reviewed that there was no proof of a request for a background check.

Resolution: Corrected: 2023-04-21

It was found in 1 of the staff files reviewed that a direct care staff did not have a CPR certificate.

Resolution: Corrected: 2023-04-21

It was found that the operation has not been updating their menu.

Resolution: Corrected: 2023-04-21

It was found that in two out of two staff records did not have documentation of an orientation.

Resolution: Corrected: 2023-04-21

It was found in two out of two staff records reviewed that the Affidavit was not notarized.

Resolution: Corrected: 2023-04-21

It was found that the last time the operation validated background checks was in January 2023.

Resolution: Corrected: 2023-04-21

It was found in two out of two staff files that were reviewed that there was no proof of a request for a background check.

Resolution: Corrected: 2023-04-21

It was found in one of the two staff records reviewed that there was no documentation of preservice training.

Resolution: Corrected: 2023-04-21

It was found that the operation did not have a written plan that included both indoor and outdoor activities per day.

Resolution: Corrected: 2023-04-21

It was found in two out of two staff records did not have the date of employment.

Resolution: Corrected: 2023-04-21

It was found in two out of two staff records reviewed there was no documentation of high school diploma or GED.

Resolution: Corrected: 2023-04-21

It was found that in two out of two staff records did not have documentation of an orientation.

Resolution: Corrected: 2023-04-21

It was found that the last time the operation validated background checks was in January 2023.

Resolution: Corrected: 2023-04-21

It was found in 1 of the staff files reviewed that a direct care staff did not have a CPR certificate.

Resolution: Corrected: 2023-04-21

It was found in two out of two staff records reviewed that the Affidavit was not notarized.

Resolution: Corrected: 2023-04-21

It was found that the operation has not been updating their menu.

Resolution: Corrected: 2023-04-21

It was found in two out of two staff records reviewed there was no documentation of high school diploma or GED.

Resolution: Corrected: 2023-04-21

It was found that in two out of two staff records did not have documentation of an orientation.

Resolution: Corrected: 2023-04-21

It was found in two out of two staff records reviewed that the Affidavit was not notarized.

Resolution: Corrected: 2023-04-21

It was found in two out of two staff files that were reviewed that there was no proof of a request for a background check.

Resolution: Corrected: 2023-04-21

It was found in one of the two staff records reviewed that there was no documentation of preservice training.

Resolution: Corrected: 2023-04-21

It was found that the operation has not been updating their menu.

Resolution: Corrected: 2023-04-21

It was found that the operation did not have a written plan that included both indoor and outdoor activities per day.

Resolution: Corrected: 2023-04-21

It was found that the last time the operation validated background checks was in January 2023.

Resolution: Corrected: 2023-04-21

It was found in two out of two staff records did not have the date of employment.

Resolution: Corrected: 2023-04-21

It was found in 1 of the staff files reviewed that a direct care staff did not have a CPR certificate.

Resolution: Corrected: 2023-04-21

It was found in two out of two staff files that were reviewed that there was no proof of a request for a background check.

Resolution: Corrected: 2023-04-21

It was found that the last time the operation validated background checks was in January 2023.

Resolution: Corrected: 2023-04-21

It was found in two out of two staff records reviewed that the Affidavit was not notarized.

Resolution: Corrected: 2023-04-21

It was found in two out of two staff records reviewed there was no documentation of high school diploma or GED.

Resolution: Corrected: 2023-04-21

It was found that the operation did not have a written plan that included both indoor and outdoor activities per day.

Resolution: Corrected: 2023-04-21

It was found in 1 of the staff files reviewed that a direct care staff did not have a CPR certificate.

Resolution: Corrected: 2023-04-21

It was found in two out of two staff records did not have the date of employment.

Resolution: Corrected: 2023-04-21

It was found that the operation has not been updating their menu.

Resolution: Corrected: 2023-04-21

It was found that in two out of two staff records did not have documentation of an orientation.

Resolution: Corrected: 2023-04-21

It was found in one of the two staff records reviewed that there was no documentation of preservice training.

Resolution: Corrected: 2023-04-21

It was found in two out of two staff records reviewed that the Affidavit was not notarized.

Resolution: Corrected: 2023-04-21

It was found that in two out of two staff records did not have documentation of an orientation.

Resolution: Corrected: 2023-04-21

It was found that the operation did not have a written plan that included both indoor and outdoor activities per day.

Resolution: Corrected: 2023-04-21

It was found in two out of two staff records reviewed there was no documentation of high school diploma or GED.

Resolution: Corrected: 2023-04-21

It was found in one of the two staff records reviewed that there was no documentation of preservice training.

Resolution: Corrected: 2023-04-21

It was found that the operation has not been updating their menu.

Resolution: Corrected: 2023-04-21

It was found in two out of two staff records did not have the date of employment.

Resolution: Corrected: 2023-04-21

It was found in 1 of the staff files reviewed that a direct care staff did not have a CPR certificate.

Resolution: Corrected: 2023-04-21

It was found that the last time the operation validated background checks was in January 2023.

Resolution: Corrected: 2023-04-21

It was found in two out of two staff files that were reviewed that there was no proof of a request for a background check.

Resolution: Corrected: 2023-04-21

It was found in two out of two staff records reviewed that the Affidavit was not notarized.

Resolution: Corrected: 2023-04-21

It was found that in two out of two staff records did not have documentation of an orientation.

Resolution: Corrected: 2023-04-21

It was found that the last time the operation validated background checks was in January 2023.

Resolution: Corrected: 2023-04-21

It was found in two out of two staff records did not have the date of employment.

Resolution: Corrected: 2023-04-21

It was found in two out of two staff files that were reviewed that there was no proof of a request for a background check.

Resolution: Corrected: 2023-04-21

It was found that the operation did not have a written plan that included both indoor and outdoor activities per day.

Resolution: Corrected: 2023-04-21

It was found in one of the two staff records reviewed that there was no documentation of preservice training.

Resolution: Corrected: 2023-04-21

It was found that the operation has not been updating their menu.

Resolution: Corrected: 2023-04-21

It was found in 1 of the staff files reviewed that a direct care staff did not have a CPR certificate.

Resolution: Corrected: 2023-04-21

It was found in two out of two staff records reviewed there was no documentation of high school diploma or GED.

Resolution: Corrected: 2023-04-21

It was found in one of the two staff records reviewed that there was no documentation of preservice training.

Resolution: Corrected: 2023-04-21

It was found in two out of two staff records reviewed there was no documentation of high school diploma or GED.

Resolution: Corrected: 2023-04-21

It was found in two out of two staff records did not have the date of employment.

Resolution: Corrected: 2023-04-21

It was found that the last time the operation validated background checks was in January 2023.

Resolution: Corrected: 2023-04-21

It was found that the operation has not been updating their menu.

Resolution: Corrected: 2023-04-21

It was found that the operation did not have a written plan that included both indoor and outdoor activities per day.

Resolution: Corrected: 2023-04-21

It was found in 1 of the staff files reviewed that a direct care staff did not have a CPR certificate.

Resolution: Corrected: 2023-04-21

It was found in two out of two staff records reviewed that the Affidavit was not notarized.

Resolution: Corrected: 2023-04-21

It was found in two out of two staff files that were reviewed that there was no proof of a request for a background check.

Resolution: Corrected: 2023-04-21

It was found that in two out of two staff records did not have documentation of an orientation.

Resolution: Corrected: 2023-04-21

It was found that in two out of two staff records did not have documentation of an orientation.

Resolution: Corrected: 2023-04-21

It was found that the last time the operation validated background checks was in January 2023.

Resolution: Corrected: 2023-04-21

It was found that the operation has not been updating their menu.

Resolution: Corrected: 2023-04-21

It was found in two out of two staff records reviewed there was no documentation of high school diploma or GED.

Resolution: Corrected: 2023-04-21

It was found in one of the two staff records reviewed that there was no documentation of preservice training.

Resolution: Corrected: 2023-04-21

It was found in 1 of the staff files reviewed that a direct care staff did not have a CPR certificate.

Resolution: Corrected: 2023-04-21

It was found in two out of two staff files that were reviewed that there was no proof of a request for a background check.

Resolution: Corrected: 2023-04-21

It was found in two out of two staff records reviewed that the Affidavit was not notarized.

Resolution: Corrected: 2023-04-21

It was found that the operation did not have a written plan that included both indoor and outdoor activities per day.

Resolution: Corrected: 2023-04-21

It was found in two out of two staff records did not have the date of employment.

Resolution: Corrected: 2023-04-21

It was found that in two out of two staff records did not have documentation of an orientation.

Resolution: Corrected: 2023-04-21

It was found that the last time the operation validated background checks was in January 2023.

Resolution: Corrected: 2023-04-21

It was found that the operation has not been updating their menu.

Resolution: Corrected: 2023-04-21

It was found in two out of two staff records reviewed there was no documentation of high school diploma or GED.

Resolution: Corrected: 2023-04-21

It was found in one of the two staff records reviewed that there was no documentation of preservice training.

Resolution: Corrected: 2023-04-21

It was found in 1 of the staff files reviewed that a direct care staff did not have a CPR certificate.

Resolution: Corrected: 2023-04-21

It was found in two out of two staff files that were reviewed that there was no proof of a request for a background check.

Resolution: Corrected: 2023-04-21

It was found in two out of two staff records reviewed that the Affidavit was not notarized.

Resolution: Corrected: 2023-04-21

It was found that the operation did not have a written plan that included both indoor and outdoor activities per day.

Resolution: Corrected: 2023-04-21

It was found in two out of two staff records did not have the date of employment.

Resolution: Corrected: 2023-04-21

It was found in two out of two staff files that were reviewed that there was no proof of a request for a background check.

Resolution: Corrected: 2023-04-21

It was found in two out of two staff records did not have the date of employment.

Resolution: Corrected: 2023-04-21

It was found in 1 of the staff files reviewed that a direct care staff did not have a CPR certificate.

Resolution: Corrected: 2023-04-21

It was found in two out of two staff files that were reviewed that there was no proof of a request for a background check.

Resolution: Corrected: 2023-04-21

It was found in two out of two staff records reviewed there was no documentation of high school diploma or GED.

Resolution: Corrected: 2023-04-21

It was found that the operation did not have a written plan that included both indoor and outdoor activities per day.

Resolution: Corrected: 2023-04-21

It was found that the operation has not been updating their menu.

Resolution: Corrected: 2023-04-21

It was found that in two out of two staff records did not have documentation of an orientation.

Resolution: Corrected: 2023-04-21

It was found in one of the two staff records reviewed that there was no documentation of preservice training.

Resolution: Corrected: 2023-04-21

It was found in two out of two staff records reviewed that the Affidavit was not notarized.

Resolution: Corrected: 2023-04-21

It was found in 1 of the staff files reviewed that a direct care staff did not have a CPR certificate.

Resolution: Corrected: 2023-04-21

It was found that in two out of two staff records did not have documentation of an orientation.

Resolution: Corrected: 2023-04-21

It was found in two out of two staff records reviewed there was no documentation of high school diploma or GED.

Resolution: Corrected: 2023-04-21

It was found in one of the two staff records reviewed that there was no documentation of preservice training.

Resolution: Corrected: 2023-04-21

It was found that the operation has not been updating their menu.

Resolution: Corrected: 2023-04-21

It was found that the last time the operation validated background checks was in January 2023.

Resolution: Corrected: 2023-04-21

It was found in two out of two staff records did not have the date of employment.

Resolution: Corrected: 2023-04-21

It was found that the operation did not have a written plan that included both indoor and outdoor activities per day.

Resolution: Corrected: 2023-04-21

It was found in two out of two staff records reviewed that the Affidavit was not notarized.

Resolution: Corrected: 2023-04-21

It was found that the operations policy included treatment services which was not allowed due to providing only emergency services. The demographic served was inconsistent throughout the operation's policy.

Resolution: Corrected: 2023-01-20

It was found that no food substitutions were found on the menu provided by the operation at inspection.

Resolution: Corrected: 2023-01-20

It was found at inspection that the operation did not have a recreational calendar for residents.

Resolution: Corrected: 2023-01-20

It was found that the last health inspection was completed 12/15/2021.

Resolution: Corrected: 2023-01-20

It was found at the inspection that there was no background check done for Administrator or owner.

Resolution: Corrected: 2023-01-09

It was found that the last health inspection was completed 12/15/2021.

Resolution: Corrected: 2023-01-20

It was found at the inspection that there was no background check done for Administrator or owner.

Resolution: Corrected: 2023-01-09

It was found that the last health inspection was completed 12/15/2021.

Resolution: Corrected: 2023-01-20

It was found at the inspection that there was no background check done for Administrator or owner.

Resolution: Corrected: 2023-01-09

It was found that no food substitutions were found on the menu provided by the operation at inspection.

Resolution: Corrected: 2023-01-20

It was found that the operations policy included treatment services which was not allowed due to providing only emergency services. The demographic served was inconsistent throughout the operation's policy.

Resolution: Corrected: 2023-01-20

It was found at inspection that the operation did not have a recreational calendar for residents.

Resolution: Corrected: 2023-01-20

It was found that the operations policy included treatment services which was not allowed due to providing only emergency services. The demographic served was inconsistent throughout the operation's policy.

Resolution: Corrected: 2023-01-20

It was found at inspection that the operation did not have a recreational calendar for residents.

Resolution: Corrected: 2023-01-20

It was found at the inspection that there was no background check done for Administrator or owner.

Resolution: Corrected: 2023-01-09

It was found that no food substitutions were found on the menu provided by the operation at inspection.

Resolution: Corrected: 2023-01-20

It was found that the last health inspection was completed 12/15/2021.

Resolution: Corrected: 2023-01-20

It was found that the operations policy included treatment services which was not allowed due to providing only emergency services. The demographic served was inconsistent throughout the operation's policy.

Resolution: Corrected: 2023-01-20

It was found at the inspection that there was no background check done for Administrator or owner.

Resolution: Corrected: 2023-01-09

It was found at inspection that the operation did not have a recreational calendar for residents.

Resolution: Corrected: 2023-01-20

It was found that no food substitutions were found on the menu provided by the operation at inspection.

Resolution: Corrected: 2023-01-20

It was found that the last health inspection was completed 12/15/2021.

Resolution: Corrected: 2023-01-20

It was found that no food substitutions were found on the menu provided by the operation at inspection.

Resolution: Corrected: 2023-01-20

It was found at the inspection that there was no background check done for Administrator or owner.

Resolution: Corrected: 2023-01-09

It was found that the operations policy included treatment services which was not allowed due to providing only emergency services. The demographic served was inconsistent throughout the operation's policy.

Resolution: Corrected: 2023-01-20

It was found that the last health inspection was completed 12/15/2021.

Resolution: Corrected: 2023-01-20

It was found at inspection that the operation did not have a recreational calendar for residents.

Resolution: Corrected: 2023-01-20

It was found that no food substitutions were found on the menu provided by the operation at inspection.

Resolution: Corrected: 2023-01-20

It was found that the operations policy included treatment services which was not allowed due to providing only emergency services. The demographic served was inconsistent throughout the operation's policy.

Resolution: Corrected: 2023-01-20

It was found that the last health inspection was completed 12/15/2021.

Resolution: Corrected: 2023-01-20

It was found at the inspection that there was no background check done for Administrator or owner.

Resolution: Corrected: 2023-01-09

It was found at inspection that the operation did not have a recreational calendar for residents.

Resolution: Corrected: 2023-01-20

It was found that no food substitutions were found on the menu provided by the operation at inspection.

Resolution: Corrected: 2023-01-20

It was found that the last health inspection was completed 12/15/2021.

Resolution: Corrected: 2023-01-20

It was found at the inspection that there was no background check done for Administrator or owner.

Resolution: Corrected: 2023-01-09

It was found that the operations policy included treatment services which was not allowed due to providing only emergency services. The demographic served was inconsistent throughout the operation's policy.

Resolution: Corrected: 2023-01-20

It was found at inspection that the operation did not have a recreational calendar for residents.

Resolution: Corrected: 2023-01-20

It was found that the operations policy included treatment services which was not allowed due to providing only emergency services. The demographic served was inconsistent throughout the operation's policy.

Resolution: Corrected: 2023-01-20

It was found that no food substitutions were found on the menu provided by the operation at inspection.

Resolution: Corrected: 2023-01-20

It was found at inspection that the operation did not have a recreational calendar for residents.

Resolution: Corrected: 2023-01-20

It was found at the inspection that there was no background check done for Administrator or owner.

Resolution: Corrected: 2023-01-09

It was found that the last health inspection was completed 12/15/2021.

Resolution: Corrected: 2023-01-20

It was found that the operations policy included treatment services which was not allowed due to providing only emergency services. The demographic served was inconsistent throughout the operation's policy.

Resolution: Corrected: 2023-01-20

It was found at the inspection that there was no background check done for Administrator or owner.

Resolution: Corrected: 2023-01-09

It was found that no food substitutions were found on the menu provided by the operation at inspection.

Resolution: Corrected: 2023-01-20

It was found that the last health inspection was completed 12/15/2021.

Resolution: Corrected: 2023-01-20

It was found at inspection that the operation did not have a recreational calendar for residents.

Resolution: Corrected: 2023-01-20

It was found that the operations policy included treatment services which was not allowed due to providing only emergency services. The demographic served was inconsistent throughout the operation's policy.

Resolution: Corrected: 2023-01-20

It was found at the inspection that there was no background check done for Administrator or owner.

Resolution: Corrected: 2023-01-09

It was found that the last health inspection was completed 12/15/2021.

Resolution: Corrected: 2023-01-20

It was found that no food substitutions were found on the menu provided by the operation at inspection.

Resolution: Corrected: 2023-01-20

It was found at inspection that the operation did not have a recreational calendar for residents.

Resolution: Corrected: 2023-01-20

It was found that the operations policy included treatment services which was not allowed due to providing only emergency services. The demographic served was inconsistent throughout the operation's policy.

Resolution: Corrected: 2023-01-20

It was found that no food substitutions were found on the menu provided by the operation at inspection.

Resolution: Corrected: 2023-01-20

It was found at inspection that the operation did not have a recreational calendar for residents.

Resolution: Corrected: 2023-01-20