Rejo Helping Hands Inc.

A staff member did not have training prior to being counted into ratio and conducting a restraint.

Resolution: Corrected: 2025-12-29

Staff admitted to placing the child's arms behind his back.

Resolution: Corrected: 2025-12-29

Staff admitted to placing the child's arms behind his back.

Resolution: Corrected: 2025-12-29

A staff member did not have training prior to being counted into ratio and conducting a restraint.

Resolution: Corrected: 2025-12-29

Staff admitted to placing the child's arms behind his back.

Resolution: Corrected: 2025-12-29

Staff admitted to placing the child's arms behind his back.

Resolution: Corrected: 2025-12-29

A staff member did not have training prior to being counted into ratio and conducting a restraint.

Resolution: Corrected: 2025-12-29

A staff member did not have training prior to being counted into ratio and conducting a restraint.

Resolution: Corrected: 2025-12-29

During the inspection it was determined that the operation's fire inspection certification was expired.

Resolution: Corrected: 2025-09-26

It was determined during this inspection that the operation's sanitation certification was expired.

Resolution: Corrected: 2025-09-19

During the inspection it was determined that the operation's fire inspection certification was expired.

Resolution: Corrected: 2025-09-26

It was determined during this inspection that the operation's sanitation certification was expired.

Resolution: Corrected: 2025-09-19

During the inspection it was determined that the operation's fire inspection certification was expired.

Resolution: Corrected: 2025-09-26

It was determined during this inspection that the operation's sanitation certification was expired.

Resolution: Corrected: 2025-09-19

During the inspection it was determined that the operation's fire inspection certification was expired.

Resolution: Corrected: 2025-09-26

It was determined during this inspection that the operation's sanitation certification was expired.

Resolution: Corrected: 2025-09-19

The operation created an incident with an incorrect child in care's name on it.

Resolution: Corrected: 2025-11-28

The operation created an incident with an incorrect child in care's name on it.

Resolution: Corrected: 2025-11-28

The operation created an incident with an incorrect child in care's name on it.

Resolution: Corrected: 2025-11-28

The operation created an incident with an incorrect child in care's name on it.

Resolution: Corrected: 2025-11-28

A caregiver restrained a child in care with force, leaving a hand print. on the child's arm.

Resolution: Corrected: 2025-10-01

A caregiver restrained a child in care with force, leaving a hand print. on the child's arm.

Resolution: Corrected: 2025-10-01

A caregiver restrained a child in care with force, leaving a hand print. on the child's arm.

Resolution: Corrected: 2025-10-01

A caregiver restrained a child in care with force, leaving a hand print. on the child's arm.

Resolution: Corrected: 2025-10-01

A child visiting the operation threatened to discipline a child in care.

Resolution: Corrected: 2025-10-10

Incident report was missing required information such as time, child's date of birth, date of admission...

Resolution: Corrected: 2025-10-10

Incident report was missing required information such as time, child's date of birth, date of admission...

Resolution: Corrected: 2025-10-10

Incident report was missing required information such as time, child's date of birth, date of admission...

Resolution: Corrected: 2025-10-10

A child visiting the operation threatened to discipline a child in care.

Resolution: Corrected: 2025-10-10

A child visiting the operation threatened to discipline a child in care.

Resolution: Corrected: 2025-10-10

Incident report was missing required information such as time, child's date of birth, date of admission...

Resolution: Corrected: 2025-10-10

A child visiting the operation threatened to discipline a child in care.

Resolution: Corrected: 2025-10-10

Names of staff involved and witnesses not listed on serious incident report. Report mentioned staff intervened but staff was not listed.

Resolution: Corrected: 2025-08-06

Names of staff involved and witnesses not listed on serious incident report. Report mentioned staff intervened but staff was not listed.

Resolution: Corrected: 2025-08-06

Names of staff involved and witnesses not listed on serious incident report. Report mentioned staff intervened but staff was not listed.

Resolution: Corrected: 2025-08-06

Names of staff involved and witnesses not listed on serious incident report. Report mentioned staff intervened but staff was not listed.

Resolution: Corrected: 2025-08-06

Staff placed youth in cares arms behind their back and during a short personal restraint.

Resolution: Corrected: 2025-08-21

Staff placed youth in cares arms behind their back and during a short personal restraint.

Resolution: Corrected: 2025-08-21

Staff placed youth in cares arms behind their back and during a short personal restraint.

Resolution: Corrected: 2025-08-21

Staff placed youth in cares arms behind their back and during a short personal restraint.

Resolution: Corrected: 2025-08-21

One of the three children's medication records reviewed was missing the times medications were administered.

Resolution: Corrected: 2025-06-17

Three out of three medications were observed to be stored in disposable cups - outside of their original packaging.

Resolution: Corrected: 2025-06-17

The operation's fire extinguisher in the rec area was due to be serviced by the end of May 2025.

Resolution: Corrected at inspection

Butter was not covered in the freezer, staff threw uncovered food.

Resolution: Corrected at inspection

Medication counts were inaccurate for all three boys' medicaition records.

Resolution: Corrected: 2025-06-17

Three of the boys' medications are being prepared between 12 to 24 hours in advance.

Resolution: Corrected: 2025-06-17

Two of the three chest freezers did not contain thermometers

Resolution: Corrected: 2025-06-17

Cleaning supplies and chemicals were on the table and under an unlocked cabinet in the rec room. This was corrected by staff at inspection.

Resolution: Corrected at inspection

One of the three children's medication records reviewed was missing the times medications were administered.

Resolution: Corrected: 2025-06-17

Two of the three chest freezers did not contain thermometers

Resolution: Corrected: 2025-06-17

Three of the boys' medications are being prepared between 12 to 24 hours in advance.

Resolution: Corrected: 2025-06-17

One of the three children's medication records reviewed was missing the times medications were administered.

Resolution: Corrected: 2025-06-17

Three out of three medications were observed to be stored in disposable cups - outside of their original packaging.

Resolution: Corrected: 2025-06-17

Medication counts were inaccurate for all three boys' medicaition records.

Resolution: Corrected: 2025-06-17

Butter was not covered in the freezer, staff threw uncovered food.

Resolution: Corrected at inspection

Cleaning supplies and chemicals were on the table and under an unlocked cabinet in the rec room. This was corrected by staff at inspection.

Resolution: Corrected at inspection

Three out of three medications were observed to be stored in disposable cups - outside of their original packaging.

Resolution: Corrected: 2025-06-17

Two of the three chest freezers did not contain thermometers

Resolution: Corrected: 2025-06-17

Three of the boys' medications are being prepared between 12 to 24 hours in advance.

Resolution: Corrected: 2025-06-17

Three of the boys' medications are being prepared between 12 to 24 hours in advance.

Resolution: Corrected: 2025-06-17

The operation's fire extinguisher in the rec area was due to be serviced by the end of May 2025.

Resolution: Corrected at inspection

Medication counts were inaccurate for all three boys' medicaition records.

Resolution: Corrected: 2025-06-17

Butter was not covered in the freezer, staff threw uncovered food.

Resolution: Corrected at inspection

Cleaning supplies and chemicals were on the table and under an unlocked cabinet in the rec room. This was corrected by staff at inspection.

Resolution: Corrected at inspection

Three out of three medications were observed to be stored in disposable cups - outside of their original packaging.

Resolution: Corrected: 2025-06-17

The operation's fire extinguisher in the rec area was due to be serviced by the end of May 2025.

Resolution: Corrected at inspection

One of the three children's medication records reviewed was missing the times medications were administered.

Resolution: Corrected: 2025-06-17

The operation's fire extinguisher in the rec area was due to be serviced by the end of May 2025.

Resolution: Corrected at inspection

Two of the three chest freezers did not contain thermometers

Resolution: Corrected: 2025-06-17

Cleaning supplies and chemicals were on the table and under an unlocked cabinet in the rec room. This was corrected by staff at inspection.

Resolution: Corrected at inspection

Butter was not covered in the freezer, staff threw uncovered food.

Resolution: Corrected at inspection

Medication counts were inaccurate for all three boys' medicaition records.

Resolution: Corrected: 2025-06-17

Unauthorized Absent Log is missing the age and gender of the victim.

Resolution: Corrected: 2025-07-29

Unauthorized Absent Log is missing the age and gender of the victim.

Resolution: Corrected: 2025-07-29

Unauthorized Absent Log is missing the age and gender of the victim.

Resolution: Corrected: 2025-07-29

Unauthorized Absent Log is missing the age and gender of the victim.

Resolution: Corrected: 2025-07-29

The operation has been operating without an Administrator for more than 60 days.

Resolution: Corrected: 2025-06-29

The operation has been operating without an Administrator for more than 60 days.

Resolution: Corrected: 2025-06-29

The operation has been operating without an Administrator for more than 60 days.

Resolution: Corrected: 2025-06-29

The operation has been operating without an Administrator for more than 60 days.

Resolution: Corrected: 2025-06-29

Staff removed a child's shirt from their body in front of other children in care while attempting to get the child to shower.

Resolution: Corrected: 2025-07-10

Staff used restraint in an effort to have child comply with taking a shower.

Resolution: Corrected: 2025-07-10

Staff used restraint in an effort to have child comply with taking a shower.

Resolution: Corrected: 2025-07-10

Staff used restraint in an effort to have child comply with taking a shower.

Resolution: Corrected: 2025-07-10

Staff removed a child's shirt from their body in front of other children in care while attempting to get the child to shower.

Resolution: Corrected: 2025-07-10

Staff removed a child's shirt from their body in front of other children in care while attempting to get the child to shower.

Resolution: Corrected: 2025-07-10

Staff removed a child's shirt from their body in front of other children in care while attempting to get the child to shower.

Resolution: Corrected: 2025-07-10

Staff used restraint in an effort to have child comply with taking a shower.

Resolution: Corrected: 2025-07-10

The operation failed to ensure a caregiver had a completed background check prior to being hired.

Resolution: Corrected: 2025-07-11

The operation failed to ensure a caregiver had a completed background check prior to being hired.

Resolution: Corrected: 2025-07-11

The operation failed to ensure a caregiver had a completed background check prior to being hired.

Resolution: Corrected: 2025-07-11

The operation failed to ensure a caregiver had a completed background check prior to being hired.

Resolution: Corrected: 2025-07-11

One of the two child case workers indicated they were not notified by the operation of the child arrest. The worker reported being notified by a Probation Officer on Monday on the incident that took place over the weekend. The worker denied missing a call over the weekend from the operation.

Resolution: Corrected: 2025-07-15

One of two child case workers indicated they had not been notified by the operation within six hours of determining their child was on unauthorized absence. The worker reported the unauthorized absence occurred on June 6, 2025, and the worker was notified by a Probation Officer on June 9, 2025, of the unauthorized absence.

Resolution: Corrected: 2025-07-15

One of the two child case workers indicated they were not notified by the operation of the child arrest. The worker reported being notified by a Probation Officer on Monday on the incident that took place over the weekend. The worker denied missing a call over the weekend from the operation.

Resolution: Corrected: 2025-07-15

One of two child case workers indicated they had not been notified by the operation within six hours of determining their child was on unauthorized absence. The worker reported the unauthorized absence occurred on June 6, 2025, and the worker was notified by a Probation Officer on June 9, 2025, of the unauthorized absence.

Resolution: Corrected: 2025-07-15

One of the two child case workers indicated they were not notified by the operation of the child arrest. The worker reported being notified by a Probation Officer on Monday on the incident that took place over the weekend. The worker denied missing a call over the weekend from the operation.

Resolution: Corrected: 2025-07-15

One of two child case workers indicated they had not been notified by the operation within six hours of determining their child was on unauthorized absence. The worker reported the unauthorized absence occurred on June 6, 2025, and the worker was notified by a Probation Officer on June 9, 2025, of the unauthorized absence.

Resolution: Corrected: 2025-07-15

One of two child case workers indicated they had not been notified by the operation within six hours of determining their child was on unauthorized absence. The worker reported the unauthorized absence occurred on June 6, 2025, and the worker was notified by a Probation Officer on June 9, 2025, of the unauthorized absence.

Resolution: Corrected: 2025-07-15

One of the two child case workers indicated they were not notified by the operation of the child arrest. The worker reported being notified by a Probation Officer on Monday on the incident that took place over the weekend. The worker denied missing a call over the weekend from the operation.

Resolution: Corrected: 2025-07-15

The operation did not document the serious incident.

Resolution: Corrected: 2025-06-16

The operation did not document the serious incident.

Resolution: Corrected: 2025-06-16

The operation did not document the serious incident.

Resolution: Corrected: 2025-06-16

The operation did not document the serious incident.

Resolution: Corrected: 2025-06-16

According to documentation and interviews, the child injured their hand on 4/3/2025 but refused medical care until 4/4/2025. Staff made a report to SWI, however, the CVS parent did not receive the I&R until 3 days later on 4/7/2025. Thus, the CVS parent was not immediately notified of the critical injury immediately after ensuring the child's safety.

Resolution: Corrected: 2025-04-25

According to documentation and interviews, the child injured their hand on 4/3/2025 but refused medical care until 4/4/2025. Staff made a report to SWI, however, the CVS parent did not receive the I&R until 3 days later on 4/7/2025. Thus, the CVS parent was not immediately notified of the critical injury immediately after ensuring the child's safety.

Resolution: Corrected: 2025-04-25

According to documentation and interviews, the child injured their hand on 4/3/2025 but refused medical care until 4/4/2025. Staff made a report to SWI, however, the CVS parent did not receive the I&R until 3 days later on 4/7/2025. Thus, the CVS parent was not immediately notified of the critical injury immediately after ensuring the child's safety.

Resolution: Corrected: 2025-04-25

According to documentation and interviews, the child injured their hand on 4/3/2025 but refused medical care until 4/4/2025. Staff made a report to SWI, however, the CVS parent did not receive the I&R until 3 days later on 4/7/2025. Thus, the CVS parent was not immediately notified of the critical injury immediately after ensuring the child's safety.

Resolution: Corrected: 2025-04-25

Personnel records were not available for review when requested, records were locked up and staff did not have a key to access records.

Resolution: Corrected: 2025-03-17

During a walk-through of the operation, cottage three had mold in the shower handel.

Resolution: Corrected: 2025-03-17

During the inspection, the children's records reviewed did not include a copy of the service plan invitation in the file. Additionally, two of the employee records reviewed lacked documentation of the drug tests taken.

Resolution: Corrected: 2025-03-17

One of four children's records reviewed did not have an initial service plan in the file.

Resolution: Corrected: 2025-03-17

During a walkthrough of the facility it was observed that there was one caregiver to 9 children in the recreational area.

Resolution: Corrected: 2025-03-17

Two of four children's records reviewed did not have an immunization record in the file.

Resolution: Corrected: 2025-03-17

Two of four children's records reviewed did not have an immunization record in the file.

Resolution: Corrected: 2025-03-17

Personnel records were not available for review when requested, records were locked up and staff did not have a key to access records.

Resolution: Corrected: 2025-03-17

One of four children's records reviewed did not have an initial service plan in the file.

Resolution: Corrected: 2025-03-17

Two of four children's records reviewed did not have an immunization record in the file.

Resolution: Corrected: 2025-03-17

During the inspection, the children's records reviewed did not include a copy of the service plan invitation in the file. Additionally, two of the employee records reviewed lacked documentation of the drug tests taken.

Resolution: Corrected: 2025-03-17

Personnel records were not available for review when requested, records were locked up and staff did not have a key to access records.

Resolution: Corrected: 2025-03-17

During a walkthrough of the facility it was observed that there was one caregiver to 9 children in the recreational area.

Resolution: Corrected: 2025-03-17

One of four children's records reviewed did not have an initial service plan in the file.

Resolution: Corrected: 2025-03-17

During a walk-through of the operation, cottage three had mold in the shower handel.

Resolution: Corrected: 2025-03-17

Two of four children's records reviewed did not have an immunization record in the file.

Resolution: Corrected: 2025-03-17

During a walkthrough of the facility it was observed that there was one caregiver to 9 children in the recreational area.

Resolution: Corrected: 2025-03-17

During a walk-through of the operation, cottage three had mold in the shower handel.

Resolution: Corrected: 2025-03-17

Personnel records were not available for review when requested, records were locked up and staff did not have a key to access records.

Resolution: Corrected: 2025-03-17

During the inspection, the children's records reviewed did not include a copy of the service plan invitation in the file. Additionally, two of the employee records reviewed lacked documentation of the drug tests taken.

Resolution: Corrected: 2025-03-17

One of four children's records reviewed did not have an initial service plan in the file.

Resolution: Corrected: 2025-03-17

During a walkthrough of the facility it was observed that there was one caregiver to 9 children in the recreational area.

Resolution: Corrected: 2025-03-17

During the inspection, the children's records reviewed did not include a copy of the service plan invitation in the file. Additionally, two of the employee records reviewed lacked documentation of the drug tests taken.

Resolution: Corrected: 2025-03-17

During a walk-through of the operation, cottage three had mold in the shower handel.

Resolution: Corrected: 2025-03-17

Employee was observed to be asleep during night shift.

Resolution: Corrected: 2025-04-15

One child initial service plan was not completed within 45 days after admission.

Resolution: Corrected: 2025-04-15

Employee was observed to be asleep during night shift.

Resolution: Corrected: 2025-04-15

One child initial service plan was not completed within 45 days after admission.

Resolution: Corrected: 2025-04-15

One child initial service plan was not completed within 45 days after admission.

Resolution: Corrected: 2025-04-15

Employee was observed to be asleep during night shift.

Resolution: Corrected: 2025-04-15

Employee was observed to be asleep during night shift.

Resolution: Corrected: 2025-04-15

One child initial service plan was not completed within 45 days after admission.

Resolution: Corrected: 2025-04-15

Staff failed to appropriately intervene during a serious incident involving a child in care exhibiting self-harm and making threats of harm to others, as well as engaging in self-injurious behavior.

Resolution: Corrected: 2025-04-18

Staff failed to appropriately intervene during a serious incident involving a child in care exhibiting self-harm and making threats of harm to others, as well as engaging in self-injurious behavior.

Resolution: Corrected: 2025-04-18

Staff failed to appropriately intervene during a serious incident involving a child in care exhibiting self-harm and making threats of harm to others, as well as engaging in self-injurious behavior.

Resolution: Corrected: 2025-04-18

Staff failed to appropriately intervene during a serious incident involving a child in care exhibiting self-harm and making threats of harm to others, as well as engaging in self-injurious behavior.

Resolution: Corrected: 2025-04-18

The top bunk bed was observed to have no safety bedrails.

Resolution: Corrected: 2025-03-28

The administrator failed to communicate with all caregivers a children's risk behaviors.

Resolution: Corrected: 2025-03-28

The top bunk bed was observed to have no safety bedrails.

Resolution: Corrected: 2025-03-28

The administrator failed to communicate with all caregivers a children's risk behaviors.

Resolution: Corrected: 2025-03-28

The administrator failed to communicate with all caregivers a children's risk behaviors.

Resolution: Corrected: 2025-03-28

The top bunk bed was observed to have no safety bedrails.

Resolution: Corrected: 2025-03-28

The administrator failed to communicate with all caregivers a children's risk behaviors.

Resolution: Corrected: 2025-03-28

The top bunk bed was observed to have no safety bedrails.

Resolution: Corrected: 2025-03-28

The required PLSP debriefing wasn't conducted with a child post hospitalization.

Resolution: Corrected: 2025-03-19

There wasn't a post hospitalization safety plan created/updated after a child's hospitalization stay.

Resolution: Corrected: 2025-03-19

There wasn't a post hospitalization safety plan created/updated after a child's hospitalization stay.

Resolution: Corrected: 2025-03-19

There wasn't a post hospitalization safety plan created/updated after a child's hospitalization stay.

Resolution: Corrected: 2025-03-19

There wasn't a post hospitalization safety plan created/updated after a child's hospitalization stay.

Resolution: Corrected: 2025-03-19

The required PLSP debriefing wasn't conducted with a child post hospitalization.

Resolution: Corrected: 2025-03-19

The required PLSP debriefing wasn't conducted with a child post hospitalization.

Resolution: Corrected: 2025-03-19

The required PLSP debriefing wasn't conducted with a child post hospitalization.

Resolution: Corrected: 2025-03-19

A staff member involved other children when attempting to de-escalate a situation with one child in care.

Resolution: Corrected: 2025-01-24

A child in care reported being attacked by other children in care by the direction of a staff member. The victim sustained injuries that required medical attention.

Resolution: Corrected: 2025-01-24

A child in care reported being attacked by other children in care by the direction of a staff member. The victim sustained injuries that required medical attention.

Resolution: Corrected: 2025-01-24

A staff member involved other children when attempting to de-escalate a situation with one child in care.

Resolution: Corrected: 2025-01-24

A child in care reported being attacked by other children in care by the direction of a staff member. The victim sustained injuries that required medical attention.

Resolution: Corrected: 2025-01-24

A staff member involved other children when attempting to de-escalate a situation with one child in care.

Resolution: Corrected: 2025-01-24

A staff member involved other children when attempting to de-escalate a situation with one child in care.

Resolution: Corrected: 2025-01-24

A child in care reported being attacked by other children in care by the direction of a staff member. The victim sustained injuries that required medical attention.

Resolution: Corrected: 2025-01-24

Case manager reported that some staff files could not be reviewed due to them being forgotten at her personal residence.

Resolution: Corrected: 2024-08-23

One of four Preliminary Service Plans reviewed was observed to be missing a signature from Treatment Director or Professional Level Service Provider.

Resolution: Corrected: 2024-08-23

One of four staff members was observed to have an expired CPR Certification.

Resolution: Corrected: 2024-08-23

Neither of the four staff files reviewed was observed to be current in Suicide Training.

Resolution: Corrected: 2024-08-23

One of the four staff files reviewed was observed to be delinquent in annual Emergency Behavior Intervention Training.

Resolution: Corrected: 2024-08-23

One of four Child Right's documents reviewed for a child admitted on 07/29/2024 was observed to be missing the child's signature.

Resolution: Corrected: 2024-08-23

Two of four Admission Assessments reviewed was observed to not be signed or dated from the Professional Level Service Provider.

Resolution: Corrected: 2024-08-23

Two of the four staff members records involved was observed to be delinquent on Normalcy Training.

Resolution: Corrected: 2024-08-23

Three of the four records reviewed was observed to have immunization records in the admission documentation.

Resolution: Corrected: 2024-08-23

Two of four Admission Assessments reviewed was observed to not be signed or dated from the Professional Level Service Provider.

Resolution: Corrected: 2024-08-23

Three of the four records reviewed was observed to have immunization records in the admission documentation.

Resolution: Corrected: 2024-08-23

One of four Child Right's documents reviewed for a child admitted on 07/29/2024 was observed to be missing the child's signature.

Resolution: Corrected: 2024-08-23

Three of the four records reviewed was observed to have immunization records in the admission documentation.

Resolution: Corrected: 2024-08-23

Two of the four staff members records involved was observed to be delinquent on Normalcy Training.

Resolution: Corrected: 2024-08-23

Case manager reported that some staff files could not be reviewed due to them being forgotten at her personal residence.

Resolution: Corrected: 2024-08-23

One of four staff members was observed to have an expired CPR Certification.

Resolution: Corrected: 2024-08-23

Two of four Admission Assessments reviewed was observed to not be signed or dated from the Professional Level Service Provider.

Resolution: Corrected: 2024-08-23

One of four Preliminary Service Plans reviewed was observed to be missing a signature from Treatment Director or Professional Level Service Provider.

Resolution: Corrected: 2024-08-23

One of four Child Right's documents reviewed for a child admitted on 07/29/2024 was observed to be missing the child's signature.

Resolution: Corrected: 2024-08-23

One of the four staff files reviewed was observed to be delinquent in annual Emergency Behavior Intervention Training.

Resolution: Corrected: 2024-08-23

Two of the four staff members records involved was observed to be delinquent on Normalcy Training.

Resolution: Corrected: 2024-08-23

Two of four Admission Assessments reviewed was observed to not be signed or dated from the Professional Level Service Provider.

Resolution: Corrected: 2024-08-23

Neither of the four staff files reviewed was observed to be current in Suicide Training.

Resolution: Corrected: 2024-08-23

Three of the four records reviewed was observed to have immunization records in the admission documentation.

Resolution: Corrected: 2024-08-23

One of four Child Right's documents reviewed for a child admitted on 07/29/2024 was observed to be missing the child's signature.

Resolution: Corrected: 2024-08-23

Two of the four staff members records involved was observed to be delinquent on Normalcy Training.

Resolution: Corrected: 2024-08-23

Case manager reported that some staff files could not be reviewed due to them being forgotten at her personal residence.

Resolution: Corrected: 2024-08-23

One of the four staff files reviewed was observed to be delinquent in annual Emergency Behavior Intervention Training.

Resolution: Corrected: 2024-08-23

Neither of the four staff files reviewed was observed to be current in Suicide Training.

Resolution: Corrected: 2024-08-23

One of four Preliminary Service Plans reviewed was observed to be missing a signature from Treatment Director or Professional Level Service Provider.

Resolution: Corrected: 2024-08-23

One of four staff members was observed to have an expired CPR Certification.

Resolution: Corrected: 2024-08-23

Case manager reported that some staff files could not be reviewed due to them being forgotten at her personal residence.

Resolution: Corrected: 2024-08-23

One of the four staff files reviewed was observed to be delinquent in annual Emergency Behavior Intervention Training.

Resolution: Corrected: 2024-08-23

Neither of the four staff files reviewed was observed to be current in Suicide Training.

Resolution: Corrected: 2024-08-23

One of four Preliminary Service Plans reviewed was observed to be missing a signature from Treatment Director or Professional Level Service Provider.

Resolution: Corrected: 2024-08-23

One of four staff members was observed to have an expired CPR Certification.

Resolution: Corrected: 2024-08-23

The annual fire inspection was not completed timely.

Resolution: Corrected: 2024-06-14

The annual fire inspection was not completed timely.

Resolution: Corrected: 2024-06-14

The annual fire inspection was not completed timely.

Resolution: Corrected: 2024-06-14

The annual fire inspection was not completed timely.

Resolution: Corrected: 2024-06-14

The annual summary log does not have how long the child was gone for. The log has a designated area for time and date of return however only the date is being entered.

Resolution: Corrected: 2023-11-28

The annual summary log does not have how long the child was gone for. The log has a designated area for time and date of return however only the date is being entered.

Resolution: Corrected: 2023-11-28

The annual summary log does not have how long the child was gone for. The log has a designated area for time and date of return however only the date is being entered.

Resolution: Corrected: 2023-11-28

The annual summary log does not have how long the child was gone for. The log has a designated area for time and date of return however only the date is being entered.

Resolution: Corrected: 2023-11-28

An incident report was observed with additional information that was not reported to SWI.

Resolution: Corrected: 2023-08-24

1 of 3 records was observed without a TB exam. Staff was hired 6/9/23.

Resolution: Corrected: 2023-08-24

An incident report was observed with additional information that was not reported to SWI.

Resolution: Corrected: 2023-08-24

An incident report was observed with additional information that was not reported to SWI.

Resolution: Corrected: 2023-08-24

1 of 3 records was observed without a TB exam. Staff was hired 6/9/23.

Resolution: Corrected: 2023-08-24

An incident report was observed with additional information that was not reported to SWI.

Resolution: Corrected: 2023-08-24

1 of 3 records was observed without a TB exam. Staff was hired 6/9/23.

Resolution: Corrected: 2023-08-24

1 of 3 records was observed without a TB exam. Staff was hired 6/9/23.

Resolution: Corrected: 2023-08-24

One medication, Guanfacine 2MG, was supposed to be administered daily at 4pm, was administered after 4pm on 7/5-7/13.

Resolution: Corrected: 2023-07-17

One medication, Guanfacine 2MG, was supposed to be administered daily at 4pm, was administered after 4pm on 7/5-7/13.

Resolution: Corrected: 2023-07-17

One medication, Guanfacine 2MG, was supposed to be administered daily at 4pm, was administered after 4pm on 7/5-7/13.

Resolution: Corrected: 2023-07-17

One medication, Guanfacine 2MG, was supposed to be administered daily at 4pm, was administered after 4pm on 7/5-7/13.

Resolution: Corrected: 2023-07-17

Service plans reviewed noted the effective date of the plans to be before the completion dates of the plan; the supervision and ratio requirements are inconsistent between the preliminary, initial, and review service plans; admission's assessments, preliminary, initial, and review service plans were not individualized and detailed for each child in care; dates did not accompany all signatures on documents, for example initial and review service plans, to show when the document was signed and to ensure compliance with minimum standards timeframes; information from the application for placement, psychological assessment, and admission's assessment were not thoroughly included in the goals and needs documented for children in care in their initial and review service plans

Resolution: Corrected: 2023-05-24

4 of 4 admissions assessments did not include the child's birth and neonatal history; (c)(6) child?s school history, including the names and dates of previous schools attended, grades earned, and special achievements; (c)(7) the reason for the previous placements.

Resolution: Corrected: 2023-05-24

3 of 4 placement agreements did not include the reason for placement and the anticipated length of time in care.

Resolution: Corrected: 2023-05-24

4 of 4 records reviewed did not include the results of the child's suicide risk screening.

Resolution: Corrected: 2023-05-24

1 of 1 service plan reviews were missing all signatures.

Resolution: Corrected: 2023-05-24

The evaluation of the child's progress was not thoroughly documented on 2 of 4 service plan reviews.

Resolution: Corrected: 2023-05-24

3 of 4 initial and review service plans did not include the date of participation for the PLSP. 1 service plan did not include the signature of the PLSP.

Resolution: Corrected: 2023-05-24

4 of 4 admissions assessments did not include the child's birth and neonatal history; (c)(6) child?s school history, including the names and dates of previous schools attended, grades earned, and special achievements; (c)(7) the reason for the previous placements.

Resolution: Corrected: 2023-05-24

3 of 4 placement agreements did not include the reason for placement and the anticipated length of time in care.

Resolution: Corrected: 2023-05-24

3 of 4 initial and review service plans did not include the date of participation for the PLSP. 1 service plan did not include the signature of the PLSP.

Resolution: Corrected: 2023-05-24

The evaluation of the child's progress was not thoroughly documented on 2 of 4 service plan reviews.

Resolution: Corrected: 2023-05-24

4 of 4 admissions assessments did not include the child's birth and neonatal history; (c)(6) child?s school history, including the names and dates of previous schools attended, grades earned, and special achievements; (c)(7) the reason for the previous placements.

Resolution: Corrected: 2023-05-24

4 of 4 records reviewed did not include the results of the child's suicide risk screening.

Resolution: Corrected: 2023-05-24

1 of 1 service plan reviews were missing all signatures.

Resolution: Corrected: 2023-05-24

Service plans reviewed noted the effective date of the plans to be before the completion dates of the plan; the supervision and ratio requirements are inconsistent between the preliminary, initial, and review service plans; admission's assessments, preliminary, initial, and review service plans were not individualized and detailed for each child in care; dates did not accompany all signatures on documents, for example initial and review service plans, to show when the document was signed and to ensure compliance with minimum standards timeframes; information from the application for placement, psychological assessment, and admission's assessment were not thoroughly included in the goals and needs documented for children in care in their initial and review service plans

Resolution: Corrected: 2023-05-24

The evaluation of the child's progress was not thoroughly documented on 2 of 4 service plan reviews.

Resolution: Corrected: 2023-05-24

Service plans reviewed noted the effective date of the plans to be before the completion dates of the plan; the supervision and ratio requirements are inconsistent between the preliminary, initial, and review service plans; admission's assessments, preliminary, initial, and review service plans were not individualized and detailed for each child in care; dates did not accompany all signatures on documents, for example initial and review service plans, to show when the document was signed and to ensure compliance with minimum standards timeframes; information from the application for placement, psychological assessment, and admission's assessment were not thoroughly included in the goals and needs documented for children in care in their initial and review service plans

Resolution: Corrected: 2023-05-24

1 of 1 service plan reviews were missing all signatures.

Resolution: Corrected: 2023-05-24

4 of 4 admissions assessments did not include the child's birth and neonatal history; (c)(6) child?s school history, including the names and dates of previous schools attended, grades earned, and special achievements; (c)(7) the reason for the previous placements.

Resolution: Corrected: 2023-05-24

4 of 4 records reviewed did not include the results of the child's suicide risk screening.

Resolution: Corrected: 2023-05-24

3 of 4 placement agreements did not include the reason for placement and the anticipated length of time in care.

Resolution: Corrected: 2023-05-24

3 of 4 initial and review service plans did not include the date of participation for the PLSP. 1 service plan did not include the signature of the PLSP.

Resolution: Corrected: 2023-05-24

The evaluation of the child's progress was not thoroughly documented on 2 of 4 service plan reviews.

Resolution: Corrected: 2023-05-24

Service plans reviewed noted the effective date of the plans to be before the completion dates of the plan; the supervision and ratio requirements are inconsistent between the preliminary, initial, and review service plans; admission's assessments, preliminary, initial, and review service plans were not individualized and detailed for each child in care; dates did not accompany all signatures on documents, for example initial and review service plans, to show when the document was signed and to ensure compliance with minimum standards timeframes; information from the application for placement, psychological assessment, and admission's assessment were not thoroughly included in the goals and needs documented for children in care in their initial and review service plans

Resolution: Corrected: 2023-05-24

1 of 1 service plan reviews were missing all signatures.

Resolution: Corrected: 2023-05-24

4 of 4 records reviewed did not include the results of the child's suicide risk screening.

Resolution: Corrected: 2023-05-24

3 of 4 placement agreements did not include the reason for placement and the anticipated length of time in care.

Resolution: Corrected: 2023-05-24

3 of 4 initial and review service plans did not include the date of participation for the PLSP. 1 service plan did not include the signature of the PLSP.

Resolution: Corrected: 2023-05-24

During interview, staff admitted to threatening a child with corporal punishment.

Resolution: Corrected: 2023-07-19

During interview, staff admitted to threatening a child with corporal punishment.

Resolution: Corrected: 2023-07-19

During interview, staff admitted to threatening a child with corporal punishment.

Resolution: Corrected: 2023-07-19

During interview, staff admitted to threatening a child with corporal punishment.

Resolution: Corrected: 2023-07-19

The annual fire inspection was due on 4/1/23.

Resolution: Corrected: 2023-04-24

The annual fire inspection was due on 4/1/23.

Resolution: Corrected: 2023-04-24

The annual fire inspection was due on 4/1/23.

Resolution: Corrected: 2023-04-24

The annual fire inspection was due on 4/1/23.

Resolution: Corrected: 2023-04-24

4 preliminary service plans did not document who would be responsible for meeting each of the child's needs.

Resolution: Corrected: 2023-01-25

4 of 4 records reviewed had medication logs with the reason for the medications not listed.

Resolution: Corrected: 2023-01-25

One file did not include the child's immunization record.

Resolution: Corrected: 2023-01-25

One preliminary service plan was missing the signature from the PLSP/Treatment Director.

Resolution: Corrected: 2023-01-25

4 of 4 admissions' assessments did not include the services the operation would provide to children in care, and the child's substance abuse history, and the child's understanding of placement.

Resolution: Corrected: 2023-01-25

One medication record reviewed showed a child received Lovastatin on 10 days, in the morning, when the instructions stated it should have been given with an evening meal. The same record showed the child was given Omega 3 Acid once a day on 1/12/23 and 1/17/23 when it was prescribed to be given twice a day. The child also received Aripiprazole only once on 1/17/23, when it was prescribed to be given twice daily.

Resolution: Corrected: 2023-01-20

4 of 4 admissions' assessments did not include the services the operation would provide to children in care, and the child's substance abuse history, and the child's understanding of placement.

Resolution: Corrected: 2023-01-25

4 of 4 records reviewed had medication logs with the reason for the medications not listed.

Resolution: Corrected: 2023-01-25

One file did not include the child's immunization record.

Resolution: Corrected: 2023-01-25

One medication record reviewed showed a child received Lovastatin on 10 days, in the morning, when the instructions stated it should have been given with an evening meal. The same record showed the child was given Omega 3 Acid once a day on 1/12/23 and 1/17/23 when it was prescribed to be given twice a day. The child also received Aripiprazole only once on 1/17/23, when it was prescribed to be given twice daily.

Resolution: Corrected: 2023-01-20

One preliminary service plan was missing the signature from the PLSP/Treatment Director.

Resolution: Corrected: 2023-01-25

4 preliminary service plans did not document who would be responsible for meeting each of the child's needs.

Resolution: Corrected: 2023-01-25

4 of 4 records reviewed had medication logs with the reason for the medications not listed.

Resolution: Corrected: 2023-01-25

4 of 4 admissions' assessments did not include the services the operation would provide to children in care, and the child's substance abuse history, and the child's understanding of placement.

Resolution: Corrected: 2023-01-25

One medication record reviewed showed a child received Lovastatin on 10 days, in the morning, when the instructions stated it should have been given with an evening meal. The same record showed the child was given Omega 3 Acid once a day on 1/12/23 and 1/17/23 when it was prescribed to be given twice a day. The child also received Aripiprazole only once on 1/17/23, when it was prescribed to be given twice daily.

Resolution: Corrected: 2023-01-20

One preliminary service plan was missing the signature from the PLSP/Treatment Director.

Resolution: Corrected: 2023-01-25

One file did not include the child's immunization record.

Resolution: Corrected: 2023-01-25

4 preliminary service plans did not document who would be responsible for meeting each of the child's needs.

Resolution: Corrected: 2023-01-25

4 of 4 records reviewed had medication logs with the reason for the medications not listed.

Resolution: Corrected: 2023-01-25

4 of 4 admissions' assessments did not include the services the operation would provide to children in care, and the child's substance abuse history, and the child's understanding of placement.

Resolution: Corrected: 2023-01-25

One medication record reviewed showed a child received Lovastatin on 10 days, in the morning, when the instructions stated it should have been given with an evening meal. The same record showed the child was given Omega 3 Acid once a day on 1/12/23 and 1/17/23 when it was prescribed to be given twice a day. The child also received Aripiprazole only once on 1/17/23, when it was prescribed to be given twice daily.

Resolution: Corrected: 2023-01-20

One preliminary service plan was missing the signature from the PLSP/Treatment Director.

Resolution: Corrected: 2023-01-25

One file did not include the child's immunization record.

Resolution: Corrected: 2023-01-25

4 preliminary service plans did not document who would be responsible for meeting each of the child's needs.

Resolution: Corrected: 2023-01-25

The administrator personnel file did not contain any of the trainings documents.

Resolution: Corrected: 2022-10-31

Of the two files reviewed, neither employee had a signed statement of reporting abuse or neglect.

Resolution: Corrected: 2022-10-31

Of the two files reviewed, neither employee had a signed statement of reporting abuse or neglect.

Resolution: Corrected: 2022-10-31

The administrator personnel file did not contain any of the trainings documents.

Resolution: Corrected: 2022-10-31

The administrator personnel file did not contain any of the trainings documents.

Resolution: Corrected: 2022-10-31

Of the two files reviewed, neither employee had a signed statement of reporting abuse or neglect.

Resolution: Corrected: 2022-10-31

The administrator personnel file did not contain any of the trainings documents.

Resolution: Corrected: 2022-10-31

Of the two files reviewed, neither employee had a signed statement of reporting abuse or neglect.

Resolution: Corrected: 2022-10-31

During this application review, it was found that the drug test for the staff C.R. was invalid. C.R. has not had drug test.

Resolution: Corrected: 2022-08-19

During this application review, it was found that the drug test for the staff C.R. was invalid. C.R. has not had drug test.

Resolution: Corrected: 2022-08-19

During this application review, it was found that the drug test for the staff C.R. was invalid. C.R. has not had drug test.

Resolution: Corrected: 2022-08-19

During this application review, it was found that the drug test for the staff C.R. was invalid. C.R. has not had drug test.

Resolution: Corrected: 2022-08-19

The tobacco and e-cigarette policy is missing from operational policies. This policy should be address both staff and children in care.

Resolution: Corrected: 2022-08-02

The child care policy is missing information including education, child's rights and religion.

Resolution: Corrected: 2022-08-02

During the inspection, the abuse and neglect policies are missing from the operational policies.

Resolution: Corrected: 2022-08-02

During the application review, the staff did not have valid First Aid and CPR Training in their file.

Resolution: Corrected: 2022-08-02

During the application review, C.R. as the PLSP job description is missing the 2 years of experience, education requirement and training does not meet the minimum standards for this position.

Resolution: Corrected: 2022-08-02

The personnel policies do not include all required information for the professional positions. The personnel policies were missing a professional staffing plan with required information.

Resolution: Corrected: 2022-08-02

The sanitation inspection was not present and needs to be sent in writing.

Resolution: Corrected: 2022-07-26

The weapons, firearms, explosive materials and projectiles policy is missing from the operational policies.

Resolution: Corrected: 2022-08-02

During the walk through there were several physical site issues such as a hole in the ceiling on the corner of bedroom 4, a broken drape handle, a hole in the wall with chipped paint in bedroom 3. Additionally, the air ducts needed to cleaned. Work orders were provided.

Resolution: Corrected at inspection

During the application review, staff files did not have an adequate amount of required training and the file was missing training hours.

Resolution: Corrected: 2022-08-02

The EBI policy is missing information, such as what restraints are acceptable.

Resolution: Corrected: 2022-08-02

During this application review, it was found that the drug test for the staff C.R. was invalid. C.R. has not had drug test.

Resolution: Corrected: 2022-08-02

During the inspection, the staff did not have a record of a TB in their file.

Resolution: Corrected: 2022-08-02

The child care policy is missing information including education, child's rights and religion.

Resolution: Corrected: 2022-08-02

During the inspection, the abuse and neglect policies are missing from the operational policies.

Resolution: Corrected: 2022-08-02

The EBI policy is missing information, such as what restraints are acceptable.

Resolution: Corrected: 2022-08-02

During the inspection, the abuse and neglect policies are missing from the operational policies.

Resolution: Corrected: 2022-08-02

The personnel policies do not include all required information for the professional positions. The personnel policies were missing a professional staffing plan with required information.

Resolution: Corrected: 2022-08-02

During the walk through there were several physical site issues such as a hole in the ceiling on the corner of bedroom 4, a broken drape handle, a hole in the wall with chipped paint in bedroom 3. Additionally, the air ducts needed to cleaned. Work orders were provided.

Resolution: Corrected at inspection

During this application review, it was found that the drug test for the staff C.R. was invalid. C.R. has not had drug test.

Resolution: Corrected: 2022-08-02

During the application review, C.R. as the PLSP job description is missing the 2 years of experience, education requirement and training does not meet the minimum standards for this position.

Resolution: Corrected: 2022-08-02

The tobacco and e-cigarette policy is missing from operational policies. This policy should be address both staff and children in care.

Resolution: Corrected: 2022-08-02

The sanitation inspection was not present and needs to be sent in writing.

Resolution: Corrected: 2022-07-26

During the application review, the staff did not have valid First Aid and CPR Training in their file.

Resolution: Corrected: 2022-08-02

During the application review, staff files did not have an adequate amount of required training and the file was missing training hours.

Resolution: Corrected: 2022-08-02

The child care policy is missing information including education, child's rights and religion.

Resolution: Corrected: 2022-08-02

The weapons, firearms, explosive materials and projectiles policy is missing from the operational policies.

Resolution: Corrected: 2022-08-02

The EBI policy is missing information, such as what restraints are acceptable.

Resolution: Corrected: 2022-08-02

The personnel policies do not include all required information for the professional positions. The personnel policies were missing a professional staffing plan with required information.

Resolution: Corrected: 2022-08-02

The sanitation inspection was not present and needs to be sent in writing.

Resolution: Corrected: 2022-07-26

The weapons, firearms, explosive materials and projectiles policy is missing from the operational policies.

Resolution: Corrected: 2022-08-02

The tobacco and e-cigarette policy is missing from operational policies. This policy should be address both staff and children in care.

Resolution: Corrected: 2022-08-02

During the inspection, the staff did not have a record of a TB in their file.

Resolution: Corrected: 2022-08-02

During this application review, it was found that the drug test for the staff C.R. was invalid. C.R. has not had drug test.

Resolution: Corrected: 2022-08-02

During the application review, C.R. as the PLSP job description is missing the 2 years of experience, education requirement and training does not meet the minimum standards for this position.

Resolution: Corrected: 2022-08-02

During the application review, staff files did not have an adequate amount of required training and the file was missing training hours.

Resolution: Corrected: 2022-08-02

During the walk through there were several physical site issues such as a hole in the ceiling on the corner of bedroom 4, a broken drape handle, a hole in the wall with chipped paint in bedroom 3. Additionally, the air ducts needed to cleaned. Work orders were provided.

Resolution: Corrected at inspection

During the application review, the staff did not have valid First Aid and CPR Training in their file.

Resolution: Corrected: 2022-08-02

The child care policy is missing information including education, child's rights and religion.

Resolution: Corrected: 2022-08-02

During the inspection, the abuse and neglect policies are missing from the operational policies.

Resolution: Corrected: 2022-08-02

The EBI policy is missing information, such as what restraints are acceptable.

Resolution: Corrected: 2022-08-02

The weapons, firearms, explosive materials and projectiles policy is missing from the operational policies.

Resolution: Corrected: 2022-08-02

The personnel policies do not include all required information for the professional positions. The personnel policies were missing a professional staffing plan with required information.

Resolution: Corrected: 2022-08-02

During the inspection, the staff did not have a record of a TB in their file.

Resolution: Corrected: 2022-08-02

The sanitation inspection was not present and needs to be sent in writing.

Resolution: Corrected: 2022-07-26

The tobacco and e-cigarette policy is missing from operational policies. This policy should be address both staff and children in care.

Resolution: Corrected: 2022-08-02

During the inspection, the staff did not have a record of a TB in their file.

Resolution: Corrected: 2022-08-02

During this application review, it was found that the drug test for the staff C.R. was invalid. C.R. has not had drug test.

Resolution: Corrected: 2022-08-02

During the application review, C.R. as the PLSP job description is missing the 2 years of experience, education requirement and training does not meet the minimum standards for this position.

Resolution: Corrected: 2022-08-02

During the application review, staff files did not have an adequate amount of required training and the file was missing training hours.

Resolution: Corrected: 2022-08-02

During the walk through there were several physical site issues such as a hole in the ceiling on the corner of bedroom 4, a broken drape handle, a hole in the wall with chipped paint in bedroom 3. Additionally, the air ducts needed to cleaned. Work orders were provided.

Resolution: Corrected at inspection

During the application review, the staff did not have valid First Aid and CPR Training in their file.

Resolution: Corrected: 2022-08-02