Castillo Childrens Center

A service plan review was indicated as an initial plan instead of review, the PLSP, therapist and child's participation is not documented or dated.

Resolution: Corrected: 2026-03-31

A service plan review was indicated as an initial plan instead of review, the PLSP, therapist and child's participation is not documented or dated.

Resolution: Corrected: 2026-03-31

A subsequent service plan for a child did not adress skills for youth 13 and older.

Resolution: Corrected: 2026-02-16

A subsequent service plan for a child did not adress skills for youth 13 and older.

Resolution: Corrected: 2026-02-16

A subsequent service plan for a child did not adress skills for youth 13 and older.

Resolution: Corrected: 2026-02-16

Two First aid kits were observed in the kitchen in an area accessible to children. This was corrected at inspection by moving them to an area that was kept locked and children not permitted to enter without an adult.

Resolution: Corrected at inspection

Two First aid kits were observed in the kitchen in an area accessible to children. This was corrected at inspection by moving them to an area that was kept locked and children not permitted to enter without an adult.

Resolution: Corrected at inspection

Two First aid kits were observed in the kitchen in an area accessible to children. This was corrected at inspection by moving them to an area that was kept locked and children not permitted to enter without an adult.

Resolution: Corrected at inspection

During a review conducted on December 19, 2025, it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan; and (2) more than 12 months had elapsed since the effective date of the plan. As you know, the heightened monitoring plan for your operation included a specific ?planned end date? at the original 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring.? As a direct result of the administrator?s failure to ensure timely compliance with the heightened monitoring plan, your operation was unable to successfully move to post-plan monitoring by the original ?planned end date? necessitating previous extension. Furthermore, due to your recent citations issued on December 1, 2025, your operation?s ?planned end date? must now be revised again, and the period of heightened monitoring must be extended again. Further details of the administrator?s failure to ensure compliance include the following: Your operation received a medium-high weighted citation in a pattern/trend category on December 1, 2025. Specifically, the operation was cited for 748.936(1) Annual Training- Caregivers must have EBI w/in 6 months from the date they last received the training if operation provides treatment services. The operation met compliance on 12/8/2025. - Operation failed to satisfy the conditions of the plan - Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring; and - Operation was unable to meet compliance with Medium-High or High weighted licensing citations Finding: 748.535(2) ? The licensed administrator must ensure the operation complies with current heightened monitoring plan. An administrative penalty will be assessed as a result of this citation, in accordance with Texas Human Resources Code Sec. 42.078. The maximum daily penalty for your operation is $100.

Resolution: Corrected: 2025-12-20

During a review conducted on December 19, 2025, it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan; and (2) more than 12 months had elapsed since the effective date of the plan. As you know, the heightened monitoring plan for your operation included a specific ?planned end date? at the original 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring.? As a direct result of the administrator?s failure to ensure timely compliance with the heightened monitoring plan, your operation was unable to successfully move to post-plan monitoring by the original ?planned end date? necessitating previous extension. Furthermore, due to your recent citations issued on December 1, 2025, your operation?s ?planned end date? must now be revised again, and the period of heightened monitoring must be extended again. Further details of the administrator?s failure to ensure compliance include the following: Your operation received a medium-high weighted citation in a pattern/trend category on December 1, 2025. Specifically, the operation was cited for 748.936(1) Annual Training- Caregivers must have EBI w/in 6 months from the date they last received the training if operation provides treatment services. The operation met compliance on 12/8/2025. - Operation failed to satisfy the conditions of the plan - Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring; and - Operation was unable to meet compliance with Medium-High or High weighted licensing citations Finding: 748.535(2) ? The licensed administrator must ensure the operation complies with current heightened monitoring plan. An administrative penalty will be assessed as a result of this citation, in accordance with Texas Human Resources Code Sec. 42.078. The maximum daily penalty for your operation is $100.

Resolution: Corrected: 2025-12-20

During a review conducted on December 19, 2025, it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan; and (2) more than 12 months had elapsed since the effective date of the plan. As you know, the heightened monitoring plan for your operation included a specific ?planned end date? at the original 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring.? As a direct result of the administrator?s failure to ensure timely compliance with the heightened monitoring plan, your operation was unable to successfully move to post-plan monitoring by the original ?planned end date? necessitating previous extension. Furthermore, due to your recent citations issued on December 1, 2025, your operation?s ?planned end date? must now be revised again, and the period of heightened monitoring must be extended again. Further details of the administrator?s failure to ensure compliance include the following: Your operation received a medium-high weighted citation in a pattern/trend category on December 1, 2025. Specifically, the operation was cited for 748.936(1) Annual Training- Caregivers must have EBI w/in 6 months from the date they last received the training if operation provides treatment services. The operation met compliance on 12/8/2025. - Operation failed to satisfy the conditions of the plan - Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring; and - Operation was unable to meet compliance with Medium-High or High weighted licensing citations Finding: 748.535(2) ? The licensed administrator must ensure the operation complies with current heightened monitoring plan. An administrative penalty will be assessed as a result of this citation, in accordance with Texas Human Resources Code Sec. 42.078. The maximum daily penalty for your operation is $100.

Resolution: Corrected: 2025-12-20

A caregiver's Emergency Behavior Intervention training was not renewed timely.

Resolution: Corrected: 2025-12-08

A caregiver's Emergency Behavior Intervention training was not renewed timely.

Resolution: Corrected: 2025-12-08

A caregiver's Emergency Behavior Intervention training was not renewed timely.

Resolution: Corrected: 2025-12-08

The pre-service training records for one employee are not signed and dated by the instructor.

Resolution: Corrected: 2025-10-29

The pre-service training records for one employee are not signed and dated by the instructor.

Resolution: Corrected: 2025-10-29

The pre-service training records for one employee are not signed and dated by the instructor.

Resolution: Corrected: 2025-10-29

The service plan reviewed during the inspection identified the child's level of care as specialized, borderline level of functioning, and the child needed follow up evaluation for autism spectrum disorder; however this was not reflected in any other records reviewed.

Resolution: Corrected: 2025-10-15

The service plan reviewed during the inspection identified the child's level of care as specialized, borderline level of functioning, and the child needed follow up evaluation for autism spectrum disorder; however this was not reflected in any other records reviewed.

Resolution: Corrected: 2025-10-15

The service plan reviewed during the inspection identified the child's level of care as specialized, borderline level of functioning, and the child needed follow up evaluation for autism spectrum disorder; however this was not reflected in any other records reviewed.

Resolution: Corrected: 2025-10-15

During an inspection, it was reported that 3 staff transported 12 children, in an 11 passenger vehicle and multiple children shared seats/safety belts while on an outing.

Resolution: Corrected: 2025-09-17

During an inspection, it was observed the operation does not have safety seats in the van and the operation has four children 8 and under.

Resolution: Corrected: 2025-09-12

During an inspection, it was reported that operation staff transported three children not in care of the operation on an outing with children in care.

Resolution: Corrected: 2025-09-17

During an inspection, it was observed the operation does not have safety seats in the van and the operation has four children 8 and under.

Resolution: Corrected: 2025-09-12

During an inspection, it was reported that operation staff transported three children not in care of the operation on an outing with children in care.

Resolution: Corrected: 2025-09-17

During an inspection, it was reported that 3 staff transported 12 children, in an 11 passenger vehicle and multiple children shared seats/safety belts while on an outing.

Resolution: Corrected: 2025-09-17

During an inspection, it was observed the operation does not have safety seats in the van and the operation has four children 8 and under.

Resolution: Corrected: 2025-09-12

During an inspection, it was reported that operation staff transported three children not in care of the operation on an outing with children in care.

Resolution: Corrected: 2025-09-17

During an inspection, it was reported that 3 staff transported 12 children, in an 11 passenger vehicle and multiple children shared seats/safety belts while on an outing.

Resolution: Corrected: 2025-09-17

A subsequent service plan for a child did not adress skills for youth 13 and older.

Resolution: Corrected: 2025-09-12

A child's bed in the girls room had a broken footboard that posed a safety hazard and a broken CD was found on the floor of a boys room. The issues were corrected at inspection by replacement of the bed and the CD was swept up from the floor and thrown away.

Resolution: Corrected at inspection

Two of ten beds being used did not have protective mattress covers. This was corrected at inspection by the operation placing mattress covers on the uncovered beds.

Resolution: Corrected at inspection

A child's admission assessment, 72 hour plan, and placement document dates do not match.

Resolution: Corrected: 2025-09-12

Two of ten beds being used did not have protective mattress covers. This was corrected at inspection by the operation placing mattress covers on the uncovered beds.

Resolution: Corrected at inspection

A child's bed in the girls room had a broken footboard that posed a safety hazard and a broken CD was found on the floor of a boys room. The issues were corrected at inspection by replacement of the bed and the CD was swept up from the floor and thrown away.

Resolution: Corrected at inspection

A subsequent service plan for a child did not adress skills for youth 13 and older.

Resolution: Corrected: 2025-09-12

A child's admission assessment, 72 hour plan, and placement document dates do not match.

Resolution: Corrected: 2025-09-12

A child's admission assessment, 72 hour plan, and placement document dates do not match.

Resolution: Corrected: 2025-09-12

A subsequent service plan for a child did not adress skills for youth 13 and older.

Resolution: Corrected: 2025-09-12

A child's bed in the girls room had a broken footboard that posed a safety hazard and a broken CD was found on the floor of a boys room. The issues were corrected at inspection by replacement of the bed and the CD was swept up from the floor and thrown away.

Resolution: Corrected at inspection

Two of ten beds being used did not have protective mattress covers. This was corrected at inspection by the operation placing mattress covers on the uncovered beds.

Resolution: Corrected at inspection

A staff member questioned a youth regarding details of allegations being report by the youth to their caseworker.

Resolution: Corrected: 2025-09-29

A professional staff member failed to demonstrate prudent judgment when he used a cell phone to audio and video record a conversation with a youth.

Resolution: Corrected: 2025-09-29

Two of two plans of service reviewed for an investigation had sections that were duplicated specifically in the type of approved contact, why visitation is not allowed, the same family members and supportive adult relationships, and information was inaccurate regarding the grade, school, and target due dates are from prior to the children's placement.

Resolution: Corrected: 2025-09-29

Two of two plans of service reviewed for an investigation had sections that were duplicated specifically in the type of approved contact, why visitation is not allowed, the same family members and supportive adult relationships, and information was inaccurate regarding the grade, school, and target due dates are from prior to the children's placement.

Resolution: Corrected: 2025-09-29

A professional staff member failed to demonstrate prudent judgment when he used a cell phone to audio and video record a conversation with a youth.

Resolution: Corrected: 2025-09-29

A staff member questioned a youth regarding details of allegations being report by the youth to their caseworker.

Resolution: Corrected: 2025-09-29

Two of two plans of service reviewed for an investigation had sections that were duplicated specifically in the type of approved contact, why visitation is not allowed, the same family members and supportive adult relationships, and information was inaccurate regarding the grade, school, and target due dates are from prior to the children's placement.

Resolution: Corrected: 2025-09-29

A professional staff member failed to demonstrate prudent judgment when he used a cell phone to audio and video record a conversation with a youth.

Resolution: Corrected: 2025-09-29

A staff member questioned a youth regarding details of allegations being report by the youth to their caseworker.

Resolution: Corrected: 2025-09-29

During a review conducted on June 17, 2025, it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan; and (2) 12 months has elapsed since the effective date of the plan. As you know, the heightened monitoring plan for your operation included a specific ?planned end date? at the original 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring.? As a direct result of the administrator?s failure to ensure timely compliance with heightened monitoring plan, your operation is now unable to successfully move to post-plan monitoring. Furthermore, your operation?s ?planned end date? must now be revised, and the period of heightened monitoring must be extended. Further details of the administrator?s failure to ensure compliance include the following: Your operation received two medium weighted citations in a pattern/trend category on June 2, 2025. Specifically, the operation was cited for 748.869(a)(3) in the category Required Trainings. The operation came into compliance on June 9, 2025. - Operation failed to satisfy the conditions of the plan; and - Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring. Finding: 748.535(2) ? The licensed administrator must ensure the operation complies with current heightened monitoring plan.

Resolution: Corrected: 2025-06-17

During a review conducted on June 17, 2025, it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan; and (2) 12 months has elapsed since the effective date of the plan. As you know, the heightened monitoring plan for your operation included a specific ?planned end date? at the original 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring.? As a direct result of the administrator?s failure to ensure timely compliance with heightened monitoring plan, your operation is now unable to successfully move to post-plan monitoring. Furthermore, your operation?s ?planned end date? must now be revised, and the period of heightened monitoring must be extended. Further details of the administrator?s failure to ensure compliance include the following: Your operation received two medium weighted citations in a pattern/trend category on June 2, 2025. Specifically, the operation was cited for 748.869(a)(3) in the category Required Trainings. The operation came into compliance on June 9, 2025. - Operation failed to satisfy the conditions of the plan; and - Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring. Finding: 748.535(2) ? The licensed administrator must ensure the operation complies with current heightened monitoring plan.

Resolution: Corrected: 2025-06-17

During a review conducted on June 17, 2025, it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan; and (2) 12 months has elapsed since the effective date of the plan. As you know, the heightened monitoring plan for your operation included a specific ?planned end date? at the original 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring.? As a direct result of the administrator?s failure to ensure timely compliance with heightened monitoring plan, your operation is now unable to successfully move to post-plan monitoring. Furthermore, your operation?s ?planned end date? must now be revised, and the period of heightened monitoring must be extended. Further details of the administrator?s failure to ensure compliance include the following: Your operation received two medium weighted citations in a pattern/trend category on June 2, 2025. Specifically, the operation was cited for 748.869(a)(3) in the category Required Trainings. The operation came into compliance on June 9, 2025. - Operation failed to satisfy the conditions of the plan; and - Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring. Finding: 748.535(2) ? The licensed administrator must ensure the operation complies with current heightened monitoring plan.

Resolution: Corrected: 2025-06-17

During a review of one employee record, pre-service training certificates were not signed or dated by the instructor.

Resolution: Corrected: 2025-06-09

During a review of one employee record, pre-service training certificates were not signed or dated by the instructor.

Resolution: Corrected: 2025-06-09

During a review of one employee record, pre-service training certificates were not signed or dated by the instructor.

Resolution: Corrected: 2025-06-09

A staff member interfered with an ongoing investigation by discussing the allegations with children in care.

Resolution: Corrected: 2025-07-22

A staff member interfered with an ongoing investigation by discussing the allegations with children in care.

Resolution: Corrected: 2025-07-22

A staff member interfered with an ongoing investigation by discussing the allegations with children in care.

Resolution: Corrected: 2025-07-22

During an inspection, prescribed medication was found stored in containers with handwritten labels.

Resolution: Corrected: 2025-05-12

During an inspection, prescribed medication was found stored in containers with handwritten labels.

Resolution: Corrected: 2025-05-12

During an inspection, prescribed medication was found stored in containers with handwritten labels.

Resolution: Corrected: 2025-05-12

A child in care did not receive sufficient doses of medication sent by provider for a visit and a child in care's medication was not stopped per a physician's order.

Resolution: Corrected: 2025-06-27

A medical consenter was not notified or made aware of changes to authorize consent of a child in care's medication regimen change.

Resolution: Corrected: 2025-06-27

A child in care did not receive sufficient doses of medication sent by provider for a visit and a child in care's medication was not stopped per a physician's order.

Resolution: Corrected: 2025-06-27

A medical consenter was not notified or made aware of changes to authorize consent of a child in care's medication regimen change.

Resolution: Corrected: 2025-06-27

A child in care did not receive sufficient doses of medication sent by provider for a visit and a child in care's medication was not stopped per a physician's order.

Resolution: Corrected: 2025-06-27

A medical consenter was not notified or made aware of changes to authorize consent of a child in care's medication regimen change.

Resolution: Corrected: 2025-06-27

A child in care did not have TB skin test record or result.

Resolution: Corrected: 2025-04-14

During a walkthrough inspection of the medication room, medication was observed outside of the blister pack in a white paper cup labeled with the initials TR.

Resolution: Corrected: 2025-04-14

A child in care did not have TB skin test record or result.

Resolution: Corrected: 2025-04-14

During a walkthrough inspection of the medication room, medication was observed outside of the blister pack in a white paper cup labeled with the initials TR.

Resolution: Corrected: 2025-04-14

A child in care did not have TB skin test record or result.

Resolution: Corrected: 2025-04-14

During a walkthrough inspection of the medication room, medication was observed outside of the blister pack in a white paper cup labeled with the initials TR.

Resolution: Corrected: 2025-04-14

A staff engaged in an inappropriate conversation with children in care; this same staff was later involved in a verbal altercation with another staff in front of children in care, using language and behavior not suitable for children.

Resolution: Corrected: 2025-02-28

A staff engaged in an inappropriate conversation with children in care; this same staff was later involved in a verbal altercation with another staff in front of children in care, using language and behavior not suitable for children.

Resolution: Corrected: 2025-02-28

A staff engaged in an inappropriate conversation with children in care; this same staff was later involved in a verbal altercation with another staff in front of children in care, using language and behavior not suitable for children.

Resolution: Corrected: 2025-02-28

During an investigation inspection a staff responsible for multiple children in care was found sleeping. The staff member was difficult to rouse and did not have an awareness of the children's ongoing activity.

Resolution: Corrected: 2025-01-29

During an investigation inspection a staff responsible for multiple children in care was found sleeping. The staff member was difficult to rouse and did not have an awareness of the children's ongoing activity.

Resolution: Corrected: 2025-01-29

During an investigation inspection a staff responsible for multiple children in care was found sleeping. The staff member was difficult to rouse and did not have an awareness of the children's ongoing activity.

Resolution: Corrected: 2025-01-29

A child in care was inadequately supervised that resulted in them acting inappropriately with a peer.

Resolution: Corrected: 2025-01-24

A child in care was inadequately supervised that resulted in them acting inappropriately with a peer.

Resolution: Corrected: 2025-01-24

A child in care was inadequately supervised that resulted in them acting inappropriately with a peer.

Resolution: Corrected: 2025-01-24

During a review conducted on December 16, 2024, it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan; and (2) 12 months has elapsed since the effective date of the plan. As you know, the heightened monitoring plan for your operation included a specific ?planned end date? at the original 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring.? As a direct result of the administrator?s failure to ensure timely compliance with heightened monitoring plan, your operation is now unable to successfully move to post-plan monitoring. Furthermore, your operation?s ?planned end date? must now be revised, and the period of heightened monitoring must be extended. Further details of the administrator?s failure to ensure compliance include the following: Your operation received two medium weighted citations in a pattern/trend category on November 19, 2024. Specifically, the operation was cited for 748.363(7) in the category Leadership Responsibilities- Personnel and 748.1333 in the category Service Plans-Preliminary. The operation came into compliance with both deficiencies on November 26, 2024. - Operation failed to satisfy the conditions of the plan. - Operation failed to satisfy the conditions of the plan; and - Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring. Finding: 748.535(2) ? The licensed administrator must ensure the operation complies with current heightened monitoring plan.

Resolution: Corrected: 2024-12-17

During a review conducted on December 16, 2024, it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan; and (2) 12 months has elapsed since the effective date of the plan. As you know, the heightened monitoring plan for your operation included a specific ?planned end date? at the original 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring.? As a direct result of the administrator?s failure to ensure timely compliance with heightened monitoring plan, your operation is now unable to successfully move to post-plan monitoring. Furthermore, your operation?s ?planned end date? must now be revised, and the period of heightened monitoring must be extended. Further details of the administrator?s failure to ensure compliance include the following: Your operation received two medium weighted citations in a pattern/trend category on November 19, 2024. Specifically, the operation was cited for 748.363(7) in the category Leadership Responsibilities- Personnel and 748.1333 in the category Service Plans-Preliminary. The operation came into compliance with both deficiencies on November 26, 2024. - Operation failed to satisfy the conditions of the plan. - Operation failed to satisfy the conditions of the plan; and - Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring. Finding: 748.535(2) ? The licensed administrator must ensure the operation complies with current heightened monitoring plan.

Resolution: Corrected: 2024-12-17

During a review conducted on December 16, 2024, it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan; and (2) 12 months has elapsed since the effective date of the plan. As you know, the heightened monitoring plan for your operation included a specific ?planned end date? at the original 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring.? As a direct result of the administrator?s failure to ensure timely compliance with heightened monitoring plan, your operation is now unable to successfully move to post-plan monitoring. Furthermore, your operation?s ?planned end date? must now be revised, and the period of heightened monitoring must be extended. Further details of the administrator?s failure to ensure compliance include the following: Your operation received two medium weighted citations in a pattern/trend category on November 19, 2024. Specifically, the operation was cited for 748.363(7) in the category Leadership Responsibilities- Personnel and 748.1333 in the category Service Plans-Preliminary. The operation came into compliance with both deficiencies on November 26, 2024. - Operation failed to satisfy the conditions of the plan. - Operation failed to satisfy the conditions of the plan; and - Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring. Finding: 748.535(2) ? The licensed administrator must ensure the operation complies with current heightened monitoring plan.

Resolution: Corrected: 2024-12-17

A child in care was restrained for not complying with staff and was not a danger to themselves or others.

Resolution: Corrected: 2025-01-13

A child in care was restrained for not complying with staff and was not a danger to themselves or others.

Resolution: Corrected: 2025-01-13

A child in care was restrained for not complying with staff and was not a danger to themselves or others.

Resolution: Corrected: 2025-01-13

Preliminary Service Plan-Treatment director or PLSP must develop, sign, and date the plan for children receiving treatment services

Resolution: Corrected: 2024-11-26

Personnel records- Include notarized Licensing Affidavit for Applicants for Employment form as specified in Human Resources Code, 42.059

Resolution: Corrected: 2024-11-26

Personnel records- Include notarized Licensing Affidavit for Applicants for Employment form as specified in Human Resources Code, 42.059

Resolution: Corrected: 2024-11-26

Preliminary Service Plan-Treatment director or PLSP must develop, sign, and date the plan for children receiving treatment services

Resolution: Corrected: 2024-11-26

Personnel records- Include notarized Licensing Affidavit for Applicants for Employment form as specified in Human Resources Code, 42.059

Resolution: Corrected: 2024-11-26

Preliminary Service Plan-Treatment director or PLSP must develop, sign, and date the plan for children receiving treatment services

Resolution: Corrected: 2024-11-26

The PM doses of medication for a youth in care were not properly documented.

Resolution: Corrected: 2024-11-01

The PM doses of medication for a youth in care were not properly documented.

Resolution: Corrected: 2024-11-01

The PM doses of medication for a youth in care were not properly documented.

Resolution: Corrected: 2024-11-01

During an inspection of the playground equipment, the slide was found to have several large, open cracks, the grounds of the play area had excessive debris, and multiple boards were missing or broken from the play-structure.

Resolution: Corrected: 2024-09-17

During an inspection of the playground equipment, the slide was found to have several large, open cracks, the grounds of the play area had excessive debris, and multiple boards were missing or broken from the play-structure.

Resolution: Corrected: 2024-09-17

During an inspection of the playground equipment, the slide was found to have several large, open cracks, the grounds of the play area had excessive debris, and multiple boards were missing or broken from the play-structure.

Resolution: Corrected: 2024-09-17

Medication logs were filled out incorrectly for a child in care. Child had not been given his PM medication; however, the medication log reflected his PM medication had already been dispensed.

Resolution: Corrected: 2024-08-19

A child was prescribed 1/2 dose of medication in AM and 1/2 dose of medication in PM. Child was being given a full dose by one staff member and a 1/2 dose by another staff member. Pill count reflected the discrepancy on the medication logs.

Resolution: Corrected: 2024-08-19

Medication logs were filled out incorrectly for a child in care. Child had not been given his PM medication; however, the medication log reflected his PM medication had already been dispensed.

Resolution: Corrected: 2024-08-19

Medication logs were filled out incorrectly for a child in care. Child had not been given his PM medication; however, the medication log reflected his PM medication had already been dispensed.

Resolution: Corrected: 2024-08-19

A child was prescribed 1/2 dose of medication in AM and 1/2 dose of medication in PM. Child was being given a full dose by one staff member and a 1/2 dose by another staff member. Pill count reflected the discrepancy on the medication logs.

Resolution: Corrected: 2024-08-19

A child was prescribed 1/2 dose of medication in AM and 1/2 dose of medication in PM. Child was being given a full dose by one staff member and a 1/2 dose by another staff member. Pill count reflected the discrepancy on the medication logs.

Resolution: Corrected: 2024-08-19

During the inspection, it was found that a child was not given the correct dose of medication on four occassions.

Resolution: Corrected: 2024-07-23

During the inspection, it was found that a child was not given the correct dose of medication on four occassions.

Resolution: Corrected: 2024-07-23

During the inspection, it was found that a child was not given the correct dose of medication on four occassions.

Resolution: Corrected: 2024-07-23

An employee's file did not have an up to date record of all training and training hours completed.

Resolution: Corrected: 2024-07-18

An employee's file did not have an up to date record of all training and training hours completed.

Resolution: Corrected: 2024-07-18

An employee's file did not have an up to date record of all training and training hours completed.

Resolution: Corrected: 2024-07-18

It was discovered that staff are denying phone calls from children.

Resolution: Corrected: 2024-03-20

It was determined that staff were listening in on children's phone calls.

Resolution: Corrected: 2024-03-20

It was discovered that staff are denying phone calls from children.

Resolution: Corrected: 2024-03-20

It was discovered that staff are denying phone calls from children.

Resolution: Corrected: 2024-03-20

It was determined that staff were listening in on children's phone calls.

Resolution: Corrected: 2024-03-20

It was determined that staff were listening in on children's phone calls.

Resolution: Corrected: 2024-03-20

In the employee record reviewed there was no documentation made to show the last five years of employment history.

Resolution: Corrected: 2023-12-15

In one of the staff records reviewed there was no documentation made to show that the potential staff's references were contacted. The application does list 5 different references, but the operation does not have any documentation to show where contact was made.

Resolution: Corrected: 2023-12-15

In reviewed of the staff records reviewed, there was no Normalcy training documented for the administrator for 2022. The record does show that it was obtaining for 2023 at the Texas Childcare Administrator Conference.

Resolution: Corrected: 2023-12-15

In one of the records reviewed the staff record did not have the notarized affidavit available for review in the record.

Resolution: Corrected: 2023-12-15

In one of the records reviewed the documentation for the 40-hour supervised experience is minimum. It does not include the date or if this is the staff's actual 40-hour shadowing experience.

Resolution: Corrected: 2023-12-15

In the employee record reviewed there was no documentation made to show the last five years of employment history.

Resolution: Corrected: 2023-12-15

In one of the staff records reviewed there was no documentation made to show that the potential staff's references were contacted. The application does list 5 different references, but the operation does not have any documentation to show where contact was made.

Resolution: Corrected: 2023-12-15

In reviewed of the staff records reviewed, there was no Normalcy training documented for the administrator for 2022. The record does show that it was obtaining for 2023 at the Texas Childcare Administrator Conference.

Resolution: Corrected: 2023-12-15

In one of the records reviewed the documentation for the 40-hour supervised experience is minimum. It does not include the date or if this is the staff's actual 40-hour shadowing experience.

Resolution: Corrected: 2023-12-15

In one of the records reviewed the staff record did not have the notarized affidavit available for review in the record.

Resolution: Corrected: 2023-12-15

In one of the staff records reviewed there was no documentation made to show that the potential staff's references were contacted. The application does list 5 different references, but the operation does not have any documentation to show where contact was made.

Resolution: Corrected: 2023-12-15

In the employee record reviewed there was no documentation made to show the last five years of employment history.

Resolution: Corrected: 2023-12-15

In one of the records reviewed the documentation for the 40-hour supervised experience is minimum. It does not include the date or if this is the staff's actual 40-hour shadowing experience.

Resolution: Corrected: 2023-12-15

In one of the records reviewed the staff record did not have the notarized affidavit available for review in the record.

Resolution: Corrected: 2023-12-15

In reviewed of the staff records reviewed, there was no Normalcy training documented for the administrator for 2022. The record does show that it was obtaining for 2023 at the Texas Childcare Administrator Conference.

Resolution: Corrected: 2023-12-15

In a review of a child's record a positive covid result was found. There was no report made to licensing to notify of the positive result.

Resolution: Corrected: 2023-09-26

In a review of four child records, it was noted that the children were missing TB tests.

Resolution: Corrected: 2023-10-18

In a review of one child's file it was noted that the child had not recieved their screening review.

Resolution: Corrected: 2023-10-03

In a review of one child's discharge summary it was noted that the PLSP did not participate in the discharge preparation, nor did they review and sign the summary. This standard was corrected at inspection.

Resolution: Corrected at inspection

In a review of a child's file, there is a positive Covid test. There was no incident report for the positive test. Due to no report, there is no documentation showing notification to licensing or the child's parent/managing conservator.

Resolution: Corrected: 2023-09-26

In a review of four child records, it was noted that the children were missing TB tests.

Resolution: Corrected: 2023-10-18

In a review of one child's file it was noted that the child had not recieved their screening review.

Resolution: Corrected: 2023-10-03

In a review of a child's record a positive covid result was found. There was no report made to licensing to notify of the positive result.

Resolution: Corrected: 2023-09-26

In a review of one child's discharge summary it was noted that the PLSP did not participate in the discharge preparation, nor did they review and sign the summary. This standard was corrected at inspection.

Resolution: Corrected at inspection

In a review of a child's file, there is a positive Covid test. There was no incident report for the positive test. Due to no report, there is no documentation showing notification to licensing or the child's parent/managing conservator.

Resolution: Corrected: 2023-09-26

In a review of four child records, it was noted that the children were missing TB tests.

Resolution: Corrected: 2023-10-18

In a review of one child's file it was noted that the child had not recieved their screening review.

Resolution: Corrected: 2023-10-03

In a review of a child's record a positive covid result was found. There was no report made to licensing to notify of the positive result.

Resolution: Corrected: 2023-09-26

In a review of one child's discharge summary it was noted that the PLSP did not participate in the discharge preparation, nor did they review and sign the summary. This standard was corrected at inspection.

Resolution: Corrected at inspection

In a review of a child's file, there is a positive Covid test. There was no incident report for the positive test. Due to no report, there is no documentation showing notification to licensing or the child's parent/managing conservator.

Resolution: Corrected: 2023-09-26

Upon review of medication records, it was found that after administering the medication, the staff member went up on the count, rather than noting that there was less medication. The count was documented incorrectly, and thus messed up the count going further on the following days. Prior to leaving the operation, the administrator provided documentation stating that the staff member will not be assigned the task of medication administration effectively immediately. Documentation was provided for the inspector.

Resolution: Corrected at inspection

Upon review of medication records, it was found that after administering the medication, the staff member went up on the count, rather than noting that there was less medication. The count was documented incorrectly, and thus messed up the count going further on the following days. Prior to leaving the operation, the administrator provided documentation stating that the staff member will not be assigned the task of medication administration effectively immediately. Documentation was provided for the inspector.

Resolution: Corrected at inspection

Upon review of medication records, it was found that after administering the medication, the staff member went up on the count, rather than noting that there was less medication. The count was documented incorrectly, and thus messed up the count going further on the following days. Prior to leaving the operation, the administrator provided documentation stating that the staff member will not be assigned the task of medication administration effectively immediately. Documentation was provided for the inspector.

Resolution: Corrected at inspection

In a review of one child's medication logs, it was found that the child missed a dose of medication for two days before getting refilled.

Resolution: Corrected: 2023-07-13

In one child's record, it was found that the child received the wrong dosage of medication on two separate occasions.

Resolution: Corrected: 2023-07-06

During a review of the child's service plan review, it was noted that there was no evaluation of the medication's effectiveness, changes in medications, changes in behaviors, or any lab work completed.

Resolution: Corrected: 2023-07-20

In one child's record, it was found that the child received the wrong dosage of medication on two separate occasions.

Resolution: Corrected: 2023-07-06

In a review of one child's medication logs, it was found that the child missed a dose of medication for two days before getting refilled.

Resolution: Corrected: 2023-07-13

In one child's record, it was found that the child received the wrong dosage of medication on two separate occasions.

Resolution: Corrected: 2023-07-06

In a review of one child's medication logs, it was found that the child missed a dose of medication for two days before getting refilled.

Resolution: Corrected: 2023-07-13

During a review of the child's service plan review, it was noted that there was no evaluation of the medication's effectiveness, changes in medications, changes in behaviors, or any lab work completed.

Resolution: Corrected: 2023-07-20

During a review of the child's service plan review, it was noted that there was no evaluation of the medication's effectiveness, changes in medications, changes in behaviors, or any lab work completed.

Resolution: Corrected: 2023-07-20

A designated emergency exit was observed to be blocked by a couch on the inside and blocked as well on the outside by children's bikes.

Resolution: Corrected: 2023-05-19

A designated emergency exit was observed to be blocked by a couch on the inside and blocked as well on the outside by children's bikes.

Resolution: Corrected: 2023-05-19

A designated emergency exit was observed to be blocked by a couch on the inside and blocked as well on the outside by children's bikes.

Resolution: Corrected: 2023-05-19

In one of the bedrooms, it was noted that the floor tile was peeling in multiple places. The tile under the legs of the bed, and in a corner against the wall had been torn up.

Resolution: Corrected: 2023-05-18

In one of the bedrooms, it was noted that the floor tile was peeling in multiple places. The tile under the legs of the bed, and in a corner against the wall had been torn up.

Resolution: Corrected: 2023-05-18

In one of the bedrooms, it was noted that the floor tile was peeling in multiple places. The tile under the legs of the bed, and in a corner against the wall had been torn up.

Resolution: Corrected: 2023-05-18

In a review of one child's records, there were six Behavior Observation Reports that were completed by another staff member, but held the name and signature of another. In another child's record, there were service plan reviews found that contained inaccurate and untruthful information.

Resolution: Corrected: 2023-07-05

In a review of one child's service plan, there was no child signature, no caregiver signature, no treatment director signature, nor normalcy signature. In a review of three other service plans, there was no treatment director signatures.

Resolution: Corrected: 2023-07-05

In a review of four children's daily progress notes for the months March through April, none were signed by staff as required. There were also three days missing daily progress notes for one child.

Resolution: Corrected: 2023-07-05

In a review of one child's records, there were six Behavior Observation Reports that were completed by another staff member, but held the name and signature of another. In another child's record, there were service plan reviews found that contained inaccurate and untruthful information.

Resolution: Corrected: 2023-07-05

In a review of four children's daily progress notes for the months March through April, none were signed by staff as required. There were also three days missing daily progress notes for one child.

Resolution: Corrected: 2023-07-05

In a review of one child's service plan, there was no child signature, no caregiver signature, no treatment director signature, nor normalcy signature. In a review of three other service plans, there was no treatment director signatures.

Resolution: Corrected: 2023-07-05

In a review of one child's records, there were six Behavior Observation Reports that were completed by another staff member, but held the name and signature of another. In another child's record, there were service plan reviews found that contained inaccurate and untruthful information.

Resolution: Corrected: 2023-07-05

In a review of four children's daily progress notes for the months March through April, none were signed by staff as required. There were also three days missing daily progress notes for one child.

Resolution: Corrected: 2023-07-05

In a review of one child's service plan, there was no child signature, no caregiver signature, no treatment director signature, nor normalcy signature. In a review of three other service plans, there was no treatment director signatures.

Resolution: Corrected: 2023-07-05

During the course of the investigation, it was found that a staff member was threatening a child with harm as a method to gain compliance.

Resolution: Corrected: 2023-06-13

During the course of the investigation, it was found that a staff member was threatening a child with harm as a method to gain compliance.

Resolution: Corrected: 2023-06-13

During the course of the investigation, it was found that a staff member was threatening a child with harm as a method to gain compliance.

Resolution: Corrected: 2023-06-13

An employee failed to comply with requirement to report being under investigation for abuse/neglect.

Resolution: Corrected: 2023-04-12

A direct care staff was aware of being under investigation for abuse/neglect and failed to make a report to Licensing.

Resolution: Corrected: 2023-04-12

A direct care staff was aware of being under investigation for abuse/neglect and failed to make a report to Licensing.

Resolution: Corrected: 2023-04-12

An employee failed to comply with requirement to report being under investigation for abuse/neglect.

Resolution: Corrected: 2023-04-12

A direct care staff was aware of being under investigation for abuse/neglect and failed to make a report to Licensing.

Resolution: Corrected: 2023-04-12

An employee failed to comply with requirement to report being under investigation for abuse/neglect.

Resolution: Corrected: 2023-04-12

It was noted that staff did not write EBI documentation in a timely manner.

Resolution: Corrected: 2023-04-11

Children interviewed reported that during restraints it was hard to breathe, or that they could not breathe.

Resolution: Corrected: 2023-04-11

It was not noted on the EBI reports nor the serious incident reports when written notice was provided to the parent after a restraint was conducted on a child.

Resolution: Corrected: 2023-04-11

Children interviewed stated that they were laid on their back and/or belly during restraints and that it hurt. Children also stated that they had witnessed staff perform restraints this way and that they heard the children say that they were being hurt.

Resolution: Corrected: 2023-04-11

Children interviewed reported that during restraints it was hard to breathe, or that they could not breathe.

Resolution: Corrected: 2023-04-11

Children interviewed stated that they were laid on their back and/or belly during restraints and that it hurt. Children also stated that they had witnessed staff perform restraints this way and that they heard the children say that they were being hurt.

Resolution: Corrected: 2023-04-11

It was not noted on the EBI reports nor the serious incident reports when written notice was provided to the parent after a restraint was conducted on a child.

Resolution: Corrected: 2023-04-11

It was noted that staff did not write EBI documentation in a timely manner.

Resolution: Corrected: 2023-04-11

Children interviewed reported that during restraints it was hard to breathe, or that they could not breathe.

Resolution: Corrected: 2023-04-11

Children interviewed stated that they were laid on their back and/or belly during restraints and that it hurt. Children also stated that they had witnessed staff perform restraints this way and that they heard the children say that they were being hurt.

Resolution: Corrected: 2023-04-11

It was not noted on the EBI reports nor the serious incident reports when written notice was provided to the parent after a restraint was conducted on a child.

Resolution: Corrected: 2023-04-11

It was noted that staff did not write EBI documentation in a timely manner.

Resolution: Corrected: 2023-04-11

Upon reviewing first aid kits, it is noticed that 3 out of 3 first aid kits do not have tweezers.

Resolution: Corrected at inspection

Upon reviewing medication logs and documentation, it is noticed that 1 of 4 childs medication logs was noted to be missing prescribing health care professional information.

Resolution: Corrected: 2023-02-24

Upon reviewing medical logs and documentation, it is noticed that 2 of 4 children medical records showed an error. On one child's record it was noted a child missed a dose. On 2 other child's records, it appears that the children received a double dose on for approximately 5 days and one for approximately 1 day. There was no documentation of medication errors in the child's records. There was no documentation of current medication review notes to accurately determine appropriate medication administration is being followed.

Resolution: Corrected: 2023-02-24

Upon discussion with the administrator regarding the volunteers, it is noted that the operation has allowed frequent visitors to be present at the operation without a background check.

Resolution: Corrected: 2023-02-17

Upon discussion with the administrator, it was noted that the operation was allowing volunteers in the form of tutoring to enter and assist the children. This practice violates the operation's own approved policies.

Resolution: Corrected: 2023-02-22

Upon reviewing the playground at the operation, it is noticed that the loose-fill does not reach the required 9 inches of height that it should be, as set by minimum standards.

Resolution: Corrected: 2023-03-15

Upon requesting files for volunteers, it is discussed by the administrator that they do not have documentation or personal files for the volunteers.

Resolution: Corrected: 2023-02-22

Upon reviewing the playground equipment, it is noticed that a swing set is not properly anchored to the ground as well as the tether ball and was noticed that the wooden play structure was just sat on top of the ground, not anchored or built into the ground.

Resolution: Corrected: 2023-02-24

Upon review of incident reports, it was found that 1 document informed of an EBI being used. Upon further review, it was found that there was no post intervention discussion conducted with the child.

Resolution: Corrected: 2023-02-24

Upon request of the severe weather drill documentation, it is noted that the operation does not have documented severe weather drills.

Resolution: Corrected: 2023-02-24

Upon reviewing the fire drill documentation, it is noted that in 2022 there was a missed fire drill, 10-7-2021 a fire drill was conducted thus one would've been due in April of 2022 the next was completed August 5th of 2022, tus being overdue by approximately 4 months.

Resolution: Corrected: 2023-02-24

Upon reviewing first aid kits, it is noticed that 3 out of 3 first aid kits do not have a thermometer.

Resolution: Corrected at inspection

Upon walking through the operation, it is noticed that 2 of the girls beds in one of the rooms was missing a mattress cover or protector.

Resolution: Corrected at inspection

Upon requesting documents, the operation stated that they do not have an overall operation evaluation review of their Emergency Behavior Intervention.

Resolution: Corrected: 2023-02-24

Upon discussion with the administrator, it is revealed that the administrator has not been inspecting the playground weekly.

Resolution: Corrected: 2023-02-24

Upon discussion with the administrator, it is noted that the volunteers are coming in contact with children without documention of TB screenings.

Resolution: Corrected: 2023-02-22

Upon reviewing EBI documentation, it is noticed that 2 of 3 debriefings did not have childs reaction.

Resolution: Corrected: 2023-02-24

Upon reviewing medication logs and documentation, it is noticed that 2 out of 4 child medical records did not show a diagnosis/reason for prescription medications. Out of the 2 child records on 1 childs; 6 medication logs were missing the reason/diagnosis and on the other childs record, 1 of their mediction log was missing the reason/diagnosis.

Resolution: Corrected: 2023-02-24

Upon review at the inspection, it was found the administrator installed new playground equipment that was not in compliance with minimum standards, was not conducting the required reviews of the playground equipment, allowing volunteers at the operation for tutoring and mentoring without background checks, and not providing oversight of the entire program and staff's duties and responsibilities.

Resolution: Corrected: 2023-02-22

During the walk through of the operation, in the medication room it was noted that the Schedule II medications were not double locked.

Resolution: Corrected at inspection

Upon reveiwing EBI documentation, it is noticed that 3 out of 3 EBI reviews did not have supervisory review.

Resolution: Corrected: 2023-02-24

Upon reviewing first aid kits, it is noticed that 3 out of 3 first aid kits do not have a thermometer.

Resolution: Corrected at inspection

Upon reviewing EBI documentation, it is noticed that 2 of 3 debriefings did not have childs reaction.

Resolution: Corrected: 2023-02-24

Upon reviewing first aid kits, it is noticed that 3 out of 3 first aid kits do not have tweezers.

Resolution: Corrected at inspection

Upon reviewing the playground at the operation, it is noticed that the loose-fill does not reach the required 9 inches of height that it should be, as set by minimum standards.

Resolution: Corrected: 2023-03-15

Upon reveiwing EBI documentation, it is noticed that 3 out of 3 EBI reviews did not have supervisory review.

Resolution: Corrected: 2023-02-24

Upon review of incident reports, it was found that 1 document informed of an EBI being used. Upon further review, it was found that there was no post intervention discussion conducted with the child.

Resolution: Corrected: 2023-02-24

Upon reviewing first aid kits, it is noticed that 3 out of 3 first aid kits do not have a thermometer.

Resolution: Corrected at inspection

Upon request of the severe weather drill documentation, it is noted that the operation does not have documented severe weather drills.

Resolution: Corrected: 2023-02-24

Upon review at the inspection, it was found the administrator installed new playground equipment that was not in compliance with minimum standards, was not conducting the required reviews of the playground equipment, allowing volunteers at the operation for tutoring and mentoring without background checks, and not providing oversight of the entire program and staff's duties and responsibilities.

Resolution: Corrected: 2023-02-22

Upon reviewing medication logs and documentation, it is noticed that 2 out of 4 child medical records did not show a diagnosis/reason for prescription medications. Out of the 2 child records on 1 childs; 6 medication logs were missing the reason/diagnosis and on the other childs record, 1 of their mediction log was missing the reason/diagnosis.

Resolution: Corrected: 2023-02-24

Upon discussion with the administrator, it is noted that the volunteers are coming in contact with children without documention of TB screenings.

Resolution: Corrected: 2023-02-22

Upon discussion with the administrator, it is revealed that the administrator has not been inspecting the playground weekly.

Resolution: Corrected: 2023-02-24

Upon reviewing medication logs and documentation, it is noticed that 1 of 4 childs medication logs was noted to be missing prescribing health care professional information.

Resolution: Corrected: 2023-02-24

Upon reviewing medical logs and documentation, it is noticed that 2 of 4 children medical records showed an error. On one child's record it was noted a child missed a dose. On 2 other child's records, it appears that the children received a double dose on for approximately 5 days and one for approximately 1 day. There was no documentation of medication errors in the child's records. There was no documentation of current medication review notes to accurately determine appropriate medication administration is being followed.

Resolution: Corrected: 2023-02-24

Upon requesting documents, the operation stated that they do not have an overall operation evaluation review of their Emergency Behavior Intervention.

Resolution: Corrected: 2023-02-24

Upon reviewing the playground equipment, it is noticed that a swing set is not properly anchored to the ground as well as the tether ball and was noticed that the wooden play structure was just sat on top of the ground, not anchored or built into the ground.

Resolution: Corrected: 2023-02-24

Upon discussion with the administrator regarding the volunteers, it is noted that the operation has allowed frequent visitors to be present at the operation without a background check.

Resolution: Corrected: 2023-02-17

Upon requesting files for volunteers, it is discussed by the administrator that they do not have documentation or personal files for the volunteers.

Resolution: Corrected: 2023-02-22

Upon reviewing EBI documentation, it is noticed that 2 of 3 debriefings did not have childs reaction.

Resolution: Corrected: 2023-02-24

Upon discussion with the administrator, it was noted that the operation was allowing volunteers in the form of tutoring to enter and assist the children. This practice violates the operation's own approved policies.

Resolution: Corrected: 2023-02-22

Upon walking through the operation, it is noticed that 2 of the girls beds in one of the rooms was missing a mattress cover or protector.

Resolution: Corrected at inspection

Upon reviewing the fire drill documentation, it is noted that in 2022 there was a missed fire drill, 10-7-2021 a fire drill was conducted thus one would've been due in April of 2022 the next was completed August 5th of 2022, tus being overdue by approximately 4 months.

Resolution: Corrected: 2023-02-24

During the walk through of the operation, in the medication room it was noted that the Schedule II medications were not double locked.

Resolution: Corrected at inspection

Upon reviewing first aid kits, it is noticed that 3 out of 3 first aid kits do not have tweezers.

Resolution: Corrected at inspection

Upon reviewing the playground at the operation, it is noticed that the loose-fill does not reach the required 9 inches of height that it should be, as set by minimum standards.

Resolution: Corrected: 2023-03-15

Upon reveiwing EBI documentation, it is noticed that 3 out of 3 EBI reviews did not have supervisory review.

Resolution: Corrected: 2023-02-24

Upon requesting files for volunteers, it is discussed by the administrator that they do not have documentation or personal files for the volunteers.

Resolution: Corrected: 2023-02-22

Upon request of the severe weather drill documentation, it is noted that the operation does not have documented severe weather drills.

Resolution: Corrected: 2023-02-24

Upon review at the inspection, it was found the administrator installed new playground equipment that was not in compliance with minimum standards, was not conducting the required reviews of the playground equipment, allowing volunteers at the operation for tutoring and mentoring without background checks, and not providing oversight of the entire program and staff's duties and responsibilities.

Resolution: Corrected: 2023-02-22

Upon reviewing medication logs and documentation, it is noticed that 2 out of 4 child medical records did not show a diagnosis/reason for prescription medications. Out of the 2 child records on 1 childs; 6 medication logs were missing the reason/diagnosis and on the other childs record, 1 of their mediction log was missing the reason/diagnosis.

Resolution: Corrected: 2023-02-24

Upon discussion with the administrator, it is noted that the volunteers are coming in contact with children without documention of TB screenings.

Resolution: Corrected: 2023-02-22

Upon discussion with the administrator, it is revealed that the administrator has not been inspecting the playground weekly.

Resolution: Corrected: 2023-02-24

Upon reviewing medication logs and documentation, it is noticed that 1 of 4 childs medication logs was noted to be missing prescribing health care professional information.

Resolution: Corrected: 2023-02-24

Upon reviewing medical logs and documentation, it is noticed that 2 of 4 children medical records showed an error. On one child's record it was noted a child missed a dose. On 2 other child's records, it appears that the children received a double dose on for approximately 5 days and one for approximately 1 day. There was no documentation of medication errors in the child's records. There was no documentation of current medication review notes to accurately determine appropriate medication administration is being followed.

Resolution: Corrected: 2023-02-24

Upon requesting documents, the operation stated that they do not have an overall operation evaluation review of their Emergency Behavior Intervention.

Resolution: Corrected: 2023-02-24

Upon reviewing the playground equipment, it is noticed that a swing set is not properly anchored to the ground as well as the tether ball and was noticed that the wooden play structure was just sat on top of the ground, not anchored or built into the ground.

Resolution: Corrected: 2023-02-24

Upon discussion with the administrator regarding the volunteers, it is noted that the operation has allowed frequent visitors to be present at the operation without a background check.

Resolution: Corrected: 2023-02-17

Upon review of incident reports, it was found that 1 document informed of an EBI being used. Upon further review, it was found that there was no post intervention discussion conducted with the child.

Resolution: Corrected: 2023-02-24

During the walk through of the operation, in the medication room it was noted that the Schedule II medications were not double locked.

Resolution: Corrected at inspection

Upon reviewing the fire drill documentation, it is noted that in 2022 there was a missed fire drill, 10-7-2021 a fire drill was conducted thus one would've been due in April of 2022 the next was completed August 5th of 2022, tus being overdue by approximately 4 months.

Resolution: Corrected: 2023-02-24

Upon walking through the operation, it is noticed that 2 of the girls beds in one of the rooms was missing a mattress cover or protector.

Resolution: Corrected at inspection

Upon discussion with the administrator, it was noted that the operation was allowing volunteers in the form of tutoring to enter and assist the children. This practice violates the operation's own approved policies.

Resolution: Corrected: 2023-02-22

In a review of staff files, there was no specifically stated learning objectives noted on the documents that were used to notate annual training. There was no objective listed on the sign in sheets.

Resolution: Corrected: 2023-03-28

Upon request of a staff member's current job description, it was found that no new job description was created and signed in the employee's record.

Resolution: Corrected: 2023-03-28

In multiple interviews with staff members, it was found that there were multiple instances where staff should have made a hotline report, but did not.

Resolution: Corrected: 2023-03-28

In a video recording, it was heard that staff was threatening to hit and beat children multiple times in a severe manner.

Resolution: Corrected: 2023-03-28

In a video recording, it was heard that a staff member was using profane language towards children.

Resolution: Corrected: 2023-03-28

In a review of staff records and files, there were no evaluation tools to determine if the staff retained the information received in trainings. In staff interviews, none of the staff stated that they had taken an assessment or any other evaluation tool to determine if they obtained or retained the information.

Resolution: Corrected: 2023-03-28

It was found that two employees had expired drivers licenses.

Resolution: Corrected: 2023-03-28

In a review of staff training, there was no curriculum that was produced to show what the staff were being taught.

Resolution: Corrected: 2023-03-28

Upon request of a staff member's current job description, it was found that no new job description was created and signed in the employee's record.

Resolution: Corrected: 2023-03-28

In a review of staff records and files, there were no evaluation tools to determine if the staff retained the information received in trainings. In staff interviews, none of the staff stated that they had taken an assessment or any other evaluation tool to determine if they obtained or retained the information.

Resolution: Corrected: 2023-03-28

In a video recording, it was heard that staff was threatening to hit and beat children multiple times in a severe manner.

Resolution: Corrected: 2023-03-28

It was found that two employees had expired drivers licenses.

Resolution: Corrected: 2023-03-28

In multiple interviews with staff members, it was found that there were multiple instances where staff should have made a hotline report, but did not.

Resolution: Corrected: 2023-03-28

Upon request of a staff member's current job description, it was found that no new job description was created and signed in the employee's record.

Resolution: Corrected: 2023-03-28

In a review of staff files, there was no specifically stated learning objectives noted on the documents that were used to notate annual training. There was no objective listed on the sign in sheets.

Resolution: Corrected: 2023-03-28

In a review of staff training, there was no curriculum that was produced to show what the staff were being taught.

Resolution: Corrected: 2023-03-28

In a video recording, it was heard that a staff member was using profane language towards children.

Resolution: Corrected: 2023-03-28

In a review of staff records and files, there were no evaluation tools to determine if the staff retained the information received in trainings. In staff interviews, none of the staff stated that they had taken an assessment or any other evaluation tool to determine if they obtained or retained the information.

Resolution: Corrected: 2023-03-28

In a video recording, it was heard that staff was threatening to hit and beat children multiple times in a severe manner.

Resolution: Corrected: 2023-03-28

It was found that two employees had expired drivers licenses.

Resolution: Corrected: 2023-03-28

In multiple interviews with staff members, it was found that there were multiple instances where staff should have made a hotline report, but did not.

Resolution: Corrected: 2023-03-28

In a review of staff files, there was no specifically stated learning objectives noted on the documents that were used to notate annual training. There was no objective listed on the sign in sheets.

Resolution: Corrected: 2023-03-28

In a review of staff training, there was no curriculum that was produced to show what the staff were being taught.

Resolution: Corrected: 2023-03-28

In a video recording, it was heard that a staff member was using profane language towards children.

Resolution: Corrected: 2023-03-28

During the course of the investigation, it was found that staff are forcing children to eat all of their food.

Resolution: Corrected: 2023-03-13

During the course of the investigation, it was found that staff are forcing children to eat all of their food.

Resolution: Corrected: 2023-03-13

During the course of the investigation, it was found that staff are forcing children to eat all of their food.

Resolution: Corrected: 2023-03-13

Food items were observed to be stored on the floor in the kitchen. Food in boxes were observed to have started to rot. Boxes were removed and thrown in dumpster.

Resolution: Corrected at inspection

The pantry was observed with evidence of rodent droppings. The pantry shelves were observed to be dirty and had sticky substances.

Resolution: Corrected: 2022-10-25

The pantry was observed with evidence of rodent droppings. The pantry shelves were observed to be dirty and had sticky substances.

Resolution: Corrected: 2022-10-25

Food items were observed to be stored on the floor in the kitchen. Food in boxes were observed to have started to rot. Boxes were removed and thrown in dumpster.

Resolution: Corrected at inspection

The pantry was observed with evidence of rodent droppings. The pantry shelves were observed to be dirty and had sticky substances.

Resolution: Corrected: 2022-10-25

Food items were observed to be stored on the floor in the kitchen. Food in boxes were observed to have started to rot. Boxes were removed and thrown in dumpster.

Resolution: Corrected at inspection

Video footage and documentation was not provided during the investigation.

Resolution: Corrected: 2022-12-01

Video footage and documentation was not provided during the investigation.

Resolution: Corrected: 2022-12-01

Video footage and documentation was not provided during the investigation.

Resolution: Corrected: 2022-12-01

One of four child records reviewed did not have documentation off a dental appointment.

Resolution: Corrected: 2022-09-30

Two of the four child records reviewed were late on the completion of the initail service plan.

Resolution: Corrected: 2022-09-14

During walk-through of the facility, it was noted that one of the fire extinguishers needed to be recharged. The fire extinguisher was switched out and replaced with one that was still in the "White"

Resolution: Corrected at inspection

One of four child records showed that a child made an allegation of abuse. The serious incident report did not note a report made to the Abuse and Neglect Hotline.

Resolution: Corrected: 2022-09-14

This was found on the child's medication logs. It was noted on three logs reviewed that there was no dose given to the child on a few dates in the month of August.

Resolution: Corrected: 2022-09-14

One of four child records reviewed showed a serious incident report that did not note how the incident was resolved.

Resolution: Corrected: 2022-09-14

Discharge summary stated that the child was notified of upcoming discharge on 8/4/2022. The child's discharge date was 8/5/2022.

Resolution: Corrected: 2022-09-14

The medication logs that were reviewed showed the count of the medications to be incorrect based on the amount of medication left in the packaging.

Resolution: Corrected: 2022-09-14

Two of the four child medication records reviewed did not have a reason for why the medication was prescribed.

Resolution: Corrected: 2022-09-14

Operation did not have a current six month evaluation of Unauthorized Absence.

Resolution: Corrected: 2022-09-14

Two of the five freezers inspected did not have a reading of 0* F. One read 8*F and the other read 24*F.

Resolution: Corrected: 2022-09-14

This was found on the child's medication logs. It was noted on three logs reviewed that there was no dose given to the child on a few dates in the month of August.

Resolution: Corrected: 2022-09-14

Two of the five freezers inspected did not have a reading of 0* F. One read 8*F and the other read 24*F.

Resolution: Corrected: 2022-09-14

Two of the four child medication records reviewed did not have a reason for why the medication was prescribed.

Resolution: Corrected: 2022-09-14

During walk-through of the facility, it was noted that one of the fire extinguishers needed to be recharged. The fire extinguisher was switched out and replaced with one that was still in the "White"

Resolution: Corrected at inspection

Two of the four child records reviewed were late on the completion of the initail service plan.

Resolution: Corrected: 2022-09-14

The medication logs that were reviewed showed the count of the medications to be incorrect based on the amount of medication left in the packaging.

Resolution: Corrected: 2022-09-14

Discharge summary stated that the child was notified of upcoming discharge on 8/4/2022. The child's discharge date was 8/5/2022.

Resolution: Corrected: 2022-09-14

Two of the five freezers inspected did not have a reading of 0* F. One read 8*F and the other read 24*F.

Resolution: Corrected: 2022-09-14

Two of the four child medication records reviewed did not have a reason for why the medication was prescribed.

Resolution: Corrected: 2022-09-14

During walk-through of the facility, it was noted that one of the fire extinguishers needed to be recharged. The fire extinguisher was switched out and replaced with one that was still in the "White"

Resolution: Corrected at inspection

Two of the four child records reviewed were late on the completion of the initail service plan.

Resolution: Corrected: 2022-09-14

One of four child records reviewed did not have documentation off a dental appointment.

Resolution: Corrected: 2022-09-30

One of four child records reviewed showed a serious incident report that did not note how the incident was resolved.

Resolution: Corrected: 2022-09-14

Operation did not have a current six month evaluation of Unauthorized Absence.

Resolution: Corrected: 2022-09-14

One of four child records reviewed showed a serious incident report that did not note how the incident was resolved.

Resolution: Corrected: 2022-09-14

Discharge summary stated that the child was notified of upcoming discharge on 8/4/2022. The child's discharge date was 8/5/2022.

Resolution: Corrected: 2022-09-14

The medication logs that were reviewed showed the count of the medications to be incorrect based on the amount of medication left in the packaging.

Resolution: Corrected: 2022-09-14

One of four child records showed that a child made an allegation of abuse. The serious incident report did not note a report made to the Abuse and Neglect Hotline.

Resolution: Corrected: 2022-09-14

One of four child records reviewed did not have documentation off a dental appointment.

Resolution: Corrected: 2022-09-30

Operation did not have a current six month evaluation of Unauthorized Absence.

Resolution: Corrected: 2022-09-14

One of four child records showed that a child made an allegation of abuse. The serious incident report did not note a report made to the Abuse and Neglect Hotline.

Resolution: Corrected: 2022-09-14

This was found on the child's medication logs. It was noted on three logs reviewed that there was no dose given to the child on a few dates in the month of August.

Resolution: Corrected: 2022-09-14

It was determined that a staff member at the operation would yell and raise their voice in front of the children.

Resolution: Corrected: 2022-08-05

It was determined that a staff member at the operation would yell and raise their voice in front of the children.

Resolution: Corrected: 2022-08-05

It was determined that a staff member at the operation would yell and raise their voice in front of the children.

Resolution: Corrected: 2022-08-05

Four chip bags were found to be opened and unprotected from external elements located in the kitchen. Administrator disposed of the open chip bags as well as puchased additional chip clips.

Resolution: Corrected at inspection

Two sinks in the girl's restroom was not draining properly. One sink in the boy's restroom was not draining properly. Administrator applied drain-o to the sinks to unclog the drains.

Resolution: Corrected at inspection

In one of four children records reviewed, in the child's Admission Assessment, it was noted to be missing the contraindications to use of restraints.

Resolution: Corrected: 2022-02-07

One of the child records reviewed showed that a child missed two medication doses on two separate dates. This was found on the child's medication logs.

Resolution: Corrected: 2022-02-07

Small freezer in pantry thermometer was reading to be approximately 10 degrees F. The pantry fridge/freezer combo was missing a thermometer in the freezer. The fridge thermometer was broken. The kitchen fridge/freezer combo was missing both thermometers.

Resolution: Corrected: 2022-02-07

Three medication logs reviewed did not have the reason for the medication and why it was prescribed to the child.

Resolution: Corrected: 2022-02-07

In the boys restroom, it was observed that the shower/tub combo was missing a shower head. Administrator installed a new shower head to the shower/tub combo.

Resolution: Corrected at inspection

In girls room 3, it was observed that a small hole, as well a tear in the dry wall, was found near a child's bed.

Resolution: Corrected: 2022-02-07

Two out of four children records reviewed showed little progress/updates in their service plan reviews.

Resolution: Corrected: 2022-02-07

Three of the medication logs reviewed did not have a prescribing physician noted on the documentation.

Resolution: Corrected: 2022-02-07

Three of the medication logs reviewed did not have a prescribing physician noted on the documentation.

Resolution: Corrected: 2022-02-07

In one of four children records reviewed, in the child's Admission Assessment, it was noted to be missing the contraindications to use of restraints.

Resolution: Corrected: 2022-02-07

Small freezer in pantry thermometer was reading to be approximately 10 degrees F. The pantry fridge/freezer combo was missing a thermometer in the freezer. The fridge thermometer was broken. The kitchen fridge/freezer combo was missing both thermometers.

Resolution: Corrected: 2022-02-07

In the boys restroom, it was observed that the shower/tub combo was missing a shower head. Administrator installed a new shower head to the shower/tub combo.

Resolution: Corrected at inspection

Four chip bags were found to be opened and unprotected from external elements located in the kitchen. Administrator disposed of the open chip bags as well as puchased additional chip clips.

Resolution: Corrected at inspection

Three medication logs reviewed did not have the reason for the medication and why it was prescribed to the child.

Resolution: Corrected: 2022-02-07

Two out of four children records reviewed showed little progress/updates in their service plan reviews.

Resolution: Corrected: 2022-02-07

In girls room 3, it was observed that a small hole, as well a tear in the dry wall, was found near a child's bed.

Resolution: Corrected: 2022-02-07

One of the child records reviewed showed that a child missed two medication doses on two separate dates. This was found on the child's medication logs.

Resolution: Corrected: 2022-02-07

Two sinks in the girl's restroom was not draining properly. One sink in the boy's restroom was not draining properly. Administrator applied drain-o to the sinks to unclog the drains.

Resolution: Corrected at inspection

Three of the medication logs reviewed did not have a prescribing physician noted on the documentation.

Resolution: Corrected: 2022-02-07

In one of four children records reviewed, in the child's Admission Assessment, it was noted to be missing the contraindications to use of restraints.

Resolution: Corrected: 2022-02-07

Small freezer in pantry thermometer was reading to be approximately 10 degrees F. The pantry fridge/freezer combo was missing a thermometer in the freezer. The fridge thermometer was broken. The kitchen fridge/freezer combo was missing both thermometers.

Resolution: Corrected: 2022-02-07

In the boys restroom, it was observed that the shower/tub combo was missing a shower head. Administrator installed a new shower head to the shower/tub combo.

Resolution: Corrected at inspection

Four chip bags were found to be opened and unprotected from external elements located in the kitchen. Administrator disposed of the open chip bags as well as puchased additional chip clips.

Resolution: Corrected at inspection

Three medication logs reviewed did not have the reason for the medication and why it was prescribed to the child.

Resolution: Corrected: 2022-02-07

Two out of four children records reviewed showed little progress/updates in their service plan reviews.

Resolution: Corrected: 2022-02-07

In girls room 3, it was observed that a small hole, as well a tear in the dry wall, was found near a child's bed.

Resolution: Corrected: 2022-02-07

One of the child records reviewed showed that a child missed two medication doses on two separate dates. This was found on the child's medication logs.

Resolution: Corrected: 2022-02-07

Two sinks in the girl's restroom was not draining properly. One sink in the boy's restroom was not draining properly. Administrator applied drain-o to the sinks to unclog the drains.

Resolution: Corrected at inspection

This standard was reviewed and found to be deficient. The medication logs provided only displayed staff initials where a signature is required for administration of medication, and no way to identify which staff member those initials belong to. On one of five medication records, there was no staff signature for the administration of medication given to a child.

Resolution: Corrected: 2021-06-18

This standard was reviewed and found to be deficient. The medication logs provided only displayed staff initials where a signature is required for administration of medication, and no way to identify which staff member those initials belong to. On one of five medication records, there was no staff signature for the administration of medication given to a child.

Resolution: Corrected: 2021-06-18

This standard was reviewed and found to be deficient. The medication logs provided only displayed staff initials where a signature is required for administration of medication, and no way to identify which staff member those initials belong to. On one of five medication records, there was no staff signature for the administration of medication given to a child.

Resolution: Corrected: 2021-06-18

Staff member utilized physical exercise as a form of discipline.

Resolution: Corrected: 2021-05-26

A staff member physically grabbed a child by the wrist and legs, leaving a mark on the child.

Resolution: Corrected: 2021-05-26

A staff member physically grabbed a child by the wrist and legs, leaving a mark on the child.

Resolution: Corrected: 2021-05-26

Staff member utilized physical exercise as a form of discipline.

Resolution: Corrected: 2021-05-26

A staff member physically grabbed a child by the wrist and legs, leaving a mark on the child.

Resolution: Corrected: 2021-05-26

Staff member utilized physical exercise as a form of discipline.

Resolution: Corrected: 2021-05-26