The Ambience Residential Treatment Center
15222 MARLOWE GROVE DR, Sugar Land, TX 77498 · Fort Bend County
Program
- Type
- General residential operation
- Licensed capacity
- 12
- Ages
- 6-17
- Hours
- -
- Director / administrator
- Tokunbo Dipo Sebolatan
- Phone
- (832) 799-4393
- Regulated since
- Sep 14, 2023
- HHSC IDs
- Operation 1405337 · number 1741914
- Official record
- HHSC Child Care Search
Violations by category
Year by year
| Year | Violations | Serious | Main categories |
|---|---|---|---|
| 2026 | 6 | 0 | Cleanliness & sanitation (2), Food & allergies (2), Other (2) |
| 2025 | 10 | 1 | Cleanliness & sanitation (1), Supervision & ratios (2), Safety & premises (2), Staff background & training (1), Other (4) |
| 2024 | 21 | 1 | Cleanliness & sanitation (2), Illness & medication (1), Supervision & ratios (7), Staff background & training (5), Records & paperwork (2), Other (4) |
| 2023 | 41 | 7 | Cleanliness & sanitation (7), Illness & medication (5), Supervision & ratios (13), Discipline & child guidance (2), Safety & premises (1), Food & allergies (1), Records & paperwork (2), Other (10) |
| 2022 | 4 | 0 | Cleanliness & sanitation (1), Supervision & ratios (3) |
Inspections, investigations & assessments
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Sep 10, 2026 Inspection · No deficiencies cited
No violations cited on this visit.
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Sep 2, 2026 Inspection · No deficiencies cited
No violations cited on this visit.
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May 13, 2026 Report · No deficiencies cited
No violations cited on this visit.
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Apr 23, 2026 Inspection · Deficiencies cited
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Other
Pre-employment screening contact results for 3 staff were not documented in the file.
HHSC 748.751(b)(2) — Pre-Employment Screening-You must document the results of any contact with an applicant's previous employers in the personnel file.
HHSC risk weight: Medium Low. Corrected 2026-04-30. Correction verified 2026-05-04.
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Other
Reference checks were not obtained for 3 staff prior to their employment.
HHSC 748.753(a)(1) — Pre-Employment Screening-You must complete reference checks by obtaining the name and contact info of two individuals who can serve as references.
HHSC risk weight: Medium. Corrected 2026-04-30. Correction verified 2026-05-04.
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Other
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Apr 20, 2026 Inspection · No deficiencies cited
No violations cited on this visit.
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Apr 10, 2026 Assessment · No deficiencies cited
No violations cited on this visit.
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Apr 8, 2026 Inspection · No deficiencies cited
No violations cited on this visit.
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Mar 28, 2026 Report · No deficiencies cited
No violations cited on this visit.
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Mar 25, 2026 Report · No deficiencies cited
No violations cited on this visit.
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Mar 2, 2026 Inspection · No deficiencies cited
No violations cited on this visit.
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Feb 19, 2026 Inspection · No deficiencies cited
No violations cited on this visit.
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Feb 4, 2026 Report · No deficiencies cited
No violations cited on this visit.
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Jan 26, 2026 Report · No deficiencies cited
No violations cited on this visit.
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Jan 20, 2026 Inspection · No deficiencies cited
No violations cited on this visit.
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Jan 18, 2026 Report · No deficiencies cited (self-report)
No violations cited on this visit.
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Jan 12, 2026 Inspection · Deficiencies cited
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Cleanliness & sanitation
During the investigation inspection, the window screen on the outside front entry, was observed torn and damaged.
HHSC 748.3301(c) — Physical Site-Windows & doors must be in good repair & free of broken glass or hazards
HHSC risk weight: Medium High. Corrected 2026-01-26. Correction verified 2026-01-14.
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Food & allergies
During the investigation inspection, a one-gallon bottle of drain clog dissolver was observed unlocked and accessible to children.
HHSC 748.3421(3) — Poisons-Ensure poisonous/flammable material isstored in an area that is inaccessible to children unless child is capable to use responsibly.
HHSC risk weight: Medium High. Corrected at inspection. Corrected 2026-01-13.
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Cleanliness & sanitation
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Jan 7, 2026 Report · Deficiencies cited (self-report)
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Cleanliness & sanitation
During the investigation inspection, the window screen on the outside front entry, was observed torn and damaged
HHSC 748.3301(c) — Physical Site-Windows & doors must be in good repair & free of broken glass or hazards
HHSC risk weight: Medium High. Corrected 2026-01-26. Correction verified 2026-01-14.
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Food & allergies
During the investigation inspection, a one-gallon bottle of drain clog dissolver was observed unlocked and accessible to children.
HHSC 748.3421(3) — Poisons-Ensure poisonous/flammable material isstored in an area that is inaccessible to children unless child is capable to use responsibly.
HHSC risk weight: Medium High. Corrected at inspection. Corrected 2026-01-13.
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Cleanliness & sanitation
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Dec 30, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
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Dec 24, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
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Dec 23, 2025 Report · No deficiencies cited (self-report)
No violations cited on this visit.
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Dec 23, 2025 Report · Deficiencies cited
-
Safety & premises
A 10-year-old child attempted to run away and staff administered a restraint to bring the child back in.
HHSC 748.2463(3) — Emergency Behavior Intervention-Never used as a means to get a child to comply
HHSC risk weight: Medium High. Corrected 2025-12-24. Correction verified 2026-03-02.
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Safety & premises
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Nov 25, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
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Nov 21, 2025 Report · No deficiencies cited
No violations cited on this visit.
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Oct 17, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
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Oct 15, 2025 Report · No deficiencies cited
No violations cited on this visit.
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Oct 14, 2025 Report · No deficiencies cited
No violations cited on this visit.
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Oct 10, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
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Oct 6, 2025 Report · Deficiencies cited
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Supervision & ratios
The operation did not adhere to their policy requiring vehicles doors to remain locked at all times.
HHSC 748.126(b) — All employees and caregivers must be aware of and follow your policies and procedures
HHSC risk weight: Medium. Corrected 2025-11-21. Correction verified 2025-11-14.
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Safety & premises Serious
A child in care was not restrained with a seat belt when secured in a vehicle.
HHSC 748.4041 — Driver & passengers must follow all laws when driving, including laws on use of child passenger safety seat systems, seat belts & liability insurance
HHSC risk weight: High. Corrected 2025-11-21. Correction verified 2025-11-14.
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Supervision & ratios
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Oct 2, 2025 Report · No deficiencies cited (self-report)
No violations cited on this visit.
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Sep 24, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
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Sep 20, 2025 Report · No deficiencies cited (self-report)
No violations cited on this visit.
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Sep 5, 2025 Report · Deficiencies cited
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Other
A child in care was found to be in need of footwear. The shoes the child was wearing were old and worn down with holes.
HHSC 748.1101(b)(3)(G) — Children's rights-comfortable clothing suitable to age/size/similar to peers in community. Teenagers have reasonable chance to select clothing
HHSC risk weight: Medium. Corrected 2025-09-29. Correction verified 2025-09-22.
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Other
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Sep 4, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
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Aug 23, 2025 Report · No deficiencies cited
No violations cited on this visit.
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Aug 7, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
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Aug 7, 2025 Report · No deficiencies cited
No violations cited on this visit.
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Jul 28, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
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Jul 23, 2025 Report · No deficiencies cited
No violations cited on this visit.
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Jul 19, 2025 Report · No deficiencies cited
No violations cited on this visit.
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Jul 1, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
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Jun 28, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
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Jun 27, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
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Jun 27, 2025 Report · No deficiencies cited
No violations cited on this visit.
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Jun 27, 2025 Report · No deficiencies cited
No violations cited on this visit.
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Jun 20, 2025 Report · Deficiencies cited (self-report)
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Cleanliness & sanitation
Repairs are needed for the window bllinds, cracked doors, stained walls, chipped paint on walls, chipped surface on picnic tables, stained bathroom tub, chipped paint on bahtroom sink.
HHSC 748.3301(a)(2) — Physical Site- Buildings must be clean and in good repair.
HHSC risk weight: Medium. Corrected 2025-07-17. Correction verified 2025-08-07.
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Cleanliness & sanitation
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Jun 5, 2025 Inspection · Deficiencies cited
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Other
The opertoion has not been administrating any suicide screening when children are being admitted into their placement.
HHSC 748.125(d)(4)(A) — Suicide Screening- A screening tool must be administered at admission for each child 10 years of age or older.
HHSC risk weight: Medium. Corrected 2025-06-06. Correction verified 2025-06-09.
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Other
During the walkthrough the chemical closet was unlocked.
HHSC 748.3421(3) — Poisons-Ensure poisonous/flammable material is stored in an area that is inaccessible to children unless child is capable to use responsibly.
HHSC risk weight: Medium High. Corrected at inspection. Corrected 2025-06-05.
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Other
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May 6, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
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May 5, 2025 Report · No deficiencies cited
No violations cited on this visit.
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May 4, 2025 Report · No deficiencies cited
No violations cited on this visit.
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Apr 23, 2025 Report · No deficiencies cited
No violations cited on this visit.
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Apr 12, 2025 Report · No deficiencies cited
No violations cited on this visit.
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Apr 7, 2025 Report · No deficiencies cited
No violations cited on this visit.
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Mar 13, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
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Mar 12, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
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Mar 11, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
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Mar 11, 2025 Report · No deficiencies cited
No violations cited on this visit.
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Mar 10, 2025 Report · No deficiencies cited
No violations cited on this visit.
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Mar 8, 2025 Report · No deficiencies cited (self-report)
No violations cited on this visit.
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Mar 7, 2025 Report · No deficiencies cited
No violations cited on this visit.
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Mar 5, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
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Mar 5, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
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Mar 1, 2025 Report · No deficiencies cited (self-report)
No violations cited on this visit.
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Feb 27, 2025 Report · No deficiencies cited (self-report)
No violations cited on this visit.
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Feb 25, 2025 Report · No deficiencies cited
No violations cited on this visit.
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Feb 22, 2025 Report · Deficiencies cited
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Supervision & ratios
The operations permit does not have IDD or Autism as services the operation can treat.
HHSC 748.63(1) — Types of services-Operation must only provide services listed on permit
HHSC risk weight: Medium. Corrected 2025-04-25. Correction verified 2025-04-28.
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Supervision & ratios
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Feb 18, 2025 Report · Deficiencies cited
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Other
The 4 SIRs reviewed had limited details regarding the incidents.
HHSC 748.311(8) — Serious Incident Documentation-Includes interventions made during and after the incident, i.e. medical interventions, contacts made, other actions
HHSC risk weight: Medium. Corrected 2025-03-21. Correction verified 2025-04-01.
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Other
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Feb 14, 2025 Inspection · Deficiencies cited
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Staff background & training
Front and Back exit doors can only be opened with the use of a staff's fingerprint. There is no written approval for these doorknobs on file from a fire inspector. The operation reports a fire inspector is scheduled to come out on 2/17/2025 to assess the doorknobs for approval.
HHSC 748.3237(c) — Safety Practices-Children must be able to open emergency exit doors easily from inside, unless written approval on file from fire inspector
HHSC risk weight: Medium High. Corrected 2025-02-21. Correction verified 2025-06-05.
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Staff background & training
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Feb 12, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
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Feb 10, 2025 Report · No deficiencies cited (self-report)
No violations cited on this visit.
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Feb 6, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
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Feb 5, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
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Feb 4, 2025 Report · No deficiencies cited (self-report)
No violations cited on this visit.
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Jan 19, 2025 Report · No deficiencies cited
No violations cited on this visit.
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Jan 18, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
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Jan 10, 2025 Report · No deficiencies cited (self-report)
No violations cited on this visit.
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Jan 7, 2025 Report · No deficiencies cited (self-report)
No violations cited on this visit.
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Dec 30, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
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Dec 23, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
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Dec 22, 2024 Report · Deficiencies cited (self-report)
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Supervision & ratios
During the course of this investigation, the operation was unable to provide a suicide screening conducted for a child that was exhibiting warning signs.
HHSC 748.125(d)(4)(E) — Suicide Screening- Must be administered immediately if the child exhibits warning signs that necessitate a suicide screening be conducted.
HHSC risk weight: Medium High. Corrected 2025-02-21. Correction verified 2025-02-26.
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Supervision & ratios
During this investigation, the operation was unable to provide documentation showing that the child met with the PLSP within 24 hours of returning to the operation.
HHSC 748.125(f)(1) — A PLSP must meet with a child within 24 hours of their return to an operation post hospitalization.
HHSC risk weight: Medium High. Corrected 2025-02-21. Correction verified 2025-02-26.
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Supervision & ratios
During the course of the investigation, the operation was unable to provide the weekly screenings after the child returned to the operation.
HHSC 748.125(f)(2)(A) — Protocols must include weekly screenings for the first 30 days or until the child is no longer reporting suicidal thoughts, whichever is longer.
HHSC risk weight: Medium High. Corrected 2025-02-21. Correction verified 2025-02-26.
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Other
During this investigation, it was found that the safety plan was not updated as needed after returning from the psych hospital.
HHSC 748.125(f)(2)(B) — Post hospitalization protocols must include creating or reviewing and updating the child?s safety plan.
HHSC risk weight: Medium High. Corrected 2025-02-21. Correction verified 2025-02-26.
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Supervision & ratios
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Dec 20, 2024 Report · No deficiencies cited
No violations cited on this visit.
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Dec 16, 2024 Report · No deficiencies cited (self-report)
No violations cited on this visit.
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Dec 15, 2024 Report · No deficiencies cited
No violations cited on this visit.
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Dec 14, 2024 Report
No violations cited on this visit.
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Dec 10, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
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Dec 10, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
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Dec 9, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
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Nov 25, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
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Nov 19, 2024 Report · No deficiencies cited
No violations cited on this visit.
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Nov 17, 2024 Report · No deficiencies cited (self-report)
No violations cited on this visit.
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Nov 8, 2024 Report · No deficiencies cited
No violations cited on this visit.
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Nov 4, 2024 Report · No deficiencies cited (self-report)
No violations cited on this visit.
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Oct 29, 2024 Report · No deficiencies cited
No violations cited on this visit.
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Oct 21, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
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Oct 17, 2024 Report · No deficiencies cited (self-report)
No violations cited on this visit.
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Oct 15, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
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Sep 25, 2024 Report · No deficiencies cited
No violations cited on this visit.
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Sep 24, 2024 Report · No deficiencies cited
No violations cited on this visit.
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Sep 23, 2024 Report · No deficiencies cited
No violations cited on this visit.
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Sep 6, 2024 Report · No deficiencies cited
No violations cited on this visit.
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Sep 4, 2024 Inspection · Deficiencies cited
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Other
The child's file was missing the required discharge documentation.
HHSC 748.1437(1) — Discharge/Transfer Documentation-Must include date and circumstances of discharge or transfer
HHSC risk weight: Medium Low. Corrected 2024-09-09. Correction verified 2024-09-11.
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Other
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Aug 20, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
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Aug 20, 2024 Inspection · Deficiencies cited
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Staff background & training
One employee fille reviewed during inspection was missing the education requirements
HHSC 748.681(2) — Caregiver qualifications- HS diploma or GED from program recognized by TEA, TPSAC, other state or documentaion of equivalency from home schooling
HHSC risk weight: Medium. Corrected 2024-08-27. Correction verified 2024-08-21.
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Staff background & training
Staff filed review last EBI training was on 12/02/2023
HHSC 748.930(b)(1)(A) — Annual Training-Caregivers in operations other than cottage homes must have 4 hrs of EBI every 6 months.
HHSC risk weight: Medium High. Corrected 2024-08-27. Correction verified 2024-08-21.
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Staff background & training
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Aug 16, 2024 Report · No deficiencies cited
No violations cited on this visit.
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Aug 1, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
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Jul 31, 2024 Report · No deficiencies cited
No violations cited on this visit.
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Jul 20, 2024 Report · Deficiencies cited
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Illness & medication
The form 2403 to document the 6/4/2024 Texas Health Steps medical exam was not completed in its entirety. Pages 6 and 8 were left blank resulting in required information left blank. The Visit Results (page 6) and Follow Up (page 8) were not documented. The form 2403 to document the 4/20/2024 Texas Health Steps dental exam was not completed in its entirety. Pages 2, 4, 6, 7,8 were left blank resulting in required information left blank. The Reason for Visit (page 2), Medication List (page 4), Visit Results (7) and Follow Up (page 8) were not documented. The form 2403 to document the 6/4/2024 Texas Health Steps physical exam was not completed in its entirety. Page 6 was left blank resulting in required information left blank. The Visit Results (page 6) were not documented. The form 2403 to document the 3/22/2024 ER Visit was not completed in its entirety. Pages 4,8, and 9 were left blank resulting in required information left blank. The Medications (page 4), Follow Up (page 8), Provider Information (page 9) were not documented. The form 2403 to document the 4/22/2024 medical exam was not completed in its entirety. Page 5 was left blank resulting in required information left blank. The form was not signed by the caregiver and/or DFPS staff.
HHSC 748.1531(b)(5) — Medical Care-Written record of each medical examination includes any documentation provided by health-care professional who performed exam
HHSC risk weight: Medium. Corrected 2024-09-20. Correction verified 2024-09-23.
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Records & paperwork
Child records for medical reviews and documents were not current. Updated forms 2403 will need to be completed and filled out at every appointment and med appointment.
HHSC 748.393(b)(3) — Active child record - Ensure record is kept accurate and current
HHSC risk weight: Medium. Corrected 2024-09-20. Correction verified 2024-09-23.
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Other
The service plan completed on 6/24/2024 was reviewed and the service plan was not signed by the child, and he is able to write. The service plan does not address plans to implement the recommendations given for medical and mental health follow up recommendations by service providers. Signatures were also missing and not dated by Caseworker for child noting that they received and reviewed the recommended service plan for child.
HHSC 748.561(2) — Responsibilities of Professional level service provider-Developing, reviewing, and updating of service plans for a child in care
HHSC risk weight: Medium. Corrected 2024-09-20. Correction verified 2024-09-23.
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Staff background & training
The Preventing and Recognizing Youth Sexual Abuse training was taken on 2/2/2023, and again on 6/10/2024, 129 days late. The Preventing and Recognizing Youth Sexual Abuse training was taken on 1/11/2023, and again on 6/11/2024, 153 days late. The Preventing and Recognizing Youth Sexual Abuse training was taken on 1/24/24 after the staff was counted in ratio on 12/25/23. The Preventing and Recognizing Youth Sexual Abuse training was taken on 5/21/2024 after the staff was counted in ratio on 5/11/2024. The Preventing and Recognizing Youth Sexual Abuse training was taken on 1/2/2024 after the staff was counted in ratio on 12/20/2023. The Preventing and Recognizing Youth Sexual Abuse training was taken on 1/2/2024 after the staff was counted in ratio on 12/24/2023.
HHSC 748.863(a)(1) — Pre-Service Training-All caregivers must receive 8 hrs of general pre-service training & 4hrs before being counted in child/caregiver ratio.
HHSC risk weight: Medium. Corrected 2024-09-20. Correction verified 2024-09-23.
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Staff background & training Serious
The DFPS Psychotropic Medication training was taken on 1/2/2024 after the staff was counted in ratio on 12/24/2023.
HHSC 748.885(1) — General pre-service training curriculum- Must include identification of psychotropic medications.
HHSC risk weight: High. Corrected 2024-09-20. Correction verified 2024-09-23.
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Staff background & training
The DFPS Trauma Informed Care Training was taken on 1/11/2023 and again on 6/11/2024, 152 days late. The DFPS Trauma Informed Care Training was taken on 5/18/2023 and again on 6/10/2024, 25 days late.
HHSC 748.930(b)(2) — Annual Training- Caregivers must have 2 hrs trauma informed care.
HHSC risk weight: Medium High. Corrected 2024-09-20. Correction verified 2024-09-23.
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Illness & medication
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Jul 12, 2024 Report · No deficiencies cited
No violations cited on this visit.
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Jul 11, 2024 Inspection · Deficiencies cited
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Cleanliness & sanitation
Multiple holes in the walls prompted a walk through. 8-10 inches in length and 4-5 inches in width. total number of holes 7. Multiple window blinds were also broken.
HHSC 748.3301(a)(2) — Physical Site- Buildings must be clean and in good repair.
HHSC risk weight: Medium. Corrected 2024-07-11. Correction verified 2024-07-24.
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Supervision & ratios
Vehicle was missing a registration sticker. Registration (proof of purchase) paperwork stated 5/23/2023. It has been over a year since purchase date.
HHSC 748.4083(b) — Vehicle and maintenance-Each vehicle used must be registered and have a current inspection sticker for the state in which it is registered
HHSC risk weight: Medium Low. Corrected 2024-07-25. Correction verified 2024-07-24.
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Cleanliness & sanitation
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Jul 1, 2024 Report · No deficiencies cited
No violations cited on this visit.
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Jun 27, 2024 Report · No deficiencies cited
No violations cited on this visit.
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Jun 27, 2024 Inspection · Deficiencies cited
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Supervision & ratios
The operations health inspection expired on 04/21/24
HHSC 748.3001(b) — Sanitation Inspection-Each inspection must meet regulations of the local health department ordinances
HHSC risk weight: Medium. Corrected 2024-07-08. Correction verified 2024-07-01.
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Supervision & ratios
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Jun 21, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
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Jun 13, 2024 Report · No deficiencies cited
No violations cited on this visit.
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Jun 6, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
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Apr 18, 2024 Inspection · Deficiencies cited
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Other
2 out of the 4 child's files reviewed 72-hour plans were missing signatures.
HHSC 748.1333 — Preliminary Service Plan-Treatment director or PLSP must develop, sign, and date the plan for children receiving treatment services
HHSC risk weight: Medium. Corrected 2024-05-02. Correction verified 2024-05-02.
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Cleanliness & sanitation
There were physical site concerns during the walk through. -A room located upstairs electric plug was missing a cover. -Blinds and the kitchen and a room located upstairs were damaged. -There was water damaged on a ceiling located in room upstairs.
HHSC 748.3301(a)(2) — Physical Site- Buildings must be clean and in good repair.
HHSC risk weight: Medium. Corrected 2024-05-02. Correction verified 2024-05-02.
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Other
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Mar 25, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
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Mar 23, 2024 Report · No deficiencies cited
No violations cited on this visit.
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Mar 23, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
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Mar 22, 2024 Report
No violations cited on this visit.
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Mar 22, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
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Mar 21, 2024 Report · No deficiencies cited (self-report)
No violations cited on this visit.
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Mar 20, 2024 Report · No deficiencies cited
No violations cited on this visit.
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Mar 19, 2024 Report · No deficiencies cited (self-report)
No violations cited on this visit.
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Mar 1, 2024 Report · No deficiencies cited
No violations cited on this visit.
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Feb 27, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
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Feb 23, 2024 Report · No deficiencies cited
No violations cited on this visit.
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Feb 9, 2024 Report · No deficiencies cited
No violations cited on this visit.
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Feb 9, 2024 Report
No violations cited on this visit.
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Feb 7, 2024 Inspection · Deficiencies cited
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Supervision & ratios
One staff file reviewed did not contain proof of education.
HHSC 748.363(5) — Personnel records-Personnel records-Include evidence of valid professional licensures, certifications, or registrations required for the position.
HHSC risk weight: Medium. Corrected 2024-02-14. Correction verified 2024-02-14.
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Records & paperwork
One staff members file reviewed did not contain documentation for reference checks.
HHSC 748.753(d)(1) — Pre-Employment-You must document in the employee record each references name, relation, date completed, info obtained and name of interviewer.
HHSC risk weight: Medium Low. Corrected 2024-02-14. Correction verified 2024-02-14.
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Supervision & ratios
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Feb 6, 2024 Report · Deficiencies cited
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Supervision & ratios
The operation was not abiding by their pre-employment drug testing policy.
HHSC 748.151(2) — Operational responsibilities - Operate according to your approved plans, policies, and procedures
HHSC risk weight: Medium. Corrected 2024-02-29. Correction verified 2024-03-04.
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Supervision & ratios
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Jan 23, 2024 Report · No deficiencies cited
No violations cited on this visit.
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Jan 20, 2024 Report · No deficiencies cited
No violations cited on this visit.
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Jan 19, 2024 Report · No deficiencies cited
No violations cited on this visit.
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Jan 18, 2024 Report · No deficiencies cited
No violations cited on this visit.
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Jan 9, 2024 Report · No deficiencies cited
No violations cited on this visit.
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Dec 20, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
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Dec 7, 2023 Assessment · Deficiencies cited
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Supervision & ratios
The operation has not removed a controlling person as prompted by licensing since 11/07/2023.
HHSC 748.153(3)(C) — Notification - Remove controlling person
HHSC risk weight: Medium High. Corrected 2023-12-12. Correction verified 2023-12-09.
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Supervision & ratios
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Dec 1, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
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Nov 29, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
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Nov 10, 2023 Assessment · No deficiencies cited
No violations cited on this visit.
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Nov 7, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
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Nov 7, 2023 Inspection · Deficiencies cited
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Supervision & ratios
During the inspection, the operation was found to have an expired fire inspection.
HHSC 748.3101(2) — Fire Inspection-Must have fire inspection at least once every 12 months from date of last fire inspection
HHSC risk weight: Medium High. Corrected 2023-12-31. Correction verified 2023-11-29.
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Safety & premises
During the inspection, all second floor windows were observed locked/screwed shut not allowing windows to be opened.
HHSC 748.3237(c) — Safety Practices-Children must be able to open emergency exit doors easily from inside, unless written approval on file from fire inspector
HHSC risk weight: Medium High. Corrected at inspection. Corrected 2023-11-07.
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Cleanliness & sanitation
Operation walls were not observed in good repair as holes were observed during the inspection of the operation.
HHSC 748.3301(a)(2) — Physical Site- Buildings must be clean and in good repair.
HHSC risk weight: Medium. Corrected 2023-11-17. Correction verified 2023-11-29.
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Other
During inspection, bees were observed to be collecting behind the paneling of the house outside in the backyard.
HHSC 748.3301(h) — Physical Site-The building must be free of rodents and insects
HHSC risk weight: Medium High. Corrected 2023-11-17. Correction verified 2023-11-29.
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Cleanliness & sanitation
During inspection, a child's bed was observed to be broken and not in good repair.
HHSC 748.3301(i) — Physical Site-Equipment and furniture must be safe for children and must be kept clean and in good repair
HHSC risk weight: Medium High. Corrected 2023-11-08. Correction verified 2023-11-29.
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Supervision & ratios
During the walkthrough of the operation a child's room was observed to have no lighting in the closet and not enough lighting in half part of the room.
HHSC 748.3307(b)(1) — Physical Site-Habitable rooms must be lighted to avoid accidents
HHSC risk weight: Medium High. Corrected 2023-11-17. Correction verified 2023-11-29.
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Cleanliness & sanitation
During the time of inspection, the following was observed: an open package of bacon, an open package of sausage links, and unmarked meat.
HHSC 748.3445(a) — Food Preparation-Food and drinks must be of safe quality, stored, prepared, and served under sanitary & safe conditions
HHSC risk weight: Medium High. Corrected 2023-11-17. Correction verified 2023-11-29.
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Supervision & ratios
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Nov 6, 2023 Report · No deficiencies cited (self-report)
No violations cited on this visit.
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Nov 3, 2023 Report · Deficiencies cited (self-report)
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Other
Children are not being allowed privacy when making phone calls to their Case Workers.
HHSC 748.1101(b)(3)(E) — Children's rights-privacy to send/receive unopened mail,have phone conversations,keep journal,have visitors unless the child's best interest
HHSC risk weight: Medium. Corrected 2024-01-05. Correction verified 2024-03-01.
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Other
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Oct 22, 2023 Report · No deficiencies cited
No violations cited on this visit.
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Oct 22, 2023 Report · No deficiencies cited (self-report)
No violations cited on this visit.
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Oct 22, 2023 Report · No deficiencies cited
No violations cited on this visit.
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Oct 20, 2023 Inspection · Deficiencies cited
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Illness & medication
During inspection, a med log for 1 child in care reviewed did not document the name and signature of the staff that administered the medication.
HHSC 748.2151(c)(6) — Medication record - must include name & signature of person who administered each medication
HHSC risk weight: Medium. Corrected 2023-10-27. Correction verified 2023-11-07.
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Cleanliness & sanitation
Operation walls were not observed in good repair as five holes were observed during the inspection of the operation.
HHSC 748.3301(a)(2) — Physical Site- Buildings must be clean and in good repair.
HHSC risk weight: Medium. Corrected 2023-10-27. Correction verified 2023-11-07.
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Other
During inspection, bees were observed to be collecting behind the paneling of the house outside in the backyard.
HHSC 748.3301(h) — Physical Site-The building must be free of rodents and insects
HHSC risk weight: Medium High. Corrected 2023-10-27. Correction verified 2023-11-07.
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Cleanliness & sanitation
The following was observed during the inspection, a package of expired ham, left over cream cheese in the original foil wrapper but exposed to other foods, 1 rotting tomato, open unwrapped sliced cheddar cheese log, unknown meat in an unmarked ziploc bag, and blueberries and bluberry debris in the freezer.
HHSC 748.3445(a) — Food Preparation-Food and drinks must be of safe quality, stored, prepared, and served under sanitary & safe conditions
HHSC risk weight: Medium High. Corrected 2023-10-27. Correction verified 2023-11-07.
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Records & paperwork
One employee fille reviewed during inspection was not found to have a notarized licensing affidavit.
HHSC 748.363(7) — Personnel records-Include notarized Licensing Affidavit for Applicants for Employment form as specified in Human Resources Code, 42.059
HHSC risk weight: Medium. Corrected 2023-10-27. Correction verified 2023-11-07.
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Illness & medication
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Oct 20, 2023 Inspection · Deficiencies cited
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Illness & medication
A medication log is missing and there is no evidence that child took medication as prescribed.
HHSC 748.2003(b)(5) — Administration of prescription medication-Ensure the child has taken the medication as prescribed
HHSC risk weight: Medium High. Corrected 2023-10-25. Correction verified 2023-11-07.
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Illness & medication
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Oct 19, 2023 Report · Deficiencies cited
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Supervision & ratios
The operation did not report serious incidents related to law enforcement responding to incidents at the facility and children in care being arrested to the hotline and/or parents.
HHSC 748.303(a)(6)(A) — Serious Incident-Report to Licensing no later than 24 hours after becoming aware that child is indicted, charged, or arrested or when police respond.
HHSC risk weight: Medium. Corrected 2023-12-05. Correction verified 2023-12-20.
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Supervision & ratios
The operations annual summary log was observed to be missing a child's name, age, gender, and date of admission for 10/8/2023.
HHSC 748.453(a)(1) — Unauthorized Absence ? Annual summary log must include name, age, gender, date of admission
HHSC risk weight: Medium. Corrected 2023-12-05. Correction verified 2023-12-06.
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Supervision & ratios
A debriefing is not being conducted and/or documented with children in care following running away and returning to the operation. This was observed for 17 incidents reviewed.
HHSC 748.455(a) — Unauthorized Absence-After a child returns from unauthorized absence, foster parent must conduct debriefing w/child no later than 24 hrs after return
HHSC risk weight: Medium High. Corrected 2023-12-05. Correction verified 2023-12-20.
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Supervision & ratios
The operation is not conducting triggered reviews for 3 children in care who ran away 3 times in a 60-day period.
HHSC 748.457(a) — Unauthorized Absence?Triggered Review of child?s unauth absences must occur ASAP, but no later than 30 days after third absence within 60-days
HHSC risk weight: Medium High. Corrected 2023-12-05. Correction verified 2023-12-20.
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Supervision & ratios
The operation has not completed an evaluation related to run aways for a six month period.
HHSC 748.463(a) — Unauthorized Absence Evaluation?Must conduct an eval every 6 mths for unauthorized absences that have occurred during that time period
HHSC risk weight: Medium. Corrected 2023-12-05. Correction verified 2023-12-20.
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Other Serious
Caregivers did not provide a safe environment when 2 upstairs windows were broken and plywood was set loosely inside the window frame.
HHSC 748.685(c)(2) — Caregiver responsibility - provide a safe environment
HHSC risk weight: High. Corrected 2023-12-05. Correction verified 2023-12-20.
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Supervision & ratios
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Oct 19, 2023 Report · No deficiencies cited
No violations cited on this visit.
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Sep 8, 2023 Inspection · Deficiencies cited
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Supervision & ratios
The operation did not have documentation to show the operation fire extinguishers were being inspected monthly.
HHSC 748.3115 — Fire Extinguisher-Must inspect fire extinguisher(s) monthly
HHSC risk weight: Medium. Corrected 2023-09-15. Correction verified 2023-09-15.
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Cleanliness & sanitation
At the time of the inspection, one of the upstairs bathrooms was found to not be maintained in good repair as the cabinet floor under the sink was observed warped and moldy.
HHSC 748.3391(a) — Bathrooms-Must be maintained in good repair & kept clean
HHSC risk weight: Medium High. Corrected 2023-09-15. Correction verified 2023-09-15.
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Supervision & ratios
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Aug 7, 2023 Assessment · No deficiencies cited
No violations cited on this visit.
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Aug 4, 2023 Inspection
No violations cited on this visit.
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Aug 4, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
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Jul 24, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
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Jul 22, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
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Jul 18, 2023 Report · No deficiencies cited
No violations cited on this visit.
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Jul 17, 2023 Report · Deficiencies cited
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Illness & medication Serious
During the walk through of the operation the medication cabinet was not locked.
HHSC 748.2101(1) — Medication Storage-Store medication in a locked container
HHSC risk weight: High. Corrected 2023-12-11. Correction verified 2023-12-20.
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Cleanliness & sanitation
During the walkthrough of the operation holes on the wall were observed in a child's room.
HHSC 748.3303(a)(2) — Physical Site- Buildings must be clean and in good repair.
HHSC risk weight: Medium. Corrected 2023-12-15. Correction verified 2023-12-20.
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Illness & medication Serious
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Jul 10, 2023 Report · Deficiencies cited
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Supervision & ratios Serious
A child in care was left unsupervised due to the child care provider being locked out of the facility.
HHSC 748.685(a)(4) — Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
HHSC risk weight: High. Corrected 2023-09-08. Correction verified 2023-10-20.
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Supervision & ratios Serious
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Jul 10, 2023 Report · No deficiencies cited
No violations cited on this visit.
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Jul 5, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
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Jun 30, 2023 Report · Deficiencies cited
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Discipline & child guidance Serious
During the course of the investigation it was determined that a child in care was subjected to corporal punishment by being pushed by staff.
HHSC 748.1101(b)(4)(A)(ii) — Children's rights-The right to be free from being subjected to or threatened with corporal punishment, including spanking or hitting
HHSC risk weight: High. Corrected 2023-07-28. Correction verified 2023-10-20.
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Other
During the course of the investigation it was determined that kids in care are subjected to yelling by staff.
HHSC 748.2307(8) — Other Prohibited Punishments-humiliating, shaming, ridiculing, rejecting, or yelling at a child
HHSC risk weight: Medium High. Corrected 2023-07-31. Correction verified 2023-10-20.
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Other
During the course of the investigation it was determined kids in care are subjected to profanity by staff.
HHSC 748.2307(9) — Other Prohibited Punishments-subjecting a child to abusive or profane language
HHSC risk weight: Medium High. Corrected 2023-07-31. Correction verified 2023-10-20.
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Discipline & child guidance Serious
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May 31, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
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May 31, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
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May 29, 2023 Report · Deficiencies cited (self-report)
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Supervision & ratios
Service plan contains two different names of children.
HHSC 748.151(3) — Operational responsibilities - Maintain current, true, accurate, and complete records
HHSC risk weight: Medium. Corrected 2023-09-08. Correction verified 2023-10-20.
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Supervision & ratios
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May 18, 2023 Report · Deficiencies cited
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Illness & medication
There were no supporting documents stating the child had taken the medications from the missing logs.
HHSC 748.2003(b)(5) — Administration of prescription medication-Ensure the child has taken the medication as prescribed
HHSC risk weight: Medium High. Corrected 2023-07-17. Correction verified 2023-10-20.
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Illness & medication
Multiple Medication logs were missing for 2/14/22-23 and 2-8-23.
HHSC 748.2151(b)(1) — Medication record - update cumulative record within 2 hours of administering medication
HHSC risk weight: Medium High. Corrected 2023-07-17. Correction verified 2023-10-20.
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Other Serious
A staff admitted to a case worker to using an inappropriate restraint towards a child in care by placing his arms behind his back.
HHSC 748.2461(b)(6) — Short Personal Restraint-Caregiver may not use restraint that twists or places the child's limb(s) behind the child's back
HHSC risk weight: High. Corrected 2023-07-21. Correction verified 2023-10-20.
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Other
There was no documentation stating the child in care was put in a restraint by a staff who advised he a placed the child in a restraint.
HHSC 748.2855(c) — EBI Documentation-If personal restraint, must include specific restraint techniques used, including prone/supine restraint used as transitional hold
HHSC risk weight: Medium. Corrected 2023-07-21. Correction verified 2023-10-20.
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Illness & medication
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Apr 19, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
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Apr 14, 2023 Inspection · Deficiencies cited
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Food & allergies
There were 5 childrens records that did not have identifying information easily accessible.
HHSC 748.393(b)(2) — Active child record-Includes known allergies and chronic conditions or "no known allergies" on exterior of record or in a clearly visible location
HHSC risk weight: Medium High. Corrected 2023-04-19. Correction verified 2023-04-17.
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Food & allergies
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Apr 5, 2023 Report · No deficiencies cited
No violations cited on this visit.
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Mar 31, 2023 Report · Deficiencies cited
-
Supervision & ratios
Operation did not document EBI documentation on serious incident report.
HHSC 748.2855(a) — EBI Documentation-Caregiver must document EBI in child's record as soon as possible, but no later than 24 hours after initiation of the intervention
HHSC risk weight: Medium. Corrected 2023-08-22. Correction verified 2023-10-20.
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Discipline & child guidance
Operation did not report to licensing allegations of physical abuse towards a child in care.
HHSC 748.303(a)(3)(A) — Serious Incident-Report to Licensing as soon as aware of allegations or indications of abuse, neglect, or exploitation of a child
HHSC risk weight: Medium High. Corrected 2023-08-22. Correction verified 2023-10-20.
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Records & paperwork
A serious incident report was not documented or provided for an incident in which children in care were having behavioral problems during the nighttime.
HHSC 748.311 — Serious Incident Documentation-Documented in written report
HHSC risk weight: Medium. Corrected 2023-08-22. Correction verified 2023-10-20.
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Other
Staff member did not use self-control when redirecting children in care and tossed the child on the bed.
HHSC 748.507(1) — Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
HHSC risk weight: Medium High. Corrected 2023-10-03. Correction verified 2023-10-20.
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Supervision & ratios Serious
There were children that were exposing themselves and the night caregiver did not take the appropriate preventative measures. The night caregiver was aware of the incidents and did not take steps to separate the children.
HHSC 748.685(a)(4) — Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
HHSC risk weight: High. Corrected 2023-10-04. Correction verified 2023-10-20.
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Supervision & ratios
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Mar 9, 2023 Inspection · Deficiencies cited
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Other Serious
There were several employees that are direct care staff that do not have their affidavits notarized.
HHSC HRC42.059 - Employment Affidavit — HRC42.059 - Employment Affidavit
HHSC risk weight: High. Corrected at inspection. Corrected 2023-03-14.
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Other Serious
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Feb 14, 2023 Assessment · No deficiencies cited
No violations cited on this visit.
-
Jan 26, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
-
Jan 6, 2023 Report · No deficiencies cited
No violations cited on this visit.
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Dec 14, 2022 Inspection · Deficiencies cited
-
Supervision & ratios
The operation did not submit their quarterly EBI for the third quarter as recommended at the 11/22/2022 monitoring inspection.
HHSC 748.2953(b) — Evaluation-Operation's quarterly data on EBI's must be reported to Licensing no later than 15 days after the end of each quarter.
HHSC risk weight: Medium. Corrected 2022-12-16. Correction verified 2022-12-16.
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Cleanliness & sanitation
There was a drawer that was broken in one of the child's bedroom.
HHSC 748.3301(i) — Physical Site-Equipment and furniture must be safe for children and must be kept clean and in good repair
HHSC risk weight: Medium High. Corrected 2022-12-16. Correction verified 2022-12-16.
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Supervision & ratios
The operation was observed to have chemicals stored under the kitchen sink.
HHSC 748.3421(3) — Poisons-Ensure poisonous/flammable material is stored in an area that is inaccessible to children unless child is capable to use responsibly.
HHSC risk weight: Medium High. Corrected at inspection. Corrected 2022-12-14.
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Supervision & ratios
The operation did not have any outdoor recreational equiment.
HHSC 748.3703 — Recreation responsibility-provide indoor & outdoor recreational areas & equipment with sufficient variety & quantity
HHSC risk weight: Medium. Corrected 2022-12-16. Correction verified 2022-12-16.
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Supervision & ratios
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Nov 22, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
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Oct 4, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
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Sep 1, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
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May 25, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
Get the full file
HHSC publishes inspections, investigations and assessments from October 2017 onward, with each cited deficiency and its risk weight. Investigation narratives, complaint files and older history require a public information request. The Texas Public Information Act (Texas Government Code Chapter 552) gives anyone the right to ask. You don't have to say why.
Email the request Printable letter (fax or mail)
- Send to
- HHSC Open Records Coordinator, MC-1070 · OpenRecordsRequest@hhs.texas.gov · fax 512-424-6586 · 4601 W. Guadalupe Street, Austin, Texas 78751-3146 · agency instructions
Show the letter text
If something is happening now, report a concern to HHSC Child Care Regulation. For suspected abuse, contact your county child protective services or law enforcement.
Source: Texas Health and Human Services Commission, Child Care Regulation datasets on data.texas.gov. Last read Oct 1, 2026. Violation text is HHSC's own wording. The categories are ours, added to help you scan. About this data.