Redicare
5311 RIVERS EDGE DR, Richmond, TX 77469 · Fort Bend County
Program
- Type
- General residential operation
- Licensed capacity
- 12
- Ages
- 7-17
- Hours
- -
- Director / administrator
- Tamra H Oliver
- Phone
- (832) 451-6863
- Regulated since
- Dec 23, 2021
- HHSC IDs
- Operation 1377816 · number 1721433
- Official record
- HHSC Child Care Search
Violations by category
Year by year
| Year | Violations | Serious | Main categories |
|---|---|---|---|
| 2026 | 8 | 0 | Illness & medication (4), Supervision & ratios (3), Safety & premises (1) |
| 2025 | 20 | 1 | Cleanliness & sanitation (2), Illness & medication (7), Supervision & ratios (3), Staff background & training (4), Records & paperwork (2), Other (2) |
| 2024 | 29 | 6 | Illness & medication (4), Supervision & ratios (5), Discipline & child guidance (1), Safety & premises (2), Staff background & training (4), Records & paperwork (6), Other (7) |
| 2023 | 14 | 1 | Illness & medication (4), Supervision & ratios (2), Staff background & training (1), Records & paperwork (1), Other (6) |
| 2022 | 43 | 4 | Illness & medication (7), Supervision & ratios (10), Discipline & child guidance (2), Safety & premises (3), Food & allergies (2), Staff background & training (13), Records & paperwork (1), Other (5) |
| 2021 | 8 | 2 | Illness & medication (1), Supervision & ratios (1), Food & allergies (1), Staff background & training (2), Records & paperwork (1), Other (2) |
Enforcement actions
- Seen Oct 1, 2026 — Adverse action in effect (HHSC operation record)
HHSC publishes these as current flags on the operation, not as dated actions. The date shown is when this site first saw the flag. The HHSC Child Care Search has the details.
Inspections, investigations & assessments
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Sep 21, 2026 Inspection · No deficiencies cited
No violations cited on this visit.
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Sep 9, 2026 Inspection · No deficiencies cited
No violations cited on this visit.
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Sep 1, 2026 Inspection · No deficiencies cited
No violations cited on this visit.
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Aug 24, 2026 Inspection · No deficiencies cited
No violations cited on this visit.
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Aug 12, 2026 Inspection · No deficiencies cited
No violations cited on this visit.
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Jul 29, 2026 Inspection · No deficiencies cited
No violations cited on this visit.
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Jul 14, 2026 Inspection · No deficiencies cited
No violations cited on this visit.
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Jul 10, 2026 Report · No deficiencies cited
No violations cited on this visit.
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Jul 3, 2026 Inspection · No deficiencies cited
No violations cited on this visit.
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Jun 26, 2026 Assessment · Deficiencies cited
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Illness & medication
Daily progress notes and shift communication forms contain documentation by staff that medications were not dispensed by them to a child on 6/21 PM and 6/22 AM. However, medication administration records for this child show that the medications were administered by these same staff on 6/21 PM and 6/22 AM. This showed that the operation did not maintain true nor accurate documentation.
HHSC 748.151(3) — Operational responsibilities - Maintain current, true, accurate, and complete records
HHSC risk weight: Medium. Corrected 2026-07-10. Correction verified 2026-07-31.
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Illness & medication
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Jun 16, 2026 Inspection · No deficiencies cited
No violations cited on this visit.
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Jun 11, 2026 Assessment · Deficiencies cited
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Illness & medication
A medication error was documented for 6/2/26 when staff dropped/stepped on a tablet. A review of the medication administration record for this tablet showed the medication's count was altered for the day before on 6/1/26 nullifying the medication error. This was confirmed by the operation. As a result, the medication record was not true or accurate.
HHSC 748.151(3) — Operational responsibilities - Maintain current, true, accurate, and complete records
HHSC risk weight: Medium. Corrected 2026-06-25. Correction verified 2026-06-28.
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Illness & medication
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Jun 2, 2026 Inspection · No deficiencies cited
No violations cited on this visit.
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Jun 2, 2026 Inspection · No deficiencies cited
No violations cited on this visit.
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May 19, 2026 Inspection · No deficiencies cited
No violations cited on this visit.
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May 8, 2026 Inspection · No deficiencies cited
No violations cited on this visit.
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May 6, 2026 Report · Deficiencies cited
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Illness & medication
Guanfacine 2mg on the medication log was prescribed as Guanfacine 2mg ER that's listed on the actual medication.
HHSC 748.2151(c)(4) — Medication record - must include medication name, strength and dosage
HHSC risk weight: Medium High. Corrected 2026-05-11. Correction verified 2026-06-02.
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Illness & medication
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May 5, 2026 Inspection · No deficiencies cited
No violations cited on this visit.
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May 5, 2026 Assessment · Deficiencies cited
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Illness & medication
The documented medication instructions and dosages recorded on the medication logs did not align with the actual medications administered. This discrepancy was observed for three different medications given to a child.
HHSC 748.393(b)(3) — Active child record - Ensure record is kept accurate and current
HHSC risk weight: Medium. Corrected 2026-05-12. Correction verified 2026-05-12.
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Illness & medication
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Apr 21, 2026 Inspection · 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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Apr 8, 2026 Assessment · Deficiencies cited
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Supervision & ratios
During a review conducted on 04/8/2026 it was determined that: (1) the Administrator failed to ensure compliance with the current HM Plan; and (2) 12 months had elapsed since the effective date of the plan. The heightened monitoring plan for this operation included a specific ?planned end date? at the 12-month mark by which the 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, this operation is now unable to successfully move to post-plan monitoring. Furthermore, the 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: - 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, including having an open investigation.
HHSC 748.535(2) — AP Child-care administrator responsibilities- Ensure the operation complies with current heightened monitoring plans, if applicable.
HHSC risk weight: Medium High. Corrected 2026-04-09. Correction verified 2026-04-09.
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Supervision & ratios
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Mar 27, 2026 Inspection · 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 24, 2026 Inspection · No deficiencies cited
No violations cited on this visit.
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Mar 9, 2026 Inspection · No deficiencies cited
No violations cited on this visit.
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Mar 9, 2026 Inspection · No deficiencies cited
No violations cited on this visit.
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Mar 4, 2026 Assessment · Deficiencies cited
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Supervision & ratios
The operation is providing services out of the scope of its permit. Specifically, the operation is providing care to a child outside of the permitted age range and offering ASD related services to children with autism.
HHSC 748.63(1) — Types of services-Operation must only provide services listed on permit
HHSC risk weight: Medium. Corrected 2026-03-09. Correction verified 2026-03-11.
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Supervision & ratios
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Feb 24, 2026 Inspection · Deficiencies cited
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Safety & premises
During a review of the incident report, it was found that the documentation did not clearly describe the circumstances surrounding the child's injury involving a razor. The report lacked sufficient detail regarding what occurred, staff awareness, and the actions taken to ensure the chid's safety following the incident.
HHSC 748.311(6) — Serious Incident Documentation-Includes nature of the incident
HHSC risk weight: Medium. Corrected 2026-03-02. Correction verified 2026-02-24.
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Safety & premises
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Feb 20, 2026 Report · No deficiencies cited
No violations cited on this visit.
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Feb 10, 2026 Inspection · No deficiencies cited
No violations cited on this visit.
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Jan 29, 2026 Inspection · No deficiencies cited
No violations cited on this visit.
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Jan 28, 2026 Assessment · Deficiencies cited
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Supervision & ratios
A child's admission date was documented as 1/14/2026 in a preliminary service plan, while the admission assessment had no date of admission. In a review of the visitor log, the child was not placed until 1/15/2026.
HHSC 748.151(3) — Operational responsibilities - Maintain current, true, accurate, and complete records
HHSC risk weight: Medium. Corrected 2026-02-04. Correction verified 2026-02-03.
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Supervision & ratios
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Jan 13, 2026 Inspection · No deficiencies cited
No violations cited on this visit.
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Jan 6, 2026 Assessment
No violations cited on this visit.
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Dec 30, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
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Dec 18, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
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Dec 3, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
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Dec 2, 2025 Inspection · Deficiencies cited
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Supervision & ratios
Communication form was observed to have inaccurate information about a child being present during an unannounced visit completed by the Administrator.
HHSC 748.151(3) — Operational responsibilities - Maintain current, true, accurate, and complete records
HHSC risk weight: Medium. Corrected 2025-12-09. Correction verified 2025-12-09.
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Supervision & ratios
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Nov 23, 2025 Report · No deficiencies cited
No violations cited on this visit.
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Nov 20, 2025 Assessment · Deficiencies cited
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Illness & medication
There was no discharge/transfer documentation that outlined what the child's reaction was to discharge or other information such as list of medications, physical condition, etc.
HHSC 748.1437(7) — Discharge/Transfer Documentation-For emergency discharge/transfer, document reason for discharge/transfer explained to child, and child's reaction
HHSC risk weight: Medium Low. Corrected 2025-12-01. Correction verified 2025-12-01.
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Illness & medication
An incident report outlined that a child was dispensed OTC on 11/12/2025 and no medication record was available at the time of the visit. The operation later provided a medication record detailing when the OTC was dispensed, and date documented on the incident report did not align with the medication record.
HHSC 748.151(3) — Operational responsibilities - Maintain current, true, accurate, and complete records
HHSC risk weight: Medium. Corrected 2025-12-01. Correction verified 2025-12-01.
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Illness & medication
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Nov 17, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
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Nov 5, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
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Oct 25, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
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Oct 22, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
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Oct 7, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
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Sep 22, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
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Sep 11, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
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Aug 26, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
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Aug 21, 2025 Inspection · Deficiencies cited
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Other
During the inspection, I observed the no trespassing sign posted by the entry way missing the required verbiage.
HHSC 748.3319(a) — Required Postings-Residential Treatment Center's must have
HHSC risk weight: Medium. Corrected 2025-08-28. Correction verified 2025-08-28.
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Staff background & training
748.505(5)-Four out of four employee files reviewed did not contain affidavit form 2912 in the file, 748.505(6) (a)-2 out of 4 employees did not have verification of previous employment and did not have references verified.
HHSC 748.505(b)(5) — Minimum qualifications for employees- Must complete a Pre-Employment Affidavit for Applicants for Employment.
HHSC risk weight: Medium. Corrected at inspection. Corrected 2025-08-28.
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Staff background & training
2 out of 4 employees did not have instructor led psychotropic training.
HHSC 748.941(b) — Training Criteria- Training on emergency behavior intervention and administering psychotropic medication must be instructor-led.
HHSC risk weight: Medium. Corrected 2025-08-28. Correction verified 2025-08-28.
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Staff background & training
3 out of 4 employee files reviewed contained training certificates missing the training hours.
HHSC 748.949(b)(5) — Annual Training Documentation-Includes the length of the training in hours
HHSC risk weight: Medium Low. Corrected 2025-08-28. Correction verified 2025-08-28.
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Other
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Aug 12, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
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Aug 1, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
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Jul 15, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
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Jul 15, 2025 Inspection · Deficiencies cited
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Illness & medication Serious
During the walkthrough of the operation, there was an open purse viewied on the kitchen counter with a staff member's OTC medication.
HHSC 748.2101(1) — Medication Storage-Store medication in a locked container
HHSC risk weight: High. Corrected at inspection. Corrected 2025-07-15.
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Illness & medication Serious
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Jul 3, 2025 Assessment · Deficiencies cited
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Illness & medication
During a heightened visit, a child's medication log was reviewed and there was no documentation if the child's prescribed Fluticasone was administered on 6/17/25.
HHSC 748.2151(b)(1) — Medication record - update cumulative record within 2 hours of administering medication
HHSC risk weight: Medium High. Corrected 2025-07-17. Correction verified 2025-07-15.
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Illness & medication
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Jul 2, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
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Jun 17, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
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Jun 17, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
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Jun 13, 2025 Inspection · Deficiencies cited
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Other
it was observed during todays inspection at the facility that the health inspectiton expired on 5-10-25. The administrator confirmed it has expired and that they have scheduled for the inspection to be completed tomorrow 6-14-25.
HHSC 748.3001(a)(2) — Sanitation Inspection-Sanitation official must conduct sanitation inspection at least once every 12 months from date of last inspection
HHSC risk weight: Medium High. Corrected 2025-06-17. Correction verified 2025-06-20.
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Other
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Jun 12, 2025 Report · Deficiencies cited
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Illness & medication
Child CONCERTA Medication was discontinued by the doctor upon child discharge from the hospital on 5-12-25. However, the medication log for CONCERTA for 5-12 and 5-13 did not state the medication was discontinued by the doctor at the hospital.
HHSC 748.393(b)(3) — Active child record - Ensure record is kept accurate and current
HHSC risk weight: Medium. Corrected 2025-06-13. Correction verified 2025-07-07.
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Illness & medication
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Jun 11, 2025 Report · Deficiencies cited
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Supervision & ratios
A service plan reviewed did not list the child's Autistic disorder diagnosis.
HHSC 748.151(3) — Operational responsibilities - Maintain current, true, accurate, and complete records
HHSC risk weight: Medium. Corrected 2025-08-15. Correction verified 2025-08-15.
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Supervision & ratios
The operation is providing services to 2 children with a diagnosis of ASD, a service not listed on their permit.
HHSC 748.63(1) — Types of services-Operation must only provide services listed on permit
HHSC risk weight: Medium. Corrected 2025-10-09. Correction verified 2025-10-09.
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Supervision & ratios
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Jun 4, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
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Jun 4, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
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Jun 4, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
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May 31, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
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May 29, 2025 Report · No deficiencies cited (self-report)
No violations cited on this visit.
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May 22, 2025 Report · No deficiencies cited
No violations cited on this visit.
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May 22, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
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May 19, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
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May 14, 2025 Report · Deficiencies cited
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Cleanliness & sanitation
Several windows at the operation did not have screens. Note: This was corrected at inspection due to window screens recently being installed on windows.
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 at inspection. Corrected 2025-06-20.
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Cleanliness & sanitation
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May 8, 2025 Report · Deficiencies cited
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Illness & medication
The victim child was seen on 3/6/2025 and was prescribed Clonidine 0.1mg to take 2 tablets in the morning and 1 table in the evening. A psychiatric evaluation was completed at In Touch Psychiatry on 3/11/2025 and reports that Clonidine is to be taken twice daily, once in the morning and once in the evening. However, after the change the medication log shows that clonidine 0.1mg was still given twice in the morning and once in the evening.
HHSC 748.2003(b)(3) — AP Administration of prescription medication-Administer medications according to instructions or a prescribing health-care professional's orders
HHSC risk weight: Medium High. Corrected 2025-06-06. Correction verified 2025-06-04.
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Illness & medication
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May 8, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
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May 1, 2025 Report · No deficiencies cited
No violations cited on this visit.
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Apr 22, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
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Apr 14, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
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Apr 9, 2025 Inspection · Deficiencies cited
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Records & paperwork
The admissions assessment for the child's file reviewed did not include a signature from the professional level service provider.
HHSC 748.1215(b) — Admission Assessment-Professional level service provider must sign & date assessment, which must be in child's record
HHSC risk weight: Low. Corrected 2025-04-15. Correction verified 2025-06-04.
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Records & paperwork
The serious incident report provided did not include the required components.
HHSC 748.311 — Serious Incident Documentation-Documented in written report
HHSC risk weight: Medium. Corrected 2025-04-15. Correction verified 2025-06-04.
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Records & paperwork
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Apr 2, 2025 Report · Deficiencies cited
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Illness & medication
The daily count on a child's medication log was observed to be inaccurate.
HHSC 748.2151(d) — Medication Record-must include accurate daily count of each prescribed medication, unless operate on a cottage home model
HHSC risk weight: Medium High. Corrected 2025-06-05. Correction verified 2025-06-04.
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Illness & medication
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Mar 28, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
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Mar 27, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
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Mar 24, 2025 Inspection · Deficiencies cited
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Staff background & training
The employee file viewed for a direct care staff member did not have a copy of the staff's high school diploma or GED.
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 2025-03-27. Correction verified 2025-03-25.
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Staff background & training
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Mar 20, 2025 Assessment · Deficiencies cited
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Cleanliness & sanitation
A bedroom window where a child in care currently resides in has been boarded up (interior) for approximately three months. There is no mechanical ventilation system.
HHSC 748.3303 — Physical Site-Living quarters, recreation & dining areas, bathrooms, bedrooms, & kitchens must be adequately ventilated
HHSC risk weight: Medium High. Corrected 2025-03-27. Correction verified 2025-03-28.
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Cleanliness & sanitation
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Mar 14, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
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Mar 14, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
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Mar 11, 2025 Report · No deficiencies cited (self-report)
No violations cited on this visit.
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Jan 3, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
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Dec 23, 2024 Report · No deficiencies cited
No violations cited on this visit.
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Dec 23, 2024 Report · No deficiencies cited
No violations cited on this visit.
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Dec 11, 2024 Report · No deficiencies cited
No violations cited on this visit.
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Dec 5, 2024 Assessment · Deficiencies cited
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Supervision & ratios Serious
A staff member at the facility has worked with the operation for about two months and never had a completed drug test.
HHSC 745.4151(c)(4)(A) — Mandatory drug testing-all applicants intended to be hired are subject to pre-employment testing, must have results prior to child access
HHSC risk weight: High. Corrected 2024-12-13. Correction verified 2024-12-13.
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Staff background & training Serious
An employee has worked with the facility since September and never received an eligible status stating that he was cleared to work at the facility.
HHSC HRC42.056(g) - BGC-persons cannot provide direct care/have d — HRC42.056(g) - BGC-persons cannot provide direct care/have direct access to children without all required background checks unless they meet certain criteria.
HHSC risk weight: High. Corrected 2024-12-13. Correction verified 2024-12-13.
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Supervision & ratios Serious
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Nov 7, 2024 Report · Deficiencies cited
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Other
Multiple children in care are not being allowed to use the phone to call caseworkers and attorneys. Multiple caseworkers are having issues getting ahold of the facility.
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 2025-01-07. Correction verified 2025-03-27.
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Other
A staff member told a child in care they would not make it in the military due to their sexuality.
HHSC 748.1101(b)(4)(A)(v) — Children's rights- To be free from being subjected to remarks that belittle or ridicule the child or the child's family
HHSC risk weight: Medium High. Corrected 2025-01-07. Correction verified 2025-03-27.
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Supervision & ratios
Multiple children in care reported staff sleeping on air mattress.
HHSC 748.685(c)(1) — Caregiver responsibility - be aware of children's habits, interests, and any special needs including supervision
HHSC risk weight: Medium High. Corrected 2025-01-07. Correction verified 2025-03-27.
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Other
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Nov 5, 2024 Report · No deficiencies cited
No violations cited on this visit.
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Nov 1, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
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Sep 23, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
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Sep 16, 2024 Report · Deficiencies cited
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Records & paperwork
I was observing the child's safety plan and noticed another child's name documented in it.
HHSC 748.393(b)(3) — Active child record - Ensure record is kept accurate and current
HHSC risk weight: Medium. Corrected 2024-09-30. Correction verified 2024-10-25.
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Other
The child's service plan is not being followed.
HHSC 748.685(c)(6) — Implement and follow the children's service plans.
HHSC risk weight: Medium. Corrected 2024-09-30. Correction verified 2024-10-25.
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Records & paperwork
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Sep 13, 2024 Inspection · Deficiencies cited
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Records & paperwork
During a review of one of the child's files, a child in care was missing her signature on her child's right form.
HHSC 748.1103(d) — Informing child of rights-Person being informed must sign statement indicating he read and understands the rights-signed copy filed in child's record
HHSC risk weight: Medium. Corrected 2024-09-20. Correction verified 2024-09-20.
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Other
The facility did not have a required no trespassing sign posted.
HHSC 748.3319(a) — Required Postings-Residential Treatment Center's must have
HHSC risk weight: Medium. Corrected 2024-09-20. Correction verified 2024-09-20.
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Staff background & training Serious
During a review of personnel records, four employees were missing proof of request for background checks.
HHSC 748.363(11) — Personnel records-Include proof of request for background checks.
HHSC risk weight: High. Corrected 2024-09-20. Correction verified 2024-09-20.
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Other
During a review of personnel files, four employees were missing documentation of reference checks.
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 2024-09-20. Correction verified 2024-09-20.
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Records & paperwork
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Aug 28, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
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Aug 27, 2024 Report · No deficiencies cited
No violations cited on this visit.
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Aug 19, 2024 Report · Deficiencies cited
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Safety & premises Serious
A child in care was performing restraints on other children.
HHSC 748.2453 — Emergency Behavior Intervention-Only a qualified caregiver may administer emergency behavior intervention, except short personal restraint
HHSC risk weight: High. Corrected 2024-11-01. Correction verified 2024-11-01.
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Other Serious
The children were inadequately supervised and led to an altercation.
HHSC 748.685(a)(5) — Caregiver responsibility - being able to intervene when necessary to ensure child's safety
HHSC risk weight: High. Corrected 2024-11-01. Correction verified 2024-11-01.
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Safety & premises Serious
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Jul 24, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
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Jul 23, 2024 Report · No deficiencies cited
No violations cited on this visit.
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Jul 15, 2024 Report · No deficiencies cited
No violations cited on this visit.
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Jun 18, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
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Jun 14, 2024 Report · No deficiencies cited
No violations cited on this visit.
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Apr 17, 2024 Inspection · Deficiencies cited
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Illness & medication
Two out of three child files reviewed did not contain a copy of the child's immunization record or any documentation indicating attempts to obtain it.
HHSC 748.1205(a)(7) — Admission Documentation-Includes child's immunization record
HHSC risk weight: Medium High. Corrected 2024-05-01. Correction verified 2024-05-07.
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Records & paperwork
One out of three employee files reviewed did not contain a copy of TB test results or a signed & notarized affidavit for employment.
HHSC 748.363(6) — Personnel records- Include copy of a cleared tuberculosis screening conducted prior to the person having contact with children in care.
HHSC risk weight: Medium. Corrected 2024-05-01. Correction verified 2024-05-02.
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Records & paperwork
One out of three child files reviewed contained conflicting names with signatures on a medical consenter form. The same child file also did not include the child's signature on the service plan. A few files reviewed contained other documents in them pertaining to other individuals.
HHSC 748.393(b)(3) — Active child record - Ensure record is kept accurate and current
HHSC risk weight: Medium. Corrected 2024-05-01. Correction verified 2024-05-07.
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Supervision & ratios
The operation's administrator has had an expired LCCA license for almost 2 months.
HHSC 748.531(a)(2) — Child-care administrator-Licensed according to HRC Chapter 43 and Subchapter N of Chapter 745
HHSC risk weight: Medium. Corrected 2024-05-01. Correction verified 2024-04-18.
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Records & paperwork
Two out of three employee files reviewed did not contain documentation of the reference and employment checks being completed.
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 2024-05-01. Correction verified 2024-05-07.
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Staff background & training
One out of three employee files reviewed did not contain all required components for the pre-service training curriculum.
HHSC 748.881(2) — General pre-service training curriculum-Includes measures to prevent, identify, treat, report suspicion of child abuse, neglect, and exploitation
HHSC risk weight: Medium High. Corrected 2024-05-01. Correction verified 2024-05-07.
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Staff background & training
One out of three employee files reviewed did not contain the required 50 hours for annual training.
HHSC 748.930(a)(2) — Caregivers at operations with 25 or more children or 30% or more of their population receiving treatment services must have 50hrs annual training
HHSC risk weight: Medium High. Corrected 2024-05-01. Correction verified 2024-05-07.
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Illness & medication
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Mar 22, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
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Mar 7, 2024 Inspection · Deficiencies cited
-
Safety & premises
The fire extinguishers upstairs and downstairs were both last inspected about 14 months ago evidenced by their tags which is over the required inspection timeframe.
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 2024-03-21. Correction verified 2024-03-22.
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Safety & premises
-
Feb 12, 2024 Assessment · Deficiencies cited
-
Supervision & ratios
The operation has not entered EBI data in their provider portal for Quarter 4 of 2023.
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 2024-02-12. Correction verified 2024-02-12.
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Supervision & ratios
-
Jan 17, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
-
Jan 9, 2024 Assessment · Deficiencies cited
-
Records & paperwork
Three out of four youth in care files reviewed did not contain an admission assessment that included the majority of the required information.
HHSC 748.1215(b) — Admission Assessment-Professional level service provider must sign & date assessment, which must be in child's record
HHSC risk weight: Low. Corrected 2024-01-12. Correction verified 2024-01-17.
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Supervision & ratios
One out of four youth files reviewed referenced another youth throughout their service plan and contained wrong admission dates on different documents in the file.
HHSC 748.151(3) — Operational responsibilities - Maintain current, true, accurate, and complete records
HHSC risk weight: Medium. Corrected 2024-01-12. Correction verified 2024-01-16.
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Other
One out of four youth files reviewed did not contain a discharge summary.
HHSC 748.561(3) — Responsibilities of Professional level service provider-Completing a discharge or transfer summary for a child
HHSC risk weight: Medium Low. Corrected 2024-01-12. Correction verified 2024-01-17.
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Records & paperwork
-
Jan 3, 2024 Report · Deficiencies cited
-
Discipline & child guidance Serious
This standard was found deficient as part of a DFPS investigation.
HHSC 748.1101(b)(1)(B) — Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation
HHSC risk weight: High. Corrected 2024-03-04. Correction verified 2024-03-05.
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Illness & medication
One medication record reviewed did not include the daily count.
HHSC 748.2151(d) — Medication Record-must include accurate daily count of each prescribed medication, unless operate on a cottage home model
HHSC risk weight: Medium High. Corrected 2024-03-04. Correction verified 2024-03-07.
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Illness & medication
Documentation was not completed for a medication count error.
HHSC 748.2203(c) — Medication Error-Operation must meet documentation requirements within 24 hrs
HHSC risk weight: Medium High. Corrected 2024-03-04. Correction verified 2024-03-07.
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Illness & medication
A caregiver didn't demonstrate prudent judgement when leaving medications unattended which resulted in a youth in care ingesting unprescribed medications.
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 2024-03-04. Correction verified 2024-03-05.
-
Discipline & child guidance Serious
-
Nov 28, 2023 Inspection · Deficiencies cited
-
Records & paperwork
Three out of four youth in care files reviewed did not contain an admission assessment that included the majority of the required information.
HHSC 748.1215(b) — Admission Assessment-Professional level service provider must sign & date assessment, which must be in child's record
HHSC risk weight: Low. Corrected 2023-12-12. Correction verified 2024-01-09.
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Staff background & training
Three out of three employee files reviewed did not contain verification of suicide training being completed.
HHSC 748.125(c)(1)(C) — Caregivers and employees must complete 1hr annual suicide training with curriculum that includes the understanding of suicide screening.
HHSC risk weight: Medium. Corrected 2023-12-12. Correction verified 2023-12-13.
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Other
Two out of four youth files reviewed did not contain a suicide screening from admission.
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 2023-12-12. Correction verified 2023-12-20.
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Other
Two out of four youth files reviewed contained a preliminary service plan that was completed more than the required 72 hours after their admission date.
HHSC 748.1331(a) — Preliminary Service Plan-Complete plan that addresses child's immediate needs within 72 hours of admission
HHSC risk weight: Medium Low. Corrected 2023-12-12. Correction verified 2023-12-13.
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Other
One out of four youth files reviewed contained a preliminary service plan that was not signed by a treatment director or a PLSP.
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 2023-12-12. Correction verified 2023-12-20.
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Supervision & ratios
One out of four youth files reviewed referenced another youth throughout their service plan and contained wrong admission dates on different documents in the file.
HHSC 748.151(3) — Operational responsibilities - Maintain current, true, accurate, and complete records
HHSC risk weight: Medium. Corrected 2023-12-12. Correction verified 2024-01-09.
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Other
One out of four youth files reviewed did not contain documentation to show that the youth had a TB skin test.
HHSC 748.1583(a) — TB exam-Persons over 1 yr old who live, work, volunteer at facility have exam w/in 30 days, unless person had previous exam that meets requirements
HHSC risk weight: Medium. Corrected 2023-12-12. Correction verified 2023-12-20.
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Illness & medication Serious
During the inspection, there was observed a youth's nasal spray in an unlocked drawer in the kitchen.
HHSC 748.2101(2) — Medication Storage-Keep medication inaccessible other than to employees responsible for stored medication
HHSC risk weight: High. Corrected at inspection. Corrected 2023-11-28.
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Illness & medication
Three out of three youth medication files reviewed contained count errors versus the actual remaining count of medications administered. One out of the three files reviewed had a medication dosage documented incorrectly.
HHSC 748.2151(a) — Medication Record-Maintain cumulative record of prescription medications dispensed to child, include nonprescription meds for child under five yrs old
HHSC risk weight: Medium High. Corrected 2023-12-12. Correction verified 2023-12-13.
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Other
One out of four youth files reviewed did not contain a discharge summary.
HHSC 748.561(3) — Responsibilities of Professional level service provider-Completing a discharge or transfer summary for a child
HHSC risk weight: Medium Low. Corrected 2023-12-12. Correction verified 2024-01-09.
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Other
Three out of three employee files reviewed did not contain documentation of the results of the reference and employment history checks.
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 2023-12-12. Correction verified 2023-12-13.
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Records & paperwork
-
Sep 6, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
-
Aug 23, 2023 Report · Deficiencies cited
-
Supervision & ratios
It was determined that a signature on the medical consent form was not signed by person listed.
HHSC 748.151(3) — Operational responsibilities - Maintain current, true, accurate, and complete records
HHSC risk weight: Medium. Corrected 2023-10-30. Correction verified 2023-11-01.
-
Supervision & ratios
-
Jun 23, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
-
Mar 20, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
-
Feb 16, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
-
Jan 15, 2023 Report · Deficiencies cited (self-report)
-
Illness & medication
Staff admitted to intentionally giving a child in care medication earlier than the child was supposed to receive the medication.
HHSC 748.2003(b)(3) — AP Administration of prescription medication-Administer medications according to instructions or a prescribing health-care professional's orders
HHSC risk weight: Medium High. Corrected 2023-03-17. Correction verified 2023-03-18.
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Illness & medication
The medication logs reviewed are prefilled for 7am and 7pm, which is not the time that multiple residence are receiving medication. The date that a resident was given medication at 2pm is still listed as being given at 7pm.
HHSC 748.2151(c)(5) — Medication record - must include date (day/month/year) & time each medication was administered
HHSC risk weight: Medium High. Corrected 2023-03-17. Correction verified 2023-03-18.
-
Illness & medication
-
Jan 5, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
-
Dec 21, 2022 Inspection · Deficiencies cited
-
Illness & medication Serious
Refrigerated medication was observed to be kept unlocked in the refrigerator.
HHSC 748.2101(1) — Medication Storage-Store medication in a locked container
HHSC risk weight: High. Corrected at inspection. Corrected 2022-12-21.
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Safety & premises
Two fire extinguishers were observed to have an outdated annual inspection.
HHSC 748.3117(a) — Fire Extinguisher-Company licensed by State Fire Marshal must inspect each fire extinguisher at least annually & conduct any service or testing
HHSC risk weight: Medium. Corrected 2023-01-04. Correction verified 2023-01-05.
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Illness & medication Serious
-
Dec 21, 2022 Inspection · Deficiencies cited
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Other
During inspection, it was verified that the treatment directdor doesn't work 32 hours per week. The treatment doctor works an average of 20 hours a week.
HHSC 748.601 — Treatment Director-Facility providing treatment services to 25 or more children or to more than 30% of children in care must have treatment director
HHSC risk weight: Medium High. Corrected 2023-01-04. Correction verified 2023-01-05.
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Staff background & training
During inspection, 3 of 4 records reviewed showed personnel with less than 50 hours of annual training.
HHSC 748.930(a)(2) — Caregivers at operations with 25 or more children or 30% or more of their population receiving treatment services must have 50hrs annual training
HHSC risk weight: Medium High. Corrected 2023-01-04. Correction verified 2023-01-05.
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Staff background & training
During review of records, it was found that 3 out of 4 records reviewed lacked documentation showing the amount of time caregivers attended transportation training.
HHSC 748.949(b)(5) — Annual Training Documentation-Includes the length of the training in hours
HHSC risk weight: Medium Low. Corrected 2023-01-04. Correction verified 2023-01-03.
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Other
-
Dec 20, 2022 Report · No deficiencies cited
No violations cited on this visit.
-
Dec 14, 2022 Report · No deficiencies cited
No violations cited on this visit.
-
Dec 6, 2022 Inspection · Deficiencies cited
-
Other
During the inspection, it was observed that the date on the menu showed 6/06/2021 ? 6/12/2021.
HHSC 748.1703(c) — Menus-must date menus and keep copies for 90 days
HHSC risk weight: Low. Corrected 2022-12-20. Correction verified 2022-12-21.
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Safety & premises
There was no documentation of the smoke detectors being tested monthly.
HHSC 748.3111(a) — Smoke Detector-Administrator or designee must test battery-operated smoke detectors monthly; date tested & name of employee that did test documented
HHSC risk weight: Medium. Corrected 2022-12-20. Correction verified 2022-12-21.
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Safety & premises
There was only one fire drill documented as completed in an annual timeframe. There was no severe weather drill documented as completed. The fire drill was indicated to be completed over the required three minutes.
HHSC 748.3239(a) — Evacuation-Must practice unannounced fire drill at least once every 6 months from date of last fire drill
HHSC risk weight: Medium. Corrected 2022-12-20. Correction verified 2022-12-21.
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Supervision & ratios
During the inspection, it was discovered a staff who transports children doesn't have a valid driver's license on file.
HHSC 748.4111(a) — Transportation records-Must maintain on file at the operation the name of each driver and a copy of that person's valid driver's license
HHSC risk weight: Low. Corrected at inspection. Corrected 2022-12-20.
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Other
The treatment director was said to only work about 20 hours per week instead of full-time hours.
HHSC 748.601 — Treatment Director-Facility providing treatment services to 25 or more children or to more than 30% of children in care must have treatment director
HHSC risk weight: Medium High. Corrected 2022-12-20. Correction verified 2022-12-21.
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Staff background & training
During inspection, it was noticed that 1 of 4 personnel records has only 8 hrs of EBI training completed within a month of hire but lacks the other 8 hrs of EBI training within 90 days.
HHSC 748.863(a)(3) — Caregiver for child-care or prog. svcs only must have 8 hours EBI training, 4 before counted in ratio, rest in 90 days; 16hrs for treatment svcs
HHSC risk weight: Medium High. Corrected 2022-12-20. Correction verified 2022-12-21.
-
Staff background & training
During inspection, 3 of 4 records reviewed showed personnel with less than 50 hours of annual training.
HHSC 748.930(a)(2) — Caregivers at operations with 25 or more children or 30% or more of their population receiving treatment services must have 50hrs annual training
HHSC risk weight: Medium High. Corrected 2022-12-20. Correction verified 2022-12-21.
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Staff background & training
During inspection, 1 of 4 records indicated personnel's last EBI training had been completed over 6 mths ago.
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 2022-12-20. Correction verified 2022-12-21.
-
Staff background & training
During review of records, it was found that 3 out of 4 records reviewed lacked documentation showing the amount of time caregivers attended transportation training.
HHSC 748.949(b)(5) — Annual Training Documentation-Includes the length of the training in hours
HHSC risk weight: Medium Low. Corrected 2022-12-20. Correction verified 2022-12-21.
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Other
-
Nov 16, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
-
Nov 10, 2022 Report · No deficiencies cited
No violations cited on this visit.
-
Nov 7, 2022 Report · Deficiencies cited
-
Supervision & ratios
It was discovered during the investigation caregivers were not aware what the service plan stated for the supervision needs of the children.
HHSC 748.1387 — Service Plan Review-Must comply with notification, participation, implementation, and documentation requirements for an initial service plan
HHSC risk weight: Medium Low. Corrected 2023-01-31. Correction verified 2023-01-31.
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Supervision & ratios Serious
It was discovered in this investigation caregivers forgot a youth alone at an event for about an hour before discovering the youth was missing.
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 2023-01-31. Correction verified 2023-01-31.
-
Supervision & ratios
-
Nov 7, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
-
Nov 2, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
-
Oct 28, 2022 Report · Deficiencies cited
-
Other
Two staff members used inappropriate language while performing their assigned tasks.
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 2022-12-02. Correction verified 2022-12-09.
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Other
-
Oct 27, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
-
Oct 21, 2022 Report · No deficiencies cited
No violations cited on this visit.
-
Oct 10, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
-
Sep 27, 2022 Report · No deficiencies cited
No violations cited on this visit.
-
Jul 11, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
-
Jun 30, 2022 Inspection · Deficiencies cited
-
Supervision & ratios
The child/caregiver ratio is currently 1:6 for children receiving treatment services.
HHSC 748.1003(a) — Child/caregiver ratio-Caregiver may care for 5 children if any require tx svcs, 8 children if not; children under 5 yrs old count as 2 children
HHSC risk weight: Medium High. Corrected 2022-07-07. Correction verified 2022-07-11.
-
Supervision & ratios
-
Jun 16, 2022 Inspection · Deficiencies cited
-
Staff background & training
The operation failed to inactivate several employees no longer associated with the operation in the portal within the required timeframe.
HHSC 745.651(1) — Background Check Validation - You must inactivate a subject who is no longer associated with your operation within 7 days of leaving
HHSC risk weight: Medium. Corrected 2022-06-23. Correction verified 2022-06-23.
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Staff background & training
The operation's current employee list in the portal has not been validated in over three months.
HHSC 745.651(2)(A) — Background Check Validation ? Every 3 months each operation, other than a licensed, registered, or listed home, must validate current list
HHSC risk weight: Medium. Corrected 2022-06-23. Correction verified 2022-06-23.
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Supervision & ratios
The operation has not reported any data regarding EBI's to Licensing.
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 2022-06-23. Correction verified 2022-06-23.
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Records & paperwork
Three out of three employee records reviewed did not indicate a date of employment.
HHSC 748.363(1) — Personnel records-Include date of employment
HHSC risk weight: Medium. Corrected 2022-06-23. Correction verified 2022-06-23.
-
Discipline & child guidance
One out of three employee records reviewed did not include a TB skin test, a signed affidavit for employment, nor a signed acknowledgment for operational policies as well as reporting abuse/neglect.
HHSC 748.363(5) — Personnel records-Include copy of a cleared tuberculosis screening conducted prior to the person having contact with children in care
HHSC risk weight: Medium. Corrected 2022-06-23. Correction verified 2022-06-23.
-
Staff background & training
-
Jun 6, 2022 Assessment · Deficiencies cited
-
Supervision & ratios
A youth in care was on an unauthorized absence from the operation for more than 6 hours, and it had failed to be reported to Licensing.
HHSC 748.303(a)(10)(A) — Serious Incident-Report to Licensing no later than 6 hours after determining unauthorized absence of a child 13 yrs old or older.
HHSC risk weight: Medium. Corrected 2022-06-10. Correction verified 2022-06-13.
-
Supervision & ratios
-
May 19, 2022 Assessment · Deficiencies cited
-
Supervision & ratios
A youth in care was on an unauthorized absence from the operation for more than 6 hours, and it had failed to be reported to Licensing.
HHSC 748.303(a)(10)(A) — Serious Incident-Report to Licensing no later than 6 hours after determining unauthorized absence of a child 13 yrs old or older.
HHSC risk weight: Medium. Corrected 2022-05-26. Correction verified 2022-06-06.
-
Supervision & ratios
-
May 16, 2022 Report · Deficiencies cited
-
Supervision & ratios
The child/caregiver ratio was 1:7 for children receiving treatment services which resulted in runaways from the operation.
HHSC 748.1003(a) — Child/caregiver ratio-Caregiver may care for 5 children if any require tx svcs, 8 children if not; children under 5 yrs old count as 2 children
HHSC risk weight: Medium High. Corrected 2022-06-28. Correction verified 2022-06-30.
-
Supervision & ratios
-
May 5, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
-
Apr 26, 2022 Report · No deficiencies cited
No violations cited on this visit.
-
Apr 21, 2022 Report · No deficiencies cited
No violations cited on this visit.
-
Apr 18, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
-
Apr 11, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
-
Mar 29, 2022 Report · Deficiencies cited
-
Illness & medication Serious
The pantry which has food for the residence, also has cleaning supply, which should be kept seperate from food.
HHSC 748.3421(2) — Poisons-The operation must ensure that poisonous or flammable materials are kept separate from medication, food, food prep and dining surfaces
HHSC risk weight: High. Corrected 2022-04-15. Correction verified 2022-04-18.
-
Illness & medication Serious
-
Mar 4, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
-
Mar 2, 2022 Report · Deficiencies cited
-
Illness & medication
Medication counts were off on two different prescribed medications.
HHSC 748.2151(d) — Medication Record-must include accurate daily count of each prescribed medication, unless operate on a cottage home model
HHSC risk weight: Medium High. Corrected 2022-04-21. Correction verified 2022-04-18.
-
Illness & medication
-
Feb 25, 2022 Report · No deficiencies cited
No violations cited on this visit.
-
Feb 18, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
-
Feb 18, 2022 Inspection · Deficiencies cited
-
Staff background & training
Staff file reviewed is missing the majority of the required trainings certificates or a collective sheet to indicate which trainings were taken.
HHSC 748.363(11) — Personnel records-Include record of training and training hours
HHSC risk weight: Medium. Corrected 2022-02-25. Correction verified 2022-02-25.
-
Staff background & training
-
Feb 18, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
-
Feb 8, 2022 Report · Deficiencies cited
-
Illness & medication
A youth in care did not receive a prescribed medication for three months.
HHSC 748.2003(b)(3) — AP Administration of prescription medication-Administer medications according to instructions or a prescribing health-care professional's orders
HHSC risk weight: Medium High. Corrected 2022-04-15. Correction verified 2022-04-18.
-
Illness & medication
-
Jan 31, 2022 Inspection · Deficiencies cited
-
Staff background & training
Child's file did not contain indication that an orientation was provided as no signed documentation was located in the file verifying this.
HHSC 748.1209(a) — Child Orientation-Provided to child who is 5 years old or older within 7 days of admission and geared to child's intellectual level
HHSC risk weight: Medium Low. Corrected 2022-02-07. Correction verified 2022-02-14.
-
Illness & medication
Daily medication log was not documented to include the remaining count.
HHSC 748.2151(d) — Medication Record-must include accurate daily count of each prescribed medication, unless operate on a cottage home model
HHSC risk weight: Medium High. Corrected 2022-02-07. Correction verified 2022-02-14.
-
Staff background & training
Staff file reviewed is missing the majority of the required trainings certificates or a collective sheet to indicate which trainings were taken.
HHSC 748.363(11) — Personnel records-Include record of training and training hours
HHSC risk weight: Medium. Corrected 2022-02-07. Correction verified 2022-02-18.
-
Supervision & ratios
Staff file reviewed is missing education required documentation .
HHSC 748.363(4) — Personnel records-Include evidence of valid professional licensures, certifications, or registrations required for the position
HHSC risk weight: Medium. Corrected 2022-02-07. Correction verified 2022-02-18.
-
Food & allergies
Child records did not provide easy access to known allergies and chronic health conditions.
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 2022-02-07. Correction verified 2022-02-14.
-
Staff background & training
-
Jan 11, 2022 Inspection · Deficiencies cited
-
Staff background & training
Child's file did not have signed orientation.
HHSC 748.1209(a) — Child Orientation-Provided to child who is 5 years old or older within 7 days of admission and geared to child's intellectual level
HHSC risk weight: Medium Low. Corrected 2022-01-25. Correction verified 2022-01-31.
-
Illness & medication
Child's file was missing immunizations records.
HHSC 748.1539(b) — Immunizations-The operation must maintain current immunizations records for each child in care, including any exemptions or exceptions
HHSC risk weight: Medium Low. Corrected 2022-01-25. Correction verified 2022-01-31.
-
Illness & medication
Medication log daily log was not documented.
HHSC 748.2151(d) — Medication Record-must include accurate daily count of each prescribed medication, unless operate on a cottage home model
HHSC risk weight: Medium High. Corrected 2022-01-25. Correction verified 2022-01-31.
-
Staff background & training
Staff file reviewed is missing the required trainings.
HHSC 748.363(11) — Personnel records-Include record of training and training hours
HHSC risk weight: Medium. Corrected 2022-01-25. Correction verified 2022-01-31.
-
Supervision & ratios
Staff file reviewed is missing education required documentation .
HHSC 748.363(4) — Personnel records-Include evidence of valid professional licensures, certifications, or registrations required for the position
HHSC risk weight: Medium. Corrected 2022-01-25. Correction verified 2022-01-31.
-
Food & allergies
Child records did not provide easy access to known allergies and chronic health conditions.
HHSC 748.393(b)(2) — Active child record-Includes known allergies and chronic conditions or
HHSC risk weight: Medium High. Corrected 2022-01-25. Correction verified 2022-01-31.
-
Staff background & training
-
Jan 8, 2022 Report · Deficiencies cited
-
Discipline & child guidance Serious
Staff threaten to use corporal punishment to child in care.
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 2022-02-10. Correction verified 2022-02-18.
-
Other
Staff member used profane language to a child in care.
HHSC 748.2307(9) — Other Prohibited Punishments-subjecting a child to abusive or profane language
HHSC risk weight: Medium High. Corrected 2022-02-10. Correction verified 2022-02-18.
-
Discipline & child guidance Serious
-
Nov 23, 2021 Inspection · Deficiencies cited
-
Supervision & ratios
One out of two child files reviewed had an acknowledgement of the child's rights signed by operational staff but not the child.
HHSC 748.1103(d) — Informing child of rights-Person being informed must sign statement indicating he read and understands the rights-signed copy filed in child's record
HHSC risk weight: Medium. Corrected 2021-12-03. Correction verified 2021-11-30.
-
Supervision & ratios
-
Nov 2, 2021 Report · No deficiencies cited
No violations cited on this visit.
-
Oct 20, 2021 Inspection · Deficiencies cited
-
Records & paperwork Serious
One out of three employee records reviewed did not contain verification that a drug test was completed.
HHSC 745.4151(c)(4)(A) — Mandatory drug testing-all applicants intended to be hired are subject to pre-employment testing, must have results prior to child access
HHSC risk weight: High. Corrected 2021-10-27. Correction verified 2021-11-05.
-
Illness & medication
One out of two child files reviewed did not contain an immunization record or documented attempts to obtain.
HHSC 748.1205(a)(7) — Admission Documentation-Includes child's immunization record
HHSC risk weight: Medium High. Corrected 2021-10-27. Correction verified 2021-11-05.
-
Other
Three out of five first aid kits did not contain cotton balls.
HHSC 748.3273(4) — First Aid Kits-Each one must contain cotton balls
HHSC risk weight: Medium Low. Corrected at inspection. Corrected 2021-10-20.
-
Other
Three out of five first aid kits did not contain scissors.
HHSC 748.3273(6) — First Aid Kits-Each one must contain scissors
HHSC risk weight: Medium Low. Corrected at inspection. Corrected 2021-10-20.
-
Food & allergies
Four out of five first aid kits did not contain a thermometer.
HHSC 748.3273(8) — First Aid Kits-Each one must contain thermometer
HHSC risk weight: Medium Low. Corrected at inspection. Corrected 2021-10-20.
-
Staff background & training Serious
One out of three employee records reviewed did not contain verification of a TB skin test completed.
HHSC 748.505(b)(2) — Minimum qualifications for employees-Record of a TB screening showing the employee is free of contagious TB as provided in 749.1583
HHSC risk weight: High. Corrected 2021-10-27. Correction verified 2021-11-05.
-
Staff background & training
One out of three employee records reviewed did not contain a signed Affidavit for Employment.
HHSC 748.505(b)(4) — Minimum qualifications for employees-Complete notarized Licensing Affidavit for Applicants for Employment form
HHSC risk weight: Medium. Corrected 2021-10-27. Correction verified 2021-11-05.
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Records & paperwork Serious
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Oct 1, 2021 Report · No deficiencies cited
No violations cited on this visit.
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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
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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.