Castillo Childrens Center
207 N NELLIUS ST, Woodville, TX 75979 · Tyler County
Program
- Type
- General residential operation
- Licensed capacity
- 18
- Ages
- 5-17
- Hours
- 12:00 AM-
- Director / administrator
- Anthony Castillo
- Phone
- (409) 200-2888
- Regulated since
- Feb 10, 2020
- HHSC IDs
- Operation 1321294 · number 1684373
- Official record
- HHSC Child Care Search
Violations by category
Year by year
| Year | Violations | Serious | Main categories |
|---|---|---|---|
| 2026 | 22 | 0 | Cleanliness & sanitation (4), Supervision & ratios (4), Records & paperwork (4), Other (10) |
| 2025 | 48 | 12 | Cleanliness & sanitation (2), Illness & medication (8), Supervision & ratios (10), Safety & premises (2), Staff background & training (10), Records & paperwork (8), Other (8) |
| 2024 | 26 | 0 | Illness & medication (8), Supervision & ratios (4), Safety & premises (4), Staff background & training (2), Records & paperwork (2), Other (6) |
| 2023 | 112 | 10 | Cleanliness & sanitation (2), Illness & medication (18), Supervision & ratios (16), Discipline & child guidance (8), Safety & premises (12), Food & allergies (4), Staff background & training (18), Records & paperwork (22), Other (12) |
| 2022 | 50 | 4 | Cleanliness & sanitation (6), Illness & medication (12), Supervision & ratios (12), Discipline & child guidance (2), Safety & premises (2), Records & paperwork (12), Other (4) |
Inspections, investigations & assessments
-
Sep 24, 2026 Inspection
No violations cited on this visit.
-
Sep 24, 2026 Inspection
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Sep 8, 2026 Inspection · No deficiencies cited
No violations cited on this visit.
-
Sep 8, 2026 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Aug 26, 2026 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Aug 26, 2026 Inspection · No deficiencies cited
No violations cited on this visit.
-
Aug 26, 2026 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Aug 26, 2026 Inspection · No deficiencies cited
No violations cited on this visit.
-
Aug 17, 2026 Inspection · Deficiencies cited
-
Cleanliness & sanitation
Documentation of use of emergency behavior intervention reviewed for one child in care inaccurately described the short personal restraint lasted 10-15 minutes. Documentation was unclear regarding an incident where a child sustained an injury to his head and reported medical care provided was "wound cleaned, medicated, and dressed."
HHSC 748.151(3) — Operational responsibilities - Maintain current, true, accurate, and complete records
HHSC risk weight: Medium. Corrected 2026-08-24. Correction verified 2026-08-25.
-
Cleanliness & sanitation
The playground and outdoor area had multiple dirty socks, cheese cracker wrappers, a hair bow, broken toy pieces, and broken bicycles.
HHSC 748.3301(g) — Physical Site-The grounds must be free of garbage & debris & maintained in a sanitary manner
HHSC risk weight: Medium. Corrected 2026-08-24. Correction verified 2026-08-26.
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Other
3 of 11 children's beds in use did not have a mattress cover.
HHSC 748.3365(b)(2) — Bedding-must provide each child with a mattress cover or protector unless mattress is waterproof
HHSC risk weight: Medium. Corrected 2026-08-24. Correction verified 2026-08-26.
-
Supervision & ratios
The surface of the outdoor play area contains compressed sand.
HHSC 748.3563(c) — Protective Surfacing-If loose-fill surfacing materials are used, the operation must install 9 inches or more of uncompressed loose-fill material
HHSC risk weight: Medium High. Corrected 2026-08-24. Correction verified 2026-08-26.
-
Records & paperwork
1 of 2 employee files reviewed did not contain the pre-employment screening record showing that references were contacted.
HHSC 748.753(a)(2) — Pre-Employment Screening-You must contact each of the two references to verify that the applicant is suitable to work with or around children.
HHSC risk weight: Medium High. Corrected 2026-08-24. Correction verified 2026-08-25.
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Cleanliness & sanitation
-
Aug 17, 2026 Inspection · Deficiencies cited
-
Cleanliness & sanitation
Documentation of use of emergency behavior intervention reviewed for one child in care inaccurately described the short personal restraint lasted 10-15 minutes. Documentation was unclear regarding an incident where a child sustained an injury to his head and reported medical care provided was "wound cleaned, medicated, and dressed."
HHSC 748.151(3) — Operational responsibilities - Maintain current, true, accurate, and complete records
HHSC risk weight: Medium. Corrected 2026-08-24. Correction verified 2026-08-25.
-
Cleanliness & sanitation
The playground and outdoor area had multiple dirty socks, cheese cracker wrappers, a hair bow, broken toy pieces, and broken bicycles.
HHSC 748.3301(g) — Physical Site-The grounds must be free of garbage & debris & maintained in a sanitary manner
HHSC risk weight: Medium. Corrected 2026-08-24. Correction verified 2026-08-26.
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Other
3 of 11 children's beds in use did not have a mattress cover.
HHSC 748.3365(b)(2) — Bedding-must provide each child with a mattress cover or protector unless mattress is waterproof
HHSC risk weight: Medium. Corrected 2026-08-24. Correction verified 2026-08-26.
-
Supervision & ratios
The surface of the outdoor play area contains compressed sand.
HHSC 748.3563(c) — Protective Surfacing-If loose-fill surfacing materials are used, the operation must install 9 inches or more of uncompressed loose-fill material
HHSC risk weight: Medium High. Corrected 2026-08-24. Correction verified 2026-08-26.
-
Records & paperwork
1 of 2 employee files reviewed did not contain the pre-employment screening record showing that references were contacted.
HHSC 748.753(a)(2) — Pre-Employment Screening-You must contact each of the two references to verify that the applicant is suitable to work with or around children.
HHSC risk weight: Medium High. Corrected 2026-08-24. Correction verified 2026-08-25.
HHSC inspection history · no longer published by HHSC; kept here
-
Cleanliness & sanitation
-
Aug 10, 2026 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Aug 10, 2026 Inspection · No deficiencies cited
No violations cited on this visit.
-
Jul 29, 2026 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Jul 29, 2026 Inspection · No deficiencies cited
No violations cited on this visit.
-
Jul 16, 2026 Inspection · Deficiencies cited
-
Records & paperwork
Two employee records did not contain the two required reference checks.
HHSC 748.753(a)(2) — Pre-Employment Screening-You must contact each of the two references to verify that the applicant is suitable to work with or around children.
HHSC risk weight: Medium High. Corrected 2026-07-23. Correction verified 2026-07-23.
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Records & paperwork
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Jul 16, 2026 Inspection · Deficiencies cited
-
Records & paperwork
Two employee records did not contain the two required reference checks.
HHSC 748.753(a)(2) — Pre-Employment Screening-You must contact each of the two references to verify that the applicant is suitable to work with or around children.
HHSC risk weight: Medium High. Corrected 2026-07-23. Correction verified 2026-07-23.
HHSC inspection history · no longer published by HHSC; kept here
-
Records & paperwork
-
Jul 16, 2026 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Jul 16, 2026 Inspection · No deficiencies cited
No violations cited on this visit.
-
Jun 29, 2026 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Jun 29, 2026 Inspection · No deficiencies cited
No violations cited on this visit.
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Jun 22, 2026 Assessment · Deficiencies cited
-
Supervision & ratios
During a review conducted on June 22, 2026, it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan; and (2) 12 months had elapsed since the effective date of the plan. As you know, the heightened monitoring plan for your operation included a specific ?planned end date? at the original 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring?. As a direct result of the administrator?s failure to ensure timely compliance with heightened monitoring plan, your operation is now unable to successfully move to post-plan monitoring. Furthermore, your operation?s ?planned end date? must now be revised, and the period of heightened monitoring must be extended. Further details of the administrator?s failure to ensure compliance include the following: Your operation received a Medium High weighted citation in a pattern/trend category on May 4, 2026. Specifically, the operation was cited for 748.1531(d) - Medical Care. Compliance was met on May 16, 2026. - Operation failed to satisfy the conditions of the plan - Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring; and - Operation was unable to meet compliance with Medium-High or High weighted licensing citations Finding: 748.535(2) ? The licensed administrator must ensure the operation complies with current heightened monitoring plan. An administrative penalty will be assessed as a result of this citation, in accordance with Texas Human Resources Code Sec. 42.078. The maximum daily penalty for your operation is $100.
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 2026-06-23. Correction verified 2026-06-23.
HHSC inspection history · no longer published by HHSC; kept here
-
Supervision & ratios
-
Jun 22, 2026 Assessment · Deficiencies cited
-
Supervision & ratios
During a review conducted on June 22, 2026, it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan; and (2) 12 months had elapsed since the effective date of the plan. As you know, the heightened monitoring plan for your operation included a specific ?planned end date? at the original 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring?. As a direct result of the administrator?s failure to ensure timely compliance with heightened monitoring plan, your operation is now unable to successfully move to post-plan monitoring. Furthermore, your operation?s ?planned end date? must now be revised, and the period of heightened monitoring must be extended. Further details of the administrator?s failure to ensure compliance include the following: Your operation received a Medium High weighted citation in a pattern/trend category on May 4, 2026. Specifically, the operation was cited for 748.1531(d) - Medical Care. Compliance was met on May 16, 2026. - Operation failed to satisfy the conditions of the plan - Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring; and - Operation was unable to meet compliance with Medium-High or High weighted licensing citations Finding: 748.535(2) ? The licensed administrator must ensure the operation complies with current heightened monitoring plan. An administrative penalty will be assessed as a result of this citation, in accordance with Texas Human Resources Code Sec. 42.078. The maximum daily penalty for your operation is $100.
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 2026-06-23. Correction verified 2026-06-23.
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Supervision & ratios
-
Jun 17, 2026 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Jun 17, 2026 Inspection · No deficiencies cited
No violations cited on this visit.
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Jun 1, 2026 Inspection · No deficiencies cited
No violations cited on this visit.
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Jun 1, 2026 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
May 20, 2026 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
May 20, 2026 Inspection · No deficiencies cited
No violations cited on this visit.
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May 4, 2026 Inspection · Deficiencies cited
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Other
A child in care did not receive recommended 30 day well child check up follow up care as recommended by the health professional.
HHSC 748.1531(d) — Medical care-Obtain follow-up medical treatment as recommended by the health-care professional
HHSC risk weight: Medium High. Corrected 2026-05-11. Correction verified 2026-05-15.
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Other
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May 4, 2026 Inspection · Deficiencies cited
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Other
A child in care did not receive recommended 30 day well child check up follow up care as recommended by the health professional.
HHSC 748.1531(d) — Medical care-Obtain follow-up medical treatment as recommended by the health-care professional
HHSC risk weight: Medium High. Corrected 2026-05-11. Correction verified 2026-05-15.
HHSC inspection history · no longer published by HHSC; kept here
-
Other
-
Apr 21, 2026 Inspection · No deficiencies cited
No violations cited on this visit.
-
Apr 21, 2026 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Apr 6, 2026 Inspection · No deficiencies cited
No violations cited on this visit.
-
Apr 6, 2026 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Mar 23, 2026 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Mar 23, 2026 Inspection · No deficiencies cited
No violations cited on this visit.
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Mar 10, 2026 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Mar 10, 2026 Inspection · No deficiencies cited
No violations cited on this visit.
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Feb 24, 2026 Inspection · Deficiencies cited
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Other
A service plan review was indicated as an initial plan instead of review, the PLSP, therapist and child's participation is not documented or dated.
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 2026-03-31. Correction verified 2026-03-20.
HHSC inspection history · no longer published by HHSC; kept here
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Other
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Feb 24, 2026 Inspection · Deficiencies cited
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Other
A service plan review was indicated as an initial plan instead of review, the PLSP, therapist and child's participation is not documented or dated.
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 2026-03-31. Correction verified 2026-03-20.
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Other
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Feb 9, 2026 Inspection · Deficiencies cited
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Other
A subsequent service plan for a child did not adress skills for youth 13 and older.
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 2026-02-16. Correction verified 2026-02-13.
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Other
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Feb 9, 2026 Inspection · Deficiencies cited
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Other
A subsequent service plan for a child did not adress skills for youth 13 and older.
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 2026-02-16. Correction verified 2026-02-13.
HHSC inspection history · no longer published by HHSC; kept here
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Other
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Jan 27, 2026 Inspection · Deficiencies cited
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Other
Two First aid kits were observed in the kitchen in an area accessible to children. This was corrected at inspection by moving them to an area that was kept locked and children not permitted to enter without an adult.
HHSC 748.3271(6) — First Aid Kits-Each one must be kept out of the reach of children
HHSC risk weight: Medium. Corrected at inspection. Corrected 2026-01-27.
HHSC inspection history · no longer published by HHSC; kept here
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Other
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Jan 27, 2026 Inspection · Deficiencies cited
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Other
Two First aid kits were observed in the kitchen in an area accessible to children. This was corrected at inspection by moving them to an area that was kept locked and children not permitted to enter without an adult.
HHSC 748.3271(6) — First Aid Kits-Each one must be kept out of the reach of children
HHSC risk weight: Medium. Corrected at inspection. Corrected 2026-01-27.
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Other
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Jan 16, 2026 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Jan 16, 2026 Inspection · No deficiencies cited
No violations cited on this visit.
-
Jan 13, 2026 Inspection · No deficiencies cited
No violations cited on this visit.
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Jan 13, 2026 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Dec 31, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Dec 31, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
-
Dec 19, 2025 Assessment · Deficiencies cited
-
Staff background & training
During a review conducted on December 19, 2025, it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan; and (2) more than 12 months had elapsed since the effective date of the plan. As you know, the heightened monitoring plan for your operation included a specific ?planned end date? at the original 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring.? As a direct result of the administrator?s failure to ensure timely compliance with the heightened monitoring plan, your operation was unable to successfully move to post-plan monitoring by the original ?planned end date? necessitating previous extension. Furthermore, due to your recent citations issued on December 1, 2025, your operation?s ?planned end date? must now be revised again, and the period of heightened monitoring must be extended again. Further details of the administrator?s failure to ensure compliance include the following: Your operation received a medium-high weighted citation in a pattern/trend category on December 1, 2025. Specifically, the operation was cited for 748.936(1) Annual Training- Caregivers must have EBI w/in 6 months from the date they last received the training if operation provides treatment services. The operation met compliance on 12/8/2025. - Operation failed to satisfy the conditions of the plan - Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring; and - Operation was unable to meet compliance with Medium-High or High weighted licensing citations Finding: 748.535(2) ? The licensed administrator must ensure the operation complies with current heightened monitoring plan. An administrative penalty will be assessed as a result of this citation, in accordance with Texas Human Resources Code Sec. 42.078. The maximum daily penalty for your operation is $100.
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 2025-12-20. Correction verified 2025-12-20.
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Staff background & training
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Dec 19, 2025 Assessment · Deficiencies cited
-
Staff background & training
During a review conducted on December 19, 2025, it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan; and (2) more than 12 months had elapsed since the effective date of the plan. As you know, the heightened monitoring plan for your operation included a specific ?planned end date? at the original 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring.? As a direct result of the administrator?s failure to ensure timely compliance with the heightened monitoring plan, your operation was unable to successfully move to post-plan monitoring by the original ?planned end date? necessitating previous extension. Furthermore, due to your recent citations issued on December 1, 2025, your operation?s ?planned end date? must now be revised again, and the period of heightened monitoring must be extended again. Further details of the administrator?s failure to ensure compliance include the following: Your operation received a medium-high weighted citation in a pattern/trend category on December 1, 2025. Specifically, the operation was cited for 748.936(1) Annual Training- Caregivers must have EBI w/in 6 months from the date they last received the training if operation provides treatment services. The operation met compliance on 12/8/2025. - Operation failed to satisfy the conditions of the plan - Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring; and - Operation was unable to meet compliance with Medium-High or High weighted licensing citations Finding: 748.535(2) ? The licensed administrator must ensure the operation complies with current heightened monitoring plan. An administrative penalty will be assessed as a result of this citation, in accordance with Texas Human Resources Code Sec. 42.078. The maximum daily penalty for your operation is $100.
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 2025-12-20. Correction verified 2025-12-20.
HHSC inspection history · no longer published by HHSC; kept here
-
Staff background & training
-
Dec 16, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
-
Dec 16, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Dec 6, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Dec 6, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
-
Dec 1, 2025 Inspection · Deficiencies cited
-
Staff background & training
A caregiver's Emergency Behavior Intervention training was not renewed timely.
HHSC 748.936(1) — Annual Training- Caregivers must have EBI w/in 6 months from the date they last received the training if operation provides treatment services
HHSC risk weight: Medium High. Corrected 2025-12-08. Correction verified 2025-12-08.
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Staff background & training
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Dec 1, 2025 Inspection · Deficiencies cited
-
Staff background & training
A caregiver's Emergency Behavior Intervention training was not renewed timely.
HHSC 748.936(1) — Annual Training- Caregivers must have EBI w/in 6 months from the date they last received the training if operation provides treatment services
HHSC risk weight: Medium High. Corrected 2025-12-08. Correction verified 2025-12-08.
HHSC inspection history · no longer published by HHSC; kept here
-
Staff background & training
-
Nov 20, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Nov 20, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
-
Nov 3, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Nov 3, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
-
Oct 22, 2025 Inspection · Deficiencies cited
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Staff background & training
The pre-service training records for one employee are not signed and dated by the instructor.
HHSC 748.869(a)(3) — Pre-Service Training- Must include a certificate, letter, or a signed and dated statement of successful completion from the training source.
HHSC risk weight: Medium Low. Corrected 2025-10-29. Correction verified 2025-10-28.
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Staff background & training
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Oct 22, 2025 Inspection · Deficiencies cited
-
Staff background & training
The pre-service training records for one employee are not signed and dated by the instructor.
HHSC 748.869(a)(3) — Pre-Service Training- Must include a certificate, letter, or a signed and dated statement of successful completion from the training source.
HHSC risk weight: Medium Low. Corrected 2025-10-29. Correction verified 2025-10-28.
HHSC inspection history · no longer published by HHSC; kept here
-
Staff background & training
-
Oct 8, 2025 Inspection · Deficiencies cited
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Records & paperwork
The service plan reviewed during the inspection identified the child's level of care as specialized, borderline level of functioning, and the child needed follow up evaluation for autism spectrum disorder; however this was not reflected in any other records reviewed.
HHSC 748.1337(b)(1)(A)(iii) — Initial Service Plan-Include intellectual functioning, including any testing and plans for recommended follow-up
HHSC risk weight: Medium Low. Corrected 2025-10-15. Correction verified 2025-10-15.
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Records & paperwork
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Oct 8, 2025 Inspection · Deficiencies cited
-
Records & paperwork
The service plan reviewed during the inspection identified the child's level of care as specialized, borderline level of functioning, and the child needed follow up evaluation for autism spectrum disorder; however this was not reflected in any other records reviewed.
HHSC 748.1337(b)(1)(A)(iii) — Initial Service Plan-Include intellectual functioning, including any testing and plans for recommended follow-up
HHSC risk weight: Medium Low. Corrected 2025-10-15. Correction verified 2025-10-15.
HHSC inspection history · no longer published by HHSC; kept here
-
Records & paperwork
-
Sep 23, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
-
Sep 23, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Sep 10, 2025 Inspection · Deficiencies cited
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Supervision & ratios Serious
During an inspection, it was observed the operation does not have safety seats in the van and the operation has four children 8 and under.
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 2025-09-12. Correction verified 2025-09-23.
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Safety & premises Serious
During an inspection, it was reported that 3 staff transported 12 children, in an 11 passenger vehicle and multiple children shared seats/safety belts while on an outing.
HHSC 748.4045 — Safety restraints-only one person may use each child passenger safety seat system or safety belt
HHSC risk weight: High. Corrected 2025-09-17. Correction verified 2025-09-23.
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Supervision & ratios
During an inspection, it was reported that operation staff transported three children not in care of the operation on an outing with children in care.
HHSC 748.705(b)(1) — Reasonable & prudent parent standard-Must consider the child's age and level of maturity
HHSC risk weight: Medium. Corrected 2025-09-17. Correction verified 2025-09-12.
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Supervision & ratios Serious
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Sep 10, 2025 Inspection · Deficiencies cited
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Supervision & ratios Serious
During an inspection, it was observed the operation does not have safety seats in the van and the operation has four children 8 and under.
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 2025-09-12. Correction verified 2025-09-23.
-
Safety & premises Serious
During an inspection, it was reported that 3 staff transported 12 children, in an 11 passenger vehicle and multiple children shared seats/safety belts while on an outing.
HHSC 748.4045 — Safety restraints-only one person may use each child passenger safety seat system or safety belt
HHSC risk weight: High. Corrected 2025-09-17. Correction verified 2025-09-23.
-
Supervision & ratios
During an inspection, it was reported that operation staff transported three children not in care of the operation on an outing with children in care.
HHSC 748.705(b)(1) — Reasonable & prudent parent standard-Must consider the child's age and level of maturity
HHSC risk weight: Medium. Corrected 2025-09-17. Correction verified 2025-09-12.
HHSC inspection history · no longer published by HHSC; kept here
-
Supervision & ratios Serious
-
Sep 5, 2025 Inspection · Deficiencies cited
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Other
A subsequent service plan for a child did not adress skills for youth 13 and older.
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 2025-09-12. Correction verified 2025-09-12.
-
Supervision & ratios
A child's admission assessment, 72 hour plan, and placement document dates do not match.
HHSC 748.151(3) — Operational responsibilities - Maintain current, true, accurate, and complete records
HHSC risk weight: Medium. Corrected 2025-09-12. Correction verified 2025-09-12.
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Cleanliness & sanitation
A child's bed in the girls room had a broken footboard that posed a safety hazard and a broken CD was found on the floor of a boys room. The issues were corrected at inspection by replacement of the bed and the CD was swept up from the floor and thrown away.
HHSC 748.3301(a)(2) — Physical Site- Buildings must be clean and in good repair.
HHSC risk weight: Medium. Corrected at inspection. Corrected 2025-09-05.
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Supervision & ratios
Two of ten beds being used did not have protective mattress covers. This was corrected at inspection by the operation placing mattress covers on the uncovered beds.
HHSC 748.3365(b)(2) — Bedding-must provide each child with a mattress cover or protector unless mattress is waterproof
HHSC risk weight: Medium. Corrected at inspection. Corrected 2025-09-05.
HHSC inspection history · no longer published by HHSC; kept here
-
Other
-
Sep 5, 2025 Inspection · Deficiencies cited
-
Other
A subsequent service plan for a child did not adress skills for youth 13 and older.
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 2025-09-12. Correction verified 2025-09-12.
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Supervision & ratios
A child's admission assessment, 72 hour plan, and placement document dates do not match.
HHSC 748.151(3) — Operational responsibilities - Maintain current, true, accurate, and complete records
HHSC risk weight: Medium. Corrected 2025-09-12. Correction verified 2025-09-12.
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Cleanliness & sanitation
A child's bed in the girls room had a broken footboard that posed a safety hazard and a broken CD was found on the floor of a boys room. The issues were corrected at inspection by replacement of the bed and the CD was swept up from the floor and thrown away.
HHSC 748.3301(a)(2) — Physical Site- Buildings must be clean and in good repair.
HHSC risk weight: Medium. Corrected at inspection. Corrected 2025-09-05.
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Supervision & ratios
Two of ten beds being used did not have protective mattress covers. This was corrected at inspection by the operation placing mattress covers on the uncovered beds.
HHSC 748.3365(b)(2) — Bedding-must provide each child with a mattress cover or protector unless mattress is waterproof
HHSC risk weight: Medium. Corrected at inspection. Corrected 2025-09-05.
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Other
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Sep 4, 2025 Report · Deficiencies cited
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Records & paperwork Serious
A staff member questioned a youth regarding details of allegations being report by the youth to their caseworker.
HHSC 745.8411(a) — Responsibilities - Not interfere with an inspection or investigation
HHSC risk weight: High. Corrected 2025-09-29. Correction verified 2025-10-08.
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Supervision & ratios
Two of two plans of service reviewed for an investigation had sections that were duplicated specifically in the type of approved contact, why visitation is not allowed, the same family members and supportive adult relationships, and information was inaccurate regarding the grade, school, and target due dates are from prior to the children's placement.
HHSC 748.151(3) — Operational responsibilities - Maintain current, true, accurate, and complete records
HHSC risk weight: Medium. Corrected 2025-09-29. Correction verified 2025-10-01.
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Records & paperwork
A professional staff member failed to demonstrate prudent judgment when he used a cell phone to audio and video record a conversation with a youth.
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 2025-09-29. Correction verified 2025-10-08.
HHSC inspection history · no longer published by HHSC; kept here
-
Records & paperwork Serious
-
Sep 4, 2025 Report · Deficiencies cited
-
Records & paperwork Serious
A staff member questioned a youth regarding details of allegations being report by the youth to their caseworker.
HHSC 745.8411(a) — Responsibilities - Not interfere with an inspection or investigation
HHSC risk weight: High. Corrected 2025-09-29. Correction verified 2025-10-08.
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Supervision & ratios
Two of two plans of service reviewed for an investigation had sections that were duplicated specifically in the type of approved contact, why visitation is not allowed, the same family members and supportive adult relationships, and information was inaccurate regarding the grade, school, and target due dates are from prior to the children's placement.
HHSC 748.151(3) — Operational responsibilities - Maintain current, true, accurate, and complete records
HHSC risk weight: Medium. Corrected 2025-09-29. Correction verified 2025-10-01.
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Records & paperwork
A professional staff member failed to demonstrate prudent judgment when he used a cell phone to audio and video record a conversation with a youth.
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 2025-09-29. Correction verified 2025-10-08.
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Records & paperwork Serious
-
Aug 25, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Aug 25, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
-
Aug 11, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Aug 11, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
-
Aug 5, 2025 Report · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Aug 5, 2025 Report · No deficiencies cited
No violations cited on this visit.
-
Jul 29, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Jul 29, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
-
Jul 16, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
-
Jul 16, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Jun 30, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Jun 30, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
-
Jun 17, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Jun 17, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
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Jun 17, 2025 Assessment · Deficiencies cited
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Staff background & training
During a review conducted on June 17, 2025, it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan; and (2) 12 months has elapsed since the effective date of the plan. As you know, the heightened monitoring plan for your operation included a specific ?planned end date? at the original 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring.? As a direct result of the administrator?s failure to ensure timely compliance with heightened monitoring plan, your operation is now unable to successfully move to post-plan monitoring. Furthermore, your operation?s ?planned end date? must now be revised, and the period of heightened monitoring must be extended. Further details of the administrator?s failure to ensure compliance include the following: Your operation received two medium weighted citations in a pattern/trend category on June 2, 2025. Specifically, the operation was cited for 748.869(a)(3) in the category Required Trainings. The operation came into compliance on June 9, 2025. - Operation failed to satisfy the conditions of the plan; and - Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring. Finding: 748.535(2) ? The licensed administrator must ensure the operation complies with current heightened monitoring plan.
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 2025-06-17. Correction verified 2025-06-18.
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Staff background & training
-
Jun 17, 2025 Assessment · Deficiencies cited
-
Staff background & training
During a review conducted on June 17, 2025, it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan; and (2) 12 months has elapsed since the effective date of the plan. As you know, the heightened monitoring plan for your operation included a specific ?planned end date? at the original 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring.? As a direct result of the administrator?s failure to ensure timely compliance with heightened monitoring plan, your operation is now unable to successfully move to post-plan monitoring. Furthermore, your operation?s ?planned end date? must now be revised, and the period of heightened monitoring must be extended. Further details of the administrator?s failure to ensure compliance include the following: Your operation received two medium weighted citations in a pattern/trend category on June 2, 2025. Specifically, the operation was cited for 748.869(a)(3) in the category Required Trainings. The operation came into compliance on June 9, 2025. - Operation failed to satisfy the conditions of the plan; and - Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring. Finding: 748.535(2) ? The licensed administrator must ensure the operation complies with current heightened monitoring plan.
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 2025-06-17. Correction verified 2025-06-18.
HHSC inspection history · no longer published by HHSC; kept here
-
Staff background & training
-
Jun 2, 2025 Inspection · Deficiencies cited
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Staff background & training
During a review of one employee record, pre-service training certificates were not signed or dated by the instructor.
HHSC 748.869(a)(3) — Pre-Service Training- Must include a certificate, letter, or a signed and dated statement of successful completion from the training source.
HHSC risk weight: Medium Low. Corrected 2025-06-09. Correction verified 2025-06-09.
HHSC inspection history · no longer published by HHSC; kept here
-
Staff background & training
-
Jun 2, 2025 Inspection · Deficiencies cited
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Staff background & training
During a review of one employee record, pre-service training certificates were not signed or dated by the instructor.
HHSC 748.869(a)(3) — Pre-Service Training- Must include a certificate, letter, or a signed and dated statement of successful completion from the training source.
HHSC risk weight: Medium Low. Corrected 2025-06-09. Correction verified 2025-06-09.
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Staff background & training
-
May 29, 2025 Report · Deficiencies cited
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Other Serious
A staff member interfered with an ongoing investigation by discussing the allegations with children in care.
HHSC 745.8411(a) — Responsibilities - Not interfere with an inspection or investigation
HHSC risk weight: High. Corrected 2025-07-22. Correction verified 2025-07-29.
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Other Serious
-
May 29, 2025 Report · Deficiencies cited
-
Other Serious
A staff member interfered with an ongoing investigation by discussing the allegations with children in care.
HHSC 745.8411(a) — Responsibilities - Not interfere with an inspection or investigation
HHSC risk weight: High. Corrected 2025-07-22. Correction verified 2025-07-29.
HHSC inspection history · no longer published by HHSC; kept here
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Other Serious
-
May 20, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
May 20, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
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May 5, 2025 Inspection · Deficiencies cited
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Illness & medication
During an inspection, prescribed medication was found stored in containers with handwritten labels.
HHSC 748.2003(b)(2) — Administration of Medication-Store medication in the original container unless there is an additional container with the same label & instructions
HHSC risk weight: Medium High. Corrected 2025-05-12. Correction verified 2025-05-12.
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Illness & medication
-
May 5, 2025 Inspection · Deficiencies cited
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Illness & medication
During an inspection, prescribed medication was found stored in containers with handwritten labels.
HHSC 748.2003(b)(2) — Administration of Medication-Store medication in the original container unless there is an additional container with the same label & instructions
HHSC risk weight: Medium High. Corrected 2025-05-12. Correction verified 2025-05-12.
HHSC inspection history · no longer published by HHSC; kept here
-
Illness & medication
-
Apr 23, 2025 Report · No deficiencies cited
No violations cited on this visit.
-
Apr 23, 2025 Report · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Apr 22, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
-
Apr 22, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Apr 21, 2025 Report · Deficiencies cited
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Illness & medication Serious
A medical consenter was not notified or made aware of changes to authorize consent of a child in care's medication regimen change.
HHSC 748.2001(a) — Administration of Medication-Must obtain a general written consent to administer routine, preventive, & emergency medications
HHSC risk weight: High. Corrected 2025-06-27. Correction verified 2025-06-30.
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Illness & medication
A child in care did not receive sufficient doses of medication sent by provider for a visit and a child in care's medication was not stopped per a physician's order.
HHSC 748.2003(b)(5) — Administration of prescription medication-Ensure the child has taken the medication as prescribed
HHSC risk weight: Medium High. Corrected 2025-06-27. Correction verified 2025-06-27.
HHSC inspection history · no longer published by HHSC; kept here
-
Illness & medication Serious
-
Apr 21, 2025 Report · Deficiencies cited
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Illness & medication Serious
A medical consenter was not notified or made aware of changes to authorize consent of a child in care's medication regimen change.
HHSC 748.2001(a) — Administration of Medication-Must obtain a general written consent to administer routine, preventive, & emergency medications
HHSC risk weight: High. Corrected 2025-06-27. Correction verified 2025-06-30.
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Illness & medication
A child in care did not receive sufficient doses of medication sent by provider for a visit and a child in care's medication was not stopped per a physician's order.
HHSC 748.2003(b)(5) — Administration of prescription medication-Ensure the child has taken the medication as prescribed
HHSC risk weight: Medium High. Corrected 2025-06-27. Correction verified 2025-06-27.
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Illness & medication Serious
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Apr 9, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
-
Apr 9, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Apr 8, 2025 Report · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Apr 8, 2025 Report · No deficiencies cited
No violations cited on this visit.
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Apr 7, 2025 Inspection · Deficiencies cited
-
Records & paperwork
A child in care did not have TB skin test record or result.
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 2025-04-14. Correction verified 2025-04-16.
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Illness & medication
During a walkthrough inspection of the medication room, medication was observed outside of the blister pack in a white paper cup labeled with the initials TR.
HHSC 748.2003(b)(4) — Administration of prescription medication-Administer each child's medication within one hour of preparation
HHSC risk weight: Medium. Corrected 2025-04-14. Correction verified 2025-04-22.
HHSC inspection history · no longer published by HHSC; kept here
-
Records & paperwork
-
Apr 7, 2025 Inspection · Deficiencies cited
-
Records & paperwork
A child in care did not have TB skin test record or result.
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 2025-04-14. Correction verified 2025-04-16.
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Illness & medication
During a walkthrough inspection of the medication room, medication was observed outside of the blister pack in a white paper cup labeled with the initials TR.
HHSC 748.2003(b)(4) — Administration of prescription medication-Administer each child's medication within one hour of preparation
HHSC risk weight: Medium. Corrected 2025-04-14. Correction verified 2025-04-22.
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Records & paperwork
-
Mar 30, 2025 Report · No deficiencies cited (self-report)
No violations cited on this visit.
-
Mar 30, 2025 Report · No deficiencies cited (self-report)
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Mar 26, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
-
Mar 26, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Mar 26, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
-
Mar 26, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Mar 12, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Mar 12, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
-
Feb 26, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
-
Feb 26, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Feb 13, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Feb 13, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
-
Feb 11, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Feb 11, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
-
Feb 2, 2025 Report · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Feb 2, 2025 Report · No deficiencies cited
No violations cited on this visit.
-
Feb 1, 2025 Report · Deficiencies cited
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Other
A staff engaged in an inappropriate conversation with children in care; this same staff was later involved in a verbal altercation with another staff in front of children in care, using language and behavior not suitable for children.
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 2025-02-28. Correction verified 2025-02-28.
HHSC inspection history · no longer published by HHSC; kept here
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Other
-
Feb 1, 2025 Report · Deficiencies cited
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Other
A staff engaged in an inappropriate conversation with children in care; this same staff was later involved in a verbal altercation with another staff in front of children in care, using language and behavior not suitable for children.
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 2025-02-28. Correction verified 2025-02-28.
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Other
-
Jan 28, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Jan 28, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
-
Jan 28, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
-
Jan 28, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Jan 27, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
-
Jan 27, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Jan 16, 2025 Report · Deficiencies cited
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Other Serious
During an investigation inspection a staff responsible for multiple children in care was found sleeping. The staff member was difficult to rouse and did not have an awareness of the children's ongoing activity.
HHSC 748.685(a)(3) — Caregiver responsibility - being aware of and accountable for each child's on-going activity
HHSC risk weight: High. Corrected 2025-01-29. Correction verified 2025-01-28.
HHSC inspection history · no longer published by HHSC; kept here
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Other Serious
-
Jan 16, 2025 Report · Deficiencies cited
-
Other Serious
During an investigation inspection a staff responsible for multiple children in care was found sleeping. The staff member was difficult to rouse and did not have an awareness of the children's ongoing activity.
HHSC 748.685(a)(3) — Caregiver responsibility - being aware of and accountable for each child's on-going activity
HHSC risk weight: High. Corrected 2025-01-29. Correction verified 2025-01-28.
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Other Serious
-
Jan 16, 2025 Report · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Jan 16, 2025 Report · No deficiencies cited
No violations cited on this visit.
-
Jan 14, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
-
Jan 14, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
-
Jan 14, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Jan 14, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Jan 13, 2025 Report · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Jan 13, 2025 Report · No deficiencies cited
No violations cited on this visit.
-
Dec 30, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
-
Dec 30, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Dec 20, 2024 Report · Deficiencies cited
-
Supervision & ratios
A child in care was inadequately supervised that resulted in them acting inappropriately with a peer.
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 2025-01-24. Correction verified 2025-01-27.
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Supervision & ratios
-
Dec 20, 2024 Report · Deficiencies cited
-
Supervision & ratios
A child in care was inadequately supervised that resulted in them acting inappropriately with a peer.
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 2025-01-24. Correction verified 2025-01-27.
HHSC inspection history · no longer published by HHSC; kept here
-
Supervision & ratios
-
Dec 19, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Dec 19, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
-
Dec 16, 2024 Assessment · Deficiencies cited
-
Supervision & ratios
During a review conducted on December 16, 2024, it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan; and (2) 12 months has elapsed since the effective date of the plan. As you know, the heightened monitoring plan for your operation included a specific ?planned end date? at the original 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring.? As a direct result of the administrator?s failure to ensure timely compliance with heightened monitoring plan, your operation is now unable to successfully move to post-plan monitoring. Furthermore, your operation?s ?planned end date? must now be revised, and the period of heightened monitoring must be extended. Further details of the administrator?s failure to ensure compliance include the following: Your operation received two medium weighted citations in a pattern/trend category on November 19, 2024. Specifically, the operation was cited for 748.363(7) in the category Leadership Responsibilities- Personnel and 748.1333 in the category Service Plans-Preliminary. The operation came into compliance with both deficiencies on November 26, 2024. - Operation failed to satisfy the conditions of the plan. - Operation failed to satisfy the conditions of the plan; and - Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring. Finding: 748.535(2) ? The licensed administrator must ensure the operation complies with current heightened monitoring plan.
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 2024-12-17. Correction verified 2024-12-17.
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Supervision & ratios
-
Dec 16, 2024 Assessment · Deficiencies cited
-
Supervision & ratios
During a review conducted on December 16, 2024, it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan; and (2) 12 months has elapsed since the effective date of the plan. As you know, the heightened monitoring plan for your operation included a specific ?planned end date? at the original 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring.? As a direct result of the administrator?s failure to ensure timely compliance with heightened monitoring plan, your operation is now unable to successfully move to post-plan monitoring. Furthermore, your operation?s ?planned end date? must now be revised, and the period of heightened monitoring must be extended. Further details of the administrator?s failure to ensure compliance include the following: Your operation received two medium weighted citations in a pattern/trend category on November 19, 2024. Specifically, the operation was cited for 748.363(7) in the category Leadership Responsibilities- Personnel and 748.1333 in the category Service Plans-Preliminary. The operation came into compliance with both deficiencies on November 26, 2024. - Operation failed to satisfy the conditions of the plan. - Operation failed to satisfy the conditions of the plan; and - Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring. Finding: 748.535(2) ? The licensed administrator must ensure the operation complies with current heightened monitoring plan.
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 2024-12-17. Correction verified 2024-12-17.
HHSC inspection history · no longer published by HHSC; kept here
-
Supervision & ratios
-
Dec 4, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Dec 4, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
-
Dec 3, 2024 Report · Deficiencies cited
-
Safety & premises
A child in care was restrained for not complying with staff and was not a danger to themselves or others.
HHSC 748.2463(3) — Emergency Behavior Intervention-Never used as a means to get a child to comply
HHSC risk weight: Medium High. Corrected 2025-01-13. Correction verified 2024-01-14.
HHSC inspection history · no longer published by HHSC; kept here
-
Safety & premises
-
Dec 3, 2024 Report · Deficiencies cited
-
Safety & premises
A child in care was restrained for not complying with staff and was not a danger to themselves or others.
HHSC 748.2463(3) — Emergency Behavior Intervention-Never used as a means to get a child to comply
HHSC risk weight: Medium High. Corrected 2025-01-13. Correction verified 2024-01-14.
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Safety & premises
-
Nov 19, 2024 Inspection · Deficiencies cited
-
Other
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 2024-11-26. Correction verified 2024-11-26.
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Records & paperwork
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 2024-11-26. Correction verified 2024-11-26.
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Other
-
Nov 19, 2024 Inspection · Deficiencies cited
-
Other
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 2024-11-26. Correction verified 2024-11-26.
-
Records & paperwork
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 2024-11-26. Correction verified 2024-11-26.
HHSC inspection history · no longer published by HHSC; kept here
-
Other
-
Nov 4, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Nov 4, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
-
Oct 29, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
-
Oct 29, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Oct 28, 2024 Assessment · Deficiencies cited
-
Illness & medication
The PM doses of medication for a youth in care were not properly documented.
HHSC 748.2151(b)(1) — Medication record - update cumulative record within 2 hours of administering medication
HHSC risk weight: Medium High. Corrected 2024-11-01. Correction verified 2024-11-01.
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Illness & medication
-
Oct 28, 2024 Assessment · Deficiencies cited
-
Illness & medication
The PM doses of medication for a youth in care were not properly documented.
HHSC 748.2151(b)(1) — Medication record - update cumulative record within 2 hours of administering medication
HHSC risk weight: Medium High. Corrected 2024-11-01. Correction verified 2024-11-01.
HHSC inspection history · no longer published by HHSC; kept here
-
Illness & medication
-
Oct 22, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
-
Oct 22, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Oct 8, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
-
Oct 8, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Sep 27, 2024 Report · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Sep 27, 2024 Report · No deficiencies cited
No violations cited on this visit.
-
Sep 23, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
-
Sep 23, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Sep 10, 2024 Inspection · Deficiencies cited
-
Safety & premises
During an inspection of the playground equipment, the slide was found to have several large, open cracks, the grounds of the play area had excessive debris, and multiple boards were missing or broken from the play-structure.
HHSC 748.3475(b)(1) — Safety Requirements-Ensure that hazards or defects identified during the playground inspection are removed or repaired promptly
HHSC risk weight: Medium High. Corrected 2024-09-17. Correction verified 2024-09-16.
HHSC inspection history · no longer published by HHSC; kept here
-
Safety & premises
-
Sep 10, 2024 Inspection · Deficiencies cited
-
Safety & premises
During an inspection of the playground equipment, the slide was found to have several large, open cracks, the grounds of the play area had excessive debris, and multiple boards were missing or broken from the play-structure.
HHSC 748.3475(b)(1) — Safety Requirements-Ensure that hazards or defects identified during the playground inspection are removed or repaired promptly
HHSC risk weight: Medium High. Corrected 2024-09-17. Correction verified 2024-09-16.
-
Safety & premises
-
Sep 10, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Sep 10, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
-
Aug 26, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
-
Aug 26, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Aug 14, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
-
Aug 14, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Aug 12, 2024 Assessment · Deficiencies cited
-
Illness & medication
A child was prescribed 1/2 dose of medication in AM and 1/2 dose of medication in PM. Child was being given a full dose by one staff member and a 1/2 dose by another staff member. Pill count reflected the discrepancy on the medication logs.
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 2024-08-19. Correction verified 2024-08-18.
-
Illness & medication
Medication logs were filled out incorrectly for a child in care. Child had not been given his PM medication; however, the medication log reflected his PM medication had already been dispensed.
HHSC 748.2151(c)(5) — Medication record - must include date (day/month/year) & time each medication was administered
HHSC risk weight: Medium High. Corrected 2024-08-19. Correction verified 2024-08-18.
-
Illness & medication
-
Aug 12, 2024 Assessment · Deficiencies cited
-
Illness & medication
A child was prescribed 1/2 dose of medication in AM and 1/2 dose of medication in PM. Child was being given a full dose by one staff member and a 1/2 dose by another staff member. Pill count reflected the discrepancy on the medication logs.
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 2024-08-19. Correction verified 2024-08-18.
-
Illness & medication
Medication logs were filled out incorrectly for a child in care. Child had not been given his PM medication; however, the medication log reflected his PM medication had already been dispensed.
HHSC 748.2151(c)(5) — Medication record - must include date (day/month/year) & time each medication was administered
HHSC risk weight: Medium High. Corrected 2024-08-19. Correction verified 2024-08-18.
HHSC inspection history · no longer published by HHSC; kept here
-
Illness & medication
-
Jul 30, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Jul 30, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
-
Jul 16, 2024 Inspection · Deficiencies cited
-
Illness & medication
During the inspection, it was found that a child was not given the correct dose of medication on four occassions.
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 2024-07-23. Correction verified 2024-07-17.
-
Illness & medication
-
Jul 16, 2024 Inspection · Deficiencies cited
-
Illness & medication
During the inspection, it was found that a child was not given the correct dose of medication on four occassions.
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 2024-07-23. Correction verified 2024-07-17.
HHSC inspection history · no longer published by HHSC; kept here
-
Illness & medication
-
Jul 11, 2024 Assessment · Deficiencies cited
-
Staff background & training
An employee's file did not have an up to date record of all training and training hours completed.
HHSC 748.363(12) — Personnel records-Include record of training and training hours.
HHSC risk weight: Medium. Corrected 2024-07-18. Correction verified 2024-07-11.
-
Staff background & training
-
Jul 11, 2024 Assessment · Deficiencies cited
-
Staff background & training
An employee's file did not have an up to date record of all training and training hours completed.
HHSC 748.363(12) — Personnel records-Include record of training and training hours.
HHSC risk weight: Medium. Corrected 2024-07-18. Correction verified 2024-07-11.
HHSC inspection history · no longer published by HHSC; kept here
-
Staff background & training
-
Jul 2, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Jul 2, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
-
Jun 18, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
-
Jun 18, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Jun 18, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Jun 18, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
-
Jun 3, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Jun 3, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
-
May 31, 2024 Report · No deficiencies cited
No violations cited on this visit.
-
May 31, 2024 Report · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
May 20, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
-
May 20, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
May 9, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
May 9, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
-
Apr 24, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
-
Apr 24, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Apr 24, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
-
Apr 24, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Apr 17, 2024 Report · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Apr 17, 2024 Report · No deficiencies cited
No violations cited on this visit.
-
Apr 17, 2024 Report · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Apr 17, 2024 Report · No deficiencies cited
No violations cited on this visit.
-
Apr 11, 2024 Report · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Apr 11, 2024 Report · No deficiencies cited
No violations cited on this visit.
-
Apr 9, 2024 Report · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Apr 9, 2024 Report · No deficiencies cited
No violations cited on this visit.
-
Apr 9, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Apr 9, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
-
Mar 25, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
-
Mar 25, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Mar 22, 2024 Report · No deficiencies cited
No violations cited on this visit.
-
Mar 22, 2024 Report · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Mar 12, 2024 Report · No deficiencies cited
No violations cited on this visit.
-
Mar 12, 2024 Report · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Mar 11, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
-
Mar 11, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Feb 28, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Feb 28, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
-
Feb 14, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
-
Feb 14, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Feb 12, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
-
Feb 12, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Feb 9, 2024 Report · No deficiencies cited
No violations cited on this visit.
-
Feb 9, 2024 Report · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Jan 30, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Jan 30, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
-
Jan 19, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
-
Jan 19, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Jan 19, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
-
Jan 19, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Jan 19, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Jan 19, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
-
Jan 10, 2024 Report · Deficiencies cited
-
Other
It was discovered that staff are denying phone calls from children.
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 2024-03-20. Correction verified 2024-03-25.
-
Other
It was determined that staff were listening in on children's phone calls.
HHSC 748.1111(a)(2) — Child Rights contact others-Not listen to or screen child's calls without permission from parents, service planning team, treatment director, or PLSP
HHSC risk weight: Medium. Corrected 2024-03-20. Correction verified 2024-03-25.
HHSC inspection history · no longer published by HHSC; kept here
-
Other
-
Jan 10, 2024 Report · Deficiencies cited
-
Other
It was discovered that staff are denying phone calls from children.
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 2024-03-20. Correction verified 2024-03-25.
-
Other
It was determined that staff were listening in on children's phone calls.
HHSC 748.1111(a)(2) — Child Rights contact others-Not listen to or screen child's calls without permission from parents, service planning team, treatment director, or PLSP
HHSC risk weight: Medium. Corrected 2024-03-20. Correction verified 2024-03-25.
-
Other
-
Jan 3, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
-
Jan 3, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Dec 29, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
-
Dec 29, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Dec 21, 2023 Report · No deficiencies cited
No violations cited on this visit.
-
Dec 21, 2023 Report · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Dec 19, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Dec 19, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
-
Dec 4, 2023 Inspection · Deficiencies cited
-
Staff background & training
In one of the records reviewed the staff record did not have the notarized affidavit available for review in the record.
HHSC 748.505(b)(4) — Minimum qualifications for employees-Complete notarized Licensing Affidavit for Applicants for Employment form
HHSC risk weight: Medium. Corrected 2023-12-15. Correction verified 2023-12-13.
-
Records & paperwork
In the employee record reviewed there was no documentation made to show the last five years of employment history.
HHSC 748.751(a)(1) — Pre-Employment Screening- You must obtain in writing an applicant's employment history for the last five years before hiring.
HHSC risk weight: Medium. Corrected 2023-12-15. Correction verified 2023-12-13.
-
Staff background & training
In one of the staff records reviewed there was no documentation made to show that the potential staff's references were contacted. The application does list 5 different references, but the operation does not have any documentation to show where contact was made.
HHSC 748.753(a)(2) — Pre-Employment Screening-You must contact each of the two references to verify that the applicant is suitable to work with or around children.
HHSC risk weight: Medium High. Corrected 2023-12-15. Correction verified 2023-12-13.
-
Staff background & training
In one of the records reviewed the documentation for the 40-hour supervised experience is minimum. It does not include the date or if this is the staff's actual 40-hour shadowing experience.
HHSC 748.861(b)(3) — Pre-Service Training - Supervised experience must be documented in personnel record
HHSC risk weight: Medium. Corrected 2023-12-15. Correction verified 2023-12-13.
-
Staff background & training
In reviewed of the staff records reviewed, there was no Normalcy training documented for the administrator for 2022. The record does show that it was obtaining for 2023 at the Texas Childcare Administrator Conference.
HHSC 748.931(c)(1) — Annual Training- Childcare administrators, PLSP's, treatment directors and case managers who hold a prof. license must have 1hr normalcy.
HHSC risk weight: Medium High. Corrected 2023-12-15. Correction verified 2023-12-13.
-
Staff background & training
-
Dec 4, 2023 Inspection · Deficiencies cited
-
Staff background & training
In one of the records reviewed the staff record did not have the notarized affidavit available for review in the record.
HHSC 748.505(b)(4) — Minimum qualifications for employees-Complete notarized Licensing Affidavit for Applicants for Employment form
HHSC risk weight: Medium. Corrected 2023-12-15. Correction verified 2023-12-13.
-
Records & paperwork
In the employee record reviewed there was no documentation made to show the last five years of employment history.
HHSC 748.751(a)(1) — Pre-Employment Screening- You must obtain in writing an applicant's employment history for the last five years before hiring.
HHSC risk weight: Medium. Corrected 2023-12-15. Correction verified 2023-12-13.
-
Staff background & training
In one of the staff records reviewed there was no documentation made to show that the potential staff's references were contacted. The application does list 5 different references, but the operation does not have any documentation to show where contact was made.
HHSC 748.753(a)(2) — Pre-Employment Screening-You must contact each of the two references to verify that the applicant is suitable to work with or around children.
HHSC risk weight: Medium High. Corrected 2023-12-15. Correction verified 2023-12-13.
-
Staff background & training
In one of the records reviewed the documentation for the 40-hour supervised experience is minimum. It does not include the date or if this is the staff's actual 40-hour shadowing experience.
HHSC 748.861(b)(3) — Pre-Service Training - Supervised experience must be documented in personnel record
HHSC risk weight: Medium. Corrected 2023-12-15. Correction verified 2023-12-13.
-
Staff background & training
In reviewed of the staff records reviewed, there was no Normalcy training documented for the administrator for 2022. The record does show that it was obtaining for 2023 at the Texas Childcare Administrator Conference.
HHSC 748.931(c)(1) — Annual Training- Childcare administrators, PLSP's, treatment directors and case managers who hold a prof. license must have 1hr normalcy.
HHSC risk weight: Medium High. Corrected 2023-12-15. Correction verified 2023-12-13.
HHSC inspection history · no longer published by HHSC; kept here
-
Staff background & training
-
Dec 4, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
-
Dec 4, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Nov 21, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Nov 21, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
-
Nov 8, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Nov 8, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
-
Oct 26, 2023 Report · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Oct 26, 2023 Report · No deficiencies cited
No violations cited on this visit.
-
Oct 25, 2023 Report · No deficiencies cited
No violations cited on this visit.
-
Oct 25, 2023 Report · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Oct 20, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Oct 20, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
-
Sep 19, 2023 Report · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Sep 19, 2023 Report · No deficiencies cited
No violations cited on this visit.
-
Sep 18, 2023 Inspection · Deficiencies cited
-
Other
In a review of one child's file it was noted that the child had not recieved their screening review.
HHSC 748.125(d)(4)(D) — Suicide Screening- Must be administered every 90 days after admission for children 10 years of age or older in a GRO that is not a RTC.
HHSC risk weight: Medium. Corrected 2023-10-03. Correction verified 2023-10-03.
-
Records & paperwork
In a review of four child records, it was noted that the children were missing TB tests.
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 2023-10-18. Correction verified 2023-10-20.
-
Illness & medication
In a review of a child's record a positive covid result was found. There was no report made to licensing to notify of the positive result.
HHSC 748.303(a)(11)(A) — Serious Incident-Report to Licensing no later than 24 hours after awareness that a child contracts reportable communicable disease
HHSC risk weight: Medium. Corrected 2023-09-26. Correction verified 2023-09-26.
-
Records & paperwork
In a review of a child's file, there is a positive Covid test. There was no incident report for the positive test. Due to no report, there is no documentation showing notification to licensing or the child's parent/managing conservator.
HHSC 748.311 — Serious Incident Documentation-Documented in written report
HHSC risk weight: Medium. Corrected 2023-09-26. Correction verified 2023-09-26.
-
Supervision & ratios
In a review of one child's discharge summary it was noted that the PLSP did not participate in the discharge preparation, nor did they review and sign the summary. This standard was corrected at inspection.
HHSC 748.565(3) — Professional level service provider-must review/approve discharge or transfer summaries; sign and date to indicate approval
HHSC risk weight: Medium Low. Corrected at inspection. Corrected 2023-09-18.
HHSC inspection history · no longer published by HHSC; kept here
-
Other
-
Sep 18, 2023 Inspection · Deficiencies cited
-
Other
In a review of one child's file it was noted that the child had not recieved their screening review.
HHSC 748.125(d)(4)(D) — Suicide Screening- Must be administered every 90 days after admission for children 10 years of age or older in a GRO that is not a RTC.
HHSC risk weight: Medium. Corrected 2023-10-03. Correction verified 2023-10-03.
-
Records & paperwork
In a review of four child records, it was noted that the children were missing TB tests.
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 2023-10-18. Correction verified 2023-10-20.
-
Illness & medication
In a review of a child's record a positive covid result was found. There was no report made to licensing to notify of the positive result.
HHSC 748.303(a)(11)(A) — Serious Incident-Report to Licensing no later than 24 hours after awareness that a child contracts reportable communicable disease
HHSC risk weight: Medium. Corrected 2023-09-26. Correction verified 2023-09-26.
-
Records & paperwork
In a review of a child's file, there is a positive Covid test. There was no incident report for the positive test. Due to no report, there is no documentation showing notification to licensing or the child's parent/managing conservator.
HHSC 748.311 — Serious Incident Documentation-Documented in written report
HHSC risk weight: Medium. Corrected 2023-09-26. Correction verified 2023-09-26.
-
Supervision & ratios
In a review of one child's discharge summary it was noted that the PLSP did not participate in the discharge preparation, nor did they review and sign the summary. This standard was corrected at inspection.
HHSC 748.565(3) — Professional level service provider-must review/approve discharge or transfer summaries; sign and date to indicate approval
HHSC risk weight: Medium Low. Corrected at inspection. Corrected 2023-09-18.
-
Other
-
Aug 31, 2023 Report · No deficiencies cited
No violations cited on this visit.
-
Aug 31, 2023 Report · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Aug 25, 2023 Report · No deficiencies cited
No violations cited on this visit.
-
Aug 25, 2023 Report · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Aug 18, 2023 Report · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Aug 18, 2023 Report · No deficiencies cited
No violations cited on this visit.
-
Aug 10, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
-
Aug 10, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Jul 26, 2023 Inspection · Deficiencies cited
-
Illness & medication
Upon review of medication records, it was found that after administering the medication, the staff member went up on the count, rather than noting that there was less medication. The count was documented incorrectly, and thus messed up the count going further on the following days. Prior to leaving the operation, the administrator provided documentation stating that the staff member will not be assigned the task of medication administration effectively immediately. Documentation was provided for the inspector.
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 at inspection. Corrected 2023-07-26.
-
Illness & medication
-
Jul 26, 2023 Inspection · Deficiencies cited
-
Illness & medication
Upon review of medication records, it was found that after administering the medication, the staff member went up on the count, rather than noting that there was less medication. The count was documented incorrectly, and thus messed up the count going further on the following days. Prior to leaving the operation, the administrator provided documentation stating that the staff member will not be assigned the task of medication administration effectively immediately. Documentation was provided for the inspector.
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 at inspection. Corrected 2023-07-26.
HHSC inspection history · no longer published by HHSC; kept here
-
Illness & medication
-
Jul 6, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Jul 6, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
-
Jun 28, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
-
Jun 28, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
May 26, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
-
May 26, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
May 22, 2023 Report · Deficiencies cited
-
Illness & medication
In one child's record, it was found that the child received the wrong dosage of medication on two separate occasions.
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 2023-07-06. Correction verified 2023-07-26.
-
Illness & medication
In a review of one child's medication logs, it was found that the child missed a dose of medication for two days before getting refilled.
HHSC 748.2003(b)(5) — Administration of prescription medication-Ensure the child has taken the medication as prescribed
HHSC risk weight: Medium High. Corrected 2023-07-13. Correction verified 2023-07-26.
-
Illness & medication
-
May 22, 2023 Report · Deficiencies cited
-
Illness & medication
In one child's record, it was found that the child received the wrong dosage of medication on two separate occasions.
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 2023-07-06. Correction verified 2023-07-26.
-
Illness & medication
In a review of one child's medication logs, it was found that the child missed a dose of medication for two days before getting refilled.
HHSC 748.2003(b)(5) — Administration of prescription medication-Ensure the child has taken the medication as prescribed
HHSC risk weight: Medium High. Corrected 2023-07-13. Correction verified 2023-07-26.
HHSC inspection history · no longer published by HHSC; kept here
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Illness & medication
-
May 22, 2023 Report · Deficiencies cited
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Illness & medication
During a review of the child's service plan review, it was noted that there was no evaluation of the medication's effectiveness, changes in medications, changes in behaviors, or any lab work completed.
HHSC 748.1385(5) — Service Plan Review-Must evaluate effectiveness & side effects of psychotropic meds, change in psychotropic meds, child's behaviors and reactions
HHSC risk weight: Medium. Corrected 2023-07-20. Correction verified 2023-07-26.
HHSC inspection history · no longer published by HHSC; kept here
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Illness & medication
-
May 22, 2023 Report · Deficiencies cited
-
Illness & medication
During a review of the child's service plan review, it was noted that there was no evaluation of the medication's effectiveness, changes in medications, changes in behaviors, or any lab work completed.
HHSC 748.1385(5) — Service Plan Review-Must evaluate effectiveness & side effects of psychotropic meds, change in psychotropic meds, child's behaviors and reactions
HHSC risk weight: Medium. Corrected 2023-07-20. Correction verified 2023-07-26.
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Illness & medication
-
May 19, 2023 Inspection · Deficiencies cited
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Safety & premises
A designated emergency exit was observed to be blocked by a couch on the inside and blocked as well on the outside by children's bikes.
HHSC 748.3233(b)(4)(B) — Evacuation-Emergency evacuation & relocation diagram includes at least 2 exit routes that are not blocked in any way
HHSC risk weight: Medium High. Corrected 2023-05-19. Correction verified 2023-05-26.
HHSC inspection history · no longer published by HHSC; kept here
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Safety & premises
-
May 19, 2023 Inspection · Deficiencies cited
-
Safety & premises
A designated emergency exit was observed to be blocked by a couch on the inside and blocked as well on the outside by children's bikes.
HHSC 748.3233(b)(4)(B) — Evacuation-Emergency evacuation & relocation diagram includes at least 2 exit routes that are not blocked in any way
HHSC risk weight: Medium High. Corrected 2023-05-19. Correction verified 2023-05-26.
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Safety & premises
-
May 4, 2023 Inspection · Deficiencies cited
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Cleanliness & sanitation
In one of the bedrooms, it was noted that the floor tile was peeling in multiple places. The tile under the legs of the bed, and in a corner against the wall had been torn up.
HHSC 748.3301(a)(2) — Physical Site- Buildings must be clean and in good repair.
HHSC risk weight: Medium. Corrected 2023-05-18. Correction verified 2023-05-19.
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Cleanliness & sanitation
-
May 4, 2023 Inspection · Deficiencies cited
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Cleanliness & sanitation
In one of the bedrooms, it was noted that the floor tile was peeling in multiple places. The tile under the legs of the bed, and in a corner against the wall had been torn up.
HHSC 748.3301(a)(2) — Physical Site- Buildings must be clean and in good repair.
HHSC risk weight: Medium. Corrected 2023-05-18. Correction verified 2023-05-19.
HHSC inspection history · no longer published by HHSC; kept here
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Cleanliness & sanitation
-
Apr 26, 2023 Report · Deficiencies cited (self-report)
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Other
In a review of one child's service plan, there was no child signature, no caregiver signature, no treatment director signature, nor normalcy signature. In a review of three other service plans, there was no treatment director signatures.
HHSC 748.1339(b) — Initial Service Plan-For treatment services, service planning team must include two professionals
HHSC risk weight: Low. Corrected 2023-07-05. Correction verified 2023-07-06.
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Supervision & ratios
In a review of one child's records, there were six Behavior Observation Reports that were completed by another staff member, but held the name and signature of another. In another child's record, there were service plan reviews found that contained inaccurate and untruthful information.
HHSC 748.151(3) — Operational responsibilities - Maintain current, true, accurate, and complete records
HHSC risk weight: Medium. Corrected 2023-07-05. Correction verified 2023-07-06.
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Other
In a review of four children's daily progress notes for the months March through April, none were signed by staff as required. There were also three days missing daily progress notes for one child.
HHSC 748.685(e) — Caregiver responsibility-for a child receiving treatment services for an emotional disorder must maintain daily, signed and dated progress notes
HHSC risk weight: Medium. Corrected 2023-07-05. Correction verified 2023-07-06.
HHSC inspection history · no longer published by HHSC; kept here
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Other
-
Apr 26, 2023 Report · Deficiencies cited (self-report)
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Other
In a review of one child's service plan, there was no child signature, no caregiver signature, no treatment director signature, nor normalcy signature. In a review of three other service plans, there was no treatment director signatures.
HHSC 748.1339(b) — Initial Service Plan-For treatment services, service planning team must include two professionals
HHSC risk weight: Low. Corrected 2023-07-05. Correction verified 2023-07-06.
-
Supervision & ratios
In a review of one child's records, there were six Behavior Observation Reports that were completed by another staff member, but held the name and signature of another. In another child's record, there were service plan reviews found that contained inaccurate and untruthful information.
HHSC 748.151(3) — Operational responsibilities - Maintain current, true, accurate, and complete records
HHSC risk weight: Medium. Corrected 2023-07-05. Correction verified 2023-07-06.
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Other
In a review of four children's daily progress notes for the months March through April, none were signed by staff as required. There were also three days missing daily progress notes for one child.
HHSC 748.685(e) — Caregiver responsibility-for a child receiving treatment services for an emotional disorder must maintain daily, signed and dated progress notes
HHSC risk weight: Medium. Corrected 2023-07-05. Correction verified 2023-07-06.
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Other
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Apr 24, 2023 Report · Deficiencies cited
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Other
During the course of the investigation, it was found that a staff member was threatening a child with harm as a method to gain compliance.
HHSC 748.1101(b)(4)(A)(vii) — Children's rights- Free from demeaning behavior to embarrass/control/harm/intimidate/isolate the child
HHSC risk weight: Medium High. Corrected 2023-06-13. Correction verified 2023-07-06.
HHSC inspection history · no longer published by HHSC; kept here
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Other
-
Apr 24, 2023 Report · Deficiencies cited
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Other
During the course of the investigation, it was found that a staff member was threatening a child with harm as a method to gain compliance.
HHSC 748.1101(b)(4)(A)(vii) — Children's rights- Free from demeaning behavior to embarrass/control/harm/intimidate/isolate the child
HHSC risk weight: Medium High. Corrected 2023-06-13. Correction verified 2023-07-06.
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Other
-
Apr 13, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Apr 13, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
-
Mar 31, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
-
Mar 31, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
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Mar 31, 2023 Assessment · Deficiencies cited
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Discipline & child guidance
A direct care staff was aware of being under investigation for abuse/neglect and failed to make a report to Licensing.
HHSC 748.303(e)(6)(A) — Serious Incident-Report to Licensing within 24 hours of awareness of abuse/neglect investigation by other entity of person under auspices of facility
HHSC risk weight: Medium. Corrected 2023-04-12. Correction verified 2023-03-31.
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Discipline & child guidance
An employee failed to comply with requirement to report being under investigation for abuse/neglect.
HHSC 748.507(3) — Employee general responsibilities-Know and comply with rules of Chapter 748 and any other rules and laws relevant to person's duties
HHSC risk weight: Medium High. Corrected 2023-04-12. Correction verified 2023-03-31.
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Discipline & child guidance
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Mar 31, 2023 Assessment · Deficiencies cited
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Discipline & child guidance
A direct care staff was aware of being under investigation for abuse/neglect and failed to make a report to Licensing.
HHSC 748.303(e)(6)(A) — Serious Incident-Report to Licensing within 24 hours of awareness of abuse/neglect investigation by other entity of person under auspices of facility
HHSC risk weight: Medium. Corrected 2023-04-12. Correction verified 2023-03-31.
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Discipline & child guidance
An employee failed to comply with requirement to report being under investigation for abuse/neglect.
HHSC 748.507(3) — Employee general responsibilities-Know and comply with rules of Chapter 748 and any other rules and laws relevant to person's duties
HHSC risk weight: Medium High. Corrected 2023-04-12. Correction verified 2023-03-31.
HHSC inspection history · no longer published by HHSC; kept here
-
Discipline & child guidance
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Mar 16, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Mar 16, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
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Mar 1, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
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Mar 1, 2023 Assessment · No deficiencies cited
No violations cited on this visit.
-
Mar 1, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Mar 1, 2023 Assessment · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
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Feb 21, 2023 Report · Deficiencies cited
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Other Serious
Children interviewed stated that they were laid on their back and/or belly during restraints and that it hurt. Children also stated that they had witnessed staff perform restraints this way and that they heard the children say that they were being hurt.
HHSC 748.2551(c)(1) — EBI Implementation-Caregiver must minimize risk of physical discomfort, harm, or pain to the child
HHSC risk weight: High. Corrected 2023-04-11. Correction verified 2023-04-13.
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Records & paperwork Serious
Children interviewed reported that during restraints it was hard to breathe, or that they could not breathe.
HHSC 748.2605(a)(1) — Personal Restraints Prohibited-Restraints that impair child's breathing by putting pressure on child's torso
HHSC risk weight: High. Corrected 2023-04-11. Correction verified 2023-04-13.
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Records & paperwork
It was noted that staff did not write EBI documentation in a timely manner.
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 2023-04-11. Correction verified 2023-04-10.
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Records & paperwork
It was not noted on the EBI reports nor the serious incident reports when written notice was provided to the parent after a restraint was conducted on a child.
HHSC 748.2857(a) — No later than 72 hours after the initiation of the intervention, you must provide written notice to the parent.
HHSC risk weight: Medium. Corrected 2023-04-11. Correction verified 2023-04-11.
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Other Serious
-
Feb 21, 2023 Report · Deficiencies cited
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Other Serious
Children interviewed stated that they were laid on their back and/or belly during restraints and that it hurt. Children also stated that they had witnessed staff perform restraints this way and that they heard the children say that they were being hurt.
HHSC 748.2551(c)(1) — EBI Implementation-Caregiver must minimize risk of physical discomfort, harm, or pain to the child
HHSC risk weight: High. Corrected 2023-04-11. Correction verified 2023-04-13.
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Records & paperwork Serious
Children interviewed reported that during restraints it was hard to breathe, or that they could not breathe.
HHSC 748.2605(a)(1) — Personal Restraints Prohibited-Restraints that impair child's breathing by putting pressure on child's torso
HHSC risk weight: High. Corrected 2023-04-11. Correction verified 2023-04-13.
-
Records & paperwork
It was noted that staff did not write EBI documentation in a timely manner.
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 2023-04-11. Correction verified 2023-04-10.
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Records & paperwork
It was not noted on the EBI reports nor the serious incident reports when written notice was provided to the parent after a restraint was conducted on a child.
HHSC 748.2857(a) — No later than 72 hours after the initiation of the intervention, you must provide written notice to the parent.
HHSC risk weight: Medium. Corrected 2023-04-11. Correction verified 2023-04-11.
HHSC inspection history · no longer published by HHSC; kept here
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Other Serious
-
Feb 17, 2023 Report · No deficiencies cited
No violations cited on this visit.
-
Feb 17, 2023 Report · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Feb 15, 2023 Report · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Feb 15, 2023 Report · No deficiencies cited
No violations cited on this visit.
-
Feb 15, 2023 Inspection · Deficiencies cited
-
Staff background & training Serious
Upon discussion with the administrator regarding the volunteers, it is noted that the operation has allowed frequent visitors to be present at the operation without a background check.
HHSC 745.641 — AP Background check results - Must receive notification prior to allowing subject to be present at your operation
HHSC risk weight: High. Corrected 2023-02-17. Correction verified 2023-02-17.
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Illness & medication
During the walk through of the operation, in the medication room it was noted that the Schedule II medications were not double locked.
HHSC 748.2101(3) — Medication Storage-Store medication covered by Schedule II of the Texas Controlled Substances Act under double lock in a separate container
HHSC risk weight: Medium High. Corrected at inspection. Corrected 2023-02-15.
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Illness & medication
Upon reviewing medication logs and documentation, it is noticed that 1 of 4 childs medication logs was noted to be missing prescribing health care professional information.
HHSC 748.2151(c)(2) — Medication record - must include prescribing health-care professional's name
HHSC risk weight: Medium. Corrected 2023-02-24. Correction verified 2023-03-01.
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Illness & medication
Upon reviewing medication logs and documentation, it is noticed that 2 out of 4 child medical records did not show a diagnosis/reason for prescription medications. Out of the 2 child records on 1 childs; 6 medication logs were missing the reason/diagnosis and on the other childs record, 1 of their mediction log was missing the reason/diagnosis.
HHSC 748.2151(c)(3) — Medication record - must include reason medication was prescribed, for prescription medication
HHSC risk weight: Medium. Corrected 2023-02-24. Correction verified 2023-03-01.
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Illness & medication
Upon reviewing medical logs and documentation, it is noticed that 2 of 4 children medical records showed an error. On one child's record it was noted a child missed a dose. On 2 other child's records, it appears that the children received a double dose on for approximately 5 days and one for approximately 1 day. There was no documentation of medication errors in the child's records. There was no documentation of current medication review notes to accurately determine appropriate medication administration is being followed.
HHSC 748.2203(c)(2) — Medication Error-Document the medication error
HHSC risk weight: Medium High. Corrected 2023-02-24. Correction verified 2023-03-01.
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Records & paperwork
Upon review of incident reports, it was found that 1 document informed of an EBI being used. Upon further review, it was found that there was no post intervention discussion conducted with the child.
HHSC 748.2851(b) — EBI Follow-Up-Caregivers involved in EBI must conduct a post discussion with child
HHSC risk weight: Medium. Corrected 2023-02-24. Correction verified 2023-03-01.
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Safety & premises
Upon reveiwing EBI documentation, it is noticed that 3 out of 3 EBI reviews did not have supervisory review.
HHSC 748.2851(d) — EBI Follow-Up-Supervisor(s) of caregivers involved in an EBI must review the use of the emergency behavior intervention within 72 hours
HHSC risk weight: Medium High. Corrected 2023-02-24. Correction verified 2023-03-01.
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Records & paperwork
Upon reviewing EBI documentation, it is noticed that 2 of 3 debriefings did not have childs reaction.
HHSC 748.2853(2) — EBI Documentation-Child's reaction to the opportunity for post discussion
HHSC risk weight: Medium Low. Corrected 2023-02-24. Correction verified 2023-03-01.
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Supervision & ratios
Upon requesting documents, the operation stated that they do not have an overall operation evaluation review of their Emergency Behavior Intervention.
HHSC 748.2951(d) — Evaluation-Results of each overall annual evaluation made available to Licensing for review.
HHSC risk weight: Medium. Corrected 2023-02-24. Correction verified 2023-03-01.
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Safety & premises
Upon reviewing the fire drill documentation, it is noted that in 2022 there was a missed fire drill, 10-7-2021 a fire drill was conducted thus one would've been due in April of 2022 the next was completed August 5th of 2022, tus being overdue by approximately 4 months.
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 2023-02-24. Correction verified 2023-03-01.
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Supervision & ratios
Upon request of the severe weather drill documentation, it is noted that the operation does not have documented severe weather drills.
HHSC 748.3239(b) — Evacuation-Must practice severe weather drill at least once every 6 months from date of last severe weather drill
HHSC risk weight: Medium. Corrected 2023-02-24. Correction verified 2023-03-01.
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Food & allergies
Upon reviewing first aid kits, it is noticed that 3 out of 3 first aid kits do not have a thermometer.
HHSC 748.3273(8) — First Aid Kits-Each one must contain thermometer
HHSC risk weight: Medium Low. Corrected at inspection. Corrected 2023-02-15.
-
Records & paperwork
Upon reviewing first aid kits, it is noticed that 3 out of 3 first aid kits do not have tweezers.
HHSC 748.3273(9) — First Aid Kits-Each one must contain tweezers
HHSC risk weight: Medium Low. Corrected at inspection. Corrected 2023-02-15.
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Supervision & ratios
Upon walking through the operation, it is noticed that 2 of the girls beds in one of the rooms was missing a mattress cover or protector.
HHSC 748.3365(b)(2) — Bedding-must provide each child with a mattress cover or protector unless mattress is waterproof
HHSC risk weight: Medium. Corrected at inspection. Corrected 2023-02-15.
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Safety & premises Serious
Upon reviewing the playground equipment, it is noticed that a swing set is not properly anchored to the ground as well as the tether ball and was noticed that the wooden play structure was just sat on top of the ground, not anchored or built into the ground.
HHSC 748.3471(5) — Safety Requirements-Equipment must be securely anchored according to manufacturer's specifications to prevent collapsing, tipping, sliding, etc.
HHSC risk weight: High. Corrected 2023-02-24. Correction verified 2023-03-01.
-
Safety & premises
Upon discussion with the administrator, it is revealed that the administrator has not been inspecting the playground weekly.
HHSC 748.3475(a) — Safety Requirements-The administrator or designee must inspect the playground weekly to ensure no hazards are present
HHSC risk weight: Medium High. Corrected 2023-02-24. Correction verified 2023-03-01.
-
Supervision & ratios
Upon reviewing the playground at the operation, it is noticed that the loose-fill does not reach the required 9 inches of height that it should be, as set by minimum standards.
HHSC 748.3563(d) — Protective Surfacing-Must ensure 9 inches of the loose-fill materials are maintained at all times
HHSC risk weight: Medium High. Corrected 2023-03-15. Correction verified 2023-03-16.
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Other
Upon discussion with the administrator, it is noted that the volunteers are coming in contact with children without documention of TB screenings.
HHSC 748.509 — TB screening-Caregivers, employees, volunteers, contract service providers screened for TB before having contact with children in care
HHSC risk weight: Medium. Corrected 2023-02-22. Correction verified 2023-02-17.
-
Staff background & training
Upon review at the inspection, it was found the administrator installed new playground equipment that was not in compliance with minimum standards, was not conducting the required reviews of the playground equipment, allowing volunteers at the operation for tutoring and mentoring without background checks, and not providing oversight of the entire program and staff's duties and responsibilities.
HHSC 748.535(1) — Child-care administrator responsibilities-Daily supervision and on-site administrative responsibility for the overall operation
HHSC risk weight: Medium. Corrected 2023-02-22. Correction verified 2023-03-01.
-
Supervision & ratios
Upon discussion with the administrator, it was noted that the operation was allowing volunteers in the form of tutoring to enter and assist the children. This practice violates the operation's own approved policies.
HHSC 748.535(3)(E) — Child-care administrator responsibilities-Administering and managing the operation according to your policies.
HHSC risk weight: Medium. Corrected 2023-02-22. Correction verified 2023-02-17.
-
Supervision & ratios
Upon requesting files for volunteers, it is discussed by the administrator that they do not have documentation or personal files for the volunteers.
HHSC 748.721(a) — Volunteer personnel record-The operation must maintain a personnel record for each volunteer
HHSC risk weight: Medium Low. Corrected 2023-02-22. Correction verified 2023-02-17.
-
Staff background & training Serious
-
Feb 15, 2023 Inspection · Deficiencies cited
-
Staff background & training Serious
Upon discussion with the administrator regarding the volunteers, it is noted that the operation has allowed frequent visitors to be present at the operation without a background check.
HHSC 745.641 — AP Background check results - Must receive notification prior to allowing subject to be present at your operation
HHSC risk weight: High. Corrected 2023-02-17. Correction verified 2023-02-17.
-
Illness & medication
During the walk through of the operation, in the medication room it was noted that the Schedule II medications were not double locked.
HHSC 748.2101(3) — Medication Storage-Store medication covered by Schedule II of the Texas Controlled Substances Act under double lock in a separate container
HHSC risk weight: Medium High. Corrected at inspection. Corrected 2023-02-15.
-
Illness & medication
Upon reviewing medication logs and documentation, it is noticed that 1 of 4 childs medication logs was noted to be missing prescribing health care professional information.
HHSC 748.2151(c)(2) — Medication record - must include prescribing health-care professional's name
HHSC risk weight: Medium. Corrected 2023-02-24. Correction verified 2023-03-01.
-
Illness & medication
Upon reviewing medication logs and documentation, it is noticed that 2 out of 4 child medical records did not show a diagnosis/reason for prescription medications. Out of the 2 child records on 1 childs; 6 medication logs were missing the reason/diagnosis and on the other childs record, 1 of their mediction log was missing the reason/diagnosis.
HHSC 748.2151(c)(3) — Medication record - must include reason medication was prescribed, for prescription medication
HHSC risk weight: Medium. Corrected 2023-02-24. Correction verified 2023-03-01.
-
Illness & medication
Upon reviewing medical logs and documentation, it is noticed that 2 of 4 children medical records showed an error. On one child's record it was noted a child missed a dose. On 2 other child's records, it appears that the children received a double dose on for approximately 5 days and one for approximately 1 day. There was no documentation of medication errors in the child's records. There was no documentation of current medication review notes to accurately determine appropriate medication administration is being followed.
HHSC 748.2203(c)(2) — Medication Error-Document the medication error
HHSC risk weight: Medium High. Corrected 2023-02-24. Correction verified 2023-03-01.
-
Records & paperwork
Upon review of incident reports, it was found that 1 document informed of an EBI being used. Upon further review, it was found that there was no post intervention discussion conducted with the child.
HHSC 748.2851(b) — EBI Follow-Up-Caregivers involved in EBI must conduct a post discussion with child
HHSC risk weight: Medium. Corrected 2023-02-24. Correction verified 2023-03-01.
-
Safety & premises
Upon reveiwing EBI documentation, it is noticed that 3 out of 3 EBI reviews did not have supervisory review.
HHSC 748.2851(d) — EBI Follow-Up-Supervisor(s) of caregivers involved in an EBI must review the use of the emergency behavior intervention within 72 hours
HHSC risk weight: Medium High. Corrected 2023-02-24. Correction verified 2023-03-01.
-
Records & paperwork
Upon reviewing EBI documentation, it is noticed that 2 of 3 debriefings did not have childs reaction.
HHSC 748.2853(2) — EBI Documentation-Child's reaction to the opportunity for post discussion
HHSC risk weight: Medium Low. Corrected 2023-02-24. Correction verified 2023-03-01.
-
Supervision & ratios
Upon requesting documents, the operation stated that they do not have an overall operation evaluation review of their Emergency Behavior Intervention.
HHSC 748.2951(d) — Evaluation-Results of each overall annual evaluation made available to Licensing for review.
HHSC risk weight: Medium. Corrected 2023-02-24. Correction verified 2023-03-01.
-
Safety & premises
Upon reviewing the fire drill documentation, it is noted that in 2022 there was a missed fire drill, 10-7-2021 a fire drill was conducted thus one would've been due in April of 2022 the next was completed August 5th of 2022, tus being overdue by approximately 4 months.
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 2023-02-24. Correction verified 2023-03-01.
-
Supervision & ratios
Upon request of the severe weather drill documentation, it is noted that the operation does not have documented severe weather drills.
HHSC 748.3239(b) — Evacuation-Must practice severe weather drill at least once every 6 months from date of last severe weather drill
HHSC risk weight: Medium. Corrected 2023-02-24. Correction verified 2023-03-01.
-
Food & allergies
Upon reviewing first aid kits, it is noticed that 3 out of 3 first aid kits do not have a thermometer.
HHSC 748.3273(8) — First Aid Kits-Each one must contain thermometer
HHSC risk weight: Medium Low. Corrected at inspection. Corrected 2023-02-15.
-
Records & paperwork
Upon reviewing first aid kits, it is noticed that 3 out of 3 first aid kits do not have tweezers.
HHSC 748.3273(9) — First Aid Kits-Each one must contain tweezers
HHSC risk weight: Medium Low. Corrected at inspection. Corrected 2023-02-15.
-
Supervision & ratios
Upon walking through the operation, it is noticed that 2 of the girls beds in one of the rooms was missing a mattress cover or protector.
HHSC 748.3365(b)(2) — Bedding-must provide each child with a mattress cover or protector unless mattress is waterproof
HHSC risk weight: Medium. Corrected at inspection. Corrected 2023-02-15.
-
Safety & premises Serious
Upon reviewing the playground equipment, it is noticed that a swing set is not properly anchored to the ground as well as the tether ball and was noticed that the wooden play structure was just sat on top of the ground, not anchored or built into the ground.
HHSC 748.3471(5) — Safety Requirements-Equipment must be securely anchored according to manufacturer's specifications to prevent collapsing, tipping, sliding, etc.
HHSC risk weight: High. Corrected 2023-02-24. Correction verified 2023-03-01.
-
Safety & premises
Upon discussion with the administrator, it is revealed that the administrator has not been inspecting the playground weekly.
HHSC 748.3475(a) — Safety Requirements-The administrator or designee must inspect the playground weekly to ensure no hazards are present
HHSC risk weight: Medium High. Corrected 2023-02-24. Correction verified 2023-03-01.
-
Supervision & ratios
Upon reviewing the playground at the operation, it is noticed that the loose-fill does not reach the required 9 inches of height that it should be, as set by minimum standards.
HHSC 748.3563(d) — Protective Surfacing-Must ensure 9 inches of the loose-fill materials are maintained at all times
HHSC risk weight: Medium High. Corrected 2023-03-15. Correction verified 2023-03-16.
-
Other
Upon discussion with the administrator, it is noted that the volunteers are coming in contact with children without documention of TB screenings.
HHSC 748.509 — TB screening-Caregivers, employees, volunteers, contract service providers screened for TB before having contact with children in care
HHSC risk weight: Medium. Corrected 2023-02-22. Correction verified 2023-02-17.
-
Staff background & training
Upon review at the inspection, it was found the administrator installed new playground equipment that was not in compliance with minimum standards, was not conducting the required reviews of the playground equipment, allowing volunteers at the operation for tutoring and mentoring without background checks, and not providing oversight of the entire program and staff's duties and responsibilities.
HHSC 748.535(1) — Child-care administrator responsibilities-Daily supervision and on-site administrative responsibility for the overall operation
HHSC risk weight: Medium. Corrected 2023-02-22. Correction verified 2023-03-01.
-
Supervision & ratios
Upon discussion with the administrator, it was noted that the operation was allowing volunteers in the form of tutoring to enter and assist the children. This practice violates the operation's own approved policies.
HHSC 748.535(3)(E) — Child-care administrator responsibilities-Administering and managing the operation according to your policies.
HHSC risk weight: Medium. Corrected 2023-02-22. Correction verified 2023-02-17.
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Supervision & ratios
Upon requesting files for volunteers, it is discussed by the administrator that they do not have documentation or personal files for the volunteers.
HHSC 748.721(a) — Volunteer personnel record-The operation must maintain a personnel record for each volunteer
HHSC risk weight: Medium Low. Corrected 2023-02-22. Correction verified 2023-02-17.
HHSC inspection history · no longer published by HHSC; kept here
-
Staff background & training Serious
-
Jan 30, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
-
Jan 30, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Jan 18, 2023 Report · Deficiencies cited
-
Discipline & child guidance Serious
In a video recording, it was heard that staff was threatening to hit and beat children multiple times in a severe manner.
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 2023-03-28. Correction verified 2023-04-04.
-
Records & paperwork
In a video recording, it was heard that a staff member was using profane language towards children.
HHSC 748.2307(9) — Other Prohibited Punishments-subjecting a child to abusive or profane language
HHSC risk weight: Medium High. Corrected 2023-03-28. Correction verified 2023-04-04.
-
Safety & premises
It was found that two employees had expired drivers licenses.
HHSC 748.363(10) — Personnel records-For each person who transports a child, include copy of valid driver's license or DPS driver's license check done in last 12 months
HHSC risk weight: Medium. Corrected 2023-03-28. Correction verified 2023-03-24.
-
Records & paperwork
Upon request of a staff member's current job description, it was found that no new job description was created and signed in the employee's record.
HHSC 748.363(3) — Personnel records-Include current job description
HHSC risk weight: Medium. Corrected 2023-03-28. Correction verified 2023-03-24.
-
Discipline & child guidance
In multiple interviews with staff members, it was found that there were multiple instances where staff should have made a hotline report, but did not.
HHSC 748.507(2) — Employee general responsibilities-Report suspected abuse, neglect, and exploitation to Child Abuse Hotline and the designated employee/administrator
HHSC risk weight: Medium High. Corrected 2023-03-28. Correction verified 2023-03-24.
-
Staff background & training
In a review of staff files, there was no specifically stated learning objectives noted on the documents that were used to notate annual training. There was no objective listed on the sign in sheets.
HHSC 748.941(a)(1) — Training Criteria- Instructor-led/Self-Instructional Training must include specifically stated learning objectives.
HHSC risk weight: Medium Low. Corrected 2023-03-28. Correction verified 2023-03-24.
-
Staff background & training
In a review of staff training, there was no curriculum that was produced to show what the staff were being taught.
HHSC 748.941(a)(2) — Training Criteria- Instructor-led/self-instructional training must include a curriculum that includes experiential or applied activities.
HHSC risk weight: Medium Low. Corrected 2023-03-28. Correction verified 2023-03-24.
-
Staff background & training
In a review of staff records and files, there were no evaluation tools to determine if the staff retained the information received in trainings. In staff interviews, none of the staff stated that they had taken an assessment or any other evaluation tool to determine if they obtained or retained the information.
HHSC 748.941(a)(3) — Training Criteria- Must include an evaluation tool to determine whether the person obtained the information necessary to meet the stated objectives
HHSC risk weight: Medium. Corrected 2023-03-28. Correction verified 2023-03-24.
HHSC inspection history · no longer published by HHSC; kept here
-
Discipline & child guidance Serious
-
Jan 18, 2023 Report · Deficiencies cited
-
Discipline & child guidance Serious
In a video recording, it was heard that staff was threatening to hit and beat children multiple times in a severe manner.
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 2023-03-28. Correction verified 2023-04-04.
-
Records & paperwork
In a video recording, it was heard that a staff member was using profane language towards children.
HHSC 748.2307(9) — Other Prohibited Punishments-subjecting a child to abusive or profane language
HHSC risk weight: Medium High. Corrected 2023-03-28. Correction verified 2023-04-04.
-
Safety & premises
It was found that two employees had expired drivers licenses.
HHSC 748.363(10) — Personnel records-For each person who transports a child, include copy of valid driver's license or DPS driver's license check done in last 12 months
HHSC risk weight: Medium. Corrected 2023-03-28. Correction verified 2023-03-24.
-
Records & paperwork
Upon request of a staff member's current job description, it was found that no new job description was created and signed in the employee's record.
HHSC 748.363(3) — Personnel records-Include current job description
HHSC risk weight: Medium. Corrected 2023-03-28. Correction verified 2023-03-24.
-
Discipline & child guidance
In multiple interviews with staff members, it was found that there were multiple instances where staff should have made a hotline report, but did not.
HHSC 748.507(2) — Employee general responsibilities-Report suspected abuse, neglect, and exploitation to Child Abuse Hotline and the designated employee/administrator
HHSC risk weight: Medium High. Corrected 2023-03-28. Correction verified 2023-03-24.
-
Staff background & training
In a review of staff files, there was no specifically stated learning objectives noted on the documents that were used to notate annual training. There was no objective listed on the sign in sheets.
HHSC 748.941(a)(1) — Training Criteria- Instructor-led/Self-Instructional Training must include specifically stated learning objectives.
HHSC risk weight: Medium Low. Corrected 2023-03-28. Correction verified 2023-03-24.
-
Staff background & training
In a review of staff training, there was no curriculum that was produced to show what the staff were being taught.
HHSC 748.941(a)(2) — Training Criteria- Instructor-led/self-instructional training must include a curriculum that includes experiential or applied activities.
HHSC risk weight: Medium Low. Corrected 2023-03-28. Correction verified 2023-03-24.
-
Staff background & training
In a review of staff records and files, there were no evaluation tools to determine if the staff retained the information received in trainings. In staff interviews, none of the staff stated that they had taken an assessment or any other evaluation tool to determine if they obtained or retained the information.
HHSC 748.941(a)(3) — Training Criteria- Must include an evaluation tool to determine whether the person obtained the information necessary to meet the stated objectives
HHSC risk weight: Medium. Corrected 2023-03-28. Correction verified 2023-03-24.
-
Discipline & child guidance Serious
-
Jan 3, 2023 Report · Deficiencies cited
-
Food & allergies
During the course of the investigation, it was found that staff are forcing children to eat all of their food.
HHSC 748.1699(a) — Nutrition-must offer a child a meal or snack, but may not force the child to eat
HHSC risk weight: Medium High. Corrected 2023-03-13. Correction verified 2023-03-16.
HHSC inspection history · no longer published by HHSC; kept here
-
Food & allergies
-
Jan 3, 2023 Report · Deficiencies cited
-
Food & allergies
During the course of the investigation, it was found that staff are forcing children to eat all of their food.
HHSC 748.1699(a) — Nutrition-must offer a child a meal or snack, but may not force the child to eat
HHSC risk weight: Medium High. Corrected 2023-03-13. Correction verified 2023-03-16.
-
Food & allergies
-
Dec 16, 2022 Report · No deficiencies cited
No violations cited on this visit.
-
Dec 16, 2022 Report · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Oct 31, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Oct 31, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
-
Oct 19, 2022 Inspection · Deficiencies cited
-
Other
The pantry was observed with evidence of rodent droppings. The pantry shelves were observed to be dirty and had sticky substances.
HHSC 748.3301(h) — Physical Site-The building must be free of rodents and insects
HHSC risk weight: Medium High. Corrected 2022-10-25. Correction verified 2022-10-31.
-
Supervision & ratios
Food items were observed to be stored on the floor in the kitchen. Food in boxes were observed to have started to rot. Boxes were removed and thrown in dumpster.
HHSC 748.3443(a)(1) — Food Preparation-Food items must be covered & stored off the floor
HHSC risk weight: Medium. Corrected at inspection. Corrected 2022-10-18.
-
Other
-
Oct 19, 2022 Inspection · Deficiencies cited
-
Other
The pantry was observed with evidence of rodent droppings. The pantry shelves were observed to be dirty and had sticky substances.
HHSC 748.3301(h) — Physical Site-The building must be free of rodents and insects
HHSC risk weight: Medium High. Corrected 2022-10-25. Correction verified 2022-10-31.
-
Supervision & ratios
Food items were observed to be stored on the floor in the kitchen. Food in boxes were observed to have started to rot. Boxes were removed and thrown in dumpster.
HHSC 748.3443(a)(1) — Food Preparation-Food items must be covered & stored off the floor
HHSC risk weight: Medium. Corrected at inspection. Corrected 2022-10-18.
HHSC inspection history · no longer published by HHSC; kept here
-
Other
-
Sep 22, 2022 Report · Deficiencies cited
-
Records & paperwork Serious
Video footage and documentation was not provided during the investigation.
HHSC 745.8417 — Licensing must have access to records
HHSC risk weight: High. Corrected 2022-12-01. Correction verified 2022-11-29.
HHSC inspection history · no longer published by HHSC; kept here
-
Records & paperwork Serious
-
Sep 22, 2022 Report · Deficiencies cited
-
Records & paperwork Serious
Video footage and documentation was not provided during the investigation.
HHSC 745.8417 — Licensing must have access to records
HHSC risk weight: High. Corrected 2022-12-01. Correction verified 2022-11-29.
-
Records & paperwork Serious
-
Sep 21, 2022 Report · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Sep 21, 2022 Report · No deficiencies cited
No violations cited on this visit.
-
Aug 31, 2022 Inspection · Deficiencies cited
-
Records & paperwork
One of four child records reviewed did not have documentation off a dental appointment.
HHSC 748.1225(b) — Admission-Dental exam for child 3 years old or older scheduled in 30 days and done in 90 days unless documentation of one within past year on file
HHSC risk weight: Medium Low. Corrected 2022-09-30. Correction verified 2022-09-12.
-
Records & paperwork
Two of the four child records reviewed were late on the completion of the initail service plan.
HHSC 748.1335 — Initial Service Plan-Complete the initial service plan within 45 days after admission
HHSC risk weight: Medium Low. Corrected 2022-09-14. Correction verified 2022-09-12.
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Other
Discharge summary stated that the child was notified of upcoming discharge on 8/4/2022. The child's discharge date was 8/5/2022.
HHSC 748.1433(e) — Discharge-If child receiving tx svcs, tell him of planned discharge/transfer 4 days in advance, unless qualified professional justifies not doing so
HHSC risk weight: Low. Corrected 2022-09-14. Correction verified 2022-09-13.
-
Illness & medication
Two of the four child medication records reviewed did not have a reason for why the medication was prescribed.
HHSC 748.2151(c)(3) — Medication record - must include reason medication was prescribed, for prescription medication
HHSC risk weight: Medium. Corrected 2022-09-14. Correction verified 2022-09-12.
-
Illness & medication
The medication logs that were reviewed showed the count of the medications to be incorrect based on the amount of medication left in the packaging.
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 2022-09-14. Correction verified 2022-09-12.
-
Illness & medication
This was found on the child's medication logs. It was noted on three logs reviewed that there was no dose given to the child on a few dates in the month of August.
HHSC 748.2203(c)(2) — Medication Error-Document the medication error
HHSC risk weight: Medium High. Corrected 2022-09-14. Correction verified 2022-09-12.
-
Discipline & child guidance
One of four child records showed that a child made an allegation of abuse. The serious incident report did not note a report made to the Abuse and Neglect Hotline.
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 2022-09-14. Correction verified 2022-09-12.
-
Records & paperwork
One of four child records reviewed showed a serious incident report that did not note how the incident was resolved.
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 2022-09-14. Correction verified 2022-09-12.
-
Safety & premises
During walk-through of the facility, it was noted that one of the fire extinguishers needed to be recharged. The fire extinguisher was switched out and replaced with one that was still in the "White"
HHSC 748.3113(c) — Fire Extinguisher-Fire extinguisher that has been used or has lost operating pressure must be serviced or replaced immediately with equivalent unit
HHSC risk weight: Medium High. Corrected at inspection. Corrected 2022-08-31.
-
Supervision & ratios
Two of the five freezers inspected did not have a reading of 0* F. One read 8*F and the other read 24*F.
HHSC 748.3443(b)(2) — Food Preparation-Must have a thermometer in freezers & store frozen food at 0 degrees Fahrenheit or below
HHSC risk weight: Medium. Corrected 2022-09-14. Correction verified 2022-09-12.
-
Supervision & ratios
Operation did not have a current six month evaluation of Unauthorized Absence.
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 2022-09-14. Correction verified 2022-09-12.
HHSC inspection history · no longer published by HHSC; kept here
-
Records & paperwork
-
Aug 31, 2022 Inspection · Deficiencies cited
-
Records & paperwork
One of four child records reviewed did not have documentation off a dental appointment.
HHSC 748.1225(b) — Admission-Dental exam for child 3 years old or older scheduled in 30 days and done in 90 days unless documentation of one within past year on file
HHSC risk weight: Medium Low. Corrected 2022-09-30. Correction verified 2022-09-12.
-
Records & paperwork
Two of the four child records reviewed were late on the completion of the initail service plan.
HHSC 748.1335 — Initial Service Plan-Complete the initial service plan within 45 days after admission
HHSC risk weight: Medium Low. Corrected 2022-09-14. Correction verified 2022-09-12.
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Other
Discharge summary stated that the child was notified of upcoming discharge on 8/4/2022. The child's discharge date was 8/5/2022.
HHSC 748.1433(e) — Discharge-If child receiving tx svcs, tell him of planned discharge/transfer 4 days in advance, unless qualified professional justifies not doing so
HHSC risk weight: Low. Corrected 2022-09-14. Correction verified 2022-09-13.
-
Illness & medication
Two of the four child medication records reviewed did not have a reason for why the medication was prescribed.
HHSC 748.2151(c)(3) — Medication record - must include reason medication was prescribed, for prescription medication
HHSC risk weight: Medium. Corrected 2022-09-14. Correction verified 2022-09-12.
-
Illness & medication
The medication logs that were reviewed showed the count of the medications to be incorrect based on the amount of medication left in the packaging.
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 2022-09-14. Correction verified 2022-09-12.
-
Illness & medication
This was found on the child's medication logs. It was noted on three logs reviewed that there was no dose given to the child on a few dates in the month of August.
HHSC 748.2203(c)(2) — Medication Error-Document the medication error
HHSC risk weight: Medium High. Corrected 2022-09-14. Correction verified 2022-09-12.
-
Discipline & child guidance
One of four child records showed that a child made an allegation of abuse. The serious incident report did not note a report made to the Abuse and Neglect Hotline.
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 2022-09-14. Correction verified 2022-09-12.
-
Records & paperwork
One of four child records reviewed showed a serious incident report that did not note how the incident was resolved.
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 2022-09-14. Correction verified 2022-09-12.
-
Safety & premises
During walk-through of the facility, it was noted that one of the fire extinguishers needed to be recharged. The fire extinguisher was switched out and replaced with one that was still in the "White"
HHSC 748.3113(c) — Fire Extinguisher-Fire extinguisher that has been used or has lost operating pressure must be serviced or replaced immediately with equivalent unit
HHSC risk weight: Medium High. Corrected at inspection. Corrected 2022-08-31.
-
Supervision & ratios
Two of the five freezers inspected did not have a reading of 0* F. One read 8*F and the other read 24*F.
HHSC 748.3443(b)(2) — Food Preparation-Must have a thermometer in freezers & store frozen food at 0 degrees Fahrenheit or below
HHSC risk weight: Medium. Corrected 2022-09-14. Correction verified 2022-09-12.
-
Supervision & ratios
Operation did not have a current six month evaluation of Unauthorized Absence.
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 2022-09-14. Correction verified 2022-09-12.
-
Records & paperwork
-
Jun 17, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Jun 17, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
-
Jun 15, 2022 Report · Deficiencies cited
-
Supervision & ratios
It was determined that a staff member at the operation would yell and raise their voice in front of the children.
HHSC 748.2307(8) — Other Prohibited Punishments-humiliating, shaming, ridiculing, rejecting, or yelling at a child
HHSC risk weight: Medium High. Corrected 2022-08-05. Correction verified 2022-08-02.
-
Supervision & ratios
-
Jun 15, 2022 Report · Deficiencies cited
-
Supervision & ratios
It was determined that a staff member at the operation would yell and raise their voice in front of the children.
HHSC 748.2307(8) — Other Prohibited Punishments-humiliating, shaming, ridiculing, rejecting, or yelling at a child
HHSC risk weight: Medium High. Corrected 2022-08-05. Correction verified 2022-08-02.
HHSC inspection history · no longer published by HHSC; kept here
-
Supervision & ratios
-
Apr 26, 2022 Report · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Apr 26, 2022 Report · No deficiencies cited
No violations cited on this visit.
-
Apr 14, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
-
Apr 14, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Apr 2, 2022 Report · No deficiencies cited
No violations cited on this visit.
-
Apr 2, 2022 Report · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Mar 31, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
-
Mar 31, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Mar 25, 2022 Report · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Mar 25, 2022 Report · No deficiencies cited
No violations cited on this visit.
-
Jan 24, 2022 Inspection · Deficiencies cited
-
Records & paperwork
In one of four children records reviewed, in the child's Admission Assessment, it was noted to be missing the contraindications to use of restraints.
HHSC 748.1205(a)(10) — Admission Documentation-Includes known contraindications to the use of restraint
HHSC risk weight: Medium High. Corrected 2022-02-07. Correction verified 2022-02-04.
-
Records & paperwork
Two out of four children records reviewed showed little progress/updates in their service plan reviews.
HHSC 748.1385(4) — Service Plan Review-Must document reasons for continued placement if review shows no progress towards meeting identified needs
HHSC risk weight: Medium Low. Corrected 2022-02-07. Correction verified 2022-02-04.
-
Illness & medication
Three of the medication logs reviewed did not have a prescribing physician noted on the documentation.
HHSC 748.2151(c)(2) — Medication record - must include prescribing health-care professional's name
HHSC risk weight: Medium. Corrected 2022-02-07. Correction verified 2022-02-04.
-
Illness & medication
Three medication logs reviewed did not have the reason for the medication and why it was prescribed to the child.
HHSC 748.2151(c)(3) — Medication record - must include reason medication was prescribed, for prescription medication
HHSC risk weight: Medium. Corrected 2022-02-07. Correction verified 2022-02-04.
-
Illness & medication
One of the child records reviewed showed that a child missed two medication doses on two separate dates. This was found on the child's medication logs.
HHSC 748.2203(c)(2) — Medication Error-Document the medication error
HHSC risk weight: Medium High. Corrected 2022-02-07. Correction verified 2022-02-04.
-
Cleanliness & sanitation Serious
In girls room 3, it was observed that a small hole, as well a tear in the dry wall, was found near a child's bed.
HHSC 748.3301(a) — Physical Site-Buildings must be structurally sound, clean, and in good repair. Paints must be lead-free
HHSC risk weight: High. Corrected 2022-02-07. Correction verified 2022-02-04.
-
Cleanliness & sanitation
In the boys restroom, it was observed that the shower/tub combo was missing a shower head. Administrator installed a new shower head to the shower/tub combo.
HHSC 748.3351(1) — Interior Space-Provide living space, appropriate furnishings, & bathroom facilities that are safe, clean and maintained in good repair
HHSC risk weight: Medium High. Corrected at inspection. Corrected 2022-01-24.
-
Cleanliness & sanitation
Two sinks in the girl's restroom was not draining properly. One sink in the boy's restroom was not draining properly. Administrator applied drain-o to the sinks to unclog the drains.
HHSC 748.3391(a) — Bathrooms-Must be maintained in good repair & kept clean
HHSC risk weight: Medium High. Corrected at inspection. Corrected 2022-01-24.
-
Supervision & ratios
Four chip bags were found to be opened and unprotected from external elements located in the kitchen. Administrator disposed of the open chip bags as well as puchased additional chip clips.
HHSC 748.3443(a)(4) — Food Preparation-Food items must be stored in a container that is protected from insects & rodents
HHSC risk weight: Medium High. Corrected at inspection. Corrected 2022-01-24.
-
Supervision & ratios
Small freezer in pantry thermometer was reading to be approximately 10 degrees F. The pantry fridge/freezer combo was missing a thermometer in the freezer. The fridge thermometer was broken. The kitchen fridge/freezer combo was missing both thermometers.
HHSC 748.3443(b)(2) — Food Preparation-Must have a thermometer in freezers & store frozen food at 0 degrees Fahrenheit or below
HHSC risk weight: Medium. Corrected 2022-02-07. Correction verified 2022-02-04.
HHSC inspection history · no longer published by HHSC; kept here
-
Records & paperwork
-
Jan 24, 2022 Inspection · Deficiencies cited
-
Records & paperwork
In one of four children records reviewed, in the child's Admission Assessment, it was noted to be missing the contraindications to use of restraints.
HHSC 748.1205(a)(10) — Admission Documentation-Includes known contraindications to the use of restraint
HHSC risk weight: Medium High. Corrected 2022-02-07. Correction verified 2022-02-04.
-
Records & paperwork
Two out of four children records reviewed showed little progress/updates in their service plan reviews.
HHSC 748.1385(4) — Service Plan Review-Must document reasons for continued placement if review shows no progress towards meeting identified needs
HHSC risk weight: Medium Low. Corrected 2022-02-07. Correction verified 2022-02-04.
-
Illness & medication
Three of the medication logs reviewed did not have a prescribing physician noted on the documentation.
HHSC 748.2151(c)(2) — Medication record - must include prescribing health-care professional's name
HHSC risk weight: Medium. Corrected 2022-02-07. Correction verified 2022-02-04.
-
Illness & medication
Three medication logs reviewed did not have the reason for the medication and why it was prescribed to the child.
HHSC 748.2151(c)(3) — Medication record - must include reason medication was prescribed, for prescription medication
HHSC risk weight: Medium. Corrected 2022-02-07. Correction verified 2022-02-04.
-
Illness & medication
One of the child records reviewed showed that a child missed two medication doses on two separate dates. This was found on the child's medication logs.
HHSC 748.2203(c)(2) — Medication Error-Document the medication error
HHSC risk weight: Medium High. Corrected 2022-02-07. Correction verified 2022-02-04.
-
Cleanliness & sanitation Serious
In girls room 3, it was observed that a small hole, as well a tear in the dry wall, was found near a child's bed.
HHSC 748.3301(a) — Physical Site-Buildings must be structurally sound, clean, and in good repair. Paints must be lead-free
HHSC risk weight: High. Corrected 2022-02-07. Correction verified 2022-02-04.
-
Cleanliness & sanitation
In the boys restroom, it was observed that the shower/tub combo was missing a shower head. Administrator installed a new shower head to the shower/tub combo.
HHSC 748.3351(1) — Interior Space-Provide living space, appropriate furnishings, & bathroom facilities that are safe, clean and maintained in good repair
HHSC risk weight: Medium High. Corrected at inspection. Corrected 2022-01-24.
-
Cleanliness & sanitation
Two sinks in the girl's restroom was not draining properly. One sink in the boy's restroom was not draining properly. Administrator applied drain-o to the sinks to unclog the drains.
HHSC 748.3391(a) — Bathrooms-Must be maintained in good repair & kept clean
HHSC risk weight: Medium High. Corrected at inspection. Corrected 2022-01-24.
-
Supervision & ratios
Four chip bags were found to be opened and unprotected from external elements located in the kitchen. Administrator disposed of the open chip bags as well as puchased additional chip clips.
HHSC 748.3443(a)(4) — Food Preparation-Food items must be stored in a container that is protected from insects & rodents
HHSC risk weight: Medium High. Corrected at inspection. Corrected 2022-01-24.
-
Supervision & ratios
Small freezer in pantry thermometer was reading to be approximately 10 degrees F. The pantry fridge/freezer combo was missing a thermometer in the freezer. The fridge thermometer was broken. The kitchen fridge/freezer combo was missing both thermometers.
HHSC 748.3443(b)(2) — Food Preparation-Must have a thermometer in freezers & store frozen food at 0 degrees Fahrenheit or below
HHSC risk weight: Medium. Corrected 2022-02-07. Correction verified 2022-02-04.
-
Records & paperwork
-
Jan 3, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Jan 3, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
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Dec 21, 2021 Report · No deficiencies cited
No violations cited on this visit.
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Dec 21, 2021 Report · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
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.