Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Activity Type: Investigation Number Date Intake Rcvd: Investigation 1557895 05/12/2011 02:45:00 Category Run date: July 17, 2018 Compliance History Report Short Description Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Warning Letter/Due Notice given Standard # Children's Rights Weight Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: This standard was evaluated and the facility was found to be in compliance. High Category Standard # Weight 748.685(a)(4) High Short Description Personnel Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being Narrative: This standard was evaluated and the facility was found to be in compliance. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2666644 01/20/2011 11:09:00 01/20/2011 11:32:44 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 1433463 01/19/2011 08:59:00 Category Short Description Warning Letter/Due Notice given N Standard # Weight Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being Narrative: Standard was evaluated and found to be in compliance. 748.685(a)(4) High Category Standard # Weight Personnel Short Description Children's Rights Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: Standard was evaluated and found to be in compliance. High Category Short Description Standard # Weight Children's rights-Adhere to the child's right to not receive unnecessary or excessive medication Narrative: Standard was evaluated and found to be in compliance. 748.1101(b)(24) Medium High Category Short Description Standard # Weight Discipline and Punishment Other Prohibited Punishments-any harsh, cruel, unusual, unnecessary, demeaning, or humiliating discipline/punishment 748.2307(1) High Children's Rights Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Page 1 of 187 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Narrative: Standard was evaluated and found to be in compliance. Category Short Description Standard # Discipline and Punishment Corporal Punishment-May not use/threaten corporal punishment, 748.2303(a) such as hitting/spanking, forced exercise, holding physical position, unproductive work. Narrative: Standard was evaluated and found to be in compliance. Weight TA Finding High Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2663164 01/19/2011 08:59:00 01/19/2011 12:20:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2663709 01/19/2011 08:47:00 01/19/2011 09:56:58 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2661809 01/18/2011 12:28:00 01/18/2011 05:15:27 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 1429505 01/17/2011 12:00:00 Category Short Description Warning Letter/Due Notice given N Standard # Controlling Person - TAC 745 Weight Controlling Person - Submit Controlling Person Form to Licensing 745.903(2) within two days after a person becomes a controlling person. See TAC 745.901 Narrative: This standard was evaluated and found to be in compliance. High Category Short Description Standard # Weight Child-care administrator responsibilities-Overseeing staffing patterns to ensure supervision and child-care services meet the needs of children Narrative: This standard was evaluated and found to be in compliance. 748.535(2)(A) Medium High Category Standard # Weight Personnel Short Description Reports and Record Keeping Serious Incident-Report to Licensing as soon as aware of 748.303(a)(3)(A) allegations or indications of abuse, neglect, or exploitation of a child Narrative: This standard was evaluated and found to be in compliance. Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Medium High Page 2 of 187 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Category Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Short Description Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Standard # Weight Mandatory Drug Testing-All Employees are Subject to Random, Unannounced Drug Testing Narrative: This standard was evaluated and found to be in compliance. 745.4151(c)(4)(B) High Category Drug Testing - TAC 745 Short Description Standard # Weight Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks Narrative: This standard was evaluated and found to be in compliance. 748.507(1) Medium High Category Standard # Weight Personnel Short Description Background Checks - TAC 745 Required background check - Each person at least 14 years of age, 745.615(a)(6)(A) other than a client in care, who counted in child-to-caregiver ratios Narrative: This standard was evaluated and found to be in compliance. High Category Standard # Weight 748.1009(b)(1) Medium Short Description Child/Caregiver Ratios Child/caregiver ratio-If operation provides treatment services, staffing plan includes enough caregivers for 24-hr & one-on-one supervision Narrative: This standard was evaluated and found to be in compliance. Activity Type: Inspection Id Date Begin: Other Inspection 2644985 01/03/2011 02:15:00 Category Short Description TA Finding TA Finding TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Warning Letter/Due Notice given 01/03/2011 05:03:00 Actions - TAC 745 Meeting Requirement of Corrective Action 745.8633 Narrative: -A master log documenting random unannounced visits to the housing units was not available for Licensing to review. Admn Rvw Compliance Date End: Standard # Admn Rvw Compliance N Weight TA Finding High Deficiency Admn Rvw Upheld -Monthly case manager conference notes were not available for Licensing to review. -Monthly shift supervisor meeting notes were not available for Licensing to review. Category Short Description Standard # Weight Organization and Administration Permit holder responsibilities-Maintain true, current, accurate, and 748.103(a)(3) complete records at operation for Licensing's review Medium Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Page 3 of 187 Deficiency Admn Rvw Upheld Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Narrative: 8 out of the 12 children's records were not maintained at the operation for Licensing to review. Activity Type: Inspection Id Date Begin: Other Inspection 2641565 12/28/2010 10:20:00 Category Short Description Date End: Warning Letter/Due Notice given 12/28/2010 12:02:00 Standard # Actions - TAC 745 Meeting Requirement of Corrective Action 745.8633 Narrative: -A master log documenting random unannounced visits to the housing units was not available for Licensing to review. N Weight TA Finding High Deficiency Admn Rvw Upheld -Monthly case manager conference notes were not available for Licensing to review. -Monthly shift supervisor meeting notes were not available for Licensing to review. Activity Type: Inspection Id Date Begin: Other Inspection 2640037 12/22/2010 02:48:00 Date End: Warning Letter/Due Notice given 12/22/2010 04:47:00 N Category Short Description Standard # Weight Actions - TAC 745 Narrative: Meeting Requirement of Corrective Action 745.8633 High TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Other Inspection 2628364 12/12/2010 03:05:00 12/12/2010 04:16:00 N Category Standard # Weight Actions - TAC 745 Meeting Requirement of Corrective Action Narrative: The conditions of Probation were evaluated and were found to be compliant. Short Description 745.8633 High Category Standard # Weight Permit holder responsibilities-Maintain true, current, accurate, and 748.103(a)(3) complete records at operation for Licensing's review Narrative: 1 out of the 3 children's records requested was not available for Licensing to review. Medium Short Description Organization and Administration Activity Type: Inspection Id Note: Prior to January 1, 2007, all Standards were not associated with a weight. Date Begin: TA Finding Admn Rvw Compliance TA Finding Date End: Deficiency Admn Rvw Upheld Warning Letter/Due Notice given Page 4 of 187 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Investigation Inspection 2615644 12/02/2010 11:30:00 Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 1394335 12/02/2010 09:00:00 N Category Short Description 12/02/2010 12:02:00 Standard # Children's Rights N Weight Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: This standard was evaluated and found to be in compliance. High Category Standard # Weight 748.685(a)(4) High Short Description Personnel Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being Narrative: This standard was evaluated and found to be in compliance. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Other Inspection 2612990 11/29/2010 04:30:00 11/29/2010 06:35:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Other Inspection 2593025 11/10/2010 11:30:00 12/10/2010 03:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2588724 11/08/2010 03:08:00 11/08/2010 07:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 1372096 11/06/2010 10:30:00 Category Short Description Warning Letter/Due Notice given N Standard # Emergency Behavior Intervention Weight EBI Implementation-Caregiver must use the minimal amount of 748.2551(c)(2) reasonable and necessary physical force Narrative: The operation staff failed to use the minimal amount of necessary force when implementing the emergency behavior intervention. High Category Weight Short Description Standard # Emergency Behavior Intervention EBI Release-Child released from personal restraint immediately in 748.2553(2)(A) emergency health situation and treatment obtained immediately Narrative: Operation staff failed to release a child from a personal restraint immediately when an emergency health situation arose. High Category Weight Short Description Note: Prior to January 1, 2007, all Standards were not associated with a weight. Standard # TA Finding Deficiency TA Finding Deficiency TA Finding Page 5 of 187 Admn Rvw Waived Admn Rvw Waived Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Emergency Behavior Intervention Not Available: 4 Personal Restraint Monitor-Qualified caregiver monitors child for 748.2601(a) signs of physical distress & ensures ample respiration, circulation, well-being Narrative: The operation staff failed to monitor a child for signs of physical distress and failed to ensure ample respiration and circulation. High Category Short Description Standard # Weight Personal Restraints Prohibited-Restraints that interfere with the child's ability to communicate or vocalize distress Narrative: The operation staff implemeted a restraint which interfered with a child's ability to vocalize distress. 748.2605(a)(4) High Category Standard # Weight Emergency Behavior Intervention Short Description Deficiency TA Finding Deficiency TA Finding Emergency Behavior Intervention Emergency Behavior Intervention-Basis for EBI is an emergency 748.2455(a)(2) Medium situation or to administer medication High Narrative: Caregiver did not adequately determine there was an emergency situation which warranted the use of emergency behavior intervention. Category Short Description Standard # Emergency Behavior Intervention Weight EBI Implementation-Must be an appropriate response to the 748.2551(a) behavior demonstrated, and de-escalation must have failed Narrative: The operation staff did not adequately make de-escalation attempts prior to initiating an emergency behavior intervention. Medium High Category Short Description Standard # Weight EBI Implementation-Caregiver must minimize risk of physical discomfort, harm, or pain to the child Narrative: The operation staff failed to implement a restraint that minimized the risk of harm to the child. 748.2551(c)(1) High Category Standard # Weight Emergency Behavior Intervention Short Description Deficiency TA Finding Deficiency TA Finding Deficiency TA Finding Emergency Behavior Intervention Personal Restraints Prohibited-Restraints that obstruct child's airway748.2605(a)(2) High Narrative: Restraints that obstruct the child's airway are prohibited. The operation staff implemented a restraint in which a child's airway was prohibited. Category Short Description Standard # Children's Rights Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: This standard was found to be deficient because the child was abused and neglected. Activity Type: Inspection Id Note: Prior to January 1, 2007, all Standards were not associated with a weight. Date Begin: Weight Deficiency TA Finding High Date End: Deficiency Waived Admn Rvw Waived Admn Rvw Waived Admn Rvw Waived Admn Rvw Waived Admn Rvw Waived Admn Rvw Waived Warning Letter/Due Notice given Page 6 of 187 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Investigation Inspection 2587146 11/06/2010 10:30:00 11/06/2010 02:15:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2584484 11/04/2010 03:18:00 11/04/2010 04:47:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 1367296 11/04/2010 12:00:00 N Category Short Description Standard # Weight Medical care-A child in care must receive medical care as needed for injury, illness, and pain Narrative: The standard was evaluted and was found to be compliant. 748.1531(a)(2) High Category Child Care Short Description Standard # Weight Short Personal Restraint-Caregiver must use minimal amount of reasonable and necessary physical force Narrative: The standard was evaluted and was found to be compliant. 748.2461(a)(2) High Category Standard # Weight Emergency Behavior Intervention Short Description Emergency Behavior Intervention EBI Documentation-Must include child's condition following EBI, 748.2855(a)(10) including any injury child sustained or any adverse effects caused by use of EBI Narrative: The standard was evaluted and was found to be compliant. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Medium Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Other Inspection 2508103 10/25/2010 03:45:00 10/25/2010 05:47:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2565066 10/19/2010 09:00:00 10/19/2010 11:40:49 N Category Short Description Standard # Weight Abuse/Neglect Definitions - TAC 745 Narrative: Omission 745.8555(c) High TA Finding Admn Rvw Pending Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2552684 10/16/2010 09:23:00 10/16/2010 10:44:00 N Note: Prior to January 1, 2007, all Standards were not associated with a weight. Page 7 of 187 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Activity Type: Investigation Number Date Intake Rcvd: Investigation 1346715 10/16/2010 12:00:00 Category Run date: July 17, 2018 Compliance History Report Short Description Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Warning Letter/Due Notice given N Standard # Personnel Weight Caregiver responsibility - being able to intervene when necessary to 748.685(a)(5) ensure child's safety Narrative: The standard was evaluated and was found to be in compliance. High Category Standard # Weight 748.303(a)(2)(A) Medium High Short Description Reports and Record Keeping Serious Incident-Report to Licensing no later than 24 hours after injury/illness that warrants treatment by a medical professional or hospitalization Narrative: The standard was evaluated and was found to be in compliance. Activity Type: Investigation Number Date Intake Rcvd: Investigation 1347216 10/15/2010 03:00:00 Category Short Description Admn Rvw Compliance TA Finding Admn Rvw Compliance Warning Letter/Due Notice given N Standard # Children's Rights Weight Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: The standard evaluated was found to be in compliance. High Category Standard # Weight Permit holder responsibilities-Operate according to the written 748.103(a)(2) policies and procedures adopted by the governing body, as directed by this chapter Narrative: The standard evaluated was found to be in compliance. Medium Short Description TA Finding Organization and Administration TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2545027 10/12/2010 02:41:00 10/12/2010 05:33:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 1332956 10/12/2010 12:00:00 Category Short Description Note: Prior to January 1, 2007, all Standards were not associated with a weight. Warning Letter/Due Notice given N Standard # Weight TA Finding Page 8 of 187 Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Children's Rights Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Children's rights-Adhere to the child's rights to be free from being 748.1101(b)(5)(F) subjected to remarks that belittle or ridicule the child or the child's family Narrative: The standard was evaluated and was found to be compliant. Medium High Category Standard # Weight 748.683(1) Medium Short Description Personnel Caregiver Supervision-Provide oversight of caregivers to protect children's health, safety and well-being Narrative: The standard was evaluated and was found to be compliant. Compliance TA Finding Admn Rvw Compliance Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 1338419 10/12/2010 12:00:00 N Category Short Description Standard # Reports and Record Keeping Weight Serious Incident-Report to Licensing as soon as aware of 748.303(a)(3)(A) allegations or indications of abuse, neglect, or exploitation of a child Narrative: Additional information is needed to determine compliance. Case is being re-assigned to the A/N investigation unit. Medium High Category Weight Short Description Standard # Personnel Caregiver Supervision-Provide oversight of caregivers to protect 748.683(1) children's health, safety and well-being Narrative: Additional information is needed to determine compliance. Case is being re-assigned to the A/N investigation unit. Medium Category Weight Short Description Standard # Children's Rights Children's rights-Adhere to the child's right to have a humane 748.1101(b)(8) environment, including any treatment environment, which provides protection from harm Narrative: Additional information is needed to determine compliance. Case is being re-assigned to the A/N investigation unit. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding High Admn Rvw Compliance Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 1338478 10/12/2010 12:00:00 N Category Short Description Emergency Behavior Intervention Standard # Short Personal Restraint-Caregiver may not use restraint that twists 748.2461(b)(6) or places the child's limb(s) behind the child's back Narrative: The standard was evauated and was found to be compliant. Note: Prior to January 1, 2007, all Standards were not associated with a weight. Weight TA Finding High Page 9 of 187 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Category Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Short Description Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Standard # Weight Caregiver Supervision-Provide oversight of caregivers to protect children's health, safety and well-being Narrative: The standard was evauated and was found to be compliant. 748.683(1) Medium Category Standard # Weight Personnel Short Description Training and Professional Development Annual Training-Every 6 months a caregiver must complete at least 748.931(a)(1)(B) 4 hours of training in EBI Narrative: The standard was evauated and was found to be compliant. Medium High Category Weight Short Description Standard # Emergency Behavior Intervention EBI Documentation-Must include the specific emergency behavior 748.2855(a)(4) intervention administered Narrative: The standard was evaluated and was found to be compliant. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Medium Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2545405 10/05/2010 10:30:00 10/05/2010 11:41:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2539105 09/30/2010 11:00:00 09/30/2010 12:37:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 1329376 09/30/2010 09:00:00 N Category Short Description Standard # Emergency Behavior Intervention Weight Short Personal Restraint-Caregiver must minimize risk of physical 748.2461(a)(1) discomfort, harm, or pain to child Narrative: This standard was evaluated and found to be in compliance. High Category Short Description Standard # Weight Short Personal Restraint-Caregiver may not use restraint that obstructs child's airways or impairs child's breathing Narrative: This standard was evaluated and found to be in compliance. 748.2461(b)(3) High Category Standard # Weight Emergency Behavior Intervention Short Description Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Page 10 of 187 Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Children's Rights Not Available: 4 Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: This standard was evaluated and found to be in compliance. High Category Short Description Standard # Weight Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks Narrative: This standard was evaluated and found to be in compliance. 748.507(1) Medium High Category Standard # Weight Personnel Short Description Emergency Behavior Intervention EBI Documentation-If personal restraint, must include specific 748.2855(c) restraint techniques used, including prone/supine restraint used as transitional hold Narrative: Operation staff failed to document "touch control", which restricted the free movement of the child's arm, as a personal restraint. Compliance TA Finding Admn Rvw Compliance TA Finding Medium Deficiency Admn Rvw Waived Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2529210 09/27/2010 03:32:00 09/27/2010 04:24:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 1318777 09/27/2010 12:00:00 N Category Short Description Standard # Weight Medical care-A child in care must receive medical care as needed for injury, illness, and pain Narrative: The standard was evaluated and was found to be compliant. 748.1531(a)(2) High Category Child Care Short Description Standard # Weight Caregiver Supervision-Provide oversight of caregivers to protect children's health, safety and well-being Narrative: The standard was evaluated and was found to be compliant. 748.683(1) Medium Category Standard # Weight 748.303(a)(2)(A) Medium High Personnel Short Description Reports and Record Keeping Serious Incident-Report to Licensing no later than 24 hours after injury/illness that warrants treatment by a medical professional or hospitalization Narrative: The standard was evaluated and was found to be compliant. Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Page 11 of 187 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 1321807 09/20/2010 11:10:00 N Category Short Description Standard # Children's Rights Weight Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: This standard was evaluated and found to be in compliance. High Category Standard # Weight 748.507(1) Medium High Short Description Personnel Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks Narrative: This standard was evaluated and found to be in compliance. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Other Inspection 2523113 09/14/2010 09:30:00 09/14/2010 03:08:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Other Inspection 2523153 09/14/2010 08:45:00 09/14/2010 09:15:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 1292495 08/26/2010 12:00:00 Category Short Description Warning Letter/Due Notice given N Standard # Weight Caregiver Supervision-Provide oversight of caregivers to protect children's health, safety and well-being Narrative: This standard was evaluated and found to be in compliance. 748.683(1) Medium Category Standard # Weight 748.303(a)(2)(A) Medium Personnel Short Description Reports and Record Keeping Serious Incident-Report to Licensing no later than 24 hours after injury/illness that warrants treatment by a medical professional or hospitalization Narrative: This standard was evaluated and found to be in compliance. Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Admn Rvw Compliance TA Finding Page 12 of 187 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2498263 08/25/2010 12:30:00 08/25/2010 03:31:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2462123 08/05/2010 09:57:00 08/05/2010 11:38:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2458024 08/02/2010 09:41:00 08/02/2010 12:31:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2455463 07/30/2010 12:00:00 07/30/2010 04:36:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 1256376 07/30/2010 12:00:00 Category Short Description Warning Letter/Due Notice given N Standard # Weight Emergency Behavior Intervention-Basis for EBI is emergency situation, to administer medication, or property damage (short personal restraint only) Narrative: An emergency medication was administered to a child in non-emergency situation. 748.2455(2) Medium Category Short Description Standard # Weight Medication Administration of Medication-Ensure a child is not physically forced to take prescription medication 748.2003(b)(8) Medium High Short Description Emergency Behavior Intervention TA Finding Deficiency TA Finding Admn Rvw Waived Admn Rvw Compliance Narrative: Technical assistance given. Category Standard # Weight Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being Narrative: This standard was evaluated and found to be in compliance. 748.685(a)(4) High Category Standard # Weight Personnel Short Description Physical Site Bedroom Space-A child may share a bedroom with an adult if the 748.3361(b)(2) child is under three years old and sleeps in the bedroom of the caregiver Narrative: Caregivers are sleeping in the bedrooms of children in care. The children are not under the age of three years. TA Finding TA Finding Medium Corrected at inspection. Note: Prior to January 1, 2007, all Standards were not associated with a weight. Admn Rvw Compliance Page 13 of 187 Deficiency Admn Rvw Waived Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 1252995 07/29/2010 12:57:00 N Category Short Description Standard # Weight Children's rights-Adhere to the child's rights to be free from any harsh, cruel, unusual, unnecessary, demeaning, or humiliating punishment Narrative: Standard was evaluated and found to be in compliance. 748.1101(b)(5) High Category Standard # Weight Children's Rights Short Description Discipline and Punishment Corporal Punishment-May not use/threaten corporal punishment, 748.2303(a) such as hitting/spanking, forced exercise, holding physical position, unproductive work. Narrative: Standard was evaluated and found to be in compliance. Medium High Category Weight Short Description Standard # Children's Rights Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: Standard was evaluated and found to be in compliance. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding High Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2451223 07/28/2010 01:00:00 07/28/2010 04:02:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 1246855 07/23/2010 10:15:00 Category Short Description Warning Letter/Due Notice given N Standard # Weight Conflict of interest policies-Code of conduct on the relationship between employees/contractors/children/families Narrative: This minimum standard was evaluated and found to be in compliance. 748.107 Medium Category Standard # Weight Organization and Administration Short Description Children's Rights Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: This minimum standard was evaluated and found to be in compliance. Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Admn Rvw Compliance TA Finding High Page 14 of 187 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Category Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Short Description Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Standard # Weight Children's rights-Adhere to the child's right to be compensated for any work done for the operation as part of the child's service plan Narrative: This minimum standard was evaluated and found to be in compliance. 748.1101(b)(18) Medium Low Category Children's Rights Short Description Standard # Weight Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being Narrative: This minimum standard was evaluated and found to be in compliance. 748.685(a)(4) High Category Standard # Weight 748.1101(b)(18) Medium Low Personnel Short Description Children's Rights Children's rights-Adhere to the child's right to be compensated for any work done for the operation as part of the child's service plan Narrative: This minimum standard was evaluated and found to be in compliance. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2443763 07/23/2010 10:15:00 07/23/2010 02:24:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Other Inspection 2433787 07/20/2010 09:00:00 Category Short Description 07/20/2010 04:45:00 Standard # Admission, Service Planning, Discharge N Weight Initial Service Plan-Service planning team must include at least one 748.1339(a)(1) of the child's current caregivers Narrative: There was no documentation to verify that caregivers are participating in the service planning team meetings. Low Category Weight Short Description Standard # Admission, Service Planning, Discharge Initial Service Plan-Child, as appropriate, and parents must be 748.1339(c) invited to the meeting to develop the service plan Narrative: There was no documentation to verify that children are participating in the service planning team meetings. Low Category Short Description Standard # Weight Admission, Service Planning, Discharge Service Plan Review-Must document reasons for continued placement if review shows no progress towards meeting identified needs 748.1385(4) Medium Low Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Deficiency TA Finding Deficiency TA Finding Page 15 of 187 Deficiency Admn Rvw Waived Admn Rvw Waived Admn Rvw Upheld Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Narrative: There was no documentation in the Service Plan Review regarding the decision to continue placement for children that are showing no progress towards meeting identified needs. Category Short Description Standard # Medication Weight Medication Record-Must include date (day, month, year) & time 748.2151(a)(4) each medication was administered Narrative: The medication logs evaluated did not include the date and time that medications were administered to children. Medium High Category Weight Short Description Standard # Medication Medication Record-Must include name & signature of person who 748.2151(a)(5) administered each medication Narrative: The medication logs reviewed did not have the name of the persons that administered the medications. Medium Category Short Description Standard # Weight Medication Record-Must include accurate running count of each prescribed medication Narrative: The running count listed on the medication logs reviewed were not accurate. 748.2151(a)(8) High Category Medication Short Description Standard # Weight Evaluation-Results of each overall annual evaluation made available to Licensing for review. Narrative: There was no annual evaluation report available for Licensing to review. 748.2951(d) Medium Low Category Standard # Weight Emergency Behavior Intervention Short Description TA Finding Deficiency TA Finding Deficiency TA Finding Deficiency TA Finding Deficiency TA Finding Admn Rvw Upheld Admn Rvw Upheld Admn Rvw Upheld Admn Rvw Waived Admn Rvw Training and Professional Development Annual Training-Caregiver that administers psychotropic 748.945 Medium Deficiency Upheld medication must receive annual training that includes same training requirements in 748.885 Narrative: During the evaluation of 6 personnel records it was noted on the training record that 2 employees did not complete their annual psychotropic medication training within the required time frame. Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 1236915 07/16/2010 04:00:00 N Category Short Description Personnel Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being Narrative: This standard was evaluated and the facility was found to be in compliance. Note: Prior to January 1, 2007, all Standards were not associated with a weight. Standard # Weight 748.685(a)(4) High TA Finding Page 16 of 187 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Category Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Short Description Weight: Id/Number: Admin Review Status: Low: 6 Standard # Children's Rights Not Available: 4 Weight Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: This standard was evaluated and the facility was found to be in compliance. High Category Weight Short Description Standard # Discipline and Punishment Corporal Punishment-May not use/threaten corporal punishment, 748.2303(a) such as hitting/spanking, forced exercise, holding physical position, unproductive work. Narrative: This standard was evaluated and the facility was found to be in compliance. Medium High Category Standard # Weight 748.2307(4) Medium High Short Description Discipline and Punishment Other Prohibited Punishments-using sarcastic or cruel humor, and verbal abuse Narrative: This standard was evaluated and the facility was found to be in compliance. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2430563 07/16/2010 04:00:00 07/16/2010 06:28:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Follow-up Inspection 2429723 07/16/2010 10:25:00 Category Short Description Background Checks - TAC 745 Background checks submitted - Every 24 months after each person's background check was first submitted Narrative: Follow-Up: It was determined that compliance with the standard has been met. 07/16/2010 05:30:00 N Standard # Weight 745.625(7) High TA Finding Admn Rvw Compliance Five employee background checks were not submitted within the required time frame. These background checks were submitted late but were cleared. Category Short Description Standard # Weight TA Finding Children's Rights Informing child of rights-Review rights with child/parents within 7 748.1103(a) Medium Compliance days of child's admission; provide child/parents with written copy Low of rights Narrative: Follow-Up: The operation has developed a procedure to ensure that all required documents are completed at admission and maintained in the child's record. Two children's records did not have documentation child's rights were reviewed with child. Note: Prior to January 1, 2007, all Standards were not associated with a weight. Page 17 of 187 Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Category Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Short Description Standard # Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Weight TA Finding Admn Rvw Medication Administration of Medication-Ensure the child has taken the 748.2003(b)(5) Medium Deficiency Waived medication as prescribed High Narrative: Follow-Up: At the time of the inspection a review of medication logs was complete and there still were problems identified with the running count. The operation has identified the problem that led to the citation; however new procedures have not been implemented yet. Bahler - The running count was accurate for 6/15/10. There was no evidence resident received medication on 6/16/10 at 7:45 am as prescribed. The log was not initialed by staff and resident, and the running count had not changed to reflect medication was administered on 6/16/10. Category Short Description Standard # Weight TA Finding Admn Rvw Medication Medication Storage & Destruction-Remove discontinued 748.2101(7) Medium Compliance medication immediately & destroy it in a way that ensures children High do not have access to it Narrative: Follow-Up: It was determined that compliance with the standard has been met. Procedures are in place to ensure that expired medications and/or medications of children that have discharged from the program are removed from the house and returned to the pharmacy. Curry I - Child in care had clindamycin GE1% prescribed on 11/12/09 to take for 3 months. Medication was still being stored with their current medications and should have been removed in 02/10. Category Short Description Medication Medication Storage & Destruction-Remove medication on/before the expiration date & destroy it in a way that ensures children do not have access Narrative: Follow-Up: It was determined that compliance with the standard has been met. Standard # Weight 748.2101(8) Medium High Standard # Weight 748.2101(9) Medium High TA Finding Admn Rvw Compliance Bedynek - Expired over the counter medication - Swim Ear - Expired March 2010. Humphrey I - Two bottles of Ipecac - Expired March 2010. Category Short Description Medication Medication Storage & Destruction-Remove medication of discharged/deceased child immediately & destroy in way that ensures children do not have access Narrative: Follow-Up: It was determined that compliance with the standard has been met. TA Finding Admn Rvw Compliance Bickerstaff I - Medication for discharged resident was stored in medication closet. Staff confirmed resident was discharged about 6 days ago. List of residents provided shows resident being discharged as Note: Prior to January 1, 2007, all Standards were not associated with a weight. Page 18 of 187 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 of 6/4/2010. Category Short Description Medication Medication Record-Must include date (day, month, year) & time each medication was administered Narrative: Follow-Up: It was determined that compliance with the standard has been met. Standard # Weight 748.2151(a)(4) Medium High TA Finding Deficiency Admn Rvw Waived Draeger II - Medication given at school was not documented in medication log. All other medication given at school is documented on log along with medication administered at facility. Bahler - In one record there was no documentation for medication administered on 6/15/10. Inspection completed on 6/16/10. Category Short Description Standard # Medication Medication Record-Must include name & signature of person who 748.2151(a)(5) administered each medication Narrative: Follow-Up: It was determined that compliance with the standard has been met. Weight TA Finding Medium Admn Rvw Compliance Red House - Staff initialed all doses for 6/15/10 on medication log when not all doses had been administered and staff initialed the first dose for 6/16/10. Humphrey I - In one record on 6/14/10 there were no initials documented on log that medication was administered. Category Short Description Standard # Weight TA Finding Medication Admn Rvw Medication Record-Must include accurate running count of each 748.2151(a)(8) High Deficiency Waived prescribed medication Narrative: Follow-Up: Medication logs were checked and all medications were accounted for; however in, Drager II and Humphrey I the running count was off. The log discrepancies were corrected at inspection to reflect the correct count. Curry I - In four separate medication records, the running count listed did not match the actual number of pills in package. Draeger II - In one record the running count listed did not match the actual number of pills in package. Bickerstaff I - In two records the running count listed did not match the actual number of pills in package. Mustang - In five records the running count listed did not match the actual number of pills in package. Red House - In one record the running count listed did not match the actual number of pills in package. Note: Prior to January 1, 2007, all Standards were not associated with a weight. Page 19 of 187 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Patterson - In one record the running count listed did not match the actual number of pills in package. Bahler - In five records the running count listed did not match the actual number of pills in package. Humphrey I - In one record the running count listed did not match the actual number of pills in package. Category Short Description Standard # Physical Site Bedding-Must provide each child with a mattress cover or protector 748.3365(a)(3) or mattress that is waterproof or washable Narrative: Follow-Up: It was determined that compliance with the standard has been met. Weight TA Finding Medium Admn Rvw Compliance Patterson - 3 beds in occupied bedrooms on the 2nd floor did not have mattress covers or protectors. Category Short Description Standard # Weight TA Finding Physical Site Swimming Pool-Pool chemicals & pumps must be inaccessible to 748.3601(4) High children Narrative: Follow-up: A new 6 Ft wooden fence has been installed to prevent children from having access to pool chemicals and the pool filter pump. Admn Rvw Compliance Curry I - There is a wooden fence approximately 4' around the filter and pool chemicals. The fence is broken in one corner and held together with a piece of wire. Various pool chemicals had stored in this area and accessible to children. Activity Type: Investigation Number Date Intake Rcvd: Investigation 1231135 07/14/2010 09:00:00 Category Short Description Warning Letter/Due Notice given N Standard # Children's Rights Weight Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: This standard was evaluated and the facility was found to be in compliance. High Category Standard # Weight 748.685(a)(4) High Short Description Personnel Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being Narrative: This standard was evaluated and the facility was found to be in compliance. Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Admn Rvw Compliance TA Finding Page 20 of 187 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2424043 07/14/2010 09:00:00 07/14/2010 11:31:00 N Category Short Description Standard # Physical Site Bedding-Must provide each child with a mattress cover or protector 748.3365(a)(3) or mattress that is waterproof or washable Narrative: The mattresses used by the residents did not have mattress covers. Weight TA Finding Medium Deficiency Admn Rvw Waived Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2418343 07/09/2010 03:00:00 07/09/2010 05:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 1227815 07/09/2010 12:00:00 Category Short Description Warning Letter/Due Notice given N Standard # Weight Children's rights-Adhere to the child's right to not receive unnecessary or excessive medication Narrative: The standard was evaluated and was found to be in compliance. 748.1101(b)(24) Medium High Category Children's Rights Short Description Standard # Weight Administration of Medication-Ensure a child is not physically forced to take prescription medication Narrative: The standard was evaluated and was found to be in compliance. 748.2003(b)(8) Medium High Category Standard # Weight 748.2261(a) Medium High Medication Short Description Medication Operation employs professional who prescribes psychotropic meds-Professional evaluates & documents child's response to the medication quarterly Narrative: The standard was evaluated and was found to be in compliance. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2408083 07/03/2010 09:15:00 07/03/2010 12:10:00 N Activity Type: Investigation Number Date Intake Rcvd: Note: Prior to January 1, 2007, all Standards were not associated with a weight. Warning Letter/Due Notice given Page 21 of 187 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Investigation Medium: 139 1214715 Category Run date: July 17, 2018 Compliance History Report Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 07/03/2010 12:00:00 Short Description N Standard # Weight Children's rights-Adhere to the child's rights to be free from any harsh, cruel, unusual, unnecessary, demeaning, or humiliating punishment Narrative: The standard was evaluated and was found to be in compliance. 748.1101(b)(5) High Category Children's Rights Short Description Standard # Weight Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks Narrative: The standard was evaluated and was found to be in compliance. 748.507(1) Medium High Category Standard # Weight 748.2307(9) Medium High Personnel Short Description Discipline and Punishment Other Prohibited Punishments-subjecting a child to abusive or profane language Narrative: The standard was evaluated and was found to be in compliance. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2402343 06/29/2010 02:15:00 06/29/2010 03:10:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Monitoring Inspection 2398985 06/26/2010 12:00:00 06/26/2010 01:50:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Other Inspection 2397123 06/24/2010 07:30:00 06/24/2010 07:51:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Other Inspection 2396043 06/24/2010 01:00:00 06/24/2010 02:15:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Other Inspection 2389572 06/21/2010 03:45:00 06/21/2010 05:15:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Monitoring Inspection 2386004 06/19/2010 11:00:00 06/19/2010 02:05:00 N Category Short Description Note: Prior to January 1, 2007, all Standards were not associated with a weight. Standard # Weight TA Finding Page 22 of 187 Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Safety and Emergency Practices First Aid Kits-Each one must contain adhesive tape 748.3273(2) Category Short Description Standard # Not Available: 4 Medium Low Narrative: This standard was evaluated and technical assistance was provided. Complete first aid kits are readily available in near by homes if needed. Weight Compliance TA Finding Safety and Emergency Practices First Aid Kits-Each one must contain scissors 748.3273(6) Low Narrative: This standard was evaluated and technical assistance was provided. Complete first aid kits are readily available in near by homes if needed. Category Short Description Standard # Weight Admn Rvw Compliance TA Finding Admn Rvw Physical Site Food Preparation-Must have a thermometer in refrigerators & store 748.3443(b)(1) Medium Compliance refrigerated food at 40 degrees Fahrenheit or below Narrative: This standard was evaluated and technical assistance was provided. The refrigerator was above the required degree, but the food did not appear effected by the temperature. Category Short Description Standard # Weight TA Finding Admn Rvw Physical Site Food Preparation-Must have a thermometer in freezers & store 748.3443(b)(2) Medium Compliance frozen food at 0 degrees Fahrenheit or below Narrative: This standard was evaluated and technical assistance was provided. The freezer was above the required degree, but the food did not appear effected by the temperature. Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2387323 06/18/2010 09:15:00 06/18/2010 11:30:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2516263 06/17/2010 04:03:00 06/17/2010 05:45:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2384643 06/17/2010 12:30:00 06/17/2010 04:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2384543 06/17/2010 12:00:00 06/17/2010 02:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2382665 06/16/2010 09:27:00 06/16/2010 03:29:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 1194715 06/15/2010 02:30:00 N Category Short Description Note: Prior to January 1, 2007, all Standards were not associated with a weight. Standard # Weight TA Finding Page 23 of 187 Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Child Care Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Medical care-A child in care must receive medical care as needed for injury, illness, and pain Narrative: This minimum standard was evaluated and found to be in compliance. 748.1531(a)(2) High Category Standard # Weight Short Description Children's Rights Children's rights-Adhere to the child's right to have adequate 748.1101(b)(12) personal clothing, suitable to his age and size and comparable with peers Narrative: This minimum standard was evaluated and found to be in compliance. Medium Category Short Description Standard # Weight Recreation responsibility-Child receiving treatment services-caregiver must ensure the child has opportunities to participate in community activity Narrative: This minimum standard was evaluated and found to be in compliance. 748.3701(e)(2)(A) Medium Low Category Standard # Weight Recreation Activities Short Description Children's Rights Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: This minimum standard was evaluated and found to be in compliance. Activity Type: Investigation Number Date Intake Rcvd: Investigation 1194335 06/15/2010 01:00:00 Category Short Description TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding High Admn Rvw Compliance Warning Letter/Due Notice given N Standard # Admission, Service Planning, Discharge Weight Placement agreement-Must include the reason for placement & 748.1207(3) anticipated length of time in care Narrative: The placement agreement did not include the reason for a child's placement or the child's anticipated length of time in care. Low Category Weight Short Description Compliance Standard # TA Finding Deficiency TA Finding Admn Rvw Waived Admn Rvw Emergency Behavior Intervention EBI Documentation-Must include the length of time the child was 748.2855(a)(7) Medium Deficiency Waived restrained or secluded Low Narrative: The individual lengths of time for three separate emergency behavioral interventions were documented on one restraint report with the beginning time being the time the first restraint was initiated and the ending time documented as the time the third restraint concluded. Category Short Description Note: Prior to January 1, 2007, all Standards were not associated with a weight. Standard # Weight TA Finding Page 24 of 187 Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Emergency Behavior Intervention Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 EBI Implementation-Caregiver must use the minimal amount of reasonable and necessary physical force Narrative: This minimum standard was evaluated and found to be in compliance. 748.2551(c)(2) Medium High Category Short Description Standard # Weight Disciplinary Measures-must not be physically or emotionally damaging to the child Narrative: This minimum standard was evaluated and found to be in compliance. 748.2301(b)(2) Medium High Category Standard # Weight Discipline and Punishment Short Description Children's Rights Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: This minimum standard was evaluated and found to be in compliance. High Category Weight Short Description Standard # Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Emergency Behavior Intervention Admn Rvw EBI Documentation-Must include the duration of the emergency 748.2855(a)(10) Low Deficiency behavior intervention Narrative: The documented duration of a series of emergency behavior interventions did not include the duration for each of the separate emergency behavioral interventions. Waived Category Admn Rvw Short Description Standard # Weight TA Finding Emergency Behavior Intervention EBI Documentation-Must include the date and time the intervention 748.2855(a)(6) Low was administered Narrative: The individual times of two out of three emergency behavioral interventions were not documented to include the date and time of the interventions. Category Short Description Child Care Medical care-A child in care must receive medical care as needed for injury, illness, and pain Narrative: This minimum standard was evaluated and found to be in compliance. Standard # Weight 748.1531(a)(2) High Deficiency TA Finding Waived Admn Rvw Compliance Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 1194376 06/15/2010 12:53:00 N Category Short Description Emergency Behavior Intervention Standard # Short Personal Restraint-Caregiver must minimize risk of physical 748.2461(a)(1) discomfort, harm, or pain to child Narrative: Standard evaluated and found to be in compliance. Note: Prior to January 1, 2007, all Standards were not associated with a weight. Weight TA Finding Medium High Page 25 of 187 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Category Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Short Description Weight: Id/Number: Admin Review Status: Low: 6 Standard # Children's Rights Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: Standard evaluated and found to be in compliance. Not Available: 4 Weight TA Finding High Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2420985 06/15/2010 12:53:00 06/15/2010 02:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 1195095 06/15/2010 12:00:00 Category Short Description Warning Letter/Due Notice given N Standard # Children's Rights Weight Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: Standard evaluated and found to be in compliance. High Category Weight Short Description Standard # Emergency Behavior Intervention Short Personal Restraint-Caregiver must minimize risk of physical 748.2461(a)(1) discomfort, harm, or pain to child Narrative: Standard evaluated and found to be in compliance. TA Finding Admn Rvw Compliance TA Finding Medium High Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2379384 06/15/2010 12:00:00 06/15/2010 05:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 1194396 06/15/2010 11:30:00 Category Short Description Warning Letter/Due Notice given N Standard # Weight Short Personal Restraint-Caregiver may not use restraint that obstructs child's airways or impairs child's breathing Narrative: This standard was evaluated and the facility was found to be in compliance. 748.2461(b)(3) High Category Short Description Standard # Weight Children's Rights Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Emergency Behavior Intervention Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Admn Rvw Compliance TA Finding High Page 26 of 187 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Narrative: This standard was evaluated and the facility was found to be in compliance. Category Short Description Standard # Child Care Weight Nutrition-Provide food of adequate variety, quality, and in sufficient 748.1693(a)(1) quantity to supply the nutrients needed for proper growth and development Narrative: This standard was evaluated and the facility was found to be in compliance. Medium High Category Short Description Standard # Weight Disciplinary Measures-must be consistent with operation policies and procedures Narrative: The loss of scheduled snacks were being used as a disciplinary measure. 748.2301(b)(1) Medium Low Category Discipline and Punishment Short Description Standard # Weight Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being Narrative: This standard was evaluated and the facility was found to be in compliance. 748.685(a)(4) High Category Standard # Weight 748.3701(e)(2)(A) Medium Low Personnel Short Description Recreation Activities Recreation responsibility-Child receiving treatment services-caregiver must ensure the child has opportunities to participate in community activity Narrative: There was no evidence that children were being offered the opportunity to attend religious activities. TA Finding Admn Rvw Compliance TA Finding Deficiency TA Finding Admn Rvw Waived Admn Rvw Compliance TA Finding Deficiency Admn Rvw Waived Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2379283 06/15/2010 11:30:00 06/15/2010 03:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 1193858 06/15/2010 11:15:00 Category Short Description Warning Letter/Due Notice given N Standard # Weight Emergency Behavior Intervention Personal Restraints Prohibited-Restraints that obstruct child's airway748.2605(a)(2) Narrative: Standard evaluated and found to be in compliance. High Category Weight Short Description Note: Prior to January 1, 2007, all Standards were not associated with a weight. Standard # TA Finding Admn Rvw Compliance TA Finding Page 27 of 187 Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Personnel Employee general responsibilities-Demonstrate competency, 748.507(1) Medium Deficiency Waived prudent judgment, self-control in presence of children and when High performing assigned tasks Narrative: Staff person removed the child's plate from the table, then moved the bench in which the child was sitting on, which escalated the child's behavior leading to a restraint. Category Short Description Standard # Children's Rights Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: Standard evaluated and found to be in compliance. Weight TA Finding High Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2379364 06/15/2010 11:15:00 06/15/2010 03:30:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2379303 06/15/2010 09:00:00 06/15/2010 02:50:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Monitoring Inspection 2378144 06/15/2010 07:00:00 Category Short Description 06/16/2010 02:44:00 Standard # N Weight TA Finding Background Checks - TAC 745 Background checks submitted - Every 24 months after each 745.625(7) High person's background check was first submitted Narrative: Five employee background checks were not submitted within the required time frame. These background checks were submitted late but were cleared. Category Short Description Standard # Children's Rights Weight Informing child of rights-Review rights with child/parents within 7 748.1103(a) days of child's admission; provide child/parents with written copy of rights Narrative: Two children's records did not have documentation child's rights were reviewed with child. Medium Low Category Weight Short Description Standard # Deficiency TA Finding Deficiency TA Finding Admn Rvw Waived Admn Rvw Waived Admn Rvw Medication Administration of Medication-Ensure the child has taken the 748.2003(b)(5) Medium Deficiency Waived medication as prescribed High Narrative: Bahler - The running count was accurate for 6/15/10. There was no evidence resident received medication on 6/16/10 at 7:45 am as prescribed. The log was not initialed by staff and resident, and the running count had not changed to reflect medication was administered on 6/16/10. Category Short Description Note: Prior to January 1, 2007, all Standards were not associated with a weight. Standard # Weight TA Finding Page 28 of 187 Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Medication Medication Storage & Destruction-Remove discontinued 748.2101(7) Medium Deficiency Waived medication immediately & destroy it in a way that ensures children High do not have access to it Narrative: Curry I - Child in care had clindamycin GE1% prescribed on 11/12/09 to take for 3 months. Medication was still being stored with their current medications and should have been removed in 02/10. Category Short Description Medication Medication Storage & Destruction-Remove medication on/before the expiration date & destroy it in a way that ensures children do not have access Narrative: Bedynek - Expired over the counter medication - Swim Ear - Expired March 2010. Standard # Weight 748.2101(8) Medium High Standard # Weight TA Finding Deficiency Admn Rvw Waived Humphrey I - Two bottles of Ipecac - Expired March 2010. Category Short Description TA Finding Admn Rvw Medication Medication Storage & Destruction-Remove medication of 748.2101(9) Medium Deficiency Waived discharged/deceased child immediately & destroy in way that High ensures children do not have access Narrative: Bickerstaff I - Medication for discharged resident was stored in medication closet. Staff confirmed resident was discharged about 6 days ago. List of residents provided shows resident being discharged as of 6/4/2010. Category Short Description Standard # Weight TA Finding Admn Rvw Medication Medication Record-Must include date (day, month, year) & time 748.2151(a)(4) Medium Deficiency Waived each medication was administered High Narrative: Draeger II - Medication given at school was not documented in medication log. All other medication given at school is documented on log along with medication administered at facility. Bahler - In one record there was no documentation for medication administered on 6/15/10. Inspection completed on 6/16/10. Category Short Description Standard # Weight TA Finding Medication Medication Record-Must include name & signature of person who 748.2151(a)(5) Medium Deficiency administered each medication Narrative: Red House - Staff initialed all doses for 6/15/10 on medication log when not all doses had been administered and staff initialed the first dose for 6/16/10. Admn Rvw Waived Humphrey I - In one record on 6/14/10 there were no initials documented on log that medication was administered. Category Short Description Note: Prior to January 1, 2007, all Standards were not associated with a weight. Standard # Weight TA Finding Page 29 of 187 Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Medication Medication Record-Must include accurate running count of each 748.2151(a)(8) prescribed medication Narrative: Curry I - In four separate medication records, the running count listed did not match the actual number of pills in package. Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 High Deficiency Waived Draeger II - In one record the running count listed did not match the actual number of pills in package. Bickerstaff I - In two records the running count listed did not match the actual number of pills in package. Mustang - In five records the running count listed did not match the actual number of pills in package. Red House - In one record the running count listed did not match the actual number of pills in package. Patterson - In one record the running count listed did not match the actual number of pills in package. Bahler - In five records the running count listed did not match the actual number of pills in package. Humphrey I - In one record the running count listed did not match the actual number of pills in package. Category Short Description Standard # Weight TA Finding Safety and Emergency Practices Fire Extinguisher-Company licensed by State Fire Marshal must 748.3117(a) Medium inspect each fire extinguisher at least annually & conduct any service or testing Narrative: This standard was evaluated and technical assistance was provided. There are three other fire extinguishers readily available for use in the home. Category Short Description Standard # Safety and Emergency Practices First Aid Kits-Each one must contain antiseptic solution or wipes 748.3273(3) Category Short Description Standard # Weight TA Finding Medium Low Narrative: This standard was evaluated and technical assistance was provided. Complete first aid kits are readily available in near by homes if needed. Weight Short Description Standard # Weight TA Finding Admn Rvw Compliance TA Finding Safety and Emergency Practices First Aid Kits-Each one must contain tweezers 748.3273(9) Low Narrative: This standard was evaluated and technical assistance was provided. Complete first aid kits are readily available in near by homes if needed. Note: Prior to January 1, 2007, all Standards were not associated with a weight. Admn Rvw Compliance Safety and Emergency Practices First Aid Kits-Each one must contain scissors 748.3273(6) Low Narrative: This standard was evaluated and technical assistance was provided. Complete first aid kits are readily available in near by homes if needed. Category Admn Rvw Compliance Page 30 of 187 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Category Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Short Description Weight: Id/Number: Admin Review Status: Low: 6 Standard # Physical Site Not Available: 4 Weight Physical Site-Buildings must be structurally sound, clean, and in 748.3301(a) good repair. Paints must be lead-free Narrative: This standard was evaluated and technical assistance was provided. The residents do not have readily access to these areas. High Category Weight Short Description Standard # TA Finding Admn Rvw Compliance TA Finding Admn Rvw Physical Site Physical Site-Outdoor areas must be well drained 748.3301(e) Medium Compliance Narrative: This standard was evaluated and technical assistance was provided. The residents do not have readily access to the septic tank area located outside of the home. Category Short Description Standard # Physical Site Weight Physical Site-The grounds must be free of garbage & debris & 748.3301(g) maintained in a sanitary manner Narrative: This standard was evaluated and technical assistance was provided. The residents do not have readily access to the barn area. Medium High Category Weight Short Description Standard # Physical Site Bedding-Must provide each child with a mattress cover or protector 748.3365(a)(3) or mattress that is waterproof or washable Narrative: Patterson - 3 beds in occupied bedrooms on the 2nd floor did not have mattress covers or protectors. Medium Category Weight Short Description Standard # TA Finding Admn Rvw Compliance TA Finding Deficiency TA Finding Admn Rvw Waived Admn Rvw Physical Site Swimming Pool-Pool chemicals & pumps must be inaccessible to 748.3601(4) High Deficiency Waived children Narrative: Curry I - There is a wooden fence approximately 4' around the filter and pool chemicals. The fence is broken in one corner and held together with a piece of wire. Various pool chemicals had stored in this area and accessible to children. Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Monitoring and Investigation Inspection 2374723 06/12/2010 09:00:00 06/12/2010 12:11:00 N Category Short Description Physical Site Standard # Physical Site-Buildings must be structurally sound, clean, and in 748.3301(a) good repair. Paints must be lead-free Narrative: At Bickerstaff II I observed a leak under a bathroom sink that has caused water damage at the bottom of the sink cabinet. Weight TA Finding High Deficiency Admn Rvw Waived A vacant building that is adjacent to Humphrey I is in bad repair and structurally unsound. I observed that there was an open door to the building, a broken window with jagged exposed glass and there is structural damage to a carport that is attached to the building. This building may be a hazard to children in care due to the proximity of this building to houses that are occupied by children. Note: Prior to January 1, 2007, all Standards were not associated with a weight. Page 31 of 187 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Category Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Short Description Weight: Id/Number: Admin Review Status: Low: 6 Standard # Physical Site Bedroom Space-A child 6 yrs old or older may not share a bedroom 748.3363(a) with a person of the other gender Narrative: Bickerstaff II: A 4 year old male child is sharing a bedroom with a 7 year old female child. Not Available: 4 Weight TA Finding Medium Deficiency Admn Rvw Waived Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 1189296 06/12/2010 12:00:00 N Category Short Description Standard # Personnel Weight Caregiver responsibility - being able to intervene when necessary to 748.685(a)(5) ensure child's safety Narrative: The standard was evaluated and was found to be in compliance. High Category Short Description Standard # Weight Medical care-A child in care must receive medical care as needed for injury, illness, and pain Narrative: The standard was evaluated and was found to be in compliance. 748.1531(a)(2) High Category Standard # Weight 748.507(1) Medium High Child Care Short Description Personnel Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks Narrative: The standard was evaluated and was found to be in compliance. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Other Inspection 2372143 06/11/2010 09:30:00 06/11/2010 01:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Monitoring Inspection 2372667 06/10/2010 07:00:00 06/10/2010 10:42:00 N Category Short Description Standard # Weight Physical Site Physical Site-Windows & doors must be in good repair & free of broken glass or hazards 748.3301(c) Medium TA Finding Narrative: Curry I House: There is a broken window at the front of the house that needs to be repaired. The window has been boarded up with ply wood to prevent access to children. Note: Prior to January 1, 2007, all Standards were not associated with a weight. Page 32 of 187 Deficiency Admn Rvw Waived Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 At the back of the house there was an exterior vent screen missing. The door to the water well house is broken and is in need of repair to prevent access to children. Note: digital photos taken. Category Short Description Standard # Weight TA Finding Physical Site Swimming-Outdoor pools must be enclosed with a 6-foot 748.3603(d) High fence/wall that prevents children's access to the pool Narrative: The fence surrounding the pool at Curry House I is damaged and has a gap which children may be able to use to gain access to the pool. Deficiency Admn Rvw Waived There is a pond directly behind Curry House I that is partially fenced. Children are allowed to fish in the pond. Note: digital photos taken. Category Short Description Standard # Human Resources Code, Chapter 42 Reporting incidents and violations-an illness of a child that requires HRC42.063(a)(3) hospitalization Narrative: The standard was evaluated and was found to be in compliance. Weight TA Finding High Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2372803 06/10/2010 04:22:00 06/10/2010 07:35:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 1186735 06/10/2010 03:07:00 N Category Short Description Standard # Discipline and Punishment Weight Other Prohibited Punishments-subjecting a child to abusive or 748.2307(9) profane language Narrative: One child and one staff person interviewed reported that another staff member uses profanity in the presence of children in care. Medium High Category Weight Short Description Children's Rights Standard # Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: Standard was evaluated and found to be in compliance. Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Deficiency TA Finding High Page 33 of 187 Compliance Admn Rvw Waived Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Category Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Short Description Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Standard # Weight Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being Narrative: Standard was evaluated and found to be in compliance. 748.685(a)(4) High Category Standard # Weight Personnel Short Description Discipline and Punishment Corporal Punishment-May not use/threaten corporal punishment, 748.2303(a) such as hitting/spanking, forced exercise, holding physical position, unproductive work. Narrative: Standard was evaluated and found to be in compliance. TA Finding Admn Rvw Compliance TA Finding Medium High Admn Rvw Compliance Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 1186337 06/09/2010 01:30:00 N Category Short Description Standard # Children's Rights Weight Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: Standard evaluated and found to be in compliance. High Category Weight Short Description Standard # Emergency Behavior Intervention Short Personal Restraint-Caregiver must minimize risk of physical 748.2461(a)(1) discomfort, harm, or pain to child Narrative: Standard evaluated and found to be in compliance. Medium High Category Weight Short Description Standard # Admission, Service Planning, Discharge Admission-Medical exam by health-care professional within 30 748.1223(a) days after admission, unless documentation of medical exam within past year available Narrative: Standard evaluated and found to be in compliance. Medium Category Short Description Standard # Weight Short Personal Restraint-Caregiver must use minimal amount of reasonable and necessary physical force Narrative: Standard evaluated and found to be in compliance. 748.2461(a)(2) Medium High Category Standard # Weight Emergency Behavior Intervention Short Description Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Page 34 of 187 Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Admission, Service Planning, Discharge Admission-Dental exam for child 3 years old or older scheduled in 748.1225(b) 30 days and done in 90 days unless documentation of one within past year on file Narrative: Standard evaluated and found to be in compliance. Not Available: 4 Medium Low Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2370624 06/09/2010 01:30:00 06/09/2010 05:24:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Other Inspection 2367644 06/08/2010 02:00:00 06/08/2010 05:43:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2334666 06/01/2010 04:34:00 06/01/2010 06:06:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2351664 05/27/2010 09:31:00 05/27/2010 12:31:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2340544 05/24/2010 01:32:00 05/24/2010 03:07:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2332366 05/18/2010 10:15:00 05/18/2010 10:48:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 1153975 05/18/2010 12:00:00 N Category Short Description Standard # Weight Children's rights-Adhere to the child's rights to be free from any harsh, cruel, unusual, unnecessary, demeaning, or humiliating punishment Narrative: The standard was evaluated and was found to be compliant. 748.1101(b)(5) High Category Standard # Weight Children's Rights Short Description Discipline and Punishment Corporal Punishment-May not use/threaten corporal punishment, 748.2303(a) such as hitting/spanking, forced exercise, holding physical position, unproductive work. Narrative: The standard was evaluated and was found to be compliant. Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Admn Rvw Compliance TA Finding Medium High Page 35 of 187 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Category Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Short Description Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Standard # Weight Other Prohibited Punishments-humiliating, shaming, ridiculing, rejecting, or yelling at a child Narrative: The standard was evaluated and was found to be compliant. 748.2307(8) Medium High Category Standard # Weight 748.507(1) Medium High Discipline and Punishment Short Description Personnel Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks Narrative: The standard was evaluated and was found to be compliant. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 1125815 04/30/2010 01:08:00 N Category Short Description Standard # Children's Rights Weight Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: Standard was evaluated and found to be in compliance. High Category Standard # Weight 748.507(1) Medium High Short Description Personnel Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks Narrative: Standard was evaluated and found to be in compliance. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2300223 04/30/2010 01:08:00 04/30/2010 02:40:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2296123 04/28/2010 03:08:00 04/28/2010 04:07:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 1113977 04/28/2010 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Note: Prior to January 1, 2007, all Standards were not associated with a weight. Page 36 of 187 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Investigation Medium: 139 1117975 Category Run date: July 17, 2018 Compliance History Report Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 04/27/2010 08:39:00 Short Description N Standard # Weight Children's rights-Adhere to the child's rights to be free from being subjected to corporal punishment Narrative: Standard was evaluated and found to be in compliance. 748.1101(b)(5)(B) High Category Standard # Weight Children's Rights Short Description Children's Rights Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: Standard was evaluated and found to be in compliance. TA Finding Admn Rvw Compliance TA Finding High Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2290443 04/27/2010 08:39:00 04/27/2010 10:40:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2222767 04/13/2010 10:13:00 04/13/2010 04:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2266845 04/13/2010 09:12:00 04/13/2010 04:04:28 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 1090736 04/13/2010 12:00:00 N Category Short Description Standard # Weight TA Finding Emergency Behavior Intervention Admn Rvw EBI Orders-PRN for emergency medication reviewed by physician 748.2507(3) Medium Deficiency at least every 30 days & includes justification for continuation of PRN order Narrative: Medication orders are being reviewed by the physician monthly, however there is not documentation in the order to justify the continuation of PRN medications. Waived Category Admn Rvw Short Description Standard # Weight TA Finding Children's Rights Children's rights-Adhere to the child's right to not receive 748.1101(b)(24) Medium unnecessary or excessive medication High Narrative: It was determined that the operation did not have reasonable cause to force a 17 year old foster child to take medication against her will. Category Short Description Standard # Weight Organization and Administration Child-care policies-Describe emergency behavior intervention techniques permitted or have a policy disallowing its use 748.235(6) Medium Note: Prior to January 1, 2007, all Standards were not associated with a weight. Deficiency TA Finding Page 37 of 187 Compliance Upheld Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Narrative: The standard was evaluated and the operation was found to be in compliance. Category Short Description Standard # Training and Professional Development Weight Annual Training-Caregiver that administers psychotropic 748.945 medication must receive annual training that includes same training requirements in 748.885 Narrative: The standard was evaluated and the operation was found to be in compliance. Medium Category Weight Short Description Standard # TA Finding Admn Rvw Compliance TA Finding Admn Rvw Emergency Behavior Intervention EBI Documentation-Must include a description and assessment of 748.2855(a)(3) Medium Deficiency Waived the circumstances and specific behaviors that were the basis for EBI Low Narrative: Emergency Medication (EM) Reports and Medical Clinic Progress Notes reviewed did not have clear descriptions of the specific behaviors observed by direct care staff and medical staff to justify the use of PRN injections. The language used by staff was vague and often times generic terms such as "agitated" was used to describe behaviors. Category Short Description Emergency Behavior Intervention Triggered Reviews-Review if emergency medication is used on same child three times in a 30-day period Narrative: A trigger review was not completed within the required time frame. Standard # Weight 748.2901(3) Medium TA Finding Deficiency Admn Rvw Overturned Note: The child was scheduled to see the Psychiatrist to be assessed but was removed from the on-site clinic due to disruptive behavior. Activity Type: Investigation Number Date Intake Rcvd: Investigation 1084735 04/07/2010 09:25:00 Category Short Description Warning Letter/Due Notice given N Standard # Weight Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks Narrative: This standard was evaluated and found to be in compliance. 748.507(1) Medium High Category Standard # Weight Personnel Short Description Children's Rights Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: This standard was evaluated and found to be in compliance. High Category Weight Short Description Note: Prior to January 1, 2007, all Standards were not associated with a weight. Standard # TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Page 38 of 187 Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Physical Site Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Bedroom Space-A child 6 yrs old or older may not share a bedroom 748.3363(a) with a person of the other gender Not Available: 4 Medium Compliance Narrative: Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2253323 04/07/2010 09:00:00 04/07/2010 11:17:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 1058057 03/22/2010 12:00:00 N Category Short Description Standard # Weight Children's rights-Adhere to the child's rights to be free from any harsh, cruel, unusual, unnecessary, demeaning, or humiliating punishment Narrative: There is insufficient evidence to sustain the allegations. 748.1101(b)(5) High Category Children's Rights Short Description Standard # Weight Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks Narrative: There is insufficient evidence to sustain the allegations. 748.507(1) Medium High Category Standard # Weight Personnel Short Description Emergency Behavior Intervention Short Personal Restraint-Caregiver may not use restraint that twists 748.2461(b)(6) or places the child's limb(s) behind the child's back Narrative: There is insufficient evidence to sustain the allegations. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding High Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2212309 03/12/2010 11:45:00 03/12/2010 12:33:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 1045635 03/12/2010 12:00:00 Warning Letter/Due Notice given N Category Short Description Personnel Caregiver responsibility - being aware of and accountable for each 748.685(a)(3) child's on-going activity Note: Prior to January 1, 2007, all Standards were not associated with a weight. Standard # Weight TA Finding High Page 39 of 187 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Narrative: Standard was evaluated and found to be in compliance. Category Short Description Standard # Weight Child/caregiver ratio-If caring for fewer children needing tx svcs, sleeping ratio for awake staff is 1:8 or 1:24, based on youngest child's age Narrative: Standard was evaluated and found to be in compliance. 748.1007(1) Medium Category Standard # Weight 748.685(a)(4) High Child/Caregiver Ratios Short Description Personnel Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being Narrative: Standard was evaluated and found to be in compliance. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Attempted Inspection 2165823 02/10/2010 04:00:00 02/10/2010 04:10:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Monitoring and Investigation Inspection 2141285 02/09/2010 09:00:00 02/09/2010 03:09:00 N Category Short Description Standard # Weight TA Finding Background Checks - TAC 745 Required FBI background checks, Child Care Centers-Directors, 745.615(b)(3)(a) High Owners, Operators, or Administrators of the Operation Narrative: There was no documentation to verify that a background check was resubmitted to DFPS after an employee was re-hired at the facility. Category Short Description Standard # Weight Deficiency TA Finding Admn Rvw Waived Admn Rvw Admission, Service Planning, Discharge Placement agreement-Must include the reason for placement & 748.1207(3) Low Deficiency Waived anticipated length of time in care Narrative: 3 out of the 6 children's records evaluated did not have section 9 and 10 on the placement agreement completed which addresses the reason for the child's placement at the facility and the anticipated length of stay. Category Short Description Admission, Service Planning, Discharge Initial Service Plan-Complete the initial service plan within 40 days 748.1335 after admission Standard # Weight TA Finding Medium Low Narrative: Note: Prior to January 1, 2007, all Standards were not associated with a weight. Page 40 of 187 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Category Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Short Description Weight: Id/Number: Admin Review Status: Low: 6 Standard # Not Available: 4 Weight TA Finding Admission, Service Planning, Discharge Service Plan Review-If child receiving treatment services for ED, 748.1381(2) Medium PDD, or PMN, review at least 90 days from date of last service plan Low Narrative: The service plan review in 1 child's record did not have all required information listed and there were no signatures captured on the review form to verify that all required participates were present. Deficiency Admn Rvw Waived Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 981335 02/03/2010 12:00:00 N Category Short Description Standard # Weight Child/caregiver ratio-If caring for more children needing tx svcs, sleeping ratio for awake staff is 1:6 or 1:15, based on youngest child's age Narrative: The standard was evaluated and found to be compliant. 748.1007(3) Medium Category Standard # Weight Child/Caregiver Ratios Short Description Reports and Record Keeping Serious Incident-Report to Licensing no later than 24 hours after an 748.303(a)(5)(A) incident of sexual abuse of a child against another child Narrative: The standard was evaluated and found to be compliant. Medium Category Weight Short Description Standard # Personnel Caregiver responsibility - being able to intervene when necessary to 748.685(a)(5) ensure child's safety Narrative: The standard was evaluated and found to be compliant. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding High Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2122003 01/27/2010 08:30:00 01/27/2010 10:32:01 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2113623 01/20/2010 03:02:00 01/20/2010 05:18:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 963995 01/20/2010 12:00:00 Category Short Description Note: Prior to January 1, 2007, all Standards were not associated with a weight. Warning Letter/Due Notice given N Standard # Weight TA Finding Page 41 of 187 Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Discipline and Punishment Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Corporal Punishment-May not use/threaten corporal punishment, 748.2303(a) such as hitting/spanking, forced exercise, holding physical position, unproductive work. Narrative: The standard was evaluated and it was found to be in compliance. Medium High Category Weight Short Description Standard # Emergency Behavior Intervention Short Personal Restraint-Caregiver may not use restraint that twists 748.2461(b)(6) or places the child's limb(s) behind the child's back Narrative: The standard was evaluated and found to be compliant. High Category Standard # Weight 748.1101(b)(5) High Short Description Children's Rights Children's rights-Adhere to the child's rights to be free from any harsh, cruel, unusual, unnecessary, demeaning, or humiliating punishment Narrative: The standard was evaluated and it was found to be in compliance. Activity Type: Investigation Number Date Intake Rcvd: Investigation 960355 01/07/2010 04:00:00 Category Short Description Weight Medium Category Standard # Weight Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks Narrative: Staff member had an inappropriate relationship with a minor child at the facility. 748.507(1) Medium High Category Standard # Weight Short Description Children's Rights Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: This standard was evaluated and to be deficient. High Category Weight Short Description Note: Prior to January 1, 2007, all Standards were not associated with a weight. Admn Rvw Compliance TA Finding Admn Rvw Compliance N Standard # Reporting serious incident-All serious incident reports to Licensing 748.309(a) must be made to the Child Abuse Hotline Narrative: The facility failed to report the incident timely. Short Description TA Finding Warning Letter/Due Notice given Reports and Record Keeping Personnel Compliance Standard # TA Finding Deficiency TA Finding Deficiency TA Finding Deficiency TA Finding Page 42 of 187 Admn Rvw Upheld Admn Rvw Upheld Admn Rvw Upheld Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Organization and Administration General operational policies-Employees must be aware of and 748.231(d) Medium Deficiency follow policies and procedures and have a copy at the operation for their review Narrative: Staff member traveled to an out of state destination to visit a minor child (ex-resident of the facility) without the consent of the agency (RTC) administration. Waived Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2101206 01/07/2010 09:35:00 01/07/2010 12:35:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 957560 01/05/2010 10:00:00 Category Short Description Warning Letter/Due Notice given N Standard # Reports and Record Keeping Weight Personnel records-Include copy of the valid driver's license for each 748.363(10) person who transports a child Narrative: Out of the 4 staff records reviewed, 2 were missing a valid driver's license. Medium Category Weight Short Description Standard # Reports and Record Keeping Personnel records-Include copy of a cleared tuberculosis screening 748.363(5) conducted prior to the person having contact with children in care Narrative: Staff who has contact with children did not have a TB screening in her employee file. TA Finding Deficiency TA Finding Medium Low Deficiency Admn Rvw Waived Admn Rvw Waived Copy of TB screening was placed in file before inspection was complete. Category Short Description Children's Rights Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Standard # Weight High Short Description Weight TA Finding Admn Rvw Compliance Narrative: Category Standard # Medication Administration of Medication-Ensure the child has taken the 748.2003(b)(5) medication as prescribed Narrative: Resident was not receiving medication as prescribed: Resident ran out of medication and went 3 days without it. TA Finding Medium High Deficiency Admn Rvw Waived Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2062203 12/08/2009 11:40:00 12/08/2009 11:53:00 N Note: Prior to January 1, 2007, all Standards were not associated with a weight. Page 43 of 187 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Activity Type: Investigation Number Date Intake Rcvd: Investigation 926195 12/01/2009 11:28:00 Category Run date: July 17, 2018 Compliance History Report Short Description Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Warning Letter/Due Notice given N Standard # Children's Rights Weight Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: Standard evaluated and found to be in compliance. High Category Weight Short Description Standard # Discipline and Punishment Corporal Punishment-May not use/threaten corporal punishment, 748.2303(a) such as hitting/spanking, forced exercise, holding physical position, unproductive work. Narrative: Standard evaluated and found to be in compliance. Activity Type: Investigation Number Date Intake Rcvd: Investigation 910055 11/16/2009 01:00:00 Category Short Description 748.2461(a)(2) Medium High Category Standard # Weight Emergency Behavior Intervention Short Personal Restraint-Caregiver must minimize risk of physical 748.2461(a)(1) discomfort, harm, or pain to child Narrative: This standard was evaluated and the facility was found to be in compliance. Medium High Category Short Description Standard # Weight Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks Narrative: This standard was evaluated and the facility was found to be in compliance. 748.507(1) Medium High Category Short Description Standard # Weight Children's Rights Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Note: Prior to January 1, 2007, all Standards were not associated with a weight. Admn Rvw Compliance N Short Personal Restraint-Caregiver must use minimal amount of reasonable and necessary physical force Narrative: This standard was evaluated and the facility was found to be in compliance. Personnel TA Finding Warning Letter/Due Notice given Weight Short Description Admn Rvw Compliance Medium High Standard # Emergency Behavior Intervention TA Finding TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding High Page 44 of 187 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Narrative: This standard was evaluated and the facility was found to be in compliance. Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2043905 11/16/2009 01:00:00 11/16/2009 04:20:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 893298 10/29/2009 12:05:00 Category Short Description Warning Letter/Due Notice given N Standard # Emergency Behavior Intervention Weight Short Personal Restraint-Caregiver may not use restraint that twists 748.2461(b)(6) or places the child's limb(s) behind the child's back Narrative: Caregiver pulled arm behind the child's back as a restraint. High Category Weight Short Description Standard # Discipline and Punishment Corporal Punishment-May not use/threaten corporal punishment, 748.2303(a) such as hitting/spanking, forced exercise, holding physical position, unproductive work. Narrative: Standard evaluated and found to be in compliance. Medium High Category Weight Short Description Standard # Children's Rights Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: Standard evaluated and found to be in compliance. TA Finding Deficiency TA Finding Admn Rvw Waived Admn Rvw Compliance TA Finding High Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2024264 10/29/2009 11:45:00 10/29/2009 12:49:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2015988 10/21/2009 05:14:00 10/21/2009 05:28:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2012863 10/21/2009 03:45:00 10/21/2009 05:12:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 885016 10/20/2009 12:00:00 N Note: Prior to January 1, 2007, all Standards were not associated with a weight. Page 45 of 187 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Category Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Short Description Standard # Human Resources Code, Chapter 42 Reporting Incidents and Violations that threaten or impair the basic HRC42.063(a) health, safety or well-being of a child Narrative: The incident is not subject to investigation by RCCL due to the client being 18 years old. Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Weight TA Finding High Admn Rvw Compliance Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 882455 10/14/2009 12:00:00 N Category Short Description Standard # Weight Medical care-A child in care must receive medical care as needed for ongoing maintenance of medical health Narrative: There was insufficient evidence to sustain the allegations. 748.1531(a)(3) Medium High Category Child Care Short Description Standard # Weight Children's rights-Adhere to the child's right to receive appropriate treatment for physical problems that affect his treatment or safety Narrative: There was insufficient evidence to sustain the allegations. 748.1101(b)(28) Medium High Category Standard # Weight 748.507(1) Medium High Children's Rights Short Description Personnel Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks Narrative: There was insufficient evidence to sustain the allegations. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 862275 09/21/2009 09:30:00 N Category Short Description Children's Rights Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Standard # Weight High Category Short Description Weight Training and Professional Development Annual Training Documentation-Includes the length of the training 748.949(b)(5) in hours TA Finding Admn Rvw Compliance Narrative: Investigation is still pending. Note: Prior to January 1, 2007, all Standards were not associated with a weight. Standard # TA Finding Low Page 46 of 187 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Narrative: Category Short Description Standard # Discipline and Punishment Corporal Punishment-May not use/threaten corporal punishment, 748.2303(a) such as hitting/spanking, forced exercise, holding physical position, unproductive work. Narrative: Staff was observed briefly pushing a resident back by her neck. This observations was seen by another resident. Activity Type: Inspection Id Date Begin: Investigation Inspection 1989083 09/21/2009 09:30:00 Category Short Description Weight 09/21/2009 12:58:00 748.3301(a) High Category Standard # Weight Bedding-Must provide each child with a mattress cover or protector 748.3365(a)(3) or mattress that is waterproof or washable Narrative: Two of the 6 beds I observed did not have protective covers. Overturned N Physical Site-Buildings must be structurally sound, clean, and in good repair. Paints must be lead-free Narrative: In 1 of the 3 bedrooms I observed there was a hole in the wall, cracked door and a loose door panel. Physical Site Admn Rvw Warning Letter/Due Notice given Weight Short Description Deficiency Date End: Standard # Physical Site TA Finding Medium High TA Finding Deficiency TA Finding Medium Deficiency Admn Rvw Waived Admn Rvw Waived Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1983091 09/16/2009 10:30:00 09/18/2009 10:45:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 857436 09/11/2009 02:30:00 Category Short Description Warning Letter/Due Notice given N Standard # Weight Intentional, knowing, or reckless act or omission-deliberately causes or might cause physical injury or emotional harm Narrative: This standard was reviewed and found to be in compliance. 745.8555(b)(1) High Category Short Description Standard # Weight Discipline and Punishment Corporal Punishment-May not use/threaten corporal punishment, 748.2303(a) such as hitting/spanking, forced exercise, holding physical position, unproductive work. Abuse/Neglect Definitions - TAC 745 Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Admn Rvw Compliance TA Finding Medium High Page 47 of 187 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Narrative: This standard was reviewed and found to be in compliance. Category Short Description Standard # Children's Rights Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: This standard was reviewed and found to be in compliance. Weight TA Finding High Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1977623 09/08/2009 03:43:00 09/08/2009 05:37:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 850779 09/08/2009 12:00:00 Category Short Description Warning Letter/Due Notice given N Standard # Weight Emergency Behavior Intervention-Never used as a means to get a child to comply Narrative: The standard was evaluated and the operation was found to be compliant. 748.2463(3) Medium High Category Standard # Weight Emergency Behavior Intervention Short Description Children's Rights Children's rights-Adhere to the child's rights to be free from being 748.1101(b)(5)(F) subjected to remarks that belittle or ridicule the child or the child's family Narrative: The standard was evaluated and the operation was found to be compliant. Medium High Category Standard # Weight 748.507(1) Medium High Short Description Personnel Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks Narrative: The standard was evaluated and the operation was found to be compliant. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Follow-up Inspection 1941523 08/20/2009 10:45:00 08/20/2009 12:50:00 N Category Short Description Standard # Weight Physical Site Physical Site-Buildings must be structurally sound, clean, and in good repair. Paints must be lead-free 748.3301(a) High Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Page 48 of 187 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Narrative: Note: During follow-up inspection I observed that all corrections have been made. Two homes inspected were in need of repairs and cleaning. Draeger 1: In the 1st bathroom mildew and dirt observed in the bath tub. In the 2nd bathroom there was a small whole underneath the bathroom sink cabinet possibly caused by a rodent. In the 3rd bathroom the toilet did not flush properly. Red House: I observed rodent droppings in a bedroom dresser drawer, the bottom kitchen cabinets and in the bottom of the food pantry. Each documented by digital photo. Category Short Description Standard # Weight TA Finding Admn Rvw Physical Site Physical Site-The building must be free of rodents and insects 748.3301(h) Medium Compliance Narrative: Note: There were no rodent droppings observed at the house. Documentation provided by the facility shows that exterminators have been treating the proberty on an on-going basis. Rodent droppings observed in kitchen of the Red house. Category Short Description Standard # Weight TA Finding Admn Rvw Physical Site Physical Site-Equipment and furniture must be safe for children and 748.3301(i) Medium Compliance must be kept clean and in good repair Narrative: Note: I observed that all Televisions in the home were secured with metal brackets to prevent them from moving. The freezer has been repaired by installing new seals around the door. The oven at the Patterson house is being cleaned ever four days prior to shift change. I observed that the oven was clean. In Mustang house (for autistic children) there were multiple television sets setting on top of furniture. The televisions were not secured and could be pulled down on top of a child. This was documented by digital photo. In the Patterson house there was a freezer that was not functioning properly. Food was defrosting and the seal on the door was broken. Oven had accumulation of grease or grime. Category Short Description Standard # Weight TA Finding Physical Site Admn Rvw Bedding-Must provide each child with pillow/bed linens 748.3365(a)(4) Medium Compliance appropriate for temperature including pillowcase top sheet, fitted or Low bottom sheet Narrative: Note: During the follow-up I observed that top sheets are being used in the Patterson house. Humphrey 3 had a shortage of sheets on two beds during the follow-up; however this was corrected at inspection. Top sheets missing from beds in multiple rooms of the Patterson house, upstairs and down. Top sheet also missing from one bed at the Humphrey 3 house. Note: Prior to January 1, 2007, all Standards were not associated with a weight. Page 49 of 187 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 This was documented by digital photo. Category Short Description Standard # Weight Physical Site Bathrooms-Must be maintained in good repair & kept clean 748.3391(a) Medium High Standard # Weight TA Finding Admn Rvw Compliance Narrative: Note: The toilets and bathtub were clean during the follow-up inspection. In Patterson house there was a toilet that required cleaning in the downstairs bathroom. In Humphrey 3 house there was accumulation of dirt or grime around a bathtub. These were documented by digital photo. Category Short Description TA Finding Physical Site Hand-washing-Provide hand-washing sinks with hot & cold 748.3395(b)(3) Medium running water under sufficient pressure to meet the demands of Low children Narrative: Note: Repairs have been made to the plumbing in the Patterson house and the water pressure has been restored to the appropriate level. Admn Rvw Compliance In Patterson house there were sinks in upstairs and downstairs bathrooms that had minimum water pressure. Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1932028 07/29/2009 02:25:00 07/29/2009 04:36:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 812055 07/28/2009 12:00:00 N Category Short Description Standard # Personnel Weight Caregiver responsibility - being able to intervene when necessary to 748.685(a)(5) ensure child's safety Narrative: The standard was evaluated and found to be compliant. High Category Standard # Weight 748.1007(4) Medium Short Description Child/Caregiver Ratios Child/caregiver ratio-If caring for more children needing tx svcs, sleeping ratio for asleep staff is 1:4 or 1:10, based on youngest child's age Narrative: The standard was evaluated and found to be compliant. Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Admn Rvw Compliance TA Finding Page 50 of 187 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Category Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Short Description Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Standard # Weight Caregiver responsibility - when deciding how close to supervise, takes into account the child's individual differences and abilities Narrative: The standard was evaluated and found to be compliant. 748.685(b)(2) High Category Standard # Weight Personnel Short Description Children's Rights Children's rights-Adhere to the child's right to have a humane 748.1101(b)(8) environment, including any treatment environment, which provides protection from harm Narrative: The standard was evaluated and found to be compliant. TA Finding Admn Rvw Compliance TA Finding High Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1918883 07/10/2009 09:30:00 07/10/2009 10:33:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Monitoring Inspection 1914087 07/07/2009 09:15:00 Category Short Description 07/07/2009 03:42:00 Standard # Background Checks - TAC 745 N Weight Required background checks-employees and applicants you intend 745.615(a)(2) to hire Narrative: One employee has not received results of background check. High Category Weight Short Description Standard # Children's Rights Informing child of rights-Person being informed must sign 748.1103(d) statement indicating he read and understands the rights-signed copy filed in child's record Narrative: In 1 of 5 children's records reviewed, there was no signature to indicate child had been made aware of their rights. Medium Low Category Short Description Standard # Weight Admission Documentation-Includes child's name, gender, race, religion, date of birth, birthplace Narrative: In 2 of 5 children's records, religion is not addressed on the Enrollment Information. 748.1205(a)(1) Medium Low Category Standard # Weight Admission, Service Planning, Discharge Short Description Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Deficiency TA Finding Deficiency TA Finding Deficiency TA Finding Page 51 of 187 Admn Rvw Waived Admn Rvw Waived Admn Rvw Waived Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Organization and Administration Behavior intervention policies-Include obtaining child's input at 748.237(5)(C) Medium Deficiency admission on preferred de-escalation & how it will be revisited after High each incident Narrative: In 5 of 5 children's records reviewed, there was no documentation that child was given an opportunity to discuss their preferred method of de-escalation at admission. Waived Category Admn Rvw Short Description Standard # Weight TA Finding Physical Site Physical Site-Equipment and furniture must be safe for children and 748.3301(i) Medium Deficiency Waived must be kept clean and in good repair Narrative: In Mustang house (for autistic children) there were multiple television sets setting on top of furniture. The televions were not secured and could be pulled down on top of a child. This was documented by digital photo. In the Patterson house there was a freezer that was not functioning properly. Food was defrosting and the seal on the door was broken. Oven had accumulation of grease or grime. Category Short Description Standard # Weight TA Finding Physical Site Bedding-Must provide each child with pillow/bed linens 748.3365(a)(4) Medium Deficiency appropriate for temperature including pillowcase top sheet, fitted or Low bottom sheet Narrative: Top sheets missing from beds in multiple rooms of the Patterson house, upstairs and down. Top sheet also missing from one bed at the Humphrey 3 house. Admn Rvw Waived This was documented by digital photo. Category Short Description Standard # Weight Physical Site Bathrooms-Must be maintained in good repair & kept clean 748.3391(a) Medium High Standard # Weight TA Finding Deficiency Admn Rvw Waived Narrative: In Patterson house there was a toilet that required cleaning in the downstairs bathroom. In Humphrey 3 house there was accumulation of dirt or grime around a bathtub. These were documented by digital photo. Category Short Description Physical Site Hand-washing-Provide hand-washing sinks with hot & cold 748.3395(b)(3) running water under sufficient pressure to meet the demands of children Narrative: In Patterson house there were sinks in upstairs and downstairs bathrooms that had minimum water pressure. Medium Low Category Weight Short Description Note: Prior to January 1, 2007, all Standards were not associated with a weight. Standard # TA Finding Deficiency TA Finding Page 52 of 187 Admn Rvw Waived Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Reports and Record Keeping Active child record-Includes known allergies and chronic 748.393(b)(2) conditions on the exterior of the child's record or in a clearly visible location Narrative: In 3 of 5 children's records reviewed, place on Enrollment Information sheet to indicate info on allergies was left blank. Not Available: 4 Medium High Deficiency Waived Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1912403 07/03/2009 09:00:00 07/03/2009 09:03:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 791131 06/25/2009 04:00:00 Category Short Description Warning Letter/Due Notice given N Standard # Weight Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks Narrative: The standard evaluated was found to be in compliance. 748.507(1) Medium High Category Standard # Weight Personnel Short Description Children's Rights Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: The standard evaluated was found to be in compliance. High Category Standard # Weight 748.683(1) Medium Short Description Personnel Caregiver Supervision-Provide oversight of caregivers to protect children's health, safety and well-being Narrative: The standard evaluated was found to be in compliance. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1896921 06/15/2009 01:30:00 06/15/2009 05:52:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 781220 06/12/2009 12:00:00 Warning Letter/Due Notice given N Category Short Description Standard # Weight Emergency Behavior Intervention Short Personal Restraint-Caregiver may not use restraint that obstructs child's airways or impairs child's breathing 748.2461(b)(3) High Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Page 53 of 187 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Narrative: The standard was evaluated and was found to be compliant. Category Short Description Standard # Reports and Record Keeping Weight Serious Incident-Report to Licensing as soon as aware of 748.303(a)(3)(A) allegations or indications of abuse, neglect, or exploitation of a child Narrative: It was determined that the allegations made involved a non-reportable incident. Medium High Category Weight Short Description Standard # Emergency Behavior Intervention Emergency Behavior Intervention-Only a qualified caregiver may 748.2453 administer emergency behavior intervention, except short personal restraint Narrative: Required EBI training has been completed by direct care staff. TA Finding Admn Rvw Compliance TA Finding Medium High Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1887700 06/04/2009 04:05:00 06/04/2009 06:20:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 773213 06/04/2009 12:00:00 N Category Standard # Weight Physical Site Physical Site-The building must be free of rodents and insects Narrative: Rodent droppings observed in kitchen of the Red house. Short Description 748.3301(h) Medium Category Short Description Standard # Weight Personal Restraints Prohibited-Restraints that twist or place the child's limb(s) behind the child's back Narrative: The standard was evaluated and it was found to be compliant. 748.2605(a)(5) Medium High Category Standard # Weight 748.3301(a) High Emergency Behavior Intervention Short Description Physical Site Physical Site-Buildings must be structurally sound, clean, and in good repair. Paints must be lead-free Narrative: Two homes inspected were in need of repairs and cleaning. TA Finding Deficiency TA Finding Admn Rvw Waived Admn Rvw Compliance TA Finding Deficiency Admn Rvw Waived Draeger 1: In the 1st bathroom mildew and dirt observed in the bath tub. In the 2nd bathroom there was a small whole underneath the bathroom sink cabinet possibly caused by a rodent. In the 3rd bathroom the toilet did not flush properly. Red House: I observed rodent droppings in a bedroom dresser drawer, the bottom kitchen cabinets and in the bottom of the food pantry. Note: Prior to January 1, 2007, all Standards were not associated with a weight. Page 54 of 187 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Each documented by digital photo. Category Short Description Standard # Weight TA Finding Admn Rvw Physical Site Food Preparation-Food items must be stored in a container that is 748.3443(a)(4) Medium Compliance protected from insects & rodents Narrative: Note: At time of follow-up food was stored in plastic containers on top of the kitchen counter and on top of the refrigerator. No food items were seen on floor in the food pantry. Snack items observed in an unsealed cardboard box at Red house did not prevent rodent contamination. Documented by digital photo. Activity Type: Investigation Number Date Intake Rcvd: Investigation 726794 04/15/2009 01:00:00 Category Short Description Warning Letter/Due Notice given N Standard # Weight Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks Narrative: This standard was evaluated and found to be in compliance. 748.507(1) Medium High Category Standard # Weight Personnel Short Description Children's Rights Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: This standard was evaluated and found to be in compliance. TA Finding Admn Rvw Compliance TA Finding High Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1834406 04/15/2009 01:00:00 04/15/2009 02:15:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 722436 04/09/2009 01:00:00 Category Short Description Children's Rights Children's rights-Adhere to the child's rights to be free from being subjected to corporal punishment Narrative: This standard was evaluated and found to be in compliance. Note: Prior to January 1, 2007, all Standards were not associated with a weight. Warning Letter/Due Notice given N Standard # Weight 748.1101(b)(5)(B) High TA Finding Page 55 of 187 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Category Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Short Description Weight: Id/Number: Admin Review Status: Low: 6 Standard # Children's Rights Not Available: 4 Weight Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: This standard was evaluated and found to be in compliance. High Category Standard # Weight 748.507(1) Medium High Short Description Personnel Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks Narrative: This standard was evaluated and found to be in compliance. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1830341 04/09/2009 01:00:00 04/09/2009 02:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1814725 03/13/2009 03:26:00 03/13/2009 03:28:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 708239 03/13/2009 02:30:00 N Category Short Description Children's Rights Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Standard # Weight High Category Short Description Standard # Weight Children's Rights Children's rights-Adhere to the child's rights to be free from being subjected to corporal punishment 748.1101(b)(5)(B) High TA Finding Admn Rvw Compliance Narrative: TA Finding Admn Rvw Compliance Narrative: Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1810340 03/11/2009 06:55:00 03/11/2009 08:03:00 N Activity Type: Investigation Number Date Intake Rcvd: Note: Prior to January 1, 2007, all Standards were not associated with a weight. Warning Letter/Due Notice given Page 56 of 187 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Investigation Medium: 139 707735 Category Run date: July 17, 2018 Compliance History Report Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 03/11/2009 12:00:00 Short Description N Standard # Weight Medical care-A child in care must receive medical care as needed for ongoing maintenance of medical health Narrative: Standard was evaluated and found to be in compliance. 748.1531(a)(3) Medium High Category Standard # Weight Child Care Short Description Children's Rights Children's rights-Adhere to the child's right to have adequate 748.1101(b)(12) personal clothing, suitable to his age and size and comparable with peers Narrative: Standard was evaluated and found to be in compliance. Medium Category Weight Short Description Standard # Human Resources Code, Chapter 42 Reporting incidents and violations-an illness of a child that requires HRC42.063(a)(3) hospitalization Narrative: Standard was evaluated and was found to be in compliance. High Category Weight Short Description Standard # Child Care Nutrition-Provide food of adequate variety, quality, and in sufficient 748.1693(a)(1) quantity to supply the nutrients needed for proper growth and development Narrative: Standard was evaluated and found to be in compliance. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Medium High Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1809711 03/10/2009 01:20:00 03/10/2009 02:20:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 703815 03/09/2009 12:00:00 N Category Short Description Standard # Weight Child-care policies-Describe discipline policies including techniques/methods that ensure appropriate discipline techniques are used with a child Narrative: Standard was evaluated and found to be in compliance. 748.235(7) Medium Category Standard # Weight Organization and Administration Short Description Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Admn Rvw Compliance TA Finding Page 57 of 187 Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Discipline and Punishment Corporal Punishment-operation may not use or threaten to use corporal punishment with any child in care Narrative: Standard was evaluated and found to be in compliance. Weight: Id/Number: Admin Review Status: Low: 6 748.2303(a) Not Available: 4 Medium High Compliance Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 688804 02/13/2009 03:00:00 N Category Short Description Standard # Children's Rights Weight Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: Standard was evaluated and found to be in compliance. High Category Standard # Weight 748.2301(b)(2) Medium High Short Description Discipline and Punishment Disciplinary Measures-must not be physically or emotionally damaging to the child Narrative: Standard was evaluated and found to be in compliance. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1749740 01/14/2009 09:51:00 01/14/2009 10:35:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Monitoring and Investigation Inspection 1752280 01/13/2009 11:00:00 01/13/2009 02:05:00 N Category Short Description Physical Site Standard # Physical Site-Equipment and furniture must be safe for children and 748.3301(i) must be kept clean and in good repair Narrative: Draeger 1: Televisions located in bedroom and common areas viewed unsecured. Weight TA Finding Medium Humphrey 2: Dresser located in bedroom 1 was viewed missing several knobs. Bickerstaff 2:Dresser located in bedroom 1 was viewed missing several knobs. Closet door in same bedroom was missing door knob. Four kitchen drawers located near stove were off track. Draeger 1:Light fixture above sink in kitchen was viewed without a cover. Note: Prior to January 1, 2007, all Standards were not associated with a weight. Page 58 of 187 Deficiency Admn Rvw Waived Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Ovens viewed in the following homes were viewed with burned unknown food particles and rust: 1.Humphrey 1 2.Bickerstaff 2 Broken blinds viewed in several homes: Draeger 2:Bedroom 2 Humphrey 1:Bedroom 2 Draeger 1: Blind viewed with dust and dirt in kitchen. All above are documented by digital photos. Category Short Description Standard # Weight Physical Site Bathrooms-Must be maintained in good repair & kept clean 748.3391(a) Medium High TA Finding Deficiency Admn Rvw Waived Narrative: Draeger 1:Mold viewed in bathroom 1 around tub. Dirt and grime viewed around the bottom of the toilet bowl in bathroom 1. Toilet did not properly flush in bathroom 1. Water stain and soap scum viewed around tub in bathroom 2. Humphery 2: Bathroom 2 viewed with mildew around tub. All the above were documented with digital photos. Activity Type: Investigation Number Date Intake Rcvd: Investigation 645676 01/13/2009 12:00:00 Category Short Description Discipline and Punishment Other Prohibited Punishments-any harsh, cruel, unusual, unnecessary, demeaning, or humiliating discipline/punishment Narrative: Standard evaluated and found in compliance. Activity Type: Investigation Number Note: Prior to January 1, 2007, all Standards were not associated with a weight. Warning Letter/Due Notice given N Standard # Weight 748.2307(1) High TA Finding Date Intake Rcvd: Admn Rvw Compliance Warning Letter/Due Notice given Page 59 of 187 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Investigation Medium: 139 649667 Category Run date: July 17, 2018 Compliance History Report Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 01/13/2009 12:00:00 Short Description N Standard # Weight Child/caregiver ratio-Must employ an adequate number of caregivers to meet children's needs and consider amount of supervision needed Narrative: Standard evaluated and found in compliance. 748.1009(a) High Category Standard # Weight Child/Caregiver Ratios Short Description Child Care Medical care-A child in care must receive medical care as needed 748.1531(a)(2) for injury, illness, and pain Narrative: Standard evaluated and found in compliance. Facility provided licensing with documentation verify medical treatment provided. TA Finding Admn Rvw Compliance TA Finding High Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1743323 01/08/2009 12:10:00 01/08/2009 01:30:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 642753 01/08/2009 09:30:00 Category Short Description Warning Letter/Due Notice given N Standard # Emergency Behavior Intervention Weight Short Personal Restraint-Caregiver must minimize risk of physical 748.2461(a)(1) discomfort, harm, or pain to child Narrative: Standard evaluated and found to be in compliance. Medium High Category Weight Short Description Standard # Children's Rights Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: Standard evaluated and found to be in compliance. TA Finding Admn Rvw Compliance TA Finding High Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1738840 01/05/2009 03:00:00 01/05/2009 05:22:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 639793 01/05/2009 12:00:00 Category Short Description Note: Prior to January 1, 2007, all Standards were not associated with a weight. Warning Letter/Due Notice given N Standard # Weight TA Finding Page 60 of 187 Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Child/Caregiver Ratios Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Child/caregiver ratio-Must employ an adequate number of caregivers to meet children's needs and consider amount of supervision needed Narrative: Standard evaluated and found in compliance. 748.1009(a) High Category Short Description Standard # Weight Medical care-A child in care must receive medical care as needed for injury, illness, and pain Narrative: Standard evaluated and found in compliance. 748.1531(a)(2) High Category Child Care Short Description Standard # Weight Serious Incident-Report to parents soon as aware of an incident of physical abuse of a child against another child Narrative: Standard evaluated and found in complance. 748.303(a)(4)(B) Medium Category Standard # Weight Reports and Record Keeping Short Description Safety and Emergency Practices Serious Incident-Report to Licensing no later than 24 hours after an 748.303(a)(4)(A) incident of physical abuse of a child against another child Narrative: Facility failed to notify licensing within the required time frame. Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Medium Deficiency Admn Rvw Waived Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1729100 12/19/2008 01:00:00 12/19/2008 01:30:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 632460 12/18/2008 01:00:00 Category Short Description Warning Letter/Due Notice given N Standard # Children's Rights Weight Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: Standard was evaluated and found to be in compliance. High Category Standard # Weight 748.685(a)(4) High Short Description Personnel Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being Narrative: Standard was evaluated and found to be in compliance. Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Admn Rvw Compliance TA Finding Page 61 of 187 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1729060 12/18/2008 01:00:00 12/18/2008 02:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Monitoring and Investigation Inspection 1718940 12/13/2008 12:00:00 12/13/2008 03:51:00 N Category Short Description Physical Site Physical Site-Buildings must be structurally sound, clean, and in good repair. Paints must be lead-free Narrative: Three out of eight houses seen with dried food particles in oven.(Curry I, Bahler and Red House) Standard # Weight 748.3301(a) High TA Finding Deficiency Admn Rvw Waived One out of eight houses seen with crack molding about 1/2 on right side of bathtub.(Mustang) Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 626834 12/12/2008 03:30:00 N Category Short Description Standard # Emergency Behavior Intervention Weight Short Personal Restraint-Caregiver must minimize risk of physical 748.2461(a)(1) discomfort, harm, or pain to child Narrative: Standard was evaluated and found to be in compliance. Medium High Category Weight Short Description Standard # Children's Rights Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: Standard was evaluated and found to be in compliance. High Category Standard # Weight 748.2461(a)(2) Medium High Short Description Emergency Behavior Intervention Short Personal Restraint-Caregiver must use minimal amount of reasonable and necessary physical force Narrative: Standard was evaluated and found to be in compliance. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1707360 12/04/2008 04:30:00 12/04/2008 05:19:00 N Activity Type: Investigation Number Date Intake Rcvd: Note: Prior to January 1, 2007, all Standards were not associated with a weight. Warning Letter/Due Notice given Page 62 of 187 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Investigation Medium: 139 603774 Category Run date: July 17, 2018 Compliance History Report Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 12/04/2008 12:00:00 Short Description N Standard # Reports and Record Keeping Weight Reporting serious incident-All serious incident reports to Licensing 748.309(a) must be made to the Child Abuse Hotline Narrative: Standard evaluated and found in compliance. Medium Category Short Description Standard # Weight Serious Incident-Report to Licensing no later than 24 hours after injury/illness that warrants treatment by a medical professional or hospitalization Narrative: Standard evaluated and found in compliance. 748.303(a)(2)(A) Medium Category Standard # Weight 748.1009(a) High Safety and Emergency Practices Short Description Child/Caregiver Ratios Child/caregiver ratio-Must employ an adequate number of caregivers to meet children's needs and consider amount of supervision needed Narrative: Standard evaluated and found in compliance. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1675008 11/07/2008 09:00:00 11/17/2008 01:39:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 587120 11/07/2008 12:00:00 N Category Short Description Standard # Children's Rights Children's rights-Adhere to the child's rights to appropriate care and 748.1101(b)(1) treatment in least restrictive setting available that meets the child's needs Narrative: This standard was evaluated, and found in compliance. Weight TA Finding Medium High Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1665516 10/21/2008 09:00:00 10/21/2008 02:17:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 576465 10/21/2008 12:00:00 N Note: Prior to January 1, 2007, all Standards were not associated with a weight. Page 63 of 187 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Category Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Short Description Weight: Id/Number: Admin Review Status: Low: 6 Standard # Children's Rights Not Available: 4 Weight Children's rights-Adhere to the child's rights to be free from being 748.1101(b)(5)(F) subjected to remarks that belittle or ridicule the child or the child's family Narrative: This standard was evaluated and found in compliance. Medium High Category Weight Short Description Standard # Discipline and Punishment Corporal Punishment-corporal punishment of hitting or spanking a 748.2303(b)(1) child with a hand or instrument is prohibited Narrative: This standard was evaluated and found in compliance. High Category Standard # Weight 748.507(1) Medium High Short Description Personnel Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks Narrative: This standard was evaluated and found in compliance. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1660438 10/11/2008 12:30:00 10/11/2008 03:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 574748 10/11/2008 12:00:00 N Category Short Description Standard # Weight Medical care-A child in care must receive medical care as needed for injury, illness, and pain Narrative: Standard evaluated and found in compliance. 748.1531(a)(2) High Category Standard # Weight 748.685(a)(4) High Child Care Short Description Personnel Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being Narrative: Standard evaluated and found in compliance. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 575468 10/11/2008 12:00:00 N Note: Prior to January 1, 2007, all Standards were not associated with a weight. Page 64 of 187 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Category Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Short Description Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Standard # Weight Caregiver Supervision-Provide oversight of caregivers to protect children's health, safety and well-being Narrative: This standard was evaluated and found in compliance. 748.683(1) Medium Category Standard # Weight 748.1531(a)(2) High Personnel Short Description Child Care Medical care-A child in care must receive medical care as needed for injury, illness, and pain Narrative: This standard was evaluated and found in compliance. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 575109 10/10/2008 02:00:00 N Category Short Description Standard # Discipline and Punishment Weight Corporal Punishment-corporal punishment of hitting or spanking a 748.2303(b)(1) child with a hand or instrument is prohibited Narrative: One facility staff member hit a child with a closed fist that resulted in bruising to his right eye. High Category Weight Short Description Standard # Children's Rights Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: The standard was evaluated and found to be deficient. High Category Weight Short Description Standard # Personnel Employee general responsibilities-Demonstrate competency, 748.507(1) prudent judgment, self-control in presence of children and when performing assigned tasks Narrative: One facility staff member failed to exercise self-control and good judgment when addressing one child's behavior. Medium High Category Weight Short Description Standard # TA Finding Deficiency TA Finding Deficiency TA Finding Deficiency TA Finding Admn Rvw Waived Admn Rvw Waived Admn Rvw Waived Admn Rvw Discipline and Punishment Disciplinary Measures-must be consistent with operation policies 748.2301(b)(1) Medium Deficiency Waived and procedures Low Narrative: A facility staff member failed to follow agency policy which does not allow staff to be alone with residents with the room door closed for any reason including discipline. Activity Type: Inspection Id Note: Prior to January 1, 2007, all Standards were not associated with a weight. Date Begin: Date End: Warning Letter/Due Notice given Page 65 of 187 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Investigation Inspection 1660480 10/10/2008 02:00:00 10/10/2008 04:30:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1653177 09/24/2008 03:00:00 09/24/2008 05:01:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 565534 09/24/2008 12:00:00 N Category Short Description Standard # Weight Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being Narrative: This standard was evaluated and found in compliance. 748.685(a)(4) High Category Standard # Weight 748.1531(a)(2) High Personnel Short Description Child Care Medical care-A child in care must receive medical care as needed for injury, illness, and pain Narrative: This standard was evaluated and found in compliance. Activity Type: Inspection Id Date Begin: Investigation Inspection 1647267 09/04/2008 10:13:00 Category Short Description N Physical Site-Windows & doors must be in good repair & free of broken glass or hazards Narrative: At the Patterson house, bedroom one closet door frame was broken and missing. 748.3301(c) Medium Category Standard # Weight Physical Site-Equipment and furniture must be safe for children and 748.3301(i) must be kept clean and in good repair Narrative: At the Mustang house, the living room couch pillow seats are torn with the cushion exposed at the corners. Medium Category Weight Short Description Standard # Physical Site Bedding-Must provide each child with a mattress cover or protector 748.3365(a)(3) or mattress that is waterproof or washable Narrative: At the Patterson house, seven out of eight beds had no protector or coverings. Medium Category Weight Short Description Note: Prior to January 1, 2007, all Standards were not associated with a weight. Standard # Admn Rvw Compliance Warning Letter/Due Notice given Weight Short Description TA Finding 09/04/2008 11:55:00 Physical Site Admn Rvw Compliance Date End: Standard # Physical Site TA Finding TA Finding Deficiency TA Finding Deficiency TA Finding Deficiency TA Finding Page 66 of 187 Admn Rvw Waived Admn Rvw Waived Admn Rvw Waived Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Physical Site Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Bathrooms-Must be maintained in good repair & kept clean Weight: Id/Number: Admin Review Status: Low: 6 748.3391(a) Not Available: 4 Medium High Deficiency Waived Narrative: At the Patterson house, the upstairs bathroom toilet had a brown calcium build-up. The downstairs bathroom shower had missing tiles on the floor. Activity Type: Investigation Number Date Intake Rcvd: Investigation 563115 08/31/2008 11:40:00 Category Short Description Warning Letter/Due Notice given N Standard # Weight Other Prohibited Punishments-any harsh, cruel, unusual, unnecessary, demeaning, or humiliating discipline/punishment Narrative: Standard was evaluated and found in compliance. 748.2307(1) High Category Standard # Weight Discipline and Punishment Short Description Children's Rights Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: Standard was evaluated and found in compliance. TA Finding Admn Rvw Compliance TA Finding High Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Monitoring Inspection 1645708 08/26/2008 09:00:00 08/26/2008 03:00:00 N Category Short Description Medication Medication Record-Must include accurate running count of each prescribed medication Narrative: One out of four resident medication record reviewed did not have an accurate running count. Standard # Weight 748.2151(a)(8) High TA Finding Deficiency Admn Rvw Waived Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1645582 08/25/2008 01:00:00 08/25/2008 04:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 561520 08/22/2008 01:37:00 N Category Short Description Note: Prior to January 1, 2007, all Standards were not associated with a weight. Standard # Weight TA Finding Page 67 of 187 Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Discipline and Punishment Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Other Prohibited Punishments-subjecting a child to abusive or profane language Narrative: A few residents disclosed that staff have used profane language in their presence on occasion. 748.2307(9) Medium High Category Short Description Standard # Weight Children's Rights Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 High Category Short Description Standard # Weight Personnel Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being 748.685(a)(4) High Category Short Description Standard # Weight Child Care Medical care-A child in care must receive medical care as needed for injury, illness, and pain 748.1531(a)(2) High Compliance TA Finding Admn Rvw Compliance Narrative: Pending TA Finding Admn Rvw Compliance Narrative: Pending TA Finding Admn Rvw Compliance Narrative: Pending Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1637444 07/11/2008 09:00:00 07/11/2008 11:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1636027 07/03/2008 09:30:00 07/03/2008 11:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 551574 06/30/2008 02:00:00 Category Short Description Warning Letter/Due Notice given N Standard # Weight Short Personal Restraint-Caregiver may not use restraint that impairs child's breathing by putting pressure on torso Narrative: This standard was evaluated and found to be in compliance. 748.2461(b)(2) High Category Standard # Weight Emergency Behavior Intervention Short Description Emergency Behavior Intervention Short Personal Restraint-Caregiver must minimize risk of physical 748.2461(a)(1) discomfort, harm, or pain to child Narrative: This standard was evaluated and found to be in compliance. Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Admn Rvw Compliance TA Finding Medium High Page 68 of 187 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Category Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Short Description Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Standard # Weight Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks Narrative: This standard was evaluated and found to be in compliance. 748.507(1) Medium High Category Standard # Weight Personnel Short Description Children's Rights Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: This standard was evaluated and found to be in compliance. High Category Short Description Standard # Weight Children's rights-Adhere to the child's rights to be free from any harsh, cruel, unusual, unnecessary, demeaning, or humiliating punishment Narrative: This standard was evaluated and found to be in compliance. 748.1101(b)(5) High Category Standard # Weight Children's Rights Short Description Training and Professional Development Annual Training-Every 6 months a caregiver must complete at least 748.931(1)(B) 4 hours of training in EBI Narrative: In reviewing staff's training reports, Ms. Howard is not current in her EBI training hours. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding High Deficiency Admn Rvw Waived Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1635758 06/30/2008 02:00:00 06/30/2008 04:15:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1634628 06/24/2008 02:00:00 06/24/2008 04:00:00 N Category Short Description Medication Medication Record-Must include accurate running count of each prescribed medication Narrative: One resident medical record reviewed did not contain running counts for six medications. Activity Type: Investigation Number Note: Prior to January 1, 2007, all Standards were not associated with a weight. Standard # Weight 748.2151(a)(8) High TA Finding Date Intake Rcvd: Deficiency Admn Rvw Waived Warning Letter/Due Notice given Page 69 of 187 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Investigation Medium: 139 550539 Category Run date: July 17, 2018 Compliance History Report Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 06/24/2008 12:00:00 Short Description N Standard # Weight Medical care-A child in care must receive medical care as needed for injury, illness, and pain Narrative: This standard was evaluated and found in compliance. 748.1531(a)(2) High Category Standard # Weight 748.1101(b)(5) High Child Care Short Description Children's Rights Children's rights-Adhere to the child's rights to be free from any harsh, cruel, unusual, unnecessary, demeaning, or humiliating punishment Narrative: This standard was evaluated and found in compliance. Activity Type: Investigation Number Date Intake Rcvd: Investigation 549450 06/19/2008 09:50:00 Category Short Description Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks Narrative: Standard evaluated and found to be in compliance. 748.507(1) Medium High Category Standard # Weight Children's Rights Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: Standard evaluated and found to be in compliance. High Category Weight Short Description TA Finding Admn Rvw Compliance N Weight Short Description Admn Rvw Compliance Warning Letter/Due Notice given Standard # Personnel TA Finding Standard # Discipline and Punishment Corporal Punishment-corporal punishment of hitting or spanking a 748.2303(b)(1) child with a hand or instrument is prohibited Narrative: Standard evaluated and found to be in compliance. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding High Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1633402 06/19/2008 09:50:00 06/19/2008 11:45:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Note: Prior to January 1, 2007, all Standards were not associated with a weight. Page 70 of 187 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Investigation Inspection 1632769 06/12/2008 02:30:00 06/12/2008 03:30:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1632682 06/12/2008 10:00:00 06/12/2008 02:32:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1633168 06/03/2008 08:30:00 06/03/2008 11:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 546883 06/02/2008 01:00:00 Category Short Description Warning Letter/Due Notice given N Standard # Children's Rights Weight Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: This standard was evaluated and found to be in compliance. High Category Weight Short Description Standard # Emergency Behavior Intervention Emergency Behavior Intervention-Basis for EBI is emergency 748.2455(2) situation, to administer medication, or property damage (short personal restraint only) Narrative: A child that is running away from the facility does not constitute an emergency situation per minimum standards. Medium Category Short Description Standard # Weight Other Prohibited Punishments-any harsh, cruel, unusual, unnecessary, demeaning, or humiliating discipline/punishment Narrative: This standard was evaluated and found to be in compliance. 748.2307(1) High Category Standard # Weight 748.507(1) Medium High Discipline and Punishment Short Description Personnel Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks Narrative: This standard was evaluated and found to be in compliance. TA Finding Admn Rvw Compliance TA Finding Deficiency TA Finding Admn Rvw Waived Admn Rvw Compliance TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1631475 06/02/2008 09:00:00 06/02/2008 11:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Note: Prior to January 1, 2007, all Standards were not associated with a weight. Warning Letter/Due Notice given Page 71 of 187 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Investigation Medium: 139 546561 Category Run date: July 17, 2018 Compliance History Report Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 06/02/2008 08:00:00 Short Description N Standard # Children's Rights Weight Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: The standard evaluated was found to be in compliance. High Category Standard # Weight 748.2455(1) Medium Short Description Emergency Behavior Intervention Emergency Behavior Intervention-Before using EBI, the caregiver must attempt less restrictive interventions that prove to be ineffective Narrative: The standard evaluated was found to be in compliance. Activity Type: Investigation Number Date Intake Rcvd: Investigation 546671 06/02/2008 08:00:00 Category Short Description Weight Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: The standard evaluated was found to be in compliance. High Category Standard # Weight Other Prohibited Punishments-any harsh, cruel, unusual, unnecessary, demeaning, or humiliating discipline/punishment Narrative: The standard evaluated was found to be in compliance. 748.2307(1) High Category Standard # Weight 748.507(1) Medium High Short Description Personnel Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks Narrative: The standard evaluated was found to be in compliance. TA Finding Admn Rvw Compliance N Children's Rights Short Description Admn Rvw Compliance Warning Letter/Due Notice given Standard # Discipline and Punishment TA Finding TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 546238 05/29/2008 04:14:00 N Category Short Description Note: Prior to January 1, 2007, all Standards were not associated with a weight. Standard # Weight TA Finding Page 72 of 187 Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Children's Rights Not Available: 4 Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: Standard was evaluated and found to be in compliance. High Category Short Description Standard # Weight Other Prohibited Punishments-any harsh, cruel, unusual, unnecessary, demeaning, or humiliating discipline/punishment Narrative: Standard was evaluated and found to be in compliance. 748.2307(1) High Category Standard # Weight Discipline and Punishment Short Description Discipline and Punishment Corporal Punishment-corporal punishment of hitting or spanking a 748.2303(b)(1) child with a hand or instrument is prohibited Narrative: Standard was evaluated and found to be in compliance. Compliance TA Finding Admn Rvw Compliance TA Finding High Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1626075 05/13/2008 01:00:00 05/13/2008 02:00:00 N Category Short Description Standard # Weight Physical Site-Buildings must be structurally sound, clean, and in good repair. Paints must be lead-free Narrative: In Curry House, there were 2 cabinets missing handles in the area of the entry of the garage. 748.3301(a) High Category Standard # Weight 748.3301(c) Medium Physical Site Short Description Physical Site Physical Site-Windows & doors must be in good repair & free of broken glass or hazards Narrative: In Curry House, the blinds were broken in the 2nd bedroom on the right hand side. TA Finding Deficiency TA Finding Deficiency Admn Rvw Waived Admn Rvw Waived Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1625991 05/06/2008 11:45:00 05/06/2008 12:30:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 541849 05/05/2008 09:00:00 N Category Short Description Children's Rights Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Note: Prior to January 1, 2007, all Standards were not associated with a weight. Standard # Weight TA Finding High Page 73 of 187 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Narrative: Category Short Description Standard # Weight TA Finding Emergency Behavior Intervention Admn Rvw Emergency Behavior Intervention-Never used as a means to get a 748.2463(3) Medium Deficiency child to comply High Narrative: After interviews with the resident and staff, the resident was restrained as he was not complying with staff and he was not being a danger to himself or to others. Overturned Category Short Description Admn Rvw Emergency Behavior Intervention Narrative: Personal Restraints Prohibited-Restraints that obstruct child's airway748.2605(a)(2) High Category Short Description Standard # Weight Personnel Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks 748.507(1) Medium High Standard # Weight TA Finding Compliance TA Finding Admn Rvw Compliance Narrative: Activity Type: Investigation Number Date Intake Rcvd: Investigation 540300 04/28/2008 10:00:00 Category Short Description Warning Letter/Due Notice given N Standard # Weight TA Finding Admn Rvw Personnel Employee general responsibilities-Report suspected abuse, neglect, 748.507(2) Medium Deficiency Overturned and exploitation to Child Abuse Hotline and the designated High employee/administrator Narrative: Staff person disclosed having knowledge of other staff persons abusing and or neglecting the residents. Staff person did not report the incidents to supervisor or administrative personnel. Category Short Description Standard # Weight TA Finding Admn Rvw Personnel Employee general responsibilities-Demonstrate competency, 748.507(1) Medium Deficiency Waived prudent judgment, self-control in presence of children and when High performing assigned tasks Narrative: Two staff persons instructed seven developmentally delayed residents to fight. Staff persons failed to intervene and discontinue the fight. Residents were given a snack as a reward for winning the fight. According to residents the staff persons laughed and cheered as the residents fought. Category Short Description Children's Rights Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Note: Prior to January 1, 2007, all Standards were not associated with a weight. Standard # Weight TA Finding High Page 74 of 187 Deficiency Admn Rvw Upheld Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Narrative: Assigned house supervisor and staff person instructed residents to fight. The incident resulted in residents sustaining injuries. Category Short Description Standard # Personnel Caregiver responsibility - being able to intervene when necessary to 748.685(a)(5) ensure child's safety Narrative: Staff persons failed to intervene and discontinue the fighting between the residents. Activity Type: Investigation Number Date Intake Rcvd: Investigation 540318 04/28/2008 10:00:00 Category Short Description Weight Weight Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: Standard has been evaluated and found to be compliant. High Category Standard # Weight EBI Implementation-Caregiver must use the minimal amount of reasonable and necessary physical force Narrative: Standard has been evaluated and found to be compliant. 748.2551(c)(2) Medium High Category Short Description Standard # Weight Emergency Behavior Intervention-Never used as a means to get a child to comply Narrative: Standard has been evaluated and found to be compliant. 748.2463(3) Medium High Category Standard # Weight Emergency Behavior Intervention Short Description Admn Rvw Waived N Children's Rights Short Description Deficiency Warning Letter/Due Notice given Standard # Emergency Behavior Intervention TA Finding High Emergency Behavior Intervention Short Personal Restraint-Caregiver may not use restraint that twists 748.2461(b)(6) or places the child's limb(s) behind the child's back Narrative: Staff pulled residents arms behind his back while performing a restraint. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding High Deficiency Admn Rvw Waived Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1621075 04/09/2008 12:45:00 04/09/2008 04:15:00 N Category Short Description Note: Prior to January 1, 2007, all Standards were not associated with a weight. Standard # Weight TA Finding Page 75 of 187 Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Personnel Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being Narrative: This standard was evaluated and found to be in compliance. Weight: Id/Number: Admin Review Status: Low: 6 748.685(a)(4) Not Available: 4 High Compliance Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 534629 04/09/2008 12:00:00 N Category Short Description Personnel Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being Narrative: This standard was evaluated and found to be in compliance. Activity Type: Investigation Number Date Intake Rcvd: Investigation 533343 03/20/2008 03:00:00 Category Short Description Standard # Weight 748.685(a)(4) High N Weight Disciplinary Measures-must not be physically or emotionally damaging to the child Narrative: This standard was evaluated and found to be in compliance. 748.2301(b)(2) Medium High Category Standard # Weight Short Description Admn Rvw Compliance Warning Letter/Due Notice given Standard # Discipline and Punishment TA Finding Children's Rights Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: This standard was evaluated and found to be in compliance. TA Finding Admn Rvw Compliance TA Finding High Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1617997 03/20/2008 02:30:00 03/20/2008 05:15:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1617261 03/17/2008 02:00:00 03/17/2008 03:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1614612 03/14/2008 11:00:00 03/14/2008 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Note: Prior to January 1, 2007, all Standards were not associated with a weight. Warning Letter/Due Notice given Page 76 of 187 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Investigation Medium: 139 531751 Category Run date: July 17, 2018 Compliance History Report Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 03/14/2008 08:00:00 Short Description N Standard # Children's Rights Weight Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: The standard evaluated was found to be in compliance. High Category Weight Short Description Standard # Safety and Emergency Practices Serious Incident-Report to Licensing as soon as aware of 748.303(a)(3)(A) allegations or indications of abuse, neglect, or exploitation of a child Narrative: The standard evaluated was found to be in compliance. Medium High Category Standard # Weight 748.685(a)(4) High Short Description Personnel Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being Narrative: The standard evaluated was found to be in compliance. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1616488 03/12/2008 03:00:00 03/12/2008 04:15:00 N Category Short Description Standard # Physical Site Food Preparation-Must keep furniture, equipment, surfaces & other 748.3441(c) areas where food is prepared, eaten or stored clean & in good repair Narrative: There was a build-up of old food on the stove. Weight TA Finding Medium Deficiency Admn Rvw Waived Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1620438 03/12/2008 11:00:00 03/12/2008 11:45:00 N Category Short Description Standard # Children's Rights Weight Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: Standard was evaluated and found to be in compliance. High Category Short Description Standard # Weight Personnel Caregiver Supervision-Provide oversight of caregivers to protect children's health, safety and well-being 748.683(1) Medium Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Admn Rvw Compliance TA Finding Page 77 of 187 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Narrative: Standard was evaluated and found to be in compliance. Activity Type: Investigation Number Date Intake Rcvd: Investigation 531385 03/08/2008 08:00:00 Warning Letter/Due Notice given N Category Short Description Standard # Weight Children's Rights Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 High Short Description TA Finding Admn Rvw Compliance Narrative: Category Standard # Weight Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks Narrative: A staff member grabbed a child around the neck in a choking manner. 748.507(1) Medium High Category Standard # Weight 748.2461(a)(2) Medium High Personnel Short Description Emergency Behavior Intervention Short Personal Restraint-Caregiver must use minimal amount of reasonable and necessary physical force Narrative: A child in care received a scratch on the nose as a result of a physical restraint. Activity Type: Investigation Number Date Intake Rcvd: Investigation 529428 03/06/2008 12:00:00 Category Short Description TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Warning Letter/Due Notice given N Standard # Weight TA Finding Admn Rvw Safety and Emergency Practices Safety Practices-Children must be able to open emergency exit 748.3237(c) Medium Compliance doors easily from inside, unless written approval on file from fire High inspector Narrative: Amy Cuellar of Daystar faxed to Licensing Rep a floor plan and fire marshall inspection which clearly documented the cottage against which the allegation was made, consisted of 4 exits within the facility designated as evacuation exits. The dresser in the bedroom that blocks a door leading to the outside is not a designated escape route. Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 530215 03/03/2008 10:00:00 N Category Short Description Note: Prior to January 1, 2007, all Standards were not associated with a weight. Standard # Weight TA Finding Page 78 of 187 Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Discipline and Punishment Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Other Prohibited Punishments-any harsh, cruel, unusual, unnecessary, demeaning, or humiliating discipline/punishment Narrative: This standard was evaluated and found to be in compliance. 748.2307(1) High Category Standard # Weight Short Description Children's Rights Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: This standard was evaluated and found to be in compliance. Compliance TA Finding High Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1614962 02/29/2008 08:30:00 02/29/2008 10:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1612493 02/20/2008 12:00:00 02/20/2008 05:30:00 N Category Short Description Standard # Background Checks - TAC 745 Background checks submitted-every 24 months after first submitted 745.625(a)(4) Narrative: One staff member did not have a current background check. Activity Type: Investigation Number Date Intake Rcvd: Investigation 527902 02/20/2008 12:00:00 Category Short Description Children's Rights Children's rights-Adhere to the child's rights to be free from any harsh, cruel, unusual, unnecessary, demeaning, or humiliating punishment Narrative: This standard was evaluated and found to be in compliance. Activity Type: Investigation Number Date Intake Rcvd: Investigation 527982 02/20/2008 12:00:00 Category Short Description Child Care Medical care-A child in care must receive medical care as needed for injury, illness, and pain Narrative: This standard was evaluated and found to be in compliance. Note: Prior to January 1, 2007, all Standards were not associated with a weight. Weight TA Finding High Deficiency Admn Rvw Waived Warning Letter/Due Notice given N Standard # Weight 748.1101(b)(5) High TA Finding Admn Rvw Compliance Warning Letter/Due Notice given N Standard # Weight 748.1531(a)(2) High TA Finding Page 79 of 187 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Category Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Short Description Personnel Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being Narrative: This standard was evaluated and found to be in compliance. Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Standard # Weight 748.685(a)(4) High TA Finding Admn Rvw Compliance Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 530128 02/19/2008 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 524683 02/01/2008 11:45:00 Category Short Description Emergency Behavior Intervention EBI Implementation-Caregiver must use the minimal amount of reasonable and necessary physical force Narrative: Standard has been evaluated and found to be compliant. N Standard # Weight 748.2551(c)(2) Medium High TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1609292 02/01/2008 11:45:00 02/01/2008 12:15:00 N Category Short Description Standard # Children's Rights Weight Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: Standard has been evaluated and found to be compliant. High Category Standard # Weight 748.2551(c)(1) Medium High Short Description Emergency Behavior Intervention EBI Implementation-Caregiver must minimize risk of physical discomfort, harm, or pain to the child Narrative: Standard has been evaluated and found to be compliant. Activity Type: Inspection Id Date Begin: Monitoring Inspection 1605982 01/14/2008 08:30:00 Category Short Description Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding TA Finding Admn Rvw Compliance Date End: Warning Letter/Due Notice given 01/14/2008 04:30:00 Standard # Admn Rvw Compliance N Weight TA Finding Page 80 of 187 Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Drug Testing - TAC 745 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Mandatory drug testing-all applicants intended to be hired are subject to pre-employment testing, must have results prior to child access Narrative: Two out of ten employee records reviewed did not contain documentation of pre-employment drug test 745.4151(c)(4)(A) High Category Short Description Standard # Weight Physical Site Physical Site-Buildings must be structurally sound, clean, and in good repair. Paints must be lead-free 748.3301(a) High Deficiency TA Finding Deficiency Waived Admn Rvw Waived Narrative: Humphrey 4 *Bedroom behind kitchen on the right was seen with a 12' crack next to the closet door and a 4' crack on the wall behind the door in need of repair. *Corner molding on half wall in kitchen was loose and needed securing. Curry House *1st bathroom seen with mold spots on ceiling and walls (needs to be clean and sanitized) *Faucet dripping in bathtub in need of tightening. *Microwave dirty with food particles. *Several cabinets in kitchen missing knobs. *Refrigerator seen with a broken handle Wood House *Microwave seen with food particles. -Broken window blind seen in 1st room. -Broken window blind in kitchen seen taped together -Drawer at the bottom of stove seen broken off track. Curry 3 *Entire house seen with thick dust (Entire house needs dusting). Bahler *Broken window blind viewed in second room on right side. Bedynek *Stove, microwave and refrigerator all seen with food particles and liquid spill. Category Short Description Standard # Weight Physical Site Physical Site-All living quarters must be provided with electric services 748.3307(a) Medium Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Page 81 of 187 Deficiency Admn Rvw Waived Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Narrative: Bedynek *Several rooms in the house were dark without working light bulbs. Category Short Description Standard # Weight Physical Site Bathrooms-Must be maintained in good repair & kept clean 748.3391(a) Medium High Standard # Weight TA Finding Deficiency Admn Rvw Waived Narrative: Bedynek *Bathtub in 1st bathroom viewed with thick rust stains. Category Short Description Physical Site Narrative: Wood House *Loaf of bread viewed untied. Food Preparation-Food items must be protected from contamination 748.3443(a)(3) Medium Category Short Description Standard # Weight Reports and Record Keeping Personnel records-Include current job description 748.363(3) Medium Low Standard # Weight TA Finding Deficiency TA Finding Deficiency Admn Rvw Waived Admn Rvw Waived Narrative: Ten employee records reviewed did not contain documentation of current job description. Category Short Description Reports and Record Keeping Personnel records-Include copy of a cleared tuberculosis screening 748.363(5) conducted prior to the person having contact with children in care Narrative: One out ot ten employee records reviewed did not contain documentation of tuberculosis screening. Medium Low Category Weight Short Description Standard # Reports and Record Keeping Personnel records-Include notarized Licensing Affidavit for 748.363(6) Applicants for Employment form as specified in Human Resources Code, 42.059 Narrative: Four out of ten employee records reviewed did not contain documentation of signed affidavits Medium Low Category Weight Short Description Standard # Training and Professional Development Pre-Service Training-Caregiver must have 16 hrs EBI training or 8 748.863(a)(2) hrs if operation prohibits EBI, before being only caregiver responsible for a child Narrative: Two out of ten employee records reviewed did not contain documentation that employee received 16 hrs EBI pre-service training Medium High Category Weight Short Description Note: Prior to January 1, 2007, all Standards were not associated with a weight. Standard # TA Finding Deficiency TA Finding Deficiency TA Finding Deficiency TA Finding Page 82 of 187 Admn Rvw Waived Admn Rvw Waived Admn Rvw Waived Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Training and Professional Development Not Available: 4 General pre-service training curriculum-Includes topics appropriate 748.881(1) to the needs of children for whom the caregiver will be providing care Narrative: Two out of ten records reviewed did not contain documentation of areas covered at orientation Medium Category Weight Short Description Standard # Training and Professional Development Annual Training-Caregivers in an operation that provides a certain 748.931(2)(A) amount of treatment services must complete 50 hrs Narrative: Two out of ten employee records reviewed did not contain verification that 50 annual training hours were obtained High Category Standard # Weight 748.981(a)(1) High Short Description Training and Professional Development First-aid-CPR training-Each caregiver must have current certification in first-aid & CPR appropriate for children served Narrative: *One out of ten employee records reviewed did not contain documentation of current 1st aid training. *Two out of ten employee records reviewed did not contain documentation of current CPR training. Activity Type: Investigation Number Date Intake Rcvd: Investigation 521017 01/14/2008 12:00:00 Category Short Description Serious Incident-Report to Licensing no later than 24 hours after injury/illness that warrants treatment by a medical professional or hospitalization Narrative: This standard was evaluated and found in compliance. 748.303(a)(2)(A)(ii) Medium Category Standard # Weight 748.1531(a)(2) High Short Description Medical care-A child in care must receive medical care as needed for injury, illness, and pain Narrative: This standard was evaluated and found in compliance. Deficiency TA Finding Deficiency Admn Rvw Waived Admn Rvw Waived N Weight Child Care TA Finding Waived Warning Letter/Due Notice given Standard # Reports and Record Keeping Deficiency TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1605098 01/08/2008 02:00:00 01/08/2008 03:00:00 N Category Short Description Standard # Physical Site Physical Site-The building must be free of rodents and insects 748.3301(h) Narrative: Worker observed dead insects in the windowsill located in the bedroom on the right side of the house in the Curry 3 house. Note: Prior to January 1, 2007, all Standards were not associated with a weight. Weight TA Finding Medium Page 83 of 187 Deficiency Admn Rvw Waived Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Category Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Short Description Weight: Id/Number: Admin Review Status: Low: 6 Standard # Physical Site Not Available: 4 Weight Physical Site-Equipment and furniture must be safe for children and 748.3301(i) must be kept clean and in good repair Narrative: One bed in two different houses (Curry 3 and Wood House) are sitting on milk crates. Medium Category Weight Short Description Standard # TA Finding Deficiency TA Finding Physical Site Poisons-Ensure poisonous or flammable materials are inaccessible 748.3421(3) Medium to children unless child has been evaluated as capable & likely to use responsibly Narrative: In the bathroom located in the bedroom on the right side of the house four bottles of cleaning solution was observed in an unlocked cabinet. Deficiency Admn Rvw Waived Admn Rvw Waived This was corrected at inspection. Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1604614 01/07/2008 01:00:00 01/07/2008 05:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 519675 01/07/2008 12:00:00 N Category Short Description Standard # Children's Rights Children's rights-Adhere to the child's rights to appropriate care and 748.1101(b)(1) treatment in least restrictive setting available that meets the child's needs Narrative: Standard was evaluated and found in compliance. Weight TA Finding Medium High Admn Rvw Compliance Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 520275 01/04/2008 01:00:00 N Category Short Description Standard # Weight Children's rights-Adhere to the child's rights to be free from being denied food, sleep, toileting facilities, mail, or family visits as punishment Narrative: Standard was evaluated and found to be compliant. 748.1101(b)(5)(E) High Category Standard # Weight Children's Rights Short Description Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Admn Rvw Compliance TA Finding Page 84 of 187 Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Children's Rights Not Available: 4 Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: Standard was evaluated and found to be compliant. High Category Standard # Weight 748.1101(b)(6) Medium High Short Description Children's Rights Children's rights-Adhere to the child's right to discipline that is appropriate to the child's age and developmental level; Narrative: Standard was evaluated and found to be compliant. Compliance TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1603929 12/31/2007 01:30:00 12/31/2007 03:30:00 N Category Short Description Standard # Weight Intentional, knowing, or reckless act or omission-deliberately causes or might cause physical injury or emotional harm Narrative: Standard evaluated and found in compliance. 745.8555(b)(1) High Category Abuse/Neglect Definitions - TAC 745 Short Description Standard # Weight Children's rights-Adhere to the child's right to have personal possessions at his home and to acquire additional possessions within limits Narrative: Standard evaluated and found in compliance. 748.1101(b)(13) Medium Low Category Children's Rights Short Description Standard # Weight Children's rights-Adhere to the child's rights to be free from being subjected to corporal punishment Narrative: Standard evaluated and found in compliance. 748.1101(b)(5)(B) High Category Standard # Weight Children's Rights Short Description Children's Rights Children's rights-Adhere to the child's right to have a humane 748.1101(b)(8) environment, including any treatment environment, which provides protection from harm Narrative: Standard evaluated and found in compliance. High Category Weight Short Description Note: Prior to January 1, 2007, all Standards were not associated with a weight. Standard # TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Page 85 of 187 Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Children's Rights Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Children's Rights prohibited techniques-Prohibited from using aversive conditioning, including any technique likely to cause a child physical pain Narrative: Standard evaluated and found in compliance. 748.1119(2) High Category Short Description Standard # Weight Behavior intervention policies-Include a complete description of emergency behavior interventions that caregivers are permitted to use Narrative: Standard evaluated and found in compliance. 748.237(1) Medium High Category Standard # Weight Organization and Administration Short Description Organization and Administration Behavior intervention policies-Include qualifications for caregivers 748.237(3) who use it, evaluation to determine qualifications met, and on-going evaluation Narrative: Standard evaluated and found in compliance. Activity Type: Investigation Number Date Intake Rcvd: Investigation 519679 12/31/2007 12:00:00 Category Short Description Compliance TA Finding Admn Rvw Compliance TA Finding Medium High Admn Rvw Compliance Warning Letter/Due Notice given N Standard # Emergency Behavior Intervention Personal Restraints Prohibited-Prone and supine restraints except as 748.2605(b)(1) a transitional hold that lasts no longer than 1 minute Narrative: Standard evaluated and found in compliance. Weight TA Finding High Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1602547 12/19/2007 09:00:00 12/19/2007 11:30:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 517523 12/14/2007 03:56:00 Category Short Description Children's Rights Warning Letter/Due Notice given N Standard # Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: This standard was evaluated and found to be in compliance. Note: Prior to January 1, 2007, all Standards were not associated with a weight. Weight TA Finding High Page 86 of 187 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Category Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Short Description Weight: Id/Number: Admin Review Status: Low: 6 Standard # Discipline and Punishment Corporal Punishment-corporal punishment of hitting or spanking a 748.2303(b)(1) child with a hand or instrument is prohibited Narrative: This standard was evaluated and found to be in compliance. Not Available: 4 Weight TA Finding High Admn Rvw Compliance Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 517606 12/14/2007 01:34:00 N Category Short Description Standard # Children's Rights Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: Standard was evaluated and found to be in compliance. Activity Type: Investigation Number Date Intake Rcvd: Investigation 512010 11/14/2007 09:00:00 Category Short Description Weight TA Finding High Admn Rvw Compliance Warning Letter/Due Notice given N Standard # Children's Rights Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: Standard was evaluated and found to be in compliance. Weight TA Finding High Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1597196 11/14/2007 09:00:00 11/14/2007 11:30:00 N Category Short Description Physical Site Physical Site-Buildings must be structurally sound, clean, and in good repair. Paints must be lead-free Narrative: The bathroom had a strong urine odor. The bath tub had a build-up of soap scum. (Curry House 1) Activity Type: Inspection Id Date Begin: Investigation Inspection 1591517 10/12/2007 02:00:00 Category Short Description Note: Prior to January 1, 2007, all Standards were not associated with a weight. Standard # Weight 748.3301(a) High TA Finding Deficiency Date End: Waived Warning Letter/Due Notice given 10/12/2007 02:45:00 Standard # Admn Rvw N Weight TA Finding Page 87 of 187 Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Physical Site Physical Site-Buildings must be structurally sound, clean, and in good repair. Paints must be lead-free Narrative: Worker observed the insulation around the front door was exposed. Weight: Id/Number: Admin Review Status: Low: 6 748.3301(a) Not Available: 4 High Deficiency Waived Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1591312 10/11/2007 02:35:00 10/11/2007 04:30:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 505718 10/11/2007 12:00:00 N Category Short Description Child/Caregiver Ratios Child/caregiver ratio-Must employ an adequate number of caregivers to meet children's needs and consider amount of supervision needed Narrative: This standard was evaluated and found to be in compliance. Standard # Weight 748.1009(a) High TA Finding Admn Rvw Compliance Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 504772 10/05/2007 11:30:00 N Category Short Description Standard # Children's Rights Weight Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: This standard was evaluated and found to be in compliance. High Category Standard # Weight 748.2301(b)(2) Medium High Short Description Discipline and Punishment Disciplinary Measures-must not be physically or emotionally damaging to the child Narrative: This standard was evaluated and found to be in compliance. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1589096 09/28/2007 01:00:00 09/28/2007 03:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 502323 09/24/2007 05:00:00 N Note: Prior to January 1, 2007, all Standards were not associated with a weight. Page 88 of 187 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Category Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Short Description Weight: Id/Number: Admin Review Status: Low: 6 Standard # Children's Rights Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: Standard was evaluated and found to be in compliance. Not Available: 4 Weight TA Finding High Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1587714 09/20/2007 12:30:00 09/20/2007 02:30:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 501536 09/20/2007 11:00:00 N Category Short Description Standard # Children's Rights Weight Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: The standard evaluated was found to be in compliance. High Category Standard # Weight 748.2301(b)(1) Medium Low Short Description Discipline and Punishment Disciplinary Measures-must be consistent with operation policies and procedures Narrative: The standard evaluated was found to be in compliance. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1589116 09/20/2007 11:00:00 09/20/2007 01:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 500434 09/14/2007 02:00:00 N Category Short Description Standard # Children's Rights Weight Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: This standard was evaluated and found to be in compliance. High Category Standard # Weight 748.2301(b)(1) Medium Low Short Description Discipline and Punishment Disciplinary Measures-must be consistent with operation policies and procedures Narrative: This standard was evaluated and found to be in compliance. Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Admn Rvw Compliance TA Finding Page 89 of 187 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Category Short Description Physical Site Physical Site-Equipment and furniture must be safe for children and 748.3301(i) must be kept clean and in good repair Standard # Not Available: 4 Weight TA Finding Medium Admn Rvw Compliance Narrative: Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1584365 08/31/2007 01:20:00 08/31/2007 02:30:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 497141 08/31/2007 12:00:00 Category Short Description Children's Rights Children's rights-Adhere to the child's rights to be free from any harsh, cruel, unusual, unnecessary, demeaning, or humiliating punishment Narrative: This standard was evaluated and found to be in compliance. Activity Type: Inspection Id Date Begin: Investigation Inspection 1584068 08/29/2007 01:00:00 Category Short Description Warning Letter/Due Notice given N Standard # Weight 748.1101(b)(5) High TA Finding Date End: Warning Letter/Due Notice given 08/29/2007 02:30:00 Standard # Admn Rvw Compliance N Weight TA Finding Physical Site Poisons-Ensure poisonous or flammable materials are inaccessible 748.3421(3) Medium Deficiency to children unless child has been evaluated as capable & likely to use responsibly Narrative: There was clorox wipes on the table near the back bedroom and disinfectant spray in the top of the closet, that was left out and accessible to the children in the home. Admn Rvw Waived Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1582764 08/24/2007 09:30:00 08/24/2007 04:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 495382 08/24/2007 12:00:00 N Category Short Description Note: Prior to January 1, 2007, all Standards were not associated with a weight. Standard # Weight TA Finding Page 90 of 187 Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Children's Rights Children's rights-Adhere to the child's rights to be free from any harsh, cruel, unusual, unnecessary, demeaning, or humiliating punishment Narrative: Standard was evaluated and found in compliance. Weight: Id/Number: Admin Review Status: Low: 6 748.1101(b)(5) Not Available: 4 High Compliance Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 496289 08/24/2007 12:00:00 N Category Short Description Emergency Behavior Intervention Emergency Behavior Intervention-Never used as a means to get a child to comply Narrative: This standard was evaluated and found to be in compliance. Activity Type: Investigation Number Date Intake Rcvd: Investigation 495611 08/17/2007 12:00:00 Category Short Description Standard # Weight 748.2463(3) Medium High Admn Rvw Compliance Warning Letter/Due Notice given N Standard # Personnel Weight Caregiver responsibility - providing the level of supervision 748.685(a)(4) necessary to ensure each child's safety and well-being Narrative: Resident has a history of self injurious behavior and she has found/gained access to a bread wrapper wire to stick into her arm. High Category Weight Short Description TA Finding Standard # Children's Rights Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: This standard was evaluated and found to be in compliance. TA Finding Deficiency TA Finding High Admn Rvw Overturned Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1579359 07/30/2007 10:30:00 07/30/2007 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 493031 07/30/2007 12:00:00 Warning Letter/Due Notice given N Category Short Description Children's Rights Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Note: Prior to January 1, 2007, all Standards were not associated with a weight. Standard # Weight TA Finding High Page 91 of 187 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Narrative: Compliance Met. Category Short Description Standard # Weight Children's Rights Children's rights-Adhere to the child's right to discipline that is appropriate to the child's age and developmental level; 748.1101(b)(6) Medium High Category Short Description Standard # Weight Personnel Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being 748.685(a)(4) High TA Finding Admn Rvw Compliance Narrative: Compliance Met. TA Finding Admn Rvw Compliance Narrative: Compliance Met. Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Other Inspection 1577594 07/18/2007 01:00:00 07/18/2007 02:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1576583 07/06/2007 02:00:00 07/06/2007 04:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1576460 07/06/2007 10:00:00 07/06/2007 12:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1574215 06/26/2007 03:00:00 06/26/2007 04:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 488128 06/26/2007 12:00:00 Category Short Description Personnel Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being Narrative: This standard was evaluated and found to be in compliance. Warning Letter/Due Notice given N Standard # Weight 748.685(a)(4) High TA Finding Admn Rvw Compliance Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 487357 06/22/2007 12:00:00 N Category Short Description Note: Prior to January 1, 2007, all Standards were not associated with a weight. Standard # Weight TA Finding Page 92 of 187 Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Children's Rights Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: Standard was evaluated and found to be in compliance. Not Available: 4 High Compliance Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 485376 06/08/2007 12:00:00 N Category Short Description Standard # Children's Rights Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: Standard was evaluated and found to be in compliance. Weight TA Finding High Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1571132 06/06/2007 09:00:00 06/06/2007 10:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1571138 06/06/2007 09:00:00 06/06/2007 11:30:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1571141 05/25/2007 09:00:00 05/25/2007 11:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 483789 05/25/2007 12:00:00 Warning Letter/Due Notice given N Category Short Description Standard # Weight Children's Rights Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 High Category Short Description Standard # Weight Discipline and Punishment Disciplinary Measures-must be consistent with operation policies and procedures 748.2301(b)(1) Medium Low TA Finding Admn Rvw Compliance Narrative: Compliance Met. TA Finding Admn Rvw Compliance Narrative: Compliance Met. Activity Type: Investigation Number Note: Prior to January 1, 2007, all Standards were not associated with a weight. Date Intake Rcvd: Warning Letter/Due Notice given Page 93 of 187 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Investigation Medium: 139 483854 Category Run date: July 17, 2018 Compliance History Report Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 05/25/2007 12:00:00 Short Description N Standard # Children's Rights Weight Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: This standard was evaluated and found to be in compliance. High Category Standard # Weight 748.2307(1) High Short Description Discipline and Punishment Other Prohibited Punishments-any harsh, cruel, unusual, unnecessary, demeaning, or humiliating discipline/punishment Narrative: This standard was evaluated and found to be in compliance. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 483593 05/24/2007 12:00:00 N Category Short Description Standard # Weight Disciplinary Measures-must be consistent with operation policies and procedures Narrative: Standard was evaluated and found to be in compliance. 748.2301(b)(1) Medium Low Category Standard # Weight Discipline and Punishment Short Description Children's Rights Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: Standard was evaluated and found to be in compliance. TA Finding Admn Rvw Compliance TA Finding High Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1568807 05/21/2007 03:00:00 05/21/2007 05:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 480915 05/21/2007 12:00:00 N Category Short Description Personnel Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being Narrative: This standard was evaluated and found to be in compliance. Note: Prior to January 1, 2007, all Standards were not associated with a weight. Standard # Weight 748.685(a)(4) High TA Finding Page 94 of 187 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1563914 04/20/2007 09:30:00 04/20/2007 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 477487 04/20/2007 12:00:00 N Category Short Description Standard # Children's Rights Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: This standard was evaluated and found to be in compliance. Weight TA Finding High Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Monitoring and Investigation Inspection 1563446 04/19/2007 08:30:00 04/19/2007 03:00:00 N Category Short Description Physical Site Physical Site-Buildings must be structurally sound, clean, and in good repair. Paints must be lead-free Narrative: In Draeger I, a window block was loose. Standard # Weight 748.3301(a) High TA Finding Deficiency Admn Rvw Waived In Bickerstaff II, there was a hole in a bedroom closet door. Category Short Description Standard # Weight Physical Site-Windows & doors must be in good repair & free of broken glass or hazards Narrative: In Mustang, there was a hole in the center bathroom window. 748.3301(c) Medium Category Physical Site Standard # Weight Physical Site Physical Site-The building must be free of rodents and insects Narrative: In Patterson, there was a wasp nest outside the back door. Short Description 748.3301(h) Medium Category Standard # Weight Short Description Physical Site Physical Site-Equipment and furniture must be safe for children and 748.3301(i) must be kept clean and in good repair Narrative: In Draeger II, the a/c filter needed cleaning and the kitchen table bench was not stable. Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Deficiency TA Finding Deficiency TA Finding Medium Page 95 of 187 Deficiency Admn Rvw Waived Admn Rvw Waived Admn Rvw Waived Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 In Bickerstaff II, the a/c filters and covers needed cleaning. In Bickerstaff I, the a/c cover needed cleaning, ther was a broken mini-blind, there was an exposed nail on the fireplace base, and the living room ceiling fan was unstable. Category Short Description Standard # Weight Physical Site Bathrooms-Must be maintained in good repair & kept clean 748.3391(a) Medium High TA Finding Deficiency Admn Rvw Waived Narrative: In Patterson, the upstairs shower and the bathroom fan were not working, and there was mold on the shower ceiling. Category Short Description Standard # Weight TA Finding Physical Site Poisons-Ensure poisonous or flammable materials are inaccessible 748.3421(3) Medium to children unless child has been evaluated as capable & likely to use responsibly Narrative: In Mustang, Patterson, and Draeger II, cleaning chemicals were found accessible to children. These were secured at the time of inspection. Deficiency Admn Rvw Waived Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1563571 04/19/2007 08:20:00 04/19/2007 04:00:00 N Category Short Description Standard # Medication Administration of Medication-Administer medications according to 748.2003(b)(3) label instructions or a prescribing health-care professional's subsequent orders Narrative: One child's record did not have proper documentation verifying a change. Weight TA Finding Medium High Deficiency Admn Rvw Waived Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 475581 04/19/2007 12:00:00 N Category Short Description Standard # Weight Medical care-A child in care must receive medical care as needed for injury, illness, and pain Narrative: This standard was evaluated and found in compliance. 748.1531(a)(2) High Category Standard # Weight Child Care Short Description Children's Rights Child Rights parent contact-Allow contact between a child and his 748.1107(a) parent whose parental rights have not been terminated Narrative: This standard was evaluated and found in compliance. Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Admn Rvw Compliance TA Finding Medium Low Page 96 of 187 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 475610 04/19/2007 12:00:00 N Category Short Description Standard # Children's Rights Children's rights-Adhere to child's right to send and receive 748.1101(b)(16) uncensored mail, have telephone conversations, visitors and keep a personal journal Narrative: This standard was evaluated and found in compliance. Weight TA Finding Medium Low Admn Rvw Compliance Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 476660 04/19/2007 12:00:00 N Category Short Description Emergency Behavior Intervention EBI Implementation-Caregiver must minimize risk of physical discomfort, harm, or pain to the child Narrative: This standard was evaluated and found to be in compliance. Standard # Weight 748.2551(c)(1) Medium High TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1559536 03/26/2007 08:30:00 03/26/2007 11:30:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 473310 03/22/2007 12:00:00 N Category Short Description Children's Rights Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Standard # Weight TA Finding High Admn Rvw Compliance Narrative: Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1557810 03/16/2007 11:30:00 03/16/2007 03:30:00 N Activity Type: Investigation Number Date Intake Rcvd: Note: Prior to January 1, 2007, all Standards were not associated with a weight. Warning Letter/Due Notice given Page 97 of 187 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Investigation Medium: 139 472089 Category Run date: July 17, 2018 Compliance History Report Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 03/16/2007 12:00:00 Short Description N Standard # Children's Rights Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: Standard was evaluated and found to be in compliance. Weight TA Finding High Admn Rvw Compliance Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 472117 03/16/2007 12:00:00 N Category Short Description Standard # Children's Rights Weight Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: Standard was evaluated and found to be in compliance. High Category Weight Short Description Standard # Emergency Behavior Intervention Short Personal Restraint-Caregiver may not use restraint that twists 748.2461(b)(6) or places the child's limb(s) behind the child's back Narrative: Two residents advised that staff have twisted their arms behind their back. (No injury has occurred.) High Category Weight Short Description Standard # Children's Rights Children's rights-Adhere to the child's rights to be free from being 748.1101(b)(5)(F) subjected to remarks that belittle or ridicule the child or the child's family Narrative: Two residents advised that staff have called them names such as "beaner" and "cracker". TA Finding Admn Rvw Compliance TA Finding Deficiency TA Finding Medium High Deficiency Admn Rvw Waived Admn Rvw Waived Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Monitoring and Investigation Inspection 1557092 03/14/2007 09:00:00 03/14/2007 04:00:00 Y Activity Type: Investigation Number Date Intake Rcvd: Investigation 470734 03/14/2007 12:00:00 Warning Letter/Due Notice given Y Category Short Description Emergency Behavior Intervention Short Personal Restraint-Caregiver must minimize risk of physical 748.2461(a)(1) discomfort, harm, or pain to child Note: Prior to January 1, 2007, all Standards were not associated with a weight. Standard # Weight TA Finding Medium High Page 98 of 187 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Narrative: A resident was observed to have visible carpet burns to his forehead, left cheek and chin area of his head. The resident stated the injuries occurred doing a restraint on 3/2/07. Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 471576 03/14/2007 12:00:00 Y Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 471739 03/13/2007 12:00:00 Category Short Description Y Standard # Children's Rights Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: Standard was evaluated and found to be in compliance. Weight TA Finding High Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1556566 03/08/2007 03:00:00 03/08/2007 05:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 470169 03/08/2007 12:00:00 Category Short Description Warning Letter/Due Notice given N Standard # Weight Medical care-A child in care must receive medical care as needed for injury, illness, and pain Narrative: This standard was evaluated and found to be in compliance. 748.1531(a)(2) High Category Standard # Weight Child Care Short Description Children's Rights Children's rights-Adhere to the child's rights to appropriate care and 748.1101(b)(1) treatment in least restrictive setting available that meets the child's needs Narrative: This standard was evaluated and found to be in compliance. Medium High Category Standard # Weight 748.507(1) Medium High Short Description Personnel Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks Narrative: This standard was evaluated and found to be in compliance. Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Page 99 of 187 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Category Short Description Standard # Weight Reports and Record Keeping Serious Incident-Report to Licensing no later than 24 hours after injury/illness that warrants treatment by a medical professional or hospitalization 748.303(a)(2)(A)(ii) Medium TA Finding Admn Rvw Compliance Narrative: Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1554810 02/27/2007 10:30:00 02/27/2007 11:30:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1553535 02/23/2007 09:00:00 02/23/2007 11:30:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1554323 02/23/2007 09:00:00 02/23/2007 11:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 467598 02/23/2007 12:00:00 N Category Short Description Standard # Children's Rights Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: This standard was evaluated and found to be in compliance. Activity Type: Investigation Number Date Intake Rcvd: Investigation 467810 02/23/2007 12:00:00 Category Short Description Weight N Standard # Weight Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: This standard was evaluated and found to be in compliance. High Category Standard # Weight 748.2605(a)(1) High Short Description Personal Restraints Prohibited-Restraints that impair child's breathing by putting pressure on child's torso Narrative: This standard was evaluated and found to be in compliance. Note: Prior to January 1, 2007, all Standards were not associated with a weight. Admn Rvw Compliance Warning Letter/Due Notice given Children's Rights Emergency Behavior Intervention TA Finding High TA Finding Admn Rvw Compliance TA Finding Page 100 of 187 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 468341 02/23/2007 12:00:00 N Category Short Description Standard # Children's Rights Weight Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: This standard was evaluated and found to be in compliance. High Category Standard # Weight 748.1101(b)(5) High Short Description Children's Rights Children's rights-Adhere to the child's rights to be free from any harsh, cruel, unusual, unnecessary, demeaning, or humiliating punishment Narrative: This standard was evaluated and found to be in compliance. Activity Type: Inspection Id Date Begin: Investigation Inspection 1553642 02/20/2007 02:00:00 Category Short Description TA Finding TA Finding Warning Letter/Due Notice given 02/20/2007 06:00:00 N Weight TA Finding Admission, Service Planning, Discharge Service Plan Review-Must include evaluation of child's progress 748.1385(1) Medium and effectiveness of strategies and techniques used to meet Low identified needs Narrative: One child's record reviewed was missing information in the treatment plan concerned a medication given as a documented PRN on 9/25/06. Activity Type: Investigation Number Date Intake Rcvd: Investigation 467812 02/20/2007 12:00:00 Category Short Description Minimum qualifications for employees-Physically, mentally, emotionally capable of performing assigned tasks; has the necessary skills Narrative: This standard was evaluated and found to be in compliance. 748.505(b)(3) Medium Category Standard # Weight Note: Prior to January 1, 2007, all Standards were not associated with a weight. Admn Rvw Waived N Weight Short Description Deficiency Warning Letter/Due Notice given Standard # Personnel Admn Rvw Compliance Date End: Standard # Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Page 101 of 187 Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Children's Rights Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Children's rights-Adhere to the child's rights to be free from any harsh, cruel, unusual, unnecessary, demeaning, or humiliating punishment Narrative: This standard was evaluated and found to be in compliance. 748.1101(b)(5) High Category Standard # Weight 748.2551(c)(1) Medium High Short Description Emergency Behavior Intervention EBI Implementation-Caregiver must minimize risk of physical discomfort, harm, or pain to the child Narrative: This standard was evaluated and found to be in compliance. Compliance TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1552972 02/14/2007 02:00:00 02/14/2007 07:00:00 N Category Short Description Standard # Emergency Behavior Intervention Weight Personal Restraints Prohibited-Prone and supine restraints except as 748.2605(b)(1) a transitional hold that lasts no longer than 1 minute Narrative: It was determined that the facility was conducting prohibited supine restraints. High Category Weight Short Description Standard # TA Finding Deficiency TA Finding Physical Site Physical Site-Buildings must be structurally sound, clean, and in 748.3301(a) High good repair. Paints must be lead-free Narrative: In Bickerstaff I, the floor in the middle bathroom needed cleaning. Also, there were exposed nails on the fireplace base in the living room. Deficiency Admn Rvw Waived Admn Rvw Waived (Photos were taken of these items). Category Short Description Standard # Physical Site Poisons-Ensure poisonous or flammable materials are inaccessible 748.3421(3) to children unless child has been evaluated as capable & likely to use responsibly Narrative: Clorox was found accessible under the bathroom sink near the laundry in the Bickerstaff I home. Activity Type: Investigation Number Date Intake Rcvd: Investigation 466232 02/14/2007 12:00:00 Category Short Description Note: Prior to January 1, 2007, all Standards were not associated with a weight. Weight TA Finding Medium Deficiency Admn Rvw Waived Warning Letter/Due Notice given N Standard # Weight TA Finding Page 102 of 187 Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Child Care Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Medical care-A child in care must receive medical care as needed for injury, illness, and pain Narrative: This standard was evaluated and found to be in compliance. 748.1531(a)(2) High Category Standard # Weight 748.507(1) Medium High Short Description Personnel Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks Narrative: This standard was evaluated and found to be in compliance. Compliance TA Finding Admn Rvw Compliance Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 466981 02/14/2007 12:00:00 N Category Short Description Personnel Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks Narrative: This standard was evaluated and found to be in compliance. Standard # Weight 748.507(1) Medium High TA Finding Admn Rvw Compliance Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 467125 02/14/2007 12:00:00 N Category Short Description Standard # Weight Minimum qualifications for employees-Physically, mentally, emotionally capable of performing assigned tasks; has the necessary skills Narrative: This standard was evaluated and found to be in compliance. 748.505(b)(3) Medium Category Standard # Weight 748.1531(a)(2) High Personnel Short Description Child Care Medical care-A child in care must receive medical care as needed for injury, illness, and pain Narrative: This standard was evaluated and found to be in compliance. Activity Type: Investigation Number Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Admn Rvw Compliance TA Finding Date Intake Rcvd: Admn Rvw Compliance Warning Letter/Due Notice given Page 103 of 187 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Investigation Medium: 139 464037 Category Run date: July 17, 2018 Compliance History Report Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 01/25/2007 12:00:00 Short Description N Standard # Children's Rights Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: Standard was evaluated and found to be in compliance. Weight TA Finding High Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1541677 11/28/2006 02:00:00 11/28/2006 03:30:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 456817 11/28/2006 12:00:00 Category Short Description Warning Letter/Due Notice given N Standard # Weight Personnel General Staffing-Caring for Children Narrative: This standard was evaluated and found to be in compliance. I24101a Medium Category Standard # Weight Short Description Service Management Admission Policies-Operational Program and Admission Criteria to I31102 Admit Children Narrative: This standard was evaluated and found to be in compliance. TA Finding Admn Rvw Compliance TA Finding Medium Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1539902 11/15/2006 01:00:00 11/15/2006 04:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 454780 11/15/2006 12:00:00 N Category Short Description Standard # Weight General Problem Management-Consistent with Policies and Procedures Narrative: This standard was evaluated and found to be in compliance. I41002a Medium Category Standard # Weight I41002b Medium Problem Management Short Description Problem Management General Problem Management-Not be Physically or Emotionally Damaging to Child Narrative: This standard was evaluated and found to be in compliance. Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Admn Rvw Compliance TA Finding Page 104 of 187 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Category Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Short Description Problem Management Monitoring Personal Restraints and Prohibited Restraints: Narrative: This standard was evaluated and found to be in compliance. Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Standard # Weight I42232 Medium TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1538424 11/08/2006 09:30:00 11/08/2006 10:30:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1554061 11/08/2006 09:30:00 11/08/2006 11:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 453831 11/07/2006 12:00:00 Category Short Description Child Care General Child Care-Protection from Abuse Neglect Narrative: This standard was evaluated and found to be in compliance. Warning Letter/Due Notice given N Standard # Weight I51001 Medium TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1533106 10/12/2006 09:00:00 10/12/2006 10:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 450494 10/12/2006 12:00:00 N Category Short Description Child Care General Child Care-Protection from Abuse Neglect Narrative: This standard was corrected at inspection because the staff member was terminated prior to inspection. Standard # Weight I51001 Medium TA Finding Deficiency Admn Rvw Waived Staff member was responsible for supervision of a 16 year old resident while bathing which resulted in extensive bruising to the child. Additionally, the finding is also for PHAB as the caretaker caused severe bruising to the child's buttocks. Category Short Description Child Care General Child Care-Protection from Abuse Neglect Narrative: It was determined a child in care was the victim of physical abuse by a staff member. Note: Prior to January 1, 2007, all Standards were not associated with a weight. Standard # Weight I51001 Medium TA Finding Page 105 of 187 Deficiency Admn Rvw Waived Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Activity Type: Investigation Number Date Intake Rcvd: Investigation 451000 10/09/2006 12:00:00 Category Run date: July 17, 2018 Compliance History Report Short Description Child Care General Child Care-Protection from Abuse Neglect Narrative: Standard evaluated and found to be in compliance. Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Warning Letter/Due Notice given N Standard # Weight I51001 Medium TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Monitoring and Investigation Inspection 1533170 10/05/2006 12:15:00 10/05/2006 04:15:00 N Category Standard # Weight Building, Grounds, and Equipment Environment-Buildings and Grounds Narrative: It was noted in the Draeger I house that the hallway bathroom's door frame had a hole that needs repair. Short Description I62001 Medium Category Standard # Weight Short Description Building, Grounds, and Equipment Food Preparation, Dining, Storage Areas, Furniture and Equipment I64001a Narrative: In Draeger I, the oven door outside panel was missing. Activity Type: Investigation Number Date Intake Rcvd: Investigation 448032 10/05/2006 12:00:00 Category Short Description TA Finding Deficiency Admn Rvw Waived Admn Rvw Waived Warning Letter/Due Notice given N Weight Problem Management Documentation of Personal Restraint Narrative: This standard was evaluated and found to be in compliance. I4225 Medium Category Standard # Weight I42232 Medium Short Description Deficiency Medium Standard # Problem Management Monitoring Personal Restraints and Prohibited Restraints: Narrative: This standard was evaluated and found to be in compliance. TA Finding TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 448243 10/05/2006 12:00:00 N Category Short Description Standard # Weight Personnel General Staffing-Caring for Children I24101a Medium Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Page 106 of 187 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Narrative: This standard was evaluated and found to be in compliance. Activity Type: Investigation Number Date Intake Rcvd: Investigation 448529 10/05/2006 12:00:00 Category Short Description Warning Letter/Due Notice given N Standard # Weight General Problem Management-Consistent with Policies and Procedures Narrative: This standard was evaluated and found to be in compliance. I41002a Medium Category Standard # Weight I41002b Medium Problem Management Short Description Problem Management General Problem Management-Not be Physically or Emotionally Damaging to Child Narrative: This standard was evaluated and found to be in compliance. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 448875 10/05/2006 12:00:00 N Category Standard # Weight VI. TC-Problem Management Problem Management No Physical Discipline Narrative: Several residents stated that a staff member hit them in the head with his fist. Short Description 4100 Medium Category Standard # Weight TFC261401 Medium Short Description Texas Family Code, Chapter 261 Abuse/Neglect for Facilities Narrative: This standard has been evaluated and found to be in compliance. TA Finding Deficiency TA Finding Admn Rvw Waived Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1531563 09/27/2006 09:30:00 09/27/2006 11:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 447984 09/27/2006 12:00:00 Category Short Description Child Care General Child Care-Protection from Abuse Neglect Narrative: This standard was evaluated and found to be in compliance. Note: Prior to January 1, 2007, all Standards were not associated with a weight. Warning Letter/Due Notice given N Standard # Weight I51001 Medium TA Finding Page 107 of 187 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1530164 09/19/2006 11:30:00 09/19/2006 12:30:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 447438 09/19/2006 12:00:00 Category Short Description Child Care General Child Care-Protection from Abuse Neglect Narrative: Standard was evaluated and found to be in compliance. Warning Letter/Due Notice given N Standard # Weight I51001 Medium TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1529753 09/15/2006 09:01:00 09/15/2006 11:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1536352 09/15/2006 09:00:00 09/15/2006 11:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 446664 09/15/2006 12:00:00 Category Short Description Texas Family Code, Chapter 261 Abuse/Neglect for Facilities Narrative: The standard evaluated was found to be in compliance. Activity Type: Investigation Number Date Intake Rcvd: Investigation 444321 09/01/2006 12:00:00 Category Short Description Warning Letter/Due Notice given N Standard # Weight TFC261401 Medium N Weight Texas Family Code, Chapter 261 Abuse/Neglect for Facilities Narrative: This standard was evalulated and found to be in compliance. TFC261401 Medium Category Standard # Weight I41004 Medium Short Description General Problem Management-Harsh, Cruel, Unusual or Unnecessary Discipline Narrative: This standard was evaluated and found to be in compliance. Note: Prior to January 1, 2007, all Standards were not associated with a weight. Admn Rvw Compliance Warning Letter/Due Notice given Standard # Problem Management TA Finding TA Finding Admn Rvw Compliance TA Finding Page 108 of 187 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1526959 08/29/2006 07:30:00 08/29/2006 08:45:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1525094 08/17/2006 10:00:00 08/17/2006 02:30:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 443074 08/17/2006 12:00:00 Warning Letter/Due Notice given N Category Short Description Standard # Weight Child Care Narrative: General Child Care-Protection from Abuse Neglect I51001 Medium TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1523833 08/11/2006 02:00:00 08/11/2006 03:30:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 442049 08/11/2006 12:00:00 Warning Letter/Due Notice given N Category Short Description Standard # Weight Child Care Narrative: Medical and Dental Care-Examinations and Treatment I52004 Medium TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1523174 08/03/2006 09:00:00 08/03/2006 11:30:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 441453 08/03/2006 12:00:00 N Category Short Description Standard # Weight General Staffing-Staff Supervised To Protect Health, Safety, Well-Being of Children Narrative: This standard was evaluated and found to be in compliance. I24102a Medium Category Standard # Weight Personnel Short Description Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Admn Rvw Compliance TA Finding Page 109 of 187 Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Drug Testing - TAC 745 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Drug testing procedures-Ensure the integrity and identity of the specimen collected from the time of collection to the time of disposal Narrative: This standard was evaluated and found to be in compliance. 745.4151(c)(5)(C) High Category Standard # Weight I24101a Medium Short Description Personnel General Staffing-Caring for Children Narrative: This standard was evaluated and found to be in compliance. Compliance TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1519201 07/07/2006 01:30:00 07/07/2006 05:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1521083 07/07/2006 09:00:00 07/07/2006 11:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 438519 07/07/2006 12:00:00 Category Short Description Problem Management Monitoring Personal Restraints and Prohibited Restraints: Narrative: This standard was evaluated and found to be in compliance. Warning Letter/Due Notice given N Standard # Weight I42232 Medium TA Finding Admn Rvw Compliance Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 438523 07/07/2006 12:00:00 N Category Short Description Child Care General Child Care-Protection from Abuse Neglect Narrative: Standard was evaluated and found to be in compliance. Standard # Weight I51001 Medium TA Finding Admn Rvw Compliance Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 438742 07/07/2006 12:00:00 N Category Short Description Standard # Weight Problem Management General Problem Management-Not be Physically or Emotionally Damaging to Child I41002b Medium Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Page 110 of 187 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Narrative: This standard was evaluated and found to be in compliance. Category Short Description Problem Management General Problem Management-Consistent with Policies and Procedures Narrative: This standard was evaluated and found to be in compliance. Standard # Weight I41002a Medium TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1518392 06/30/2006 10:00:00 06/30/2006 11:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 437854 06/30/2006 12:00:00 Category Short Description Child Care General Child Care-Protection from Abuse Neglect Narrative: Standard was evaluated and found to be in compliance. Warning Letter/Due Notice given N Standard # Weight I51001 Medium TA Finding Admn Rvw Compliance Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 438339 06/30/2006 12:00:00 N Category Short Description Child Care General Child Care-Protection from Abuse Neglect Narrative: This standard evaluated was found to be in compliance. Standard # Weight I51001 Medium TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1518369 06/29/2006 10:00:00 06/30/2006 11:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1515603 06/09/2006 01:00:00 06/09/2006 02:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Monitoring and Investigation Inspection 1515243 06/07/2006 09:00:00 06/07/2006 05:00:00 N Category Short Description Note: Prior to January 1, 2007, all Standards were not associated with a weight. Standard # Weight TA Finding Page 111 of 187 Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Administration Accurate and Current Records for Each Child I14001 Medium Narrative: One child's record reviewed contained incomplete daily progress notes, in that there was no mention of a child's self-injurious behavior on 5/23/06. Category Short Description Standard # Weight Deficiency TA Finding Waived Admn Rvw Personnel Personnel Records-Reports and Notes Relating to Employment I22001c Medium Deficiency Waived Narrative: One staff record reviewed did not document (supervisor's signature and date) that orientation, pre-service training, and 40 hours of supervised direct care experience had been completed. Category Short Description Standard # Weight TA Finding Admn Rvw Child Care Medical and Dental Care-Date and Time Administered I520012d Medium Deficiency Waived Narrative: Two resident medication logs were not accurately maintained. One was missing staff initials for the evening of 6/6/06 and the morning of 6/7/06. The other was initialed in advance of the 5pm medication administration for 6/7/06. Category Short Description Standard # Weight Child Care Medical and Dental Care-Locked Storage of Medication I520016 Narrative: At Wood House there were vitamins and staff medications accessible in a cabinet in one of the bathrooms. Medium Category Weight Short Description Standard # TA Finding Deficiency TA Finding Admn Rvw Waived Admn Rvw Building, Grounds, and Equipment Environment-Buildings and Grounds I62001 Medium Deficiency Waived Narrative: At Wood House, the a/c vent and filter needed to be cleaned. Also in the backyard there was a scrap wood pile with many nail points accessible and a live ant hill accessible. Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 434697 06/07/2006 12:00:00 N Category Short Description Standard # Weight Training and Orientation-First Aid Training within 90 days of hire for new staff Narrative: This standard was evaluated and found to be in compliance. I26002 Medium Category Standard # Weight Staff-Child Ratio Short Description Personnel General Staffing-Sufficient Qualified Staff to Protect Children and I24101 Perform: Narrative: This standard was evaluated and found to be in compliance. Medium Category Short Description Standard # Weight Problem Management General Problem Management-Consistent with Policies and Procedures I41002a Medium Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Page 112 of 187 Deficiency Admn Rvw Waived Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Narrative: It was determined one staff used a disciplinary measure (throwing shoes) inconsistent with facility policy and procedure. Activity Type: Investigation Number Date Intake Rcvd: Investigation 435075 06/07/2006 12:00:00 Category Short Description Warning Letter/Due Notice given N Standard # Weight Problem Management General Problem Management-Policies and Procedures Narrative: The standard was evaluated and found to be in compliance. I41001 Medium Category Standard # Weight Problem Management Restraint and Seclusion: Restraints or Seclusions may not be used Narrative: The standard was evaluated and found to be in compliance. Short Description I42113 Medium Category Standard # Weight Problem Management Personal Restraint-When Restraints May be Used Narrative: The standard was evaluated and found to be in compliance. Short Description I42211 Medium Category Short Description Standard # Weight Training and Orientation-First Aid Training within 90 days of hire for new staff Narrative: The standard was evaluated and found to be in compliance. I26002 Medium Category Standard # Weight I41002 Medium Staff-Child Ratio Short Description Problem Management General Problem Management-Requirements for Disciplinary Measures Narrative: The standard was evaluated and found to be in compliance. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1513226 05/24/2006 09:00:00 05/24/2006 11:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 434051 05/24/2006 12:00:00 Category Short Description Child Care General Child Care-Protection from Abuse Neglect Narrative: This standard was evaluated and found to be in compliance. Note: Prior to January 1, 2007, all Standards were not associated with a weight. Warning Letter/Due Notice given N Standard # Weight I51001 Medium TA Finding Page 113 of 187 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1512574 05/17/2006 02:00:00 05/17/2006 04:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 433035 05/17/2006 12:00:00 Category Short Description Warning Letter/Due Notice given N Standard # Weight General Problem Management-Consistent with Policies and Procedures Narrative: Staff violated agency's policy regarding discipline when she slapped two children on the face. I41002a Medium Category Short Description Standard # Weight Child Care Narrative: General Child Care-Protection from Abuse Neglect I51001 Medium Problem Management Activity Type: Investigation Number Date Intake Rcvd: Investigation 433242 05/17/2006 12:00:00 Category Short Description Child Care General Child Care-Protection from Abuse Neglect Narrative: Standard evaluated and found to be in compliance. TA Finding Deficiency TA Finding Admn Rvw Waived Admn Rvw Compliance Warning Letter/Due Notice given N Standard # Weight I51001 Medium TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1512358 05/16/2006 02:00:00 05/16/2006 05:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 433420 05/16/2006 12:00:00 Category Short Description Warning Letter/Due Notice given N Standard # Weight Personnel General Staffing-Caring for Children Narrative: This standard was evaluated and found to be in compliance. I24101a Medium Category Short Description Standard # Weight Child Care Medical and Dental Care-Examinations and Treatment I52004 Medium Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Admn Rvw Compliance TA Finding Page 114 of 187 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Narrative: This standard was evaluated and found to be in compliance. Category Short Description Standard # Weight Medical and Dental Care-Documentation of Medical and Dental Care Narrative: This standard was evaluated and found to be in compliance. I52005 Medium Category Standard # Weight I15001 Medium Child Care Short Description Administration Requirement for Written Serious Incident Reports Narrative: This standard was evaluated and found to be in compliance. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1506828 04/10/2006 02:15:00 04/10/2006 03:30:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 428993 04/10/2006 12:00:00 Warning Letter/Due Notice given N Category Short Description Standard # Weight Child Care Narrative: General Child Care-Protection from Abuse Neglect I51001 Medium Category Short Description Standard # Weight Problem Management General Problem Management-Harsh, Cruel, Unusual or Unnecessary Discipline I41004 Medium TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Narrative: Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1499967 04/04/2006 10:15:00 04/04/2006 10:45:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 428435 04/04/2006 12:00:00 N Category Short Description Texas Family Code, Chapter 261 Abuse/Neglect for Facilities Narrative: Standard evaluated and found not to be in compliance. Note: Prior to January 1, 2007, all Standards were not associated with a weight. Standard # Weight TFC261401 Medium TA Finding Page 115 of 187 Deficiency Admn Rvw Overturned Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Category Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Short Description Problem Management General Problem Management-Harsh, Cruel, Unusual or Unnecessary Discipline Narrative: Residents at the facility admitted that staff calls them out of their names. Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Standard # Weight I41004 Medium TA Finding Deficiency Admn Rvw Overturned A special needs resident was crawling on the floor like a dog and a staff member grabbed the resident by the shirt collar and walked the resident around the house. Residents admitted that a staff member encourage them to hit one another. Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1504701 03/28/2006 02:00:00 03/28/2006 05:00:00 N Category Standard # Weight Background Checks - TAC 745 Background Checks Submitted within 2 days of Hire Date Narrative: This standard was evaluated and found to be in compliance. Short Description 745.625(2) Medium Category Standard # Weight Personnel Personnel Records-Tuberculosis Test Reports I22001b Narrative: One staff record reviewed contained TB test results that were not obtained before staff was assigned to care of children. Short Description Medium Category Standard # Weight I4225 Medium Short Description Problem Management Documentation of Personal Restraint Narrative: One child's record reviewed did not document a restraint conducted on 2/27/06. TA Finding Admn Rvw Compliance TA Finding Deficiency TA Finding Deficiency Admn Rvw Waived Admn Rvw Waived Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 426611 03/28/2006 12:00:00 N Category Short Description Standard # Weight General Problem Management-Consistent with Policies and Procedures Narrative: This standard was evaluated and found to be in compliance. I41002a Medium Category Short Description Standard # Weight Problem Management General Problem Management-Not be Physically or Emotionally Damaging to Child I41002b Medium Problem Management Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Admn Rvw Compliance TA Finding Page 116 of 187 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Narrative: This standard was evaluated and found to be in compliance. Category Short Description Personnel General Staffing-Caring for Children Narrative: This standard was evaluated and found to be in compliance. Standard # Weight I24101a Medium TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1504289 03/24/2006 10:00:00 03/24/2006 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 426936 03/24/2006 12:00:00 Category Short Description Child Care General Child Care-Protection from Abuse Neglect Narrative: Standard evaluated and found to be in compliance. Warning Letter/Due Notice given N Standard # Weight I51001 Medium TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1503499 03/21/2006 10:00:00 03/21/2006 12:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1503496 03/21/2006 09:30:00 03/21/2006 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 426206 03/21/2006 12:00:00 Category Short Description Warning Letter/Due Notice given N Standard # Weight TA Finding Admn Rvw Child Care General Child Care-Protection from Abuse Neglect I51001 Medium Deficiency Waived Narrative: This standard was evaluated and found to be deficient as an 8 year old boy received multiple marks to his lower back and bottom. The doctor stated the injuries are not consistent with the staff's explanation as the child is non-verbal. Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 426207 03/21/2006 12:00:00 N Category Short Description Standard # Weight Child Care General Child Care-Protection from Abuse Neglect I51001 Medium Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Page 117 of 187 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Narrative: This standard was evaluated and found to be in compliance. Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1501764 03/08/2006 09:30:00 03/08/2006 11:45:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 424593 03/08/2006 12:00:00 Category Short Description Personnel General Staffing-Caring for Children Narrative: This standard was evaluated and found to be in compliance. Warning Letter/Due Notice given N Standard # Weight I24101a Medium TA Finding Admn Rvw Compliance Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 424674 03/08/2006 12:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1499285 02/17/2006 10:30:00 02/17/2006 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 422798 02/17/2006 12:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1497944 02/08/2006 11:00:00 02/08/2006 01:30:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 421873 02/08/2006 12:00:00 N Category Short Description Personnel General Staffing-Caring for Children Narrative: This standard was evaluated and found to be in compliance. Standard # Weight I24101a Medium TA Finding Admn Rvw Compliance Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 422067 02/08/2006 12:00:00 N Category Short Description Standard # Weight Personnel General Staffing-Caring for Children I24101a Medium Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Page 118 of 187 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Narrative: This standard was evaluated and found to be in compliance. Category Short Description Standard # Weight General Problem Management-Consistent with Policies and Procedures Narrative: This standard was evaluated and found to be in compliance. I41002a Medium Category Standard # Weight I41002b Medium Problem Management Short Description Problem Management General Problem Management-Not be Physically or Emotionally Damaging to Child Narrative: This standard was evaluated and found to be in compliance. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1494914 01/26/2006 11:30:00 01/26/2006 04:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 420680 01/26/2006 12:00:00 Category Short Description Warning Letter/Due Notice given N Standard # Weight Personnel General Staffing-Caring for Children Narrative: This standard was evaluated and found to be in compliance. I24101a Medium Category Short Description Standard # Weight General Problem Management-Consistent with Policies and Procedures Narrative: This standard was evaluated and found to be in compliance. I41002a Medium Category Standard # Weight I41002b Medium Problem Management Short Description Problem Management General Problem Management-Not be Physically or Emotionally Damaging to Child Narrative: This standard was evaluated and found to be in compliance. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 420392 01/10/2006 12:00:00 N Category Short Description Note: Prior to January 1, 2007, all Standards were not associated with a weight. Standard # Weight TA Finding Page 119 of 187 Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Personnel General Staffing-Caring for Children Narrative: This standard was evaluated and found to be in compliance. Activity Type: Investigation Number Date Intake Rcvd: Investigation 419731 01/04/2006 12:00:00 Category Run date: July 17, 2018 Compliance History Report Short Description Texas Family Code, Chapter 261 Abuse/Neglect for Facilities Narrative: This standard was evaluated and found to be in compliance. Weight: Id/Number: Admin Review Status: Low: 6 I24101a Not Available: 4 Medium Compliance Warning Letter/Due Notice given N Standard # Weight TFC261401 Medium TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1490596 12/13/2005 01:30:00 12/13/2005 04:30:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 418259 12/13/2005 12:00:00 N Category Short Description Standard # Weight TA Finding Admn Rvw Administration Explanations to Children-Behavior Intervention I12108 Medium Deficiency Waived Narrative: One child's record reviewed did not have a signed acknowledgement that the facility's policies and practices on the use of restraint had been explained to the resident at or before admission. Category Standard # Weight Problem Management Documentation of Personal Restraint Narrative: One child's record reviewed did not have documentation of a restraint conducted 12/3/05. Short Description I4225 Medium Category Standard # Weight Short Description TA Finding Deficiency TA Finding Admn Rvw Waived Admn Rvw Administration Requirement to Post Policies or Provide to Children-Behavior I12107 Medium Deficiency Waived Intervention Narrative: One child's record reviewed did not have a signed acknowledgement that the facility's behavior intervention information had been shared with the resident at admission. Category Short Description Standard # Weight General Problem Management-Consistent with Policies and Procedures Narrative: This standard was evaluated and found to be in compliance. I41002a Medium Category Standard # Weight Problem Management Short Description Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Admn Rvw Compliance TA Finding Page 120 of 187 Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Problem Management Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 General Problem Management-Not be Physically or Emotionally Damaging to Child Narrative: This standard was evaluated and found to be in compliance. I41002b Medium Category Standard # Weight I42232 Medium Short Description Problem Management Monitoring Personal Restraints and Prohibited Restraints: Narrative: This standard was evaluated and found to be in compliance. Compliance TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1490024 12/07/2005 09:30:00 12/07/2005 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 417884 12/07/2005 12:00:00 N Category Standard # Weight Child Care General Child Care-Protection from Abuse Neglect Narrative: This standard was evaluated and found to be in compliance. Short Description I51001 Medium Category Standard # Weight Short Description TA Finding Admn Rvw Compliance TA Finding Building, Grounds, and Equipment Environment-Flammable and Poisonous Substances I62002 Medium Narrative: Worker observed the bathroom sink cabinet was unlocked and there were cleaning supplies in there. The supervisor locked the cabinet. Deficiency Admn Rvw Waived Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1488362 11/22/2005 01:00:00 11/22/2005 03:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1486727 11/09/2005 02:00:00 Category Short Description 11/09/2005 05:30:00 Standard # N Weight TA Finding Admn Rvw Problem Management Documentation of Personal Restraint I4225 Medium Deficiency Waived Narrative: One child's record reviewed did not have documentation of restraints conducted on 8/4/05 and 10/21/05. The report of the restraint on 10/21/05 was located during the inspection. Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 415591 11/09/2005 12:00:00 N Note: Prior to January 1, 2007, all Standards were not associated with a weight. Page 121 of 187 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Category Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Short Description Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Standard # Weight Personnel General Staffing-Caring for Children Narrative: This standard was evaluated and found to be in compliance. I24101a Medium Category Short Description Standard # Weight General Problem Management-Consistent with Policies and Procedures Narrative: This standard was evaluated and found to be in compliance. I41002a Medium Category Standard # Weight I41002b Medium Problem Management Short Description Problem Management General Problem Management-Not be Physically or Emotionally Damaging to Child Narrative: This standard was evaluated and found to be in compliance. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1491078 11/04/2005 09:00:00 11/04/2005 10:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 414553 11/04/2005 12:00:00 N Category Short Description Standard # Weight Texas Family Code, Chapter 261 Narrative: Standard Evaluated. Abuse/Neglect TFC261001 Medium Activity Type: Inspection Id Date Begin: Investigation Inspection 1485749 11/03/2005 12:30:00 Category Short Description TA Finding Date End: Warning Letter/Due Notice given 11/03/2005 03:00:00 Standard # Admn Rvw Compliance N Weight TA Finding Admn Rvw Personnel Personnel Records-Requirements for Personnel Records I22001 Medium Deficiency Waived Narrative: One staff record reviewed contained inaccurate training dates, stating 20.5 hrs. of training was completed on 7/20/05 and 27.5 hrs. of training was completed on 2/3/04. Category Short Description Staff-Child Ratio Training and Orientation-Conducted by Red Cross Instructor or Licensed Professional Narrative: One staff record reviewed did not document current first aid certification. Note: Prior to January 1, 2007, all Standards were not associated with a weight. Standard # Weight I26002b Medium TA Finding Page 122 of 187 Deficiency Admn Rvw Waived Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Category Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Short Description Weight: Id/Number: Admin Review Status: Low: 6 Standard # Not Available: 4 Weight TA Finding Child Care Medical and Dental Care-Date and Time Administered I520012d Medium Deficiency Narrative: A review of medication documentation in the Curry 1 house indicated that medication administration was not logged for 11/2/05 (pm) and 11/3/05 (am). Activity Type: Investigation Number Date Intake Rcvd: Investigation 415257 11/03/2005 12:00:00 Category Short Description N Weight General Problem Management-Consistent with Policies and Procedures Narrative: This standard was evaluated and found to be in compliance. I41002a Medium Category Standard # Weight I41002b Medium Short Description Problem Management General Problem Management-Not be Physically or Emotionally Damaging to Child Narrative: This standard was evaluated and found to be in compliance. Waived Warning Letter/Due Notice given Standard # Problem Management Admn Rvw TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1485420 11/02/2005 09:00:00 11/02/2005 11:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 414751 11/02/2005 12:00:00 Category Short Description Child Care General Child Care-Protection from Abuse Neglect Narrative: Standard evaluated and found to be in compliance. Warning Letter/Due Notice given N Standard # Weight I51001 Medium TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1482986 10/13/2005 10:00:00 10/13/2005 03:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 413340 10/13/2005 12:00:00 N Category Short Description Standard # Weight Child Care General Child Care-Protection from Abuse Neglect I51001 Medium Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Page 123 of 187 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Narrative: This standard was evaluated and found to be in compliance. Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1482961 10/11/2005 09:00:00 10/11/2005 12:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1557369 10/11/2005 09:00:00 10/11/2005 01:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 412088 10/11/2005 12:00:00 N Category Short Description Child Care General Child Care-Protection from Abuse Neglect Narrative: There is no evidence of any abuse/neglect Standard # Weight I51001 Medium TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1482958 10/06/2005 09:00:00 10/06/2005 04:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 412247 10/06/2005 12:00:00 Category Short Description Child Care General Child Care-Protection from Abuse Neglect Narrative: This standard was evaluated and found to be in compliance. Warning Letter/Due Notice given N Standard # Weight I51001 Medium TA Finding Admn Rvw Compliance Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 412271 10/06/2005 12:00:00 N Category Short Description Standard # Weight General Staffing-Sufficient Qualified Staff to Protect Children and I24101 Perform: Narrative: Staff did not follow the facility's policy and procedures when he allowed residents to horseplay by hitting on each other. Medium Category Short Description Standard # Weight Child Care General Child Care-Protection from Abuse Neglect I51001 Medium Personnel Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Deficiency TA Finding Page 124 of 187 Compliance Admn Rvw Waived Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Narrative: This standard was evaluated and found to be in compliance. Activity Type: Investigation Number Date Intake Rcvd: Investigation 412341 10/06/2005 12:00:00 Category Short Description Child Care General Child Care-Protection from Abuse Neglect Narrative: This standard was evaluated and found to be in compliance Warning Letter/Due Notice given N Standard # Weight I51001 Medium TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Other Inspection 1481131 09/29/2005 03:30:00 09/29/2005 04:45:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1480857 09/28/2005 08:15:00 09/28/2005 11:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 411045 09/16/2005 12:00:00 N Category Short Description Texas Family Code, Chapter 261 Abuse/Neglect Narrative: This standard was evaluated and found to be in compliant. Activity Type: Inspection Id Date Begin: Monitoring Inspection 1479143 09/14/2005 10:00:00 Category Short Description Standard # Weight TFC261001 Medium Warning Letter/Due Notice given 09/14/2005 05:00:00 N Weight Medical and Dental Care-Double Locked Storage for Controlled Substances Narrative: In Wood house, the medication was not double-locked (corrected during inspection). I520016b Medium Category Standard # Weight Short Description Admn Rvw Compliance Date End: Standard # Child Care TA Finding TA Finding Deficiency TA Finding Admn Rvw Waived Admn Rvw Building, Grounds, and Equipment Environment-Buildings and Grounds I62001 Medium Deficiency Waived Narrative: In Curry 3 house, a light fixture cover was off (replaced during inspection), there was a light socket without a bulb (above the stove), and there was a hole in the wall (bedroom hallway). In Wood house, a shower curtain was missing and the light was not working in the water heater closet. Note: Prior to January 1, 2007, all Standards were not associated with a weight. Page 125 of 187 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 In Bahler house, there was an electrical outlet cover missing in one of the bedrooms. In Patterson house, there was a hole in the upper bathroom wall. In Mustang house, there were three aerosol spray cans accessible ( corrected during inspection). In Red house, there was a cracked light switch cover near the entrance to the home. Category Short Description Building, Grounds, and Equipment Environment-Equipment and Furniture Narrative: In Curry 3, one of the flashlights was not working. Standard # Weight I62001c Medium Standard # Weight I62002 Medium TA Finding Deficiency Admn Rvw Waived In Patterson house, the toilet in the downstairs master bathroom was stopped up and dirty. In the Humphrey 4 house, a toilet was not working and dirty. Category Short Description Building, Grounds, and Equipment Environment-Flammable and Poisonous Substances Narrative: There were two bottles of lighter fluid accessible in a garage cabinet left unlocked at Curry House. TA Finding Deficiency Admn Rvw Waived Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 410030 09/09/2005 12:00:00 N Category Short Description Texas Family Code, Chapter 261 Abuse/Neglect Narrative: This standard was evaluated and found to be in compliant. Standard # Weight TFC261001 Medium TA Finding Admn Rvw Compliance Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 410032 09/09/2005 12:00:00 N Category Short Description Texas Family Code, Chapter 261 Abuse/Neglect Narrative: This standard was evaluated and found to be in compliant. Note: Prior to January 1, 2007, all Standards were not associated with a weight. Standard # Weight TFC261001 Medium TA Finding Page 126 of 187 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1484605 08/31/2005 08:00:00 08/31/2005 10:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 409165 08/31/2005 12:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1478474 08/22/2005 02:00:00 08/22/2005 04:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 408358 08/22/2005 12:00:00 Category Short Description Child Care General Child Care-Protection from Abuse Neglect Narrative: Standard evaluated and found to be in compliance. Warning Letter/Due Notice given N Standard # Weight I51001 Medium TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1474060 08/03/2005 02:00:00 08/03/2005 05:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 406366 08/03/2005 12:00:00 N Category Short Description Standard # Weight General Problem Management-Consistent with Policies and Procedures Narrative: This standard was evaluated and found to be in compliance. I41002a Medium Category Standard # Weight I41002b Medium Problem Management Short Description Problem Management General Problem Management-Not be Physically or Emotionally Damaging to Child Narrative: This standard was evaluated and found to be in compliance. Activity Type: Investigation Number Date Intake Rcvd: Investigation 406481 08/03/2005 12:00:00 Category Short Description Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Warning Letter/Due Notice given N Standard # Weight TA Finding Page 127 of 187 Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Service Management Not Available: 4 Admission Policies-Operational Program and Admission Criteria to I31102 Admit Children Narrative: This standard was evaluated and found to be in compliance. Medium Category Standard # Weight Child Care General Child Care-Daily Schedule Narrative: This standard was evaluated and found to be in compliance. Short Description I51002 Medium Category Standard # Weight I24101a Medium Short Description Personnel General Staffing-Caring for Children Narrative: This standard was evaluated and found to be in compliance. Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1473766 08/02/2005 11:00:00 08/02/2005 12:30:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1473901 08/02/2005 10:30:00 08/02/2005 11:45:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 406767 08/02/2005 12:00:00 N Category Short Description Standard # Weight Child Care Narrative: General Child Care-Protection from Abuse Neglect I51001 Medium Activity Type: Investigation Number Date Intake Rcvd: Investigation 406907 08/01/2005 12:00:00 Category Short Description Texas Family Code, Chapter 261 Abuse/Neglect Narrative: This standard was evaluated and found to be in compliant. TA Finding Admn Rvw Compliance Warning Letter/Due Notice given N Standard # Weight TFC261001 Medium TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1472888 07/25/2005 01:00:00 07/25/2005 03:00:00 N Note: Prior to January 1, 2007, all Standards were not associated with a weight. Page 128 of 187 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Activity Type: Inspection Id Date Begin: Investigation Inspection 1472881 07/25/2005 10:00:00 Category Run date: July 17, 2018 Compliance History Report Short Description Child Care General Child Care-Protection from Abuse Neglect Narrative: Standard evaluated was found to be in compliance. Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Date End: Warning Letter/Due Notice given 07/25/2005 11:00:00 N Standard # Weight I51001 Medium TA Finding Admn Rvw Compliance Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 405839 07/25/2005 12:00:00 N Category Short Description Standard # Weight Person may be present if results of background check do not indicate criminal conviction or a central-registry finding that may preclude person Narrative: Standard evaluated was found to be in compliance. 745.703(1) High Category Standard # Weight I51001 Medium Background Checks - TAC 745 Short Description Child Care General Child Care-Protection from Abuse Neglect Narrative: Standard evaluated was found to be in compliance. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1472744 07/22/2005 10:00:00 07/22/2005 02:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 405594 07/22/2005 12:00:00 N Category Short Description Child Care General Child Care-Protection from Abuse Neglect Narrative: Standard evaluated and found to be in compliance. Standard # Weight I51001 Medium TA Finding Admn Rvw Compliance Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 406048 07/22/2005 12:00:00 N Category Short Description Standard # Weight Child Care General Child Care-Protection from Abuse Neglect I51001 Medium Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Page 129 of 187 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Narrative: Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1470173 06/29/2005 01:00:00 06/29/2005 02:30:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 404108 06/29/2005 12:00:00 Category Short Description Child Care General Child Care-Protection from Abuse Neglect Narrative: This standard was evaluated and found to be in compliance. Warning Letter/Due Notice given N Standard # Weight I51001 Medium TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1469486 06/24/2005 10:00:00 06/24/2005 01:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1469341 06/24/2005 08:30:00 06/24/2005 10:15:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 402795 06/24/2005 12:00:00 Category Short Description Child Care General Child Care-Protection from Abuse Neglect Narrative: Standard evaluated and found to be in compliance. Warning Letter/Due Notice given N Standard # Weight I51001 Medium TA Finding Admn Rvw Compliance Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 403141 06/24/2005 12:00:00 N Category Short Description Child Care General Child Care-Protection from Abuse Neglect Narrative: This standard was evaluated and found to be in compliance. Standard # Weight I51001 Medium TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1466891 06/06/2005 10:00:00 06/06/2005 11:30:00 N Note: Prior to January 1, 2007, all Standards were not associated with a weight. Page 130 of 187 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1466738 05/31/2005 11:30:00 05/31/2005 12:30:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 400731 05/31/2005 12:00:00 N Category Short Description Child Care General Child Care-Protection from Abuse Neglect Narrative: This standard was evaluated and found to be in compliance. Standard # Weight I51001 Medium TA Finding Admn Rvw Compliance Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 398813 05/09/2005 12:00:00 N Category Short Description Standard # Weight Child Care Narrative: General Child Care-Protection from Abuse Neglect I51001 Medium Category Short Description Standard # Weight Personnel General Staffing-Staff Supervised To Protect Health, Safety, Well-Being of Children I24102a Medium TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Narrative: Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1462513 04/28/2005 09:30:00 04/28/2005 11:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 398664 04/28/2005 12:00:00 N Category Standard # Weight Child Care General Child Care-Protection from Abuse Neglect Narrative: Standard evaluated was found to be in compliance. Short Description I51001 Medium Category Short Description Standard # Weight Background Checks - TAC 745 Person may be present if results of background check do not indicate criminal conviction or a central-registry finding that may preclude person 745.703(1) High Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Admn Rvw Compliance TA Finding Page 131 of 187 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Narrative: Standard evaluated was found to be in compliance. Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1459410 04/06/2005 09:30:00 04/06/2005 11:30:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 396123 04/06/2005 12:00:00 Category Short Description Texas Family Code, Chapter 261 Abuse/Neglect for Facilities Narrative: Standard investigated was found to be in compliance. Warning Letter/Due Notice given N Standard # Weight TFC261401 Medium TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1456209 03/10/2005 01:30:00 03/10/2005 05:30:00 N Category Short Description Administration Accurate and Current Records for Each Child Narrative: Recreational activity logs observed were not current. Standard # Weight I14001 Medium Standard # Weight I62001 Medium TA Finding Deficiency Admn Rvw Waived Note: A photograph was taken of this deficiency Category Short Description Building, Grounds, and Equipment Environment-Buildings and Grounds Narrative: This standard was evaluated and found to be in compliance. Activity Type: Investigation Number Date Intake Rcvd: Investigation 393724 03/10/2005 12:00:00 Category Short Description Admn Rvw Compliance Warning Letter/Due Notice given N Standard # Weight Personnel General Staffing-Caring for Children Narrative: This standard was evaluated and found to be in compliance. I24101a Medium Category Short Description Standard # Weight Personnel General Staffing-Staff Supervised To Protect Health, Safety, Well-Being of Children I24102a Medium Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding TA Finding Admn Rvw Compliance TA Finding Page 132 of 187 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Narrative: This standard was evaluated and found to be in compliance. Category Standard # Weight Child Care General Child Care-Daily Schedule Narrative: This standard was evaluated and found to be in compliance. Short Description I51002 Medium Category Standard # Weight I52004 Medium Short Description Child Care Medical and Dental Care-Examinations and Treatment Narrative: This standard was evaluated and found to be in compliance. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1455858 03/03/2005 09:00:00 03/03/2005 10:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1478774 03/03/2005 09:00:00 03/03/2005 11:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 393533 03/03/2005 12:00:00 Category Short Description Warning Letter/Due Notice given N Standard # Weight TA Finding Child Care General Child Care-Protection from Abuse Neglect I51001 Medium Narrative: Based on the information gathered, RCCL was unable to determine if abuse or neglect occurred. Therefore, this standard will not be cited at this time Category Short Description Background Checks - TAC 745 Person may be present if results of background check do not indicate criminal conviction or a central-registry finding that may preclude person Narrative: Standard evaluated was found to be in compliance. Standard # Weight 745.703(1) High Admn Rvw Compliance TA Finding Admn Rvw Compliance Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 393880 03/03/2005 12:00:00 N Category Short Description Standard # Weight Background Checks - TAC 745 Person may be present if results of background check do not indicate criminal conviction or a central-registry finding that may preclude person 745.703(1) High Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Page 133 of 187 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Narrative: Standard evaluated was found to be in compliance. Category Standard # Weight Child Care Medical and Dental Care-Child's Name Narrative: Standard evaluated was found to be in compliance. Short Description I520012a Medium Category Standard # Weight I51001 Medium Short Description Child Care General Child Care-Protection from Abuse Neglect Narrative: Standard evaluated was found to be in compliance. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1453974 02/22/2005 01:00:00 02/22/2005 03:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 392254 02/22/2005 12:00:00 N Category Standard # Weight Personnel General Staffing-Caring for Children Narrative: This standard was evaluated and found to be in compliance. Short Description I24101a Medium Category Standard # Weight I52004 Medium Short Description Child Care Medical and Dental Care-Examinations and Treatment Narrative: This standard was evaluated and found to be in compliance. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1450327 01/25/2005 01:00:00 01/25/2005 02:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Other Inspection 1450268 01/24/2005 10:30:00 01/24/2005 11:15:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 390046 01/21/2005 12:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1449191 01/15/2005 09:00:00 01/15/2005 11:30:00 N Note: Prior to January 1, 2007, all Standards were not associated with a weight. Page 134 of 187 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Activity Type: Investigation Number Date Intake Rcvd: Investigation 389224 01/12/2005 12:00:00 Category Run date: July 17, 2018 Compliance History Report Short Description Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Warning Letter/Due Notice given N Standard # Weight Child Care General Child Care-Protection from Abuse Neglect Narrative: Standard evaluated was found to be in compliance. I51001 Medium Category Standard # Weight 745.703(1) High Short Description Background Checks - TAC 745 Person may be present if results of background check do not indicate criminal conviction or a central-registry finding that may preclude person Narrative: Standard evaluated was found to be in compliance. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1448342 01/06/2005 09:00:00 01/06/2005 11:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 388956 01/06/2005 12:00:00 Category Short Description Warning Letter/Due Notice given N Standard # Weight Child Care General Child Care-Protection from Abuse Neglect Narrative: Standard evaluated was found to be in compliance. I51001 Medium Category Standard # Weight 745.703(1) High Short Description Background Checks - TAC 745 Person may be present if results of background check do not indicate criminal conviction or a central-registry finding that may preclude person Narrative: Standard evaluated was found to be in compliance. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Monitoring and Investigation Inspection 1446972 12/22/2004 01:00:00 12/22/2004 04:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1446935 12/22/2004 07:20:00 12/22/2004 01:00:00 N Note: Prior to January 1, 2007, all Standards were not associated with a weight. Page 135 of 187 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Activity Type: Investigation Number Date Intake Rcvd: Investigation 387743 12/22/2004 12:00:00 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Warning Letter/Due Notice given N Category Short Description Standard # Weight Child Care Narrative: There was no deficiency noted. General Child Care-Protection from Abuse Neglect I51001 Medium Category Short Description Standard # Weight Personnel Personnel Policies-Personnel Must Meet Requirements for Background Checks I21006 Medium TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Narrative: There was no deficiency noted. Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 387827 12/22/2004 12:00:00 N Category Short Description Problem Management Monitoring Personal Restraints and Prohibited Restraints: Narrative: This standard was evaluated and found to be in compliance. Activity Type: Investigation Number Date Intake Rcvd: Investigation 388236 12/22/2004 12:00:00 Standard # Weight I42232 Medium TA Finding Admn Rvw Compliance Warning Letter/Due Notice given N Category Short Description Standard # Weight Child Care Narrative: There was no deficiency noted. General Child Care-Protection from Abuse Neglect I51001 Medium Category Short Description Standard # Weight Personnel Personnel Policies-Personnel Must Meet Requirements for Background Checks I21006 Medium TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Narrative: There was no deficiency noted. Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1445457 12/09/2004 09:00:00 12/09/2004 11:30:00 N Note: Prior to January 1, 2007, all Standards were not associated with a weight. Page 136 of 187 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Activity Type: Investigation Number Date Intake Rcvd: Investigation 386488 12/09/2004 12:00:00 Category Run date: July 17, 2018 Compliance History Report Short Description Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Warning Letter/Due Notice given N Standard # Weight Person may be present if results of background check do not indicate criminal conviction or a central-registry finding that may preclude person Narrative: Standard evaluated was found to be in compliance. 745.703(1) High Category Standard # Weight Background Checks - TAC 745 Short Description Personnel General Staffing-Sufficient Qualified Staff to Protect Children and I24101 Perform: Narrative: Standard evaluated was found to be in compliance. TA Finding Admn Rvw Compliance TA Finding Medium Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1444270 12/01/2004 01:30:00 12/01/2004 06:30:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1444142 12/01/2004 09:00:00 12/16/2004 04:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 386231 12/01/2004 12:00:00 N Category Standard # Weight Child Care Medical and Dental Care-Examinations and Treatment Narrative: This standard was evaluated and found to be in compliance. Short Description I52004 Medium Category Standard # Weight Service Management Service Planning-Results of Reviewing and Updating Plan Narrative: This standard was evaluated and found to be in compliance. Short Description I3210b Medium Category Standard # Weight Short Description Problem Management Emergency Medications-Use of and Authorization For Emergency I42311 Medications Narrative: This standard was evaluated and found to be in compliance. Medium Category Weight Short Description Note: Prior to January 1, 2007, all Standards were not associated with a weight. Standard # TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Page 137 of 187 Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Problem Management Implementation of Emergency Medication-Qualified Caregiver Narrative: This standard was evaluated and found to be in compliance. I42331 Medium Category Standard # Weight Problem Management Emergency Medication Documentation Required Narrative: This standard was evaluated and found to be in compliance. Short Description I42341 Medium Category Standard # Weight Child Care General Child Care-Daily Schedule Narrative: This standard was evaluated and found to be in compliance. Short Description I51002 Medium Category Standard # Weight Short Description Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Child Care Medical and Dental Care-Medication Record Must Include I520012 Medium Deficiency Waived Narrative: Two medication records reviewed were not maintained, in that one had an incomplete medication change form which did not indicate from what dosage the medication had been increased, while the other had several blanks in the spaces where the facility has the children initial to indicate they received a particular medication. Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1444147 11/30/2004 09:00:00 12/16/2004 04:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 386165 11/30/2004 12:00:00 Category Short Description Warning Letter/Due Notice given N Standard # Weight General Problem Management-Consistent with Policies and Procedures Narrative: Standard evaluated and found to be in compliance. I41002a Medium Category Standard # Weight Problem Management Short Description Personnel General Staffing-Sufficient Qualified Staff to Protect Children and I24101 Perform: Narrative: Standard evaluated and found to be in compliance. Medium Category Weight Short Description Background Checks - TAC 745 Standard # Required background checks-employees and applicants you intend 745.615(a)1 to hire Narrative: Standard evaluated and found to be in compliance. Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding High Page 138 of 187 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 386169 11/30/2004 12:00:00 N Category Short Description Standard # Personnel Weight General Staffing-Sufficient Qualified Staff to Protect Children and I24101 Perform: Narrative: Standard evaluated and found to be in compliance. Medium Category Weight Short Description Standard # Problem Management General Problem Management-Consistent with Policies and I41002a Procedures Narrative: Staff violated your agency's policy regarding physical discipline when he hit the child on the head with a brush. TA Finding Admn Rvw Compliance TA Finding Medium Deficiency Admn Rvw Waived Three children interviewed indicated that they witnessed the staff hit a child on the head with a wooden brush. Category Short Description Standard # Background Checks - TAC 745 Weight Required background checks-employees and applicants you intend 745.615(a)1 to hire Narrative: Standard evaluated and found to be in compliance. High Category Standard # Weight I41004 Medium Short Description Problem Management General Problem Management-Harsh, Cruel, Unusual or Unnecessary Discipline Narrative: Staff used unusual punishment when he hit a child on the head with a wooden brush. TA Finding Admn Rvw Compliance TA Finding Deficiency Admn Rvw Waived Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1443118 11/19/2004 12:00:00 11/19/2004 02:30:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 385537 11/19/2004 12:00:00 Warning Letter/Due Notice given N Category Short Description Standard # Personnel General Staffing-Sufficient Qualified Staff to Protect Children and I24101 Perform: Weight TA Finding Medium Narrative: Note: Prior to January 1, 2007, all Standards were not associated with a weight. Page 139 of 187 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Category Short Description Standard # Weight Child Care Narrative: General Child Care-Protection from Abuse Neglect I51001 Medium TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1442004 11/10/2004 03:00:00 11/10/2004 05:30:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 384411 11/10/2004 12:00:00 N Category Short Description Standard # Weight TA Finding Admn Rvw Personnel General Staffing-Caring for Children I24101a Medium Deficiency Narrative: Two children were not adequately supervised, in that they were able to gain access to a pornographic video. The staff person deemed responsible was terminated. Waived Category Admn Rvw Short Description Personnel General Staffing-Staff Supervised To Protect Health, Safety, Well-Being of Children Narrative: This standard was evaluated and found to be in compliance. Standard # Weight I24102a Medium TA Finding Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1441234 11/05/2004 09:00:00 11/05/2004 11:30:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1441249 11/04/2004 09:00:00 12/10/2004 04:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 381245 11/04/2004 12:00:00 N Category Short Description Standard # Personnel Weight General Staffing-Sufficient Qualified Staff to Protect Children and I24101 Perform: Narrative: Standard evaluated and found to be in compliance. Medium Category Short Description Standard # Weight Staff-Child Ratio Staff-Child Ratio-Hour Staff Coverage I25001 Medium Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Admn Rvw Compliance TA Finding Page 140 of 187 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Narrative: Standard evaluated and found to be in compliance. Category Short Description Standard # Background Checks - TAC 745 Required background checks-employees and applicants you intend 745.615(a)1 to hire Narrative: Standard evaluated and found to be in compliance. Activity Type: Investigation Number Date Intake Rcvd: Investigation 382470 11/01/2004 12:00:00 Category Short Description Weight N Personnel Weight General Staffing-Sufficient Qualified Staff to Protect Children and I24101 Perform: Narrative: Standard evaluated was found to be in compliance. Medium Category Short Description Standard # Weight General Problem Management-Consistent with Policies and Procedures Narrative: Standard evaluated was found to be in compliance. I41002a Medium Category Standard # Weight 745.703(1) High Short Description Background Checks - TAC 745 Person may be present if results of background check do not indicate criminal conviction or a central-registry finding that may preclude person Narrative: Standard evaluated was found to be in compliance. Admn Rvw Compliance Warning Letter/Due Notice given Standard # Problem Management TA Finding High TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1439049 10/19/2004 01:00:00 10/19/2004 05:30:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 382277 10/19/2004 12:00:00 Category Short Description Personnel General Staffing-Caring for Children Narrative: This standard was evaluated and found to be in compliance. Note: Prior to January 1, 2007, all Standards were not associated with a weight. Warning Letter/Due Notice given N Standard # Weight I24101a Medium TA Finding Page 141 of 187 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Category Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Short Description Weight: Id/Number: Admin Review Status: Low: 6 Standard # Problem Management Not Available: 4 Weight General Problem Management-Consistent with Policies and I41002a Procedures Narrative: It was determined a staff person used a disciplinary measure that was not consistent with the facility's policy. Medium Category Standard # Weight I41002b Medium Short Description Problem Management General Problem Management-Not be Physically or Emotionally Damaging to Child Narrative: This standard was evaluated and found to be in compliance. TA Finding Deficiency TA Finding Admn Rvw Waived Admn Rvw Compliance Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 382403 10/19/2004 12:00:00 N Category Short Description Child Care Medical and Dental Care-Examinations and Treatment Narrative: This standard was evaluated and found to be in compliance. Activity Type: Investigation Number Date Intake Rcvd: Investigation 382515 10/19/2004 12:00:00 Category Short Description Standard # Weight I52004 Medium TA Finding Admn Rvw Compliance Warning Letter/Due Notice given N Standard # Weight TA Finding Admn Rvw Personnel General Staffing-Caring for Children I24101a Medium Deficiency Waived Narrative: It was determined that supervision was inadequate when there was no facility staff person at the airport to meet a 15 year old resident who was returning alone after attending his father's funeral. Activity Type: Inspection Id Date Begin: Monitoring Inspection 1435869 10/06/2004 10:00:00 Category Short Description Date End: Warning Letter/Due Notice given 10/06/2004 05:00:00 Standard # N Weight TA Finding Administration Accurate and Current Records for Each Child I14001 Medium Narrative: One child's record reviewed was not accurate, in that it contained documentation of a serious incident/restraint pertaining to a different child. Category Short Description Standard # Weight Deficiency TA Finding Admn Rvw Waived Admn Rvw Problem Management Personal Restraint-When Restraints May be Used I42211 Medium Deficiency Waived Narrative: One child's record reviewed contained documentation of an inappropriate restraint, in that the restraint was conducted in a situation which did not qualify as an emergency, according to the available information in the written report. Note: Prior to January 1, 2007, all Standards were not associated with a weight. Page 142 of 187 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1441242 09/23/2004 08:00:00 09/23/2004 11:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 379483 09/23/2004 12:00:00 Category Short Description Warning Letter/Due Notice given N Standard # Problem Management Weight General Problem Management-Not be Physically or Emotionally I41002b Damaging to Child Narrative: The restraint conducted on the child was physically damaging as he received injuries as a result of the restraint. Medium Category Weight Short Description Standard # TA Finding Deficiency TA Finding Problem Management Caregivers Qualified to Restrain I42235 Medium Deficiency Narrative: Staff reported that he had not been trained in conducting restraints (behavior intervention) at the time of the incident nor since he'd been employed with the agency. Admn Rvw Waived Admn Rvw Waived Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1433673 09/08/2004 01:00:00 09/08/2004 05:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 378587 09/08/2004 12:00:00 N Category Short Description Personnel General Staffing-Caring for Children Narrative: This standard was evaluated and found to be in compliance. Standard # Weight I24101a Medium TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1446206 08/31/2004 09:00:00 08/31/2004 11:30:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1446195 08/24/2004 09:00:00 08/24/2004 11:30:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 376213 08/19/2004 12:00:00 Category Short Description Note: Prior to January 1, 2007, all Standards were not associated with a weight. Warning Letter/Due Notice given N Standard # Weight TA Finding Page 143 of 187 Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Background Checks - TAC 745 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Person may be present if results of background check do not indicate criminal conviction or a central-registry finding that may preclude person Narrative: Standard evaluated was found to be in compliance. 745.703(1) High Category Standard # Weight I24102 Medium Short Description Personnel General Staffing-Supervision of Staff Narrative: Standard evaluated was found to be in compliance. Compliance TA Finding Admn Rvw Compliance Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 376674 08/16/2004 12:00:00 N Category Short Description Background Checks - TAC 745 Person may be present if results of background check do not indicate criminal conviction or a central-registry finding that may preclude person Narrative: Standard evaluated was found to be in compliance. Standard # Weight 745.703(1) High TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1441240 08/06/2004 10:00:00 10/01/2004 05:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 375507 08/06/2004 12:00:00 N Category Short Description Standard # Personnel Weight General Staffing-Sufficient Qualified Staff to Protect Children and I24101 Perform: Narrative: Standard evaluated and found to be in compliance. Medium Category Weight Short Description Standard # Background Checks - TAC 745 Required background checks-employees and applicants you intend 745.615(a)1 to hire Narrative: Standard evaluated and found to be in compliance. High Category Short Description Standard # Weight Problem Management General Problem Management-Policies and Procedures I41001 Medium Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Page 144 of 187 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Narrative: Standard evaluated and found to be in compliance. Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1428418 07/26/2004 01:00:00 07/26/2004 05:30:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 373913 07/26/2004 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 371460 06/18/2004 12:00:00 N Category Short Description Standard # Weight Problem Management General Problem Management-Denial of Food, Mail or Visits as Discipline I41006 Medium Category Short Description Standard # Weight Child Care Narrative: General Child Care-Protection from Abuse Neglect I51001 Medium TA Finding Admn Rvw Compliance Narrative: Activity Type: Investigation Number Date Intake Rcvd: Investigation 371474 06/17/2004 12:00:00 Category Short Description N Weight Personnel General Staffing-Caring for Children Narrative: This standard was evaluated and found to be in compliance. I24101a Medium Category Standard # Weight I41002b Medium Short Description General Problem Management-Not be Physically or Emotionally Damaging to Child Narrative: This standard was evaluated and found to be in compliance. Admn Rvw Compliance Warning Letter/Due Notice given Standard # Problem Management TA Finding TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1424398 06/17/2004 12:00:00 06/17/2004 12:00:00 N Note: Prior to January 1, 2007, all Standards were not associated with a weight. Page 145 of 187 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Activity Type: Investigation Number Date Intake Rcvd: Investigation 370642 06/09/2004 12:00:00 Category Run date: July 17, 2018 Compliance History Report Short Description Personnel General Staffing-Caring for Children Narrative: This standard was evaluated and found to be in compliance. Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Warning Letter/Due Notice given N Standard # Weight I24101a Medium TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1423495 06/09/2004 12:00:00 06/09/2004 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 369803 06/02/2004 12:00:00 N Category Short Description Standard # Weight General Problem Management-Not be Physically or Emotionally Damaging to Child Narrative: This standard was evaluated and found to be in compliance. I41002b Medium Category Problem Management Short Description Standard # Weight General Problem Management-Be Individualized to Meet Each Child's Needs Narrative: This standard was evaluated and found to be in compliance. I41002c Medium Category Problem Management Standard # Weight Problem Management Restraint and Seclusion not used as-Convenience for Caregivers Narrative: This standard was evaluated and found to be in compliance. Short Description I42113b Medium Category Short Description Standard # Weight Restraint and Seclusion not used as-Substitute for Program Treatment Narrative: This standard was evaluated and found to be in compliance. I42113c Medium Category Standard # Weight I42312 Medium Problem Management Short Description Problem Management Emergency Medications-Chemical Restraints are Prohibited Narrative: This standard was evaluated and found to be in compliance. Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Page 146 of 187 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1422683 06/02/2004 12:00:00 06/02/2004 12:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1422071 05/26/2004 12:00:00 05/26/2004 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 369371 05/25/2004 12:00:00 N Category Short Description Standard # Weight Medical and Dental Care-Legend Medications Only When Prescribed by Physician Narrative: This standard was evaluated and found to be in compliance. I520010a Medium Category Standard # Weight I520015 Medium Child Care Short Description Child Care Medical and Dental Care-Side Effects to Medication Narrative: This standard was evaluated and found to be in compliance. Activity Type: Investigation Number Date Intake Rcvd: Investigation 369538 05/25/2004 12:00:00 Category Short Description Weight Medium Category Standard # Weight Person may be present if results of background check do not indicate criminal conviction or a central-registry finding that may preclude person Narrative: Standard evaluated was found to be in compliance. 745.703(1) High Category Standard # Weight I41002a Medium Short Description Problem Management General Problem Management-Consistent with Policies and Procedures Narrative: Standard evaluated was found to be in compliance. Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Admn Rvw Compliance N Standard # General Staffing-Sufficient Qualified Staff to Protect Children and I24101 Perform: Narrative: Standard evaluated was found to be in compliance. Short Description Admn Rvw Compliance Warning Letter/Due Notice given Personnel Background Checks - TAC 745 TA Finding TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Page 147 of 187 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 369540 05/25/2004 12:00:00 N Category Short Description Standard # Personnel Weight General Staffing-Sufficient Qualified Staff to Protect Children and I24101 Perform: Narrative: Standard evaluated was found to be in compliance. Medium Category Short Description Standard # Weight General Problem Management-Harsh, Cruel, Unusual or Unnecessary Discipline Narrative: Standard evaluated was found to be in compliance. I41004 Medium Category Standard # Weight 745.703(1) High Problem Management Short Description Background Checks - TAC 745 Person may be present if results of background check do not indicate criminal conviction or a central-registry finding that may preclude person Narrative: Standard evaluated was found to be in compliance. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1421982 05/25/2004 12:00:00 05/25/2004 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 368076 05/17/2004 12:00:00 N Category Short Description Personnel General Staffing-Sufficient Qualified Staff to Protect Children and I24101 Perform: Standard # Weight Medium Category Short Description Standard # Weight II. Basic Care-Personnel Narrative: Staff-Child Ratio-Waking Hours II25001 Medium Category Short Description Standard # Weight TA Finding Admn Rvw Compliance Narrative: Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Admn Rvw Compliance TA Finding Page 148 of 187 Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Personnel Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Personnel Policies-Personnel Must Meet Requirements for Background Checks Weight: Id/Number: Admin Review Status: Low: 6 I21006 Not Available: 4 Medium Compliance Narrative: Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1420880 05/17/2004 12:00:00 05/17/2004 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 368268 05/13/2004 12:00:00 N Category Standard # Weight Problem Management Emergency Medications-Chemical Restraints are Prohibited Narrative: This standard was evaluated and found to be in compliance. Short Description I42312 Medium Category Standard # Weight Short Description Problem Management Emergency Medications-Use of and Authorization For Emergency I42311 Medications Narrative: This standard was evaluated and found to be in compliance. TA Finding Admn Rvw Compliance TA Finding Medium Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1420487 05/13/2004 12:00:00 05/13/2004 12:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1419553 05/12/2004 12:00:00 05/12/2004 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 367740 05/06/2004 12:00:00 N Category Short Description Standard # Weight TA Finding Problem Management Emergency Medication Documentation Required-Child's Reaction I42342i Medium to Discuss Situation Narrative: There was no documented child's reaction to the oppportunity to discuss the need for an emergency medication administered to her on 4/19/04. Category Short Description Problem Management Emergency Medications-Use of and Authorization For Emergency I42311 Medications Note: Prior to January 1, 2007, all Standards were not associated with a weight. Standard # Weight Deficiency TA Finding Medium Page 149 of 187 Compliance Admn Rvw Waived Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Narrative: This standard was evaluated and found to be in compliance. Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1419520 05/06/2004 12:00:00 05/06/2004 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 367388 04/28/2004 12:00:00 Category Short Description Warning Letter/Due Notice given N Standard # Personnel Weight General Staffing-Sufficient Qualified Staff to Protect Children and I24101 Perform: Narrative: Standard evaluated was found to be in compliance. Medium Category Short Description Standard # Weight General Problem Management-Consistent with Policies and Procedures Narrative: Standard evaluated was found to be in compliance. I41002a Medium Category Standard # Weight 745.703(1) High Problem Management Short Description Background Checks - TAC 745 Person may be present if results of background check do not indicate criminal conviction or a central-registry finding that may preclude person Narrative: Standard evaluate was found to be in compliance. Activity Type: Inspection Id Date Begin: Monitoring Inspection 1417036 04/15/2004 12:00:00 Category Short Description Admn Rvw Compliance TA Finding Admn Rvw Compliance 04/15/2004 12:00:00 N Human Resources Code, Chapter 42 Employment Affidavit Narrative: One staff record reviewed did not have the required applicant affidavit on file. HRC42.059 High Category Standard # Weight Personnel Personnel Records-Tuberculosis Test Reports Narrative: TB test results were not on file in one of the staff records reviewed. I22001b Medium Category Standard # Weight Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Warning Letter/Due Notice given Weight Short Description Admn Rvw Compliance Date End: Standard # Short Description TA Finding TA Finding Deficiency TA Finding Deficiency TA Finding Page 150 of 187 Admn Rvw Waived Admn Rvw Waived Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Staff-Child Ratio Training and Orientation-Documentation of Training Narrative: Required training documentation was not on file in four of the staff records reviewed. I26004 Medium Category Standard # Weight Short Description Child Care Medical and Dental Care-Date and Time Administered I520012d Narrative: Medication logs were not complete with required staff initials in Red House, Bickerstaff 2, Draeger 2, and Draeger 1. Medium Category Weight Short Description Standard # Deficiency TA Finding Deficiency TA Finding Waived Admn Rvw Waived Admn Rvw Building, Grounds, and Equipment Environment-Buildings and Grounds I62001 Medium Deficiency Waived Narrative: There were a/c filters needing to be changed in Humphrey 2 and Bickerstaff 1. There were holes in the wall in Humphrey 2 and Draeger 1. An overhead light fixture was loose and the shower drain needed to be cleaned in a bathroom in Draeger 2. Category Short Description Standard # Weight TA Finding Building, Grounds, and Equipment Environment-Equipment and Furniture I62001c Medium Narrative: Smoke detectors were not operating in Bickerstaff 1 and Draeger 2, and the front door fire extinguisher was undercharged in Bickerstaff 2. Category Short Description Standard # Building, Grounds, and Equipment Environment-Flammable and Poisonous Substances I62002 Narrative: There was an aerosol can accessible in Draeger 3 and a large cosmetics box with unlabeled medication accessible in Bickerstaff 2. Weight Deficiency TA Finding Medium Deficiency Admn Rvw Waived Admn Rvw Waived Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 364444 04/06/2004 12:00:00 N Category Short Description Standard # Weight General Problem Management-Consistent with Policies and Procedures Narrative: This standard was evaluated and found to be in compliance. I41002a Medium Category Standard # Weight I41002b Medium Problem Management Short Description Problem Management General Problem Management-Not be Physically or Emotionally Damaging to Child Narrative: This standard was evaluated and found to be in compliance. Activity Type: Investigation Number Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Admn Rvw Compliance TA Finding Date Intake Rcvd: Admn Rvw Compliance Warning Letter/Due Notice given Page 151 of 187 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Investigation Medium: 139 365037 Category Run date: July 17, 2018 Compliance History Report Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 04/06/2004 12:00:00 Short Description N Standard # Weight General Problem Management-Consistent with Policies and Procedures Narrative: This standard was evaluated and found to be in compliance. I41002a Medium Category Standard # Weight I41002b Medium Problem Management Short Description Problem Management General Problem Management-Not be Physically or Emotionally Damaging to Child Narrative: This standard was evaluated and found to be in compliance. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1415836 04/06/2004 12:00:00 04/06/2004 12:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1414366 03/26/2004 12:00:00 03/26/2004 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 364059 03/25/2004 12:00:00 Category Short Description Warning Letter/Due Notice given N Standard # Weight Personnel General Staffing-Caring for Children Narrative: This standard was evaluated and found to be in compliance. I24101a Medium Category Short Description Standard # Weight General Staffing-Staff Supervised To Protect Health, Safety, Well-Being of Children Narrative: This standard was evaluated and found to be in compliance. I24102a Medium Category Personnel Short Description Standard # Weight Medical and Dental Care-Need and Frequency for Medical Examinations Narrative: This standard was evaluated and found to be in compliance. I52002 Medium Category Short Description Standard # Weight Child Care Medical and Dental Care-Examinations and Treatment I52004 Medium Child Care Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Page 152 of 187 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Narrative: This standard was evaluated and found to be in compliance. Category Short Description Standard # Weight General Problem Management-Consistent with Policies and Procedures Narrative: This standard was evaluated and found to be in compliance. I41002a Medium Category Standard # Weight I41004 Medium Problem Management Short Description Problem Management General Problem Management-Harsh, Cruel, Unusual or Unnecessary Discipline Narrative: This standard was evaluated and found to be in compliance. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1414659 03/25/2004 12:00:00 03/25/2004 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 364020 03/23/2004 12:00:00 Category Short Description Warning Letter/Due Notice given N Standard # Personnel Weight General Staffing-Sufficient Qualified Staff to Protect Children and I24101 Perform: Narrative: Standard evaluated was found to be in compliance. Medium Category Short Description Standard # Weight Personnel Policies-Personnel Must Meet Requirements for Background Checks Narrative: Standard evaluated was found to be in compliance. I21006 Medium Category Personnel Standard # Weight II. Basic Care-Personnel Staff-Child Ratio-Waking Hours Narrative: Standard evaluated was found to be in compliance. Short Description II25001 Medium Category Standard # Weight II25002 Medium Short Description II. Basic Care-Personnel Staff-Child Ration-Sleeping Hours Narrative: Standard evaluated was found to be in compliance. Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Page 153 of 187 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 362577 03/10/2004 12:00:00 N Category Short Description Problem Management Monitoring Personal Restraints and Prohibited Restraints: Narrative: This standard was evaluated and found to be in compliance. Standard # Weight I42232 Medium TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1412751 03/10/2004 12:00:00 03/10/2004 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 361156 02/26/2004 12:00:00 Category Short Description Personnel General Staffing-Caring for Children Narrative: This standard was evaluated and found to be in compliance. Warning Letter/Due Notice given N Standard # Weight I24101a Medium TA Finding Admn Rvw Compliance Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 361164 02/26/2004 12:00:00 N Category Standard # Weight Problem Management Monitoring Personal Restraints and Prohibited Restraints: Narrative: This standard was evaluated and found to be in compliance. Short Description I42232 Medium Category Standard # Weight Short Description TA Finding Admn Rvw Compliance TA Finding Admn Rvw Problem Management General Problem Management-Consistent with Policies and I41002a Medium Deficiency Waived Procedures Narrative: The disciplinary measures used by a staff person were not consistent with the facility's policies and procedures; specifically, regarding an incident at school during which a staff was assaulted and a resident was restrained. Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1411286 02/26/2004 12:00:00 02/26/2004 12:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Note: Prior to January 1, 2007, all Standards were not associated with a weight. Page 154 of 187 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Investigation Inspection 1410972 02/25/2004 12:00:00 Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 361395 02/23/2004 12:00:00 N Category Short Description 02/25/2004 12:00:00 Standard # Personnel General Staffing-Sufficient Qualified Staff to Protect Children and I24101 Perform: Narrative: Standard evaluated was found to be in compliance. Activity Type: Investigation Number Date Intake Rcvd: Investigation 359476 02/10/2004 12:00:00 Category Short Description Personnel General Staffing-Caring for Children Narrative: This standard was evaluated and found to be in compliance. Activity Type: Investigation Number Date Intake Rcvd: Investigation 360047 02/10/2004 12:00:00 Category Short Description N Weight N Standard # Weight I24101a Medium I24101a Medium Category Standard # Weight Service Management Admission Policies-Operational Program and Admission Criteria to I31102 Admit Children Narrative: This standard was evaluated and found to be in compliance. Medium Category Standard # Weight Service Management Admission Assessment Narrative: This standard was evaluated and found to be in compliance. I31201 Medium Category Standard # Weight I52004 Medium Short Description Note: Prior to January 1, 2007, all Standards were not associated with a weight. Admn Rvw Compliance N Personnel General Staffing-Caring for Children Narrative: This standard was evaluated and found to be in compliance. Child Care Medical and Dental Care-Examinations and Treatment Narrative: This standard was evaluated and found to be in compliance. TA Finding Warning Letter/Due Notice given Weight Short Description Admn Rvw Compliance Warning Letter/Due Notice given Standard # Short Description TA Finding Medium TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Page 155 of 187 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1409267 02/10/2004 12:00:00 02/10/2004 12:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1408485 02/06/2004 12:00:00 02/06/2004 12:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1408482 02/04/2004 12:00:00 02/04/2004 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 359525 02/03/2004 12:00:00 N Category Short Description Standard # Personnel General Staffing-Sufficient Qualified Staff to Protect Children and I24101 Perform: Narrative: Standard evaluated was found to be in compliance. Activity Type: Investigation Number Date Intake Rcvd: Investigation 359676 02/03/2004 12:00:00 Category Short Description Weight TA Finding Medium Admn Rvw Compliance Warning Letter/Due Notice given N Standard # Personnel General Staffing-Sufficient Qualified Staff to Protect Children and I24101 Perform: Narrative: Standard evaluated was found to be in compliance. Weight TA Finding Medium Admn Rvw Compliance Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 356722 12/19/2003 12:00:00 N Category Standard # Weight Problem Management Emergency Medications-Chemical Restraints are Prohibited Narrative: This standard was evaluated and found to be in compliance. Short Description I42312 Medium Category Short Description Standard # Weight Problem Management Information Physician's Orders Must Include I42321 Medium Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Admn Rvw Compliance TA Finding Page 156 of 187 Deficiency Admn Rvw Waived Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Narrative: In a child's file reviewed, the physician's order allowing emergency medication did not include a description of the behaviors and circumstances under which medication may be administered to restrain the child. Category Short Description Standard # Weight TA Finding Problem Management Admn Rvw Implementation of Emergency Medication- Combination With I42332 Medium Deficiency Restraint Justification Narrative: A child's file reviewed did not document by a physician's written order that emergency medication was allowed to be used in combination with personal restraint. Waived Category Admn Rvw Short Description Standard # Weight TA Finding Problem Management Orders for Emergency Medication -Contraindications the Physician I42322 Medium Deficiency Waived Must Consider Narrative: A child's file reviewed did not document that the physician ordering emergency medication had taken into consideration potential medical and behavioral contraindications. Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1404177 12/19/2003 12:00:00 12/19/2003 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 356316 12/12/2003 12:00:00 N Category Short Description Standard # Personnel General Staffing-Sufficient Qualified Staff to Protect Children and I24101 Perform: Narrative: Standard evaluated was found to be in compliance. Activity Type: Investigation Number Date Intake Rcvd: Investigation 355690 12/08/2003 12:00:00 Category Short Description Weight TA Finding Medium Warning Letter/Due Notice given N Standard # Weight TA Finding Problem Management General Problem Management-Harsh, Cruel, Unusual or I41004 Medium Unnecessary Discipline Narrative: Staff admitted that because a resident had stolen his chips, he made the resident go room to room and say to staff and residents that he was a thief. Category Short Description Personnel General Staffing-Caring for Children Narrative: The facility must ensure that sufficient qualified staff is employed to care for children in care. Note: Prior to January 1, 2007, all Standards were not associated with a weight. Admn Rvw Compliance Standard # Weight I24101a Medium Deficiency TA Finding Page 157 of 187 Deficiency Admn Rvw Waived Admn Rvw Waived Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Category Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Short Description Weight: Id/Number: Admin Review Status: Low: 6 Standard # Not Available: 4 Weight TA Finding Admn Rvw Problem Management General Problem Management-Requirements for Disciplinary I41002 Medium Deficiency Waived Measures Narrative: Staff admitted that he tried to force a resident to eat chips that he had stolen from the staff. Staff also admitted that he poured the chips in the resident's lap for no reason Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1407248 12/08/2003 12:00:00 12/08/2003 12:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1402005 12/03/2003 12:00:00 12/03/2003 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 354448 11/26/2003 12:00:00 Category Short Description Warning Letter/Due Notice given N Standard # Personnel General Staffing-Licensed Child Care Administrator I24201 Narrative: The facility must ensure that sufficient qualified staff are employed to protect the health, safety and well-being of children in care . Weight TA Finding Medium Deficiency Admn Rvw Waived Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 354797 11/26/2003 12:00:00 N Category Short Description Standard # Personnel Weight General Staffing-Sufficient Qualified Staff to Protect Children and I24101 Perform: Narrative: This standard was evaluated and found to be in compliance. Medium Category Standard # Weight I41002b Medium Short Description Problem Management General Problem Management-Not be Physically or Emotionally Damaging to Child Narrative: This standard was evaluated and found to be in compliance. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1407555 11/26/2003 12:00:00 11/26/2003 12:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Note: Prior to January 1, 2007, all Standards were not associated with a weight. Page 158 of 187 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Investigation Inspection 1407719 11/26/2003 12:00:00 Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 355458 11/21/2003 12:00:00 N Category Short Description 11/27/2003 12:00:00 Standard # Personnel General Staffing-Sufficient Qualified Staff to Protect Children and I24101 Perform: Narrative: Standard evaluated was found to be in compliance. Activity Type: Investigation Number Date Intake Rcvd: Investigation 353768 11/11/2003 12:00:00 Category Short Description N Weight TA Finding Medium Admn Rvw Compliance Warning Letter/Due Notice given N Standard # Personnel General Staffing-Sufficient Qualified Staff to Protect Children and I24101 Perform: Narrative: Standard evaluated was found to be in compliance. Weight TA Finding Medium Admn Rvw Compliance Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 352508 10/24/2003 12:00:00 N Category Short Description Standard # Personnel General Staffing-Sufficient Qualified Staff to Protect Children and I24101 Perform: Narrative: Standard evaluated was found to be in compliance. Activity Type: Investigation Number Date Intake Rcvd: Investigation 351849 10/16/2003 12:00:00 Category Short Description Weight Admn Rvw Compliance Warning Letter/Due Notice given N Standard # Weight Problem Management General Problem Management-Policies and Procedures Narrative: Standard evaluated and found to be in compliance. I41001 Medium Category Short Description Standard # Weight Personnel General Staffing-Sufficient Qualified Staff to Protect Children and I24101 Perform: Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Medium TA Finding Admn Rvw Compliance TA Finding Medium Page 159 of 187 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Narrative: Standard evaluated and found to be in compliance. Activity Type: Investigation Number Date Intake Rcvd: Investigation 349733 09/19/2003 12:00:00 Category Short Description Warning Letter/Due Notice given N Standard # Weight Administration Requirement for Written Serious Incident Reports Narrative: This standard was evaluated and found to be in compliance. I15001 Medium Category Standard # Weight Administration Required Documentation for Absence Without Permission Narrative: This standard was evaluated and found to be in compliance. Short Description I15005 Medium Category Standard # Weight I24101a Medium Short Description Personnel General Staffing-Caring for Children Narrative: This standard was evaluated and found to be in compliance. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1392363 09/11/2003 12:00:00 09/11/2003 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 348234 08/29/2003 12:00:00 Category Short Description Warning Letter/Due Notice given N Standard # Personnel General Staffing-Sufficient Qualified Staff to Protect Children and I24101 Perform: Narrative: Standard evaluated was found to be in compliance. Weight TA Finding Medium Admn Rvw Compliance Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 348225 08/28/2003 12:00:00 N Category Short Description Personnel General Staffing-Caring for Children Narrative: This standard was evaluated and found to be in compliance. Note: Prior to January 1, 2007, all Standards were not associated with a weight. Standard # Weight I24101a Medium TA Finding Page 160 of 187 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1390837 08/28/2003 12:00:00 08/28/2003 12:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1389558 08/20/2003 12:00:00 08/20/2003 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 347289 08/19/2003 12:00:00 Category Short Description Warning Letter/Due Notice given N Standard # Weight Problem Management Personal Restraint-When Restraints May be Used Narrative: It was determined that a staff conducted two restraints in what were not emergency situations. I42211 Medium Category Standard # Weight Short Description Problem Management Personal Restraint-Less Restrictive Techniques Must be Attempted I42213 Narrative: This standard was evaluated and found to be in compliance. Medium Category Weight Short Description Standard # TA Finding Deficiency TA Finding Admn Rvw Waived Admn Rvw Compliance TA Finding Admn Rvw Problem Management Monitoring Personal Restraints and Prohibited Restraints: I42232 Medium Deficiency Narrative: It was determined that a staff person conducted two restraints where more than the minimum amount of reasonable and necessary physical force was used. Waived Category Admn Rvw Short Description Standard # Problem Management Protecting the Child's Safety, Privacy, Personal Dignity and I42236 Well-Being Narrative: It was determined that a staff person's tone and verbal taunt did not act to protect a child's personal dignity during a restraint. Activity Type: Investigation Number Date Intake Rcvd: Investigation 347220 08/12/2003 12:00:00 Category Short Description Weight General Problem Management-Harsh, Cruel, Unusual or Unnecessary Discipline Narrative: Staff member observed hitting and kicking a resident. I41004 Medium Category Standard # Weight Note: Prior to January 1, 2007, all Standards were not associated with a weight. Waived N Weight Short Description Deficiency Warning Letter/Due Notice given Standard # Problem Management TA Finding Medium TA Finding Deficiency TA Finding Page 161 of 187 Admn Rvw Waived Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Personnel General Staffing-Sufficient Qualified Staff to Protect Children and I24101 Perform: Narrative: Staff member was observed hitting and kicking resident. Not Available: 4 Medium Deficiency Waived Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1386470 07/24/2003 12:00:00 07/24/2003 12:00:00 N Category Standard # Weight Personnel General Staffing-Caring for Children Narrative: This standard was evaluated and found in compliance. Short Description I24101a Medium Category Standard # Weight Short Description TA Finding TA Finding Child Care Medical and Dental Care-Medication Record Must Include I520012 Medium Narrative: One prescription medication record reviewed showed staff initials on 7/25/03 for a medication administered to the resident on 7/24/03. Category Short Description Child Care Medical and Dental Care-Documentation of Medical and Dental Care Narrative: This standard was evaluated and found in compliance. Standard # Weight I52005 Medium Admn Rvw Compliance Deficiency TA Finding Admn Rvw Waived Admn Rvw Compliance Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 344872 07/22/2003 12:00:00 N Category Short Description Standard # Weight General Problem Management-Consistent with Policies and Procedures Narrative: This standard was evaluated and found in compliance. I41002a Medium Category Standard # Weight I41002b Medium Problem Management Short Description Problem Management General Problem Management-Not be Physically or Emotionally Damaging to Child Narrative: This standard was evaluated and found in compliance. Activity Type: Inspection Id Note: Prior to January 1, 2007, all Standards were not associated with a weight. Date Begin: TA Finding Admn Rvw Compliance TA Finding Date End: Admn Rvw Compliance Warning Letter/Due Notice given Page 162 of 187 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Monitoring Inspection 1383974 07/03/2003 12:00:00 07/03/2003 12:00:00 Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 343405 06/30/2003 12:00:00 N Standard # N Category Short Description Personnel General Staffing-Sufficient Qualified Staff to Protect Children and I24101 Perform: Weight Medium Category Short Description Standard # Weight Child Care Narrative: General Child Care-Protection from Abuse Neglect I51001 Medium TA Finding Admn Rvw Compliance Narrative: TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1383685 06/20/2003 09:00:00 06/20/2003 10:10:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 343176 06/18/2003 12:00:00 Warning Letter/Due Notice given N Category Short Description Standard # Category name not available General Staffing 24101 Weight TA Finding Admn Rvw Not Deficiency Waived Available Narrative: The facility did not protect the health, safety, and well-being of the children in their care when staff allowed children to buy and use tobacco products. This practice is also against Texas law for minors and staff could be charged with "distribution". Activity Type: Inspection Id Date Begin: Monitoring Inspection 1381977 06/17/2003 12:00:00 Category Short Description Date End: Warning Letter/Due Notice given 06/17/2003 12:00:00 Standard # N Weight TA Finding Admn Rvw Administration Explanations to Children-Behavior Intervention I12108 Medium Deficiency Narrative: Two children's records reviewed did not contain signed documentation to indicate the children had received explanations of the facility's behavior interventions. Waived Category Admn Rvw Short Description Building, Grounds, and Equipment Environment-Buildings and Grounds Narrative: I observed holes in the walls in the Red House, Draeger II, Curry House, Curry II, and Patterson. Note: Prior to January 1, 2007, all Standards were not associated with a weight. Standard # Weight I62001 Medium TA Finding Page 163 of 187 Deficiency Waived Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Category Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Short Description Weight: Id/Number: Admin Review Status: Low: 6 Standard # Not Available: 4 Weight TA Finding Admn Rvw Building, Grounds, and Equipment Environment-Equipment and Furniture I62001c Medium Deficiency Waived Narrative: I observed a smoke detector not working (without batteries) in Bahler house. The oven door hinge was broken in Bedynek I. There was a broken toilet seat hinge in Curry III. Category Short Description Standard # Weight Building, Grounds, and Equipment Environment-Flammable and Poisonous Substances I62002 Narrative: There were three containers of charcoal lighter fluid and several aerosol cans accessible in an unlocked closet in Bickerstaff II. Medium Category Weight Short Description Standard # Building, Grounds, and Equipment Food Preparation, Dining, Storage Areas, Furniture and Equipment I64001a Narrative: The microwave oven was observed to need cleaning in Curry III. Medium Category Standard # Weight Preliminary Treatment Plan-Completed Within 72 Hours of IV32101 Admission and Documented Narrative: There was no preliminary (72 hour) treatment plan on file in one of the records reviewed for a child admitted on 6/2/03. Medium Short Description IV. RTC-Service Management TA Finding Deficiency TA Finding Deficiency TA Finding Deficiency Admn Rvw Waived Admn Rvw Waived Admn Rvw Waived Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1368025 02/27/2003 12:00:00 02/28/2003 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 330939 02/05/2003 12:00:00 Category Short Description Warning Letter/Due Notice given N Standard # Weight Personnel General Staffing-Caring for Children Narrative: This standard was evaluated and found to be in compliance. I24101a Medium Category Short Description Standard # Weight General Problem Management-Consistent with Policies and Procedures Narrative: This standard was evaluated and found to be in compliance. I41002a Medium Category Standard # Weight I41002b Medium Problem Management Short Description Problem Management General Problem Management-Not be Physically or Emotionally Damaging to Child Narrative: This standard was evaluated and found to be in compliance. Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Page 164 of 187 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Monitoring Inspection 1364186 01/28/2003 12:00:00 01/28/2003 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 335708 01/24/2003 12:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1363069 01/17/2003 10:30:00 03/17/2003 12:00:00 Y Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1361784 01/09/2003 10:00:00 03/09/2003 12:00:00 Y Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Monitoring and Investigation Inspection 1360113 12/20/2002 12:00:00 12/20/2002 12:00:00 N Category Standard # Weight Building, Grounds, and Equipment Environment-Buildings and Grounds Narrative: The living room carpet in the Wood House needed to be cleaned. Short Description I62001 Medium Category Standard # Weight Short Description Building, Grounds, and Equipment Environment-Equipment and Furniture I62001c Narrative: None of the five flashlights on a shelf in the living room area of the Curry 2 house were observed to be in working order. TA Finding Deficiency TA Finding Medium Deficiency Admn Rvw Waived Admn Rvw Waived Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 328511 12/17/2002 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 328517 12/16/2002 12:00:00 N Category Short Description Standard # Weight Personnel General Staffing-Caring for Children I24101a Narrative: Staff used unnessary and excessive force against a resident, resulting in resident receiving a fractured wrist and finger. Medium Category Short Description Standard # Weight Personnel General Staffing-Supervision of Staff I24102 Medium Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Deficiency TA Finding Page 165 of 187 Deficiency Admn Rvw Waived Admn Rvw Waived Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Narrative: Staff was not properly supervised and as a result a resident was physically harmed. Activity Type: Investigation Number Date Intake Rcvd: Investigation 327626 12/13/2002 12:00:00 Category Short Description Warning Letter/Due Notice given N Standard # Weight TA Finding Admn Rvw Personnel General Staffing-Caring for Children I24101a Medium Deficiency Waived Narrative: A staff person did not adequately protect the well-being of a child when the staff did not sufficiently intervene to prevent the child from engaging in reckless physical activity which resulted in the child fracturing his upper right arm. Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Monitoring Inspection 1355479 11/14/2002 12:00:00 11/14/2002 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 326559 10/29/2002 12:00:00 N Category Short Description Standard # Weight Category name not available Children's Records 1400 Not Available Category Short Description Standard # Weight Category name not available Staffing 2400 Not Available TA Finding Admn Rvw Compliance Narrative: TA Finding Admn Rvw Pending Narrative: Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 326676 10/29/2002 12:00:00 N Category Short Description Standard # Weight Category name not available Children's Records 1400 Not Available Short Description Standard # Weight TA Finding Admn Rvw Compliance Narrative: Category Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Page 166 of 187 Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Administration Narrative: Reports and Records 1500 Medium Category Short Description Standard # Weight Category name not available Personnel Records 2200 Not Available Compliance TA Finding Admn Rvw Compliance Narrative: Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Monitoring and Investigation Inspection 1352700 10/24/2002 12:00:00 10/24/2002 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 323153 10/15/2002 12:00:00 N Category Short Description Standard # Weight TA Finding Problem Management General Problem Management-Consistent with Policies and I41002a Medium Procedures Narrative: A disciplinary measure used by a staff during a restraint, i.e., the staff biting the child, was not consistent with the facility's policies and procedures. Deficiency Admn Rvw Waived Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 324034 10/03/2002 12:00:00 N Category Short Description Standard # Weight General Problem Management-Consistent with Policies and Procedures Narrative: Standard evaluated was found to be in compliance. I41002a Medium Category Short Description Standard # Weight Problem Management Narrative: Monitoring Personal Restraints and Prohibited Restraints: I42232 Medium Problem Management TA Finding Admn Rvw Compliance TA Finding Admn Rvw Pending Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 326708 10/03/2002 12:00:00 N Note: Prior to January 1, 2007, all Standards were not associated with a weight. Page 167 of 187 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Category Short Description Standard # Weight Category name not available Children's Records 1400 Not Available Category Short Description Standard # Weight Administration Narrative: Reports and Records 1500 Medium Category Short Description Standard # Weight Category name not available Personnel Records 2200 Not Available TA Finding Admn Rvw Compliance Narrative: TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Narrative: Activity Type: Inspection Id Date Begin: Monitoring Inspection 1347737 09/19/2002 12:00:00 Category Short Description Date End: Warning Letter/Due Notice given 09/19/2002 12:00:00 N Standard # Weight Personnel Personnel Policies-Tuberculosis Testing I21009 Narrative: The TB test results documented for 8 staff were obtained after staff were assigned responsibility for the care of children. Medium Category Short Description Standard # Weight Personnel Records-Application or Resume that Documents Qualifications Narrative: Two staff records did not contain qualifying educational documentation (i.e. diploma or transcript). I22001a Medium Category Personnel Standard # Weight Staff-Child Ratio Training and Orientation for New Staff Narrative: Five staff records did not include documentation of pre-service training. Short Description I26001 Medium Category Standard # Weight Short Description TA Finding Deficiency TA Finding Deficiency TA Finding Deficiency TA Finding Staff-Child Ratio Training and Orientation-First Aid Training within 90 days of hire I26002 Medium for new staff Narrative: One staff record did not contain documentation to show current first aid certification. The certification documented had recently expired (7/22/02). Category Short Description Note: Prior to January 1, 2007, all Standards were not associated with a weight. Standard # Weight Deficiency TA Finding Page 168 of 187 Admn Rvw Waived Admn Rvw Waived Admn Rvw Waived Admn Rvw Waived Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 IV. RTC-Personnel Training for Staff With no Previous Child Care Experience IV26001 Medium Deficiency Waived Narrative: Two staff records did not contain documentation to show the staff (new staff without experience) had received the required 40 hours of supervised experience prior to being assigned sole responsibility for a group of children. Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Monitoring and Investigation Inspection 1343969 08/21/2002 12:00:00 08/21/2002 12:00:00 N Category Short Description Standard # Weight TA Finding Admn Rvw Building, Grounds, and Equipment Environment-Buildings and Grounds I62001 Medium Deficiency Waived Narrative: The Patterson home was not maintained so as not to be hazardous to safety, in that there were four light bulbs without covers above the sink in the ground level large bathroom. Additionally, the home was not maintained so as not to be hazardous to health, in that the living room ceiling fans had a large accumulation of dust on the blades. Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 318743 08/15/2002 12:00:00 N Category Short Description Standard # Weight Personnel Narrative: General Staffing-Planning and Providing Services I24101b Medium Category Short Description Standard # Weight Child Care Narrative: Medical and Dental Care-Self-Medication Program I52009 Medium Category Short Description Standard # Weight IV. RTC-Service Management Treatment Plan Must Include Evaluation of-Specific Strategies and IV32203 Techniques Medium Category Short Description Standard # Weight IV. RTC-Service Management Treatment Plan -Information to Child and Child's Parents or Managing Conservator IV32203c Medium TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Narrative: TA Finding Narrative: Note: Prior to January 1, 2007, all Standards were not associated with a weight. Page 169 of 187 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Activity Type: Investigation Number Date Intake Rcvd: Investigation 320180 07/05/2002 12:00:00 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Warning Letter/Due Notice given N Category Short Description Standard # Weight Category name not available Childrens Records 1400 Not Available Category Short Description Standard # Weight Administration Narrative: Reports and Records 1500 Medium TA Finding Admn Rvw Compliance Narrative: TA Finding Admn Rvw Compliance Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 318054 06/25/2002 12:00:00 N Category Short Description Standard # Weight Personnel Narrative: General Staffing-Caring for Children I24101a Medium Category Short Description Standard # Weight Personnel General Staffing-Staff Supervised To Protect Health, Safety, Well-Being of Children I24102a Medium TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Narrative: Activity Type: Inspection Id Date Begin: Monitoring Inspection 1336119 06/14/2002 12:00:00 Category Short Description Date End: Warning Letter/Due Notice given 06/14/2002 12:00:00 Standard # N Weight Child Care Nutrition-Retention of Menus I53004 Narrative: Lunch menu substitutions were not noted on the menus at the Draeger 1 house and the Humphrey 3 house. Medium Category Standard # Weight I62001 Medium Short Description Building, Grounds, and Equipment Environment-Buildings and Grounds Narrative: There was a door stop protruding up from the floor in a bedroom in the Draeger 3 house. TA Finding Deficiency TA Finding There was a hole in the door under a bathroom sink in the Humphrey 3 house. Note: Prior to January 1, 2007, all Standards were not associated with a weight. Page 170 of 187 Deficiency Admn Rvw Waived Admn Rvw Waived Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Category Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Short Description Building, Grounds, and Equipment Environment-Equipment and Furniture Narrative: There were dryer lint filters that needed cleaning in the Draeger 3 house and Curry 4 trailer. Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Standard # Weight I62001c Medium TA Finding Deficiency Admn Rvw Waived There was a portable stereo on the edge of a bathroom sink, with the cord hanging in the sink, in one of the bathrooms in the Curry 4 trailer. Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Other Inspection 1334368 05/31/2002 12:00:00 05/31/2002 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 318056 05/17/2002 12:00:00 Category Short Description Warning Letter/Due Notice given N Standard # Weight TA Finding Admn Rvw Problem Management General Problem Management-Consistent with Policies and I41002a Medium Deficiency Waived Procedures Narrative: A staff person failed to use disciplinary measures consistent with the facility's policies and procedures when she was observed by another staff member to have slapped residents on at least three occasions for displaying non-compliant behavior. Activity Type: Investigation Number Date Intake Rcvd: Investigation 308840 03/26/2002 12:00:00 Warning Letter/Due Notice given N Category Short Description Standard # Weight Administration Narrative: Reports and Records 1500 Medium Category Short Description Standard # Weight Category name not available Personnel Records 2200 Not Available Category Short Description Standard # Weight Category name not available Childrens Records 1400 Not Available TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Narrative: TA Finding Narrative: Note: Prior to January 1, 2007, all Standards were not associated with a weight. Page 171 of 187 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 307657 02/24/2002 12:00:00 N Category Standard # Weight Personnel General Staffing-Supervision of Staff Narrative: Daystar staff were not properly supervised to ensure that duties were performed adequately Short Description I24102 Medium Category Standard # Weight Personnel Program Staff-Education Requirement Narrative: Proof of high school diploma was not located in a Daystar staff file. Short Description I24302 Medium Category Short Description Standard # Weight General Problem Management-Requirements for Disciplinary Measures Narrative: Daystar policy was not followed during a restraint of a resident. I41002 Medium Category Standard # Weight Problem Management Short Description TA Finding Deficiency TA Finding Deficiency TA Finding Deficiency TA Finding Problem Management Monitoring Personal Restraints and Prohibited Restraints: I42232 Medium Narrative: The use of force during a restraint of resident at Daystar was not reasonable and did not minimize risk of physical discomfort, harm or pain. Category Short Description Standard # Personnel General Staffing-Sufficient Qualified Staff to Protect Children and I24101 Perform: Narrative: Excessive force was used during a restraint Weight Deficiency TA Finding Medium Deficiency Admn Rvw Upheld Admn Rvw Upheld Admn Rvw Overturned Admn Rvw Upheld Admn Rvw Upheld Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Monitoring and Investigation Inspection 1321202 02/14/2002 12:00:00 02/14/2002 12:00:00 N Category Short Description Standard # Weight Problem Management Personal Restraint-When Restraints May be Used I42211 Narrative: An 11/30/01 restraint as documented was not necessary, since the client was restrained for trying to push his way out of the room. Medium Category Weight Short Description Note: Prior to January 1, 2007, all Standards were not associated with a weight. Standard # TA Finding Deficiency TA Finding Page 172 of 187 Admn Rvw Waived Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Problem Management Documentation of Personal Restraint-Actions to Facilitate Return to I422511 Medium Normal Activities Narrative: There was no description documented of the actions the caregiver took to facilitate the client's return to normal activities after the 11/30/01 restraint. Category Short Description Standard # Problem Management Weight Documentation of Personal Restraint-Alternative Strategies I42253 Attempted Narrative: There was no documentation regarding the child's reaction to alternative strategies used prior to the restraint done on 11/30/01. Medium Category Weight Short Description Standard # IV. RTC-Service Management Admission Procedures-Written Psychiatric or Psychological IV31201 Diagnostic Evaluation Narrative: The psychological evaluation for a resident admitted 8/15/01 was dated 12/21/00 (more than six months prior to admission). Deficiency TA Finding Deficiency TA Finding Medium Deficiency Waived Admn Rvw Waived Admn Rvw Waived Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 304546 12/19/2001 12:00:00 N Category Short Description Standard # Weight Problem Management General Problem Management-Not be Physically or Emotionally Damaging to Child I41002b Medium TA Finding Admn Rvw Compliance Narrative: Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 305319 10/21/2001 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 297367 10/15/2001 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 298607 10/10/2001 12:00:00 N Category Short Description Standard # Weight TA Finding Admn Rvw Personnel General Staffing-Supervision of Staff I24102 Medium Deficiency Waived Narrative: Staff was not adequately supervised when staff restrained resident improperly and without cause, which caused resident to lose consciousness and/or his breath for several seconds. Category Short Description Note: Prior to January 1, 2007, all Standards were not associated with a weight. Standard # Weight TA Finding Page 173 of 187 Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Category name not available Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Problem Management Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 41002 Not Deficiency Waived Available Narrative: Staff failed to comply with facility policy when staff restrained resident without cause and improperly, which caused resident to lose consciousness and/opr his breath for several seconds Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 297361 10/05/2001 12:00:00 N Category Short Description Standard # Weight Problem Management Narrative: Monitoring Personal Restraints and Prohibited Restraints: I42232 Medium TA Finding Admn Rvw Compliance Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259863 08/21/2001 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 295779 08/08/2001 12:00:00 N Category Short Description Standard # Weight VI. TC-Child Care Professional Consultation and Treatment for Children With Developmental Disabilities 5100 Medium TA Finding Admn Rvw Compliance Narrative: See CAPS case #24360473. Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 294300 07/27/2001 12:00:00 N Category Short Description Standard # Weight Category name not available inappropriate restraint 141001 Not Available Category Short Description Standard # Weight Category name not available no documentation of restraint 114001 Not Available TA Finding Admn Rvw Compliance Narrative: TA Finding Narrative: Note: Prior to January 1, 2007, all Standards were not associated with a weight. Page 174 of 187 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1113548 04/23/2001 12:00:00 04/23/2001 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259864 04/17/2001 12:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1113547 01/18/2001 12:00:00 01/18/2001 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259865 01/16/2001 12:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1113546 01/12/2001 12:00:00 01/12/2001 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259866 01/04/2001 12:00:00 N Activity Type: Inspection Id Date Begin: Monitoring Inspection 1113545 11/10/2000 12:00:00 Date End: Warning Letter/Due Notice given 11/10/2000 12:00:00 N Category Short Description Standard # Weight Category name not available Noncompliance 31203C Not Available TA Finding Admn Rvw Deficiency Narrative: ACCLAIM CONVERSION 08/25/2001 Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1113544 11/03/2000 12:00:00 11/03/2000 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259867 10/25/2000 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259868 10/23/2000 12:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1113543 09/06/2000 12:00:00 09/06/2000 12:00:00 N Note: Prior to January 1, 2007, all Standards were not associated with a weight. Page 175 of 187 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259869 09/01/2000 12:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1113542 04/13/2000 12:00:00 04/13/2000 12:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Monitoring Inspection 1113541 04/06/2000 12:00:00 04/06/2000 12:00:00 N Category Short Description VI. TC-Health, Safety and Environment Knowledgeable Adults Must Supervise Explosive Materials, Firearms, Other Weapons, Hunting Equipment and Projectiles Narrative: ACCLAIM CONVERSION 08/25/2001 Standard # Weight 62001 Medium TA Finding Admn Rvw Deficiency Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1113540 04/05/2000 12:00:00 04/05/2000 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259870 04/03/2000 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259871 03/24/2000 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259872 03/24/2000 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259873 03/22/2000 12:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1113539 03/22/2000 12:00:00 03/22/2000 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259874 03/16/2000 12:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1113538 02/25/2000 12:00:00 02/25/2000 12:00:00 N Note: Prior to January 1, 2007, all Standards were not associated with a weight. Page 176 of 187 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259875 02/23/2000 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259876 02/22/2000 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259877 02/08/2000 12:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1113537 02/01/2000 12:00:00 02/01/2000 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259878 01/07/2000 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259879 01/06/2000 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259880 01/03/2000 12:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1113535 12/29/1999 12:00:00 12/29/1999 12:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1113536 12/29/1999 12:00:00 12/30/1999 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259881 12/28/1999 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259882 12/28/1999 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259883 12/14/1999 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259884 12/14/1999 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Note: Prior to January 1, 2007, all Standards were not associated with a weight. Page 177 of 187 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Investigation 259885 12/14/1999 12:00:00 Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1113534 11/22/1999 12:00:00 11/22/1999 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259886 11/17/1999 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259887 10/18/1999 12:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1113533 10/07/1999 12:00:00 10/07/1999 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259888 09/28/1999 12:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1113532 09/28/1999 12:00:00 09/28/1999 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259889 09/17/1999 12:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1113531 09/17/1999 12:00:00 09/17/1999 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259890 07/22/1999 12:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1113530 07/22/1999 12:00:00 07/22/1999 12:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Monitoring Inspection 1113529 07/20/1999 12:00:00 07/20/1999 12:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1113528 06/29/1999 12:00:00 06/29/1999 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259891 06/09/1999 12:00:00 N Note: Prior to January 1, 2007, all Standards were not associated with a weight. N Page 178 of 187 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1113526 05/20/1999 12:00:00 05/20/1999 12:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Monitoring Inspection 1113527 05/20/1999 12:00:00 05/20/1999 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259892 05/06/1999 12:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1113525 05/03/1999 12:00:00 05/03/1999 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259893 04/30/1999 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259894 04/30/1999 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259895 04/29/1999 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259896 04/27/1999 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259897 04/26/1999 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259898 04/26/1999 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259899 04/22/1999 12:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1113524 04/16/1999 12:00:00 04/16/1999 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259900 04/15/1999 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Note: Prior to January 1, 2007, all Standards were not associated with a weight. Page 179 of 187 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Investigation 259901 04/07/1999 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259902 04/07/1999 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259903 03/12/1999 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259904 03/05/1999 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259905 03/05/1999 12:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1113522 03/05/1999 12:00:00 03/05/1999 12:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1113523 03/05/1999 12:00:00 03/06/1999 12:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1113518 03/03/1999 12:00:00 03/03/1999 12:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1113519 03/03/1999 12:00:00 03/04/1999 12:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1113520 03/03/1999 12:00:00 03/05/1999 12:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1113521 03/03/1999 12:00:00 03/06/1999 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259906 03/02/1999 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259907 03/01/1999 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259908 02/26/1999 12:00:00 N Note: Prior to January 1, 2007, all Standards were not associated with a weight. Page 180 of 187 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Activity Type: Inspection Id Date Begin: Follow-up Inspection 1113517 02/23/1999 12:00:00 Category Run date: July 17, 2018 Compliance History Report Short Description Problem Management General Problem Management-Remarks that Belittle or Ridicule Child or His Family Narrative: ACCLAIM CONVERSION 08/25/2001 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Date End: Warning Letter/Due Notice given 02/23/1999 12:00:00 N Standard # Weight I41005 Medium TA Finding Admn Rvw Deficiency Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259909 02/19/1999 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259910 02/11/1999 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259911 02/11/1999 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259912 02/11/1999 12:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1113516 01/25/1999 12:00:00 01/25/1999 12:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1113515 01/13/1999 12:00:00 01/13/1999 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259913 01/06/1999 12:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1113514 01/06/1999 12:00:00 01/06/1999 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259914 12/23/1998 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259915 12/07/1998 12:00:00 N Note: Prior to January 1, 2007, all Standards were not associated with a weight. Page 181 of 187 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259916 12/04/1998 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259917 11/14/1998 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259918 11/09/1998 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259919 11/04/1998 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259920 10/21/1998 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259922 10/14/1998 12:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1113513 10/14/1998 12:00:00 10/14/1998 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259921 10/09/1998 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259923 09/18/1998 12:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1113512 09/18/1998 12:00:00 09/18/1998 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259924 09/01/1998 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259925 08/20/1998 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259926 07/23/1998 12:00:00 N Activity Type: Inspection Id Date Begin: Note: Prior to January 1, 2007, all Standards were not associated with a weight. Date End: Warning Letter/Due Notice given Page 182 of 187 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Investigation Inspection 1113511 06/08/1998 12:00:00 06/08/1998 12:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Monitoring Inspection 1113510 06/03/1998 12:00:00 06/03/1998 12:00:00 N Category Standard # Weight Child Care Medical and Dental Care-Locked Storage of Medication Narrative: ACCLAIM CONVERSION 08/25/2001 Short Description I520016 Medium Category Standard # Weight I62001 Medium Short Description Building, Grounds, and Equipment Environment-Buildings and Grounds Narrative: ACCLAIM CONVERSION 08/25/2001 TA Finding Admn Rvw Deficiency TA Finding Admn Rvw Deficiency Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259927 06/01/1998 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259928 05/30/1998 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259929 05/27/1998 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259930 05/18/1998 12:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1113509 04/13/1998 12:00:00 04/13/1998 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259931 04/08/1998 12:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1113508 04/08/1998 12:00:00 04/08/1998 12:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1113507 04/06/1998 12:00:00 04/06/1998 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Note: Prior to January 1, 2007, all Standards were not associated with a weight. Warning Letter/Due Notice given Page 183 of 187 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Investigation 259932 04/03/1998 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259933 02/13/1998 12:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Follow-up Inspection 1113506 01/15/1998 12:00:00 01/15/1998 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259934 12/29/1997 12:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Monitoring Inspection 1113505 12/18/1997 12:00:00 12/18/1997 12:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1113504 10/15/1997 12:00:00 10/15/1997 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259935 10/09/1997 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259936 10/03/1997 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259937 09/26/1997 12:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1113502 09/23/1997 12:00:00 09/23/1997 12:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1113503 09/23/1997 12:00:00 09/24/1997 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259938 09/18/1997 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259939 09/15/1997 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259940 07/02/1997 12:00:00 N Note: Prior to January 1, 2007, all Standards were not associated with a weight. Page 184 of 187 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Activity Type: Inspection Id Date Begin: Monitoring Inspection 1113501 06/17/1997 12:00:00 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Date End: Warning Letter/Due Notice given 06/17/1997 12:00:00 N Category Short Description Standard # Weight Category name not available Noncompliance I31203C Not Available TA Finding Admn Rvw Deficiency Narrative: ACCLAIM CONVERSION 08/25/2001 Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1113500 05/06/1997 12:00:00 05/06/1997 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259941 04/23/1997 12:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1113499 04/16/1997 12:00:00 04/16/1997 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259942 04/11/1997 12:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1113498 04/03/1997 12:00:00 04/03/1997 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259943 03/31/1997 12:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1113497 03/27/1997 12:00:00 03/27/1997 12:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1113496 03/21/1997 12:00:00 03/21/1997 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259944 02/17/1997 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259945 02/12/1997 12:00:00 N Note: Prior to January 1, 2007, all Standards were not associated with a weight. Page 185 of 187 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259946 02/12/1997 12:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1113495 02/12/1997 12:00:00 02/12/1997 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259947 02/10/1997 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259948 02/06/1997 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259949 01/27/1997 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259950 01/21/1997 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259951 10/08/1996 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259952 09/05/1996 12:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Monitoring Inspection 1113494 06/28/1996 12:00:00 06/28/1996 12:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 1113493 05/07/1996 12:00:00 05/07/1996 12:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 259953 03/27/1996 12:00:00 N Activity Type: Inspection Id Date Begin: Monitoring Inspection 1113492 12/28/1995 12:00:00 Category Short Description Child Care Medical and Dental Care-Medication Record Must Include Narrative: ACCLAIM CONVERSION 08/25/2001 Note: Prior to January 1, 2007, all Standards were not associated with a weight. Date End: Warning Letter/Due Notice given 12/28/1995 12:00:00 N Standard # Weight I520012 Medium TA Finding Page 186 of 187 Deficiency Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 516827 Daystar Residential Inc. License Type: Full Permit Dt Issued: 12/29/1995 Total Deficiencies cited: 238 High: 45 Medium High: 30 Run date: July 17, 2018 Compliance History Report Medium: 139 Report Criteria Period: 01/01/1995 To 7/17/2018 Category: Standard: Type: ALL Finding: Medium Low: 18 Weight: Id/Number: Admin Review Status: Low: 6 Not Available: 4 Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Other Inspection 1113491 05/09/1995 12:00:00 05/09/1995 12:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Other Inspection 1113490 05/04/1995 12:00:00 05/04/1995 12:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Application Inspection 1113489 04/14/1995 12:00:00 04/14/1995 12:00:00 N Note: Prior to January 1, 2007, all Standards were not associated with a weight. Page 187 of 187