Safe Haven Youth Ranch

During the course of this investigation, it was determined that a staff member was utilized inappropriate disciplinary practices by referring to a child using derogatory names.

Medication errors were not documented for missed dosages of prescription medication for six children in care.

Six children in care missed dosages of prescribed medications on multiple occasions for consecutive days.

While reviewing the child service plan it was discovered in the "Transitioning To Successful Adulthood," several statements indicated the child was a twelve-year-old, which was not true or accurate at the time this plan was completed. This section of the plan was also not current, as the child plan was a review and this section should've been completed at the time of the review as the child was fourteen years old at the time the plan was completed.

A child admitted on 06/11/2024 did not receive an initial medical visit until 08/14/2024.

Documentation related to the medical records of a child admitted in June 2024 was not observed in the child's file.

An employee file was observed to lack documentation related to pre-employment screening.

One caregiver was observed to be supervising 7 children in Llanos House.

A staff member choked a child in care as a form of discipline.

The allegations are related to a DFPS abuse/neglect investigation.

One of four records revewed observed EBI was not completed; last completion was 07/23/2024.

Medical attention was sought for a child in care after a restraint was administered. Child reported of having stomach pains and was taken to the doctor the next day. Serious incident occurred on 2.11.2025, but was not called into RCCR.

Records were supplied in two formats: electronic and paper. However, the documents in both formats lacked uniformity, which created challenges in processing the information. Additionally, there were several missing documents in both the electronic and paper submissions, further complicating the review and analysis of the records.

One of four child's records reviewed had a different child's name listed in file.Additionally, one of the employee records reviewed lacked documentation of a drug tests being taken

Children's records reviewed did not have an immunization record in the file.

Children's records reviewed did not have documentation that the service plan meeting letter was sent to all parties.

During the review of files, services plans were not signed by all parties involved.

During the review of four employee records, it was noted that two of them lacked documentation verifying the completion of reference checks.

Children's records reviewed did not have current service plans completed in the file.

Three of four employee records reviewed were observed to be missing recent training certificates.

A child in care suffered pain to the face as a result of a staff member horseplaying with the child.

Staff described physically picking up a child in care and placing him in his bedroom after an altercation with another child.

748.2003(b)(5) - Administration of prescription medication-Ensure the child has taken the medication as prescribed

748.2001(b) - Administration of Medication-Must obtain written, signed, & dated consent for a new psychotropic medication

There were three serious incidents involving one child in care exhibiting suicidal ideations. There were no documented suicide screenings for neither incident.

It was observed in one of four employee files reviewed that the operation did not contact each employer included in the five-year employment history.

One of four employee files reviewed was observed to be missing notarization on the Licensing Affidavit for Applicants for Employment form.

The person list in the portal shows 8 active employees that are not documented on the employee list provided by the operation.

Three serious incidents for one child in care indicated suicide ideations and/or attempts. Neither of the three incidents were reported to Licensing.

It was determined that two trainings were over a year old.

Children in care reported that staff were asleep on shift, staff were observed unresponsive with their eyes closed shut.

A caregiver sought assistance from other children in care to restrain a child.

One child in care was not administered prescribed medication for one month. A second child in care received two more milligrams of medication than what was prescribed.

One of the child files reviewed was observed to have an inaccurate count of two medications documented on the medication log.

Staff and residents interviewed stated a staff member called a resident a derogatory name.

Caregiver did not provide the 1:1 supervision required for a youth in care.

It was determined a staff member made inappropriate comments to a child in care regarding family and also engaged in an unnecessary power struggle with a child in care.

Several incident reports do not document the length of time a child was restrained.

Staff have fallen asleep when supervising children in care.

Admission Assessments did not include medications the children were taking.

It was observed that an employee transported children in care with an expired driver's license.

Admission Assessments does not include known allergies.

Log shows that smoke detectors were not tested in May 2023.

Admission Assessments reviewed did not include any known contraindications to restraints.

Admission Assessments did not include information for parents.

Video camera footage, captured by the facility, showed a staff using her forearm to push a child back into his room, forcing him to comply to directives for quiet, calm down time.

While conducting the investigation of the facility it was found that the medication error was found on 1-18-23 and the child had still not received any medical attention as of 2-2-23 when the investigation was initiated.

During the course of the investigation, it was found that the medication error happened on 1-9-23 and it was not documented until 1-20-23.

Staff performed a personal restraint on a child in care without there being an emergency situation.

A child was inappropriately touched by another child while outside and under the supervision of staff.

The reportable incident occurred on 10.15.22 and it was not reported by the operation to licensing until 10.19.22

2 children in care were given one extra dosage of medication.

Two staff members administered an additional prescription medication dosage to a child in care.

A child in care was administered an incorrect dosage of medication.

2 children in care were given one extra dosage of medication.

In one of the four employee files reviewed, it was observed that an employee who began 01/24/22 did not have a notarized Affidavit for Applicants until 06/13/22.

One of the four employee files reviewed was observed to be missing a high school diploma. The employee has been working at the operation since 01/24/22.

Four of the four child records reviewed were observed to be missing immunization records.

On the date of the incident the agency was not in ratio.

During the inspection it was observed that the operation had expired food in the pantry and not stored properly. There were two open food boxes in the pantry..mash potatoes, pancakes (photos taken).

During the walk through it was observed that one building had a door with a board over the window. Photos taken.

It was reported that a staff member was asleep while providing supervision to children in care.

It was determined that a child in care was restrained for walking/not listening.

Operation does not have documented report of serious incident that occurred.

Children in care reported that a staff member would make derogatory remarks in reference to the sexuality of a child in care.

Children in care reported that a staff member would force a child in care to eat food that he did not want to eat.

Four out of five children interviewed reported to hearing profane language being used to redirect the children. Three out of five staff interviewed acknowledged being aware of profane language being used to redirect the children.

Observed First Aid Kit did not contain (4) cotton balls or (6) scissors.

One child's record did not include an Immunization Record.

Four of four children's medication log showed that the children did not get their medication as prescribed, Out of the four children records it was seen 18 times that medication was missed.

Four of four Children's recorders had errors based on the cumulative medication count with a total of 16 times.

Three of Four Children's medication record indicated no reason for prescription with a total of 16 logs without a reason.

Three of four children's record did not have the signature of staff that administrated the medication, with a total of 4 errors.

One of four children's records does not document the dosage of the medication.

Three of four children's record showed that there was medication corrections without the required documentation to follow with a total 4 errors.

It was found that a child in care was pushed by a caregiver.