Abundance of Joy Home Shelter

There is no record of practice severe weather drills.

Medication logs reviewed, show no record of medication that was administered.

During the course of the investigation, a child in care reported not being able to breathe during a restraint involving staff sitting on them. The child reported breathing heavily once released. Three children interviewed also reported hearing the child say they could not breathe.

During the course of the investigation, it was reported that staff sat on a child?s lungs and belly during a restraint. Three children interviewed corroborated the child's statement.

The operation did not provide a requested medication log after multiple requests.

The operation provided medication logs for the month of November that do not contain consistent information.

Several staff members failed to complete required training prior to being counted in ratio.

The administrator did not have all required annual trainings.

One out of three employee files reviewed only contained 34 annual training hours instead of the required 50 hours.

Two out of four youth files reviewed did not include known contrindications to restraints for the youth.

One out of four youth files reviewed did not contain all required documentation detailing a youth's discharge.

One of three youth files reviewed did not contain a signature by the PLSP on the most recent service plan.

A caregiver took five children in care, ages 9-13, to see a horror movie rated PG-13. Several of these children have history of self-harm and have experienced significant trauma. One child?s Conservatorship worker stated that due to her diagnosis, her mindset is much younger than her age.

During an inspection at the operation, scissors were observed to be accessible in a drawer to youth in care recently after an incident involving scissors occurred with a youth at the operation.

The operation has not entered EBI data in their provider portal for Quarter 4 of 2023.

A suicide risk screening was not conducted with a child post returning from the psych hospital.

Four out of four fire/evacuation drills reviewed were not completed within the required three minutes. One out of the four drills reviewed did not indicate the smoke alarm was set off.

A serious incident that was reported to the statewide intake hotline by the operation did not have a coinciding report documented at the operation.

Two out of three child records reviewed did not contain a signed statement to acknowledge the child's rights.

It was found in 2 out of 3 children files reviewed that no child orientation was provided upon admission.

It was found that 2 out of 3 staff records that there was no high school diploma or GED in the file.

One out of seven employee files reviewed did not contain an updated professional licensure as required for their job position nor any record of training completed. Another employee file did not contain a job description.

The last validation of the employee list in the provider portal was four months ago.

One out of three child files reviewed did not contain a copy of the initial service plan in the file. Two out of three children's files did not contain the most recently updated service plan in the file.

The operation has not had an administrator in 90 days.

There is information to confirm staff use profane language while caring for children.

The operation has not had an administrator in 60 days.

A window blind in one of the bedrooms was damaged.

A window blind in one of the bedrooms was damaged.

One of two bathroom had a broken toilet paper holder. There was an exposed electrical socket in the kitchen dinning area.

The purpose of this standard is to ensure child care regulation is able to assess records and documentation for accuracy and compliance.

Two of two bathrooms utilized by children in care did not contain: paper towel or any hand drying agent. One of two bathrooms did not contain toilet paper, One of two bathrooms had a broken vanity exposing piping. One of two bathroom had a broken toilet paper holder. There was an exposed electrical socket in the kitchen dinning area. There was bag of meat in the freezer in a ripped bag exposing the meat. There was a clump of hair in the freezer.

A window blind in one of the bedrooms was damaged.

Two out of two restraints reviewed did not include a notification to the parent.

One out of three medication records reviewed indicate that the medication count was inaccurately logged.

One out of three medication records reviewed had signatures documented/signed prior to administering any medication to children in care.

A window blind in one of the bedrooms was damaged.

During the inspection, two out of three restraint reports had missing post discussion documentation.

No debriefing documentation was given to inspector regarding AWOL of victim

Operation did not send any post EBI documentation regarding the victim or any child in care from the operation

Due to 5 out of 8 staff EBI records no being current. 5 staff are not qualified to perform EBI.

There was no documentation sent to inspector regarding EBI being performed on victim and documentation on EBI performed on other children in care who were interviewed

annual summary log was not given to inspector regarding AWOL as requested

No serious incident report was given to inspector regarding AWOL of victim that was called in to licensing

Reviewing staff training 5 out of 8 staff do not have up to date training for EBI

One staff member supervised 6 children in a van on 03/20/2022 when a physical altercation occurred.

The operation documents on their incident reports that children are being evaluated by their concierge doctor however there is not always documentation to go along with this and when a document is provided it does not have any official signatures or letterhead and it is unknown who is filling out the document .

Staff failed to report serious incidents involving children in their care to the hotline. Incidents involving physical abuse between children were not reported timely.

Staff failed to complete EBI documentation for serious incidents involving children in their care.

Two children used one seat belt while being transported for an outing.

Staff failed to report serious incidents involving children in care to the parents. Children have been involved in serious incidents requiring medical evaluations after and parents have not been informed within required time frames.

Medication logs reviewed did not include the reason medication was prescribed.

During the inspection; medication was observed accessible to the children in care and child in care pick up a pill off the floor.

During the inspection; a post discussion was not completed after restraint conducted on a child in care.

One of the window blinds in bedroom three contained mold.

One out of two youth files reviewed contained an incident report that did not match the emergency behavior intervention report to coincide with it.