Guardian Angels I Residential Treatment Center

There operation had expired over the counter medication, medication for a child whom has been discharge and current children stored in the same box.

3 out of 4 files child files reviewed were incomplete. 72-hour service plans, initial service plans, and a signed copy of the child rights was not in the file.

Licensing arrived at the facility at 10:30A to conduct an unannounced inspection. After a 2-hour waiting period there was access to active records.

The operations physical address, and telephone number were missing from a serious incident report that was submitted.

A resident in care was able to ingest objects on multiple occasions. A safety plan was put into place after multiple self harming incidents occurred, resulting in repeated hospitalizations and surgery.

A physical altercation between 2 children in care occurred and a staff member was unable to intervene as she was the only staff member on duty.

Only 3 serious incident reports out of 8 children who went on an unauthorized leave of absence on two different days were provided to licensing.

During an inspection, it was observed that two staff members were not practicing self-control, as a child was exhibiting escalating behaviors.

A child was given another child in care's medication.

An unauthorized staff gave a child the wrong medication.

Staff were observed sleeping by children in care.

Suicide screenings were not immediately administered on a child who attempted to self-harm on three occasions by swallowing inanimate objects.

A suicide attempt that occurred on 04/01/25 was not reported until 04/03/25. Suicide attempts that occurred on 04/21/25 and 05/05/25 were not reported to Licensing.

3 serious incident reports did not contain all required documentation regarding an elopement. This includes the time and date law enforcement, and parents were notified, along with the names of those notified.

4 triggered reviews did not contain all required documentation. This includes a review of the previous unauthorized absences and previous debriefings required in 748.461(1) and level of supervision as required in 748.461(2).

A staff member failed to follow policy and procedures. The staff member admitted to not conducting checks every 20 minutes as per policy.

Children in care were able to run away from the facility while being supervised by staff.

During the monitoring inspection, the recreational chart provided did not contain a of indoor and outdoor recreational activities for the children daily.

The initial service plan for a child in care does not have the signatures or dates of participation for a professional level service provider or managing conservator. Therefore, it is unknown if they participated in the initial service plan meeting or reviewed the initial service plan.

Multiple children and staff interviewed confirmed an inappropriate was made to a child by staff.

Multiple children interviewed confirmed a member of staff made an inappropriate comment to a child in care.

During the team inspection, complete children's files, and the EBI annual evaluation were not available for review.

Serious incident reports were reviewed and they did not contain the required minimal standard criteria. The serious incident reports did not discuss the interventions made after the child returned to the facility.

During the incident / physical altercation, a staff member was heard to be cursing.

Children's clothing are still being taken away as a form discipline.

A child in care had a high-risk behavior of suicidal ideation and was able to grab multiple objects and self-harm.

A caregiver became belligerent, yelled, and used profanity in reference to and at a child in care.

A caregiver physically pushed and used a close fist to punch a child in care.

A staff member became both verbally and physically aggressive with a child in care. A staff member with protective capacity physically positioned herself between the staff and child in care in an attempt to protect the child.

The incident report does not contain the required elements for reporting non serious medical incidents as required. The document does not have the physical address or phone number of the operation.

During the investigation, there were multiple accounts of a caregiver pushing a child in care.

During the investigation, it was found that a child was cursed at by a caregiver during a confrontation.

During the investigation, a caregiver failed to maintain self-control when they positioned themselves for a physical confrontation with a child, and verbally provoked the child.

Three children left the operation on 05/30 in the 4pm hour and the unauthorized absence was not reported until 05/31 in the 8am hour.

Child in care went on AWOL on 5-16-24 immediately after child got down from the school bus at about 3:25pm and did not return until the next day. Operation staff stated that AWOL report was made on 5-16-24 around 11:50pm which is more than 6 hours report timeframe.

Staff is using an oven to heat the home on multiple occasions.

Two children and one agency staff witnessed an agency staff member sleeping.

During a review of external documentation, the operation did not complete a suicide screening, as well as a safety plan at the time of admission.

The operation does not have a Treatment Director to oversee the treatment program that provides treatment services for children with emotional disorders.

Medication was not accurately accounted for medication logs for children in care.

Prudent judgment was not applied to a situation where a staff member immediately noticed a change and did not verify the information before preforming assigned tasks.

Scheduled II medication was improperly stored in a kitchen drawer that is not double locked.

During a review of external documentation, the operation did not complete a suicide screening, as well as a safety plan at the time of admission.

Caregiver conducted restraint on a youth utilizing unapproved technique.

Staff were not able to intervene which resulted in child self-harming herself with a sharp object.

Two youth beds were observed to not have a mattress cover during a walkthrough of the operation.

Caregivers at the operation are not physically intervening when children are engaging in a physical altercation.

During a review of the investigation it was determined that a staff member threatened a child in care was threatened with corporal punishment verbally and with hand gestures.

Staff used unnecessary force when pushing a child before restraining her three separate times.

Three children in care expressed that a DCS used inappropriate language when talking to them.

A staff member got into a verbal argument with a resident.

A staff member used profane language in an argument with a resident,

A staff member used profanity directed at a child in care during a heated exchange between the two.

A staff member failed to exercise prudent judgment and self-control by engaging in an argument with a child in care.

A staff member yelled at and subjected a child in care to humiliation by referencing the child's family and weight in a demeaning manner.

Four children's service plans were not updated at review to include therapy/skills training frequency, education changes, and/or medication changes.

According to the Incident Report, a child was restrained in the supine position for 3-10 minutes.

Four of four reviewed Supervision sections of the children's Service Plans all have the same Supervision needs and goals.

A log for Unauthorized Absences has not been created by the operation.

After being involved in a physical altercation that resulted in a bloody nose. Later the child was transported to have the injuries examined by a medical professional.

Two children engaged in two separate physical altercations in a very short period of time. After the first altercation; there was no attempts remove the children from close proximity.

Staff engaged in a verbal altercation with a child.

The preponderance of information gathered determine that profane language is being used at the agency in front of children.