Triple 7 Ranch GRO

Condition #1- Not Met There is not documentation of at least two child records reviewed during the following weeks: 7/21/2025-7/27/2025 7/28/2025-8/3/2025 8/4/2025-8/10/2025 8/11/2025-8/17/2025 8/18/2025-8/24/2025 Condition #2- Not Met As of 8/14/2025 the operation has not had a Medication Technician for the ongoing oversight of medication administration and documentation. Condition #3- Not Met There is no record within 30 days that two new hires completed a Serious Incident Reporting Training with a source outside of Triple 7. There is no proof of training, including a sign-in sheet and or a signed and dated certificate on file and available for review. Condition #4- Not Met There is not documentation of at least two staff records reviewed during the following weeks: 7/19/2025- 7/25/2025 7/26/2025- 8/1/2025 8/2/2025-8/8/2025 8/9/2025-8/15/2025 8/16/2025-8/22/2025 8/23/2025- 8/28/2025 Condition #6- Not Met Triple 7 Ranch GRO has hired 5 new staff members and there is no record of them being informed about the operation being on probation and or a signed acknowledgement of probation conditions form on file. Although there are sign-in sheets for Monday Weekly Meetings being conducted on 8/25/2025, 8/18/2025, 8/11/2025, 8/4/2025, and 7/28/2025 there are no meeting notes on file.

On 8/15/2025 a youth in care was arrested and taken into custody. Although a written reportable serious incident report was completed by the facility, this incident was not reported to Licensing/Statewide Intake.

Based on the information gathered and obtained throughout the investigation it was determined staff members use profane language towards children in care.

The staff that accompanied the children on the hunting trip left the children with staff from the hunting facility, while operation staff were in a different facility.

Several children in care admitted to going on a hunting trip where they were allowed to hold a real gun and pull the trigger.

The management staff did not provide the direct care staff that accompanied the children on the hunting trip the proper supervision requirements to ensure that the staff that were in charge of the children were properly supervising the children at all times.

The children at the operation engage in treatment services, therefore they should not be allowed to use any firearms due to the children's behaviors and trauma, as this can pose a risk to the safety of children in care.

The staff that accompanied the children to the hunting trip were not with the children while they were hunting deer, therefore ratio was not complaint.

The staff that accompanied the children on the hunting trip, were not supervising the children properly due to the children being with left with staff from the hunting grounds. The staff allowed the children to engage in high-risk activities by using firearms to hunt. Furthermore, the operations weapons policy states that no child may use a firearms during recreational activities.

During the inspection, it was discovered that a former employee is no longer employed at the operation, but has yet to be inactivated.

During the inspection, multiple holes were observed in the walls of the operation in various places, including the bathroom and the bedrooms. Broken blinds and broken electrical wall plugs were also observed at the operation. Missing light bulbs were observed in two refrigerators on the property.

During the inspection, it was observed that multiple items in the refrigerator were not properly stored. Multiple expired items were also observed in the refrigerator as well.

It was determined that the operation did not use prudent judgement when they picked up prescription medication for a child no longer in their care. The child was without medication for more than a day due to this. The operation also misplaced the child's cream and inhaler.

Condition #5 - Not Met. There is no documentation that the 12/24/2024 scheduled emergency drills were conducted. There is no documentation that the 12/24/2024 scheduled smoke detectors check was conducted. There is no documentation that the 12/24/2024 scheduled first aid kits check was conducted. There is no documentation that the 12/24/2024 scheduled fire extinguishers check was conducted.

Triple 7 Ranch is a GRO only licensed for emotional disorders treatment services. Records reviewed show five placed youth in care require ASD and IDD treatment services which the operation is not licensed for.

Medication logs reviewed did not reflect an accurate pill count.

Three fire extinguishers were observed to be out of compliance.

Cleaning supplies were observed unlocked and accessible to children.

The 2nd. Quarter EBI Report has not been submitted to Child Care Regulation.

Two out of three youth files reviewed did not include known allergies or chronic conditions on the exterior or in an easily visible location on the file.

One smoke detector in House 2 did not have a battery in it causing it to continuously beep.

The operation did not have documentation indicating the battery-operated smoke detectors are being tested on a monthly basis.

The operation's first aid kit did not contain adhesive tape, antiseptic wipes/solution, and scissors as required.

One freezer in House 2 did not contain a thermometer inside.

The operation's evacuation diagram does not indicate a location designated inside the operation to take shelter in severe weather.

The vehicle registration has been expired for over a year, as it expired 01/2023

The air conditioning vents in operations van only works in the front set and are missing from the remaining body of the van.

The 1st. Quarter EBI Report has not been submitted to Child Care Regulation.

In 2 staff files out of the 4 reviewed the pre-service training was conducted untimely, in addition there is no indication in any of the files when staff was counted into ratio.

In 1 out of 4 staff files there was a statement regarding immediately reporting suspected child, abuse, neglect, or exploitation however it was not signed or dated.

In 1 of the refrigerator's there was no thermometer.

There is no unauthorized absence log and is non-existent at this time. In addition, there is no overall operation evaluation for unauthorized absences as required by 748.463(a).

In 4 out of 4 staff files there was no job description in the personnel record.

1 of 4 staff records reviewed did not contain instructor led psych med training.

In 4 out of 4 staff files there is no documentation regarding any drug testing being done prior to having access to children.

The serious incident documentation is missing some of the required components such as the operations physical address, telephone number, individuals involved (children & staff), child's age and gender.

In a review of files for staff hired after 8/9/23, two staff records were observed to not have pre-employment screenings completed.

All child bathrooms were observed with nothing for them to dry their hands.

At the time of the inspection, 2 out of 4 files reviewed were missing proof of child's orientation.

At the time of inspection, 3 out of 4 files reviewed child's prelimanary plan was not completed within 72 hours.

This standard was found deficient as part of a DFPS Investigation.

This standard was found deficient as part of a DFPS Investigation.

During the course of the investigation, documentation reviewed contained inaccurate information as well as incomplete sections.

One child's admission assessment reviewed did not list the services the operation planned to provide the child.

At the time of the inspection, the medication administration records did not consist of reason for medication prescribed.

4 out of 5 children records reviewed did not consist of child's initial service plan.

Review of incident reports revealed an alleged sexual abuse incident was not called in to Licensing.

1 out of 5 children records reviewed did not consist of proof of TB test.

At the time of the inspection, the medication administration records did not consist of prescribing health-care professional's name.

2 out of 4 medication records reviewed were missing documentation of medication administration.

Based on a review of medication administration records, it was found that medication logs were not completed properly.

Based on interviews conducted and records reviewed, it was determined that children were not administered their medications on multiple days.

3 out of 4 children's records reviewed did not consist of child orientation.

2 out of 4 medication records reviewed were missing documentation of medication administration.

3 out of 4 children's records reviewed did not consist of child's initial service plan.

3 out of 4 children records reviewed did not consist of a preliminary service plan..

3 out of 4 children records reviewed did not consist of an admission assessment.

1 out of 4 children records reviewed did not consist of proof medical exam with 30 days of admission.

3 out of 4 children records reviewed did not consist of proof of TB test.

2 out of 4 children records reviewed did not consist of proof of dental exam.

1 out of 4 children's records reviewed did not consist of current immunization record.

Review of incident reports revealed an alleged sexual abuse incident was not called in to Licensing.

During a CCI inspection, it was observed one staff member did not follow the condition of their provisional background while providing supervision of children in care at the operation.

A caregiver witnessed a child being hit with a belt by another caregiver and failed to report the incident.

A caregiver was observed using corporal punishment on a child.

A caregiver failed to adhere to the child's rights to be free of abuse, neglect, and exploitation as defined in Texas Family Code 261.401.

Caregiver observed corporal punishment of a child, and failed to intervene.

Caregiver observed corporal punishment of a child, and failed to intervene.

A caregiver failed to adhere to the child's rights to be free of abuse, neglect, and exploitation as defined in Texas Family Code 261.401. A caregiver failed to protect a child from abuse as defined in Texas family Code 261.401

A caregiver was observed using corporal punishment on a child.

A caregiver witnessed a child being hit with a belt by another caregiver and failed to report the incident.

The operation reported a serious injury of a youth in care that required professional medical treatment to Licensing more than 24 hours after the discovery.

During a monitoring inspections one of the two staff files reviewed the affidavit of application for employment was not completed.

During a monitoring inspections one of the two staff files reviewed the TB testing was missing.

During a monitoring inspections one staff member did not follow the condition of their provisional background while providing supervision of children in care at the operation.

During the monitoring inspection one of the two files reviewed was missing EBI training. The last documented EBI training for the staff occurred on 12.02.2021.

During a walk through the following area are in need of repair: Location East bathroom 5112 Door broken 5112 and 5110 check all outlet cover and replace covers. 5112 hole next to closet door and 5110 repair holes in walls in common area and rooms. (Maintenance Report provided.

During a monitoring inspection, the operations health inspection was expired on 12/04/2021.

Operation's last fire inspection occurred on 02/17/2021. Operation failed to complete a fire inspection within 12 months of last fire inspection.

The operation provided documentation that they conducted their own drug tests on the four employees whose files were reviewed in this investigation.

During the inspection three out of four medication records did not include an accurate daily count for multiple medication doses.

During the inspection four out of four medication logs reviewed had missing signatures for doses administered.

The operation does not have completed preliminary service plans for the four children placed at the facility.

Four out four children's records did not have an admissions assessment completed for non-emergency admissions to the operation.

The operation's vehicle used to transport the children registration expired in October 2021.

The operation does not currently have an administrator. The last administrator left the operation in October 2021.

A staff member who is no longer associated with the operation is still listed as active

There was a green lighter found outside of building 10

There was a hole in a bathroom located in building 10.

The health insepction was expired on 10/7/2021

The operation has not validated the background list in 5 months

A controlling person is no longer associated with the operation and thus needs to be removed.

Several of the tubs has dead bugs in them. The toilet paper roll handle was broken in one of the bathrooms located in building 10

One out one personnel record reviewed was missing the affidavit form and several other components that should be in the personnel file. Including date of hire, orientation, normalcy training, job description.

The operation has not reported the EBI numbers.

There was a saw blade located behind unit 5110. The blade was removed and disposed of properly

The operation does not have access to funds for the first 3 months of operating.

There were several cleaning items accessible to children in the laundry room.

The doors to the hot water heaters did not have a lock. A wooden table located in the laundry room was damaged on the side with exposed wood that can cause splinters. There were chairs outside the units and a rug in the kitchen area of one of the units that had several stains.

There were several bird nets and wasps nets in the walking areas outside. Several spiders and spiderwebs found in the bedrooms. There were dead bugs in the closets and other area of the units. Overall there were area of the units that need to be cleaned.

The operation did not have a telephone or any line of communication for the units that will house children.

There was one toilet that had large brown stains in the laundry room bathroom. There were two showers/bathtubs that were unclean.

There was a mattress on one of the bunk beds that did not have a waterproof covering over the mattress.

There were large pieces of wood located on the basketball goal, large debris of rocks/bricks located on several areas of the grounds, two wooden boards with nails in areas accessible to children and a large trailer with debris inside.

There was an outside light fixture that is damaged and had exposed wiring. There was also a smoke detector that was missing the cover with exposed wiring in one of the bedrooms. On the back of one of the units there was a green and black substance at the bottom of brick wall.