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4000 Inspections

4100 Inspecting Child-Care Homes and Operations

LPPH August 2012

Policy

Licensing staff inspect child-care operations to assess the risk to children in those operations, in accordance with licensing law, administrative rules, and minimum standard rules.

To determine an operation’s compliance, Licensing staff:

a.   observe the operation’s performance;

b.   review the records and files maintained by the operation;

c.   cite the operation’s deficiencies, based on the minimum standards;

d.   document observations to capture scope and severity;

e.   consider the risks posed by violations of the minimum standards;

f.    use critical thinking to assess the operation’s overall compliance history;

g.   help the permit holder identify problems that contribute to deficiencies and provide technical assistance to help the permit holder understand how to comply; and

h.   consider all of the relevant information together for a broad perspective.

The operation is responsible for developing and implementing plans to correct problems and prevent risk to children.

Licensing staff are not responsible for managing the operation.

DFPS Rules, 40 TAC §745.8403; 745.8401

Procedure

Licensing staff evaluate the risk associated with deficiencies and help the permit holder understand that he or she must comply with licensing law, administrative rules, and minimum standard rules.

Determining Compliance With Licensing Law and Rules

For specific procedures on determining compliance with licensing law, administrative rules, and minimum standard rules, see the Policy section above.

Documenting Findings

Once compliance is determined, Licensing staff document the results of:

  •  their observations, to capture the scope and severity of issues that potentially pose a risk to children in care; and

  •  their inspections, within the specified time frame.

All monitoring activities, inspections, technical assistance, and administrative reviews must be documented in the CLASS system. Form 2936 Child-Care Facility Inspection is generated from CLASSMate.

See 4160 Documenting the Results of an Inspection.

4110 The Authority to Monitor Child Care in Texas

LPPH November 2011

Policy

Licensing staff may visit an operation during operating hours to investigate, inspect, and evaluate.

Texas Human Resources Code §42.044(a)

DFPS Rules, 40 TAC §§745.8401, 745.8403, 745.8407(1)

Licensing staff have the authority to:

a.   determine whether an operation is subject to regulation;

b.   verify the operation’s compliance with licensing law, administrative rules; and minimum standard rules; and

c.   investigate reports related to all operations.

4120 Types of Inspections

LPPH December 2015

Policy

Licensing staff select the most appropriate inspection type to record an inspection in the CLASS system. Except for inspections of child-placing agencies, all inspections at all operations must include a walk-through for obvious minimum standard deficiencies (deficiencies that are in plain view).

See:

4121 Application Inspections

4122 Attempted Inspections

4123 Follow-Up Inspections

4124 Initial Inspections

4125 Investigation Inspections

4126 Monitoring Inspections

4127 Monitoring and Investigation Inspections

4128 Other Types of Inspections

4150 Conducting Inspections

4121 Application Inspections

LPPH December 2011

Procedure

Application inspections are conducted during the application phase and generally include an evaluation of all applicable subchapters. See 3313 Inspecting the Operation (Except Listed Homes).

4122 Attempted Inspections

LPPH August 2012

Procedure

Attempted inspections include inspections conducted without making contact with the operation. See 4156 When an Inspection Is Attempted.

4123 Follow-Up Inspections

LPPH August 2012

Procedure

Follow-up inspections include evaluating individual minimum standards, conditions, or restrictions, rather than evaluating an entire subchapter of minimum standards or all conditions or restrictions associated with the operation. See 4300 Conducting a Follow-Up With an Operation.

Examples of reasons follow-up inspections are made include, but are not limited to:

a.   ensuring that recent deficiencies or a pattern of repeated deficiencies are addressed;

b.   meeting with the designated director at a licensed day care center (see 4131.3 Child Day Care – Annual Meeting with the Designated Director);

c.   amending a permit or certificate (see 3810 Circumstances That May Require Amending the Permit);

d.   ensuring that background check matches are completed (see 5300 Central Registry and Criminal History Searches);

e.   evaluating an operation’s compliance with the conditions established to address the issues identified during a risk evaluation (see 4152 Reviewing Restrictions and Conditions and 5300 Central Registry and Criminal History Searches);

f.    following up on suspension, revocation, or denial (see 7636 Follow-Up to Suspension, Revocation, or Denial);

g.   monitoring during the appeal process (see 7731 Regulation During Appeal Process);

h.   following up on a waiver-variance condition (see 4152 Reviewing Restrictions and Conditions and 5120 Setting and Monitoring Conditions for the Waiver or Variance); or

i.    monitoring the temporary relocation of an operation (see 7320 Temporary Relocation).

4124 Initial Inspections

LPPH December 2015

Procedure

Initial inspections are inspections that are conducted during the initial period for a licensing permit.

See 3511 Conducting Inspections During the Initial License Period.

4125 Investigation Inspections

LPPH December 2015

Procedure

Investigation inspections include the investigation of reports alleging:

  •  abuse;

  •  neglect;

  •  violations of Licensing statutes;

  •  violations of administrative rules;

  •  violations of minimum standards; or

  •  a combination of these.

If an investigation interview is conducted at an operation other than the one named in the report, the inspection is classified as Other in CLASS. See 6000 Investigations.

4126 Monitoring Inspections

LPPH December 2015

Procedure

Monitoring inspections must include evaluation of at least one entire subchapter of the applicable minimum standards and may include evaluation of additional individual laws, administrative rules, or minimum standards, or any conditions or restrictions. See 4140 Preparing for Inspections.

4127 Monitoring and Investigation Inspections

LPPH December 2015

Monitoring and investigation inspections include the investigation of a report during a monitoring inspection.

See 4125 Investigation Inspections and 4126 Monitoring Inspections.  

4128 Other Types of Inspections

LPPH March 2017

Other types of inspections are conducted for purposes other than determining compliance with pre-identified minimum standards, such as:

a.  consulting with an operation’s administrator or director;

b.  hand-delivering a corrective or adverse action notice; or

c.  conducting an investigation interview.

4130 Minimum Requirements for Monitoring Inspections

LPPH December 2016

Policy

The operation’s permit type determines:

  •  the minimum frequency with which monitoring inspections are conducted; and

  •  the timeframe by which compliance with all minimum standards have to be evaluated.

An operation’s deficiencies and the associated weight of the deficiencies may indicate a need for more frequent inspections. The recommended monitoring frequency can be found on the Enforcement Recommendations page in CLASS.

See:

4131 Minimum Requirements for Licensed Operations

4132 Minimum Requirements for Registered Child-Care Homes

4133 Operations That Are Not Regularly Inspected

4500 Evaluating Risk to Children

7425 Inspecting an Operation During a Corrective Action

4131 Minimum Requirements for Licensed Operations

LPPH November 2017

First 12 Months After Issuance of a Nonexpiring License

Policy

During the first 12 months following the issuance of a nonexpiring license, the inspector:

  •  conducts at least one unannounced monitoring inspection every six months; and

  •  evaluates for compliance with all minimum standards within 12 months from the date the license was issued.

For information on conducting a monitoring inspection on an operation that holds an initial license, see 3511 Conducting Inspections During the Initial License Period.

Subsequent Years After Issuance of a Nonexpiring License

Policy

After the first 12 months following the issuance of a nonexpiring license, the inspector:

  •  conducts an unannounced monitoring inspection at least annually (not more than 366 days), based upon an assessment of risk to children; and

  •  evaluates for compliance with the following minimum standards, depending on the operation type:

Type of Operation

What Standards and In What Time Frame

Licensed Child Care Centers, School-Age Programs, Before- or After-School Programs, and Licensed Child Care Homes

  •  All minimum standards every two years.

  •  Core health and safety minimum standards annually.

See 4131.4 Health and Safety Audits for Licensed Child Day Care Operations

Licensed residential operations

All minimum standards every two years.

Texas Human Resources Code §42.044(b)

45 Code of Federal Regulations §98.41

Required Inspections During Night or Weekend Hours

Policy

At least once every two years, Licensing staff must inspect an operation that provides night or weekend care during the night or weekend hours that the operation provides care.

For an inspection to count towards this requirement for a residential operation (other than a child-placing agency), Licensing staff must begin the inspection after 7 p.m. on a weekday or anytime on the weekend.

For an inspection to count towards this requirement for a daycare operation that provides nighttime care, Licensing staff must conduct at least some portion of the inspection between 9 p.m. and 6 a.m. during hours of operation.

Procedure

If an inspection cannot be made during night or weekend care, Licensing staff:

  a.  obtain supervisory approval to conduct the inspection during regular visiting hours;

  b.  document the justification for conducting the inspection during regular visiting hours in the CLASS system as a Chronology with a category of Monitoring; and

  c.  document a plan for how night and weekend care will be evaluated for compliance with minimum standards.

Two-Year Period Measurement

Procedure

The inspector measures a two-year period by beginning with the first day of the month in which Licensing issued the nonexpiring license and counting in two-year increments. For example, if the license was issued on September 10, the two-year period would begin on September 1 and end on August 31 two years later.

4131.1 Residential Child Care: Monitoring Inspections for CPA Branch Offices

LPPH December 2016

Policy

When a child-placing agency (CPA) with a nonexpiring license opens a branch office, the inspector conducts a monitoring inspection at the branch office.

Branch Office Opens During the First 12 Months After the CPA Is Issued a Nonexpiring License

Procedure

When a CPA opens a branch office during the first 12 months following the issuance of the CPA’s nonexpiring license, the inspector:

  •  conducts a monitoring inspection at the branch office evaluating compliance with all minimum standards within six months after the branch office opens; and

  •  schedules and conducts additional inspections at the branch office according to the monitoring frequency of the CPA’s main office, until the CPA has had a nonexpiring license for one year.

After the CPA has had a nonexpiring license for more than 12 months, the inspector:

  •  conducts additional monitoring inspections at the branch office at least annually, based upon an assessment of the risk to children (see 4130 Minimum Requirements for Monitoring Inspections); and

  •  evaluates each CPA branch office for compliance with all minimum standards during each two-year period.

Branch Office Opens More than 12 Months After the CPA is Issued a Nonexpiring License

Procedure

When a CPA opens a branch office after the first 12 months following the issuance of the CPA’s nonexpiring license, the inspector conducts a monitoring inspection at the branch office and evaluates for compliance with all minimum standards within six months after the branch office opens.

Thereafter, the inspector:

  •  schedules inspections in the CLASS system.

  •  conducts additional monitoring inspections at least annually, based upon an assessment of the risk to children (see 4130 Minimum Requirements for Monitoring Inspections); and

  •  evaluates each CPA branch office for compliance with all minimum standards during each two year period.

4131.2 Residential Child Care: Team Inspections

LPPH December 2011

Policy

Licensing staff conduct an unannounced team inspection at each residential child care facility, including each child-placing agency (CPA) branch office, at least once annually. A team inspection is an inspection that is conducted by at least two residential child care inspectors.

Texas Human Resources Code §42.044(b-1)

Procedure

Licensing staff conduct team inspections at each residential child care facility, including CPA branch offices, at least once per year. Each team inspection must:

  •  be unannounced; and

  •  be conducted by at least two residential child care inspectors who work at different residential child care inspection units.

If the inspectors do not work at different inspection units, Licensing staff:

  •  document the reason in the CLASS Chronology / Monitoring Category; and

  •  obtain approval from a Licensing supervisor before conducting the team inspection.

4131.3 Child Day Care: Annual Meeting With the Designated Director at a Licensed Child Care Center

LPPH November 2017

Policy

The inspector meets with the designated director at least once annually during an unannounced inspection at a licensed child care center, to determine whether the designated director:

  •  complies with DFPS rules, 40 TAC §746.1001 and §746.1003; and

  •  meets minimum standard qualifications in 40 TAC §746.1015 and §746.1017.

If the director is not present during at least one of the unannounced inspections within a 12-month period, the inspector schedules a meeting with the director to review the director’s qualifications. This meeting must be held at the operation.

Texas Human Resources Code §42.044(b-2)

Procedure

Annual Review of the Designated Director’s Qualifications

The inspector meets with the designated director of a licensed child care center during at least one monitoring inspection within a 12-month period. During this meeting, the inspector evaluates the director’s qualifications by reviewing:

  a. The original Child-Care Center Director’s Certificate or approved waiver or variance for director qualifications; and

  b. Most recent background check to ensure it is current.

The inspector documents the review of the director’s qualifications by selecting the Dir Qual Eval box on the Inspection Detail page in CLASS.

The inspector cites the appropriate minimum standard and unchecks the Valid Director Certificate checkbox on the Governing Body Designation page in CLASS, if:

  •   the director does not meet the qualifications or have a current waiver or variance for director qualifications; or

  •   the director’s certificate has expired.

If the designated director has an approved waiver or variance for director qualifications, the inspector documents whether the director has made progress toward compliance in the Narrative text box on the Inspection Detail page in CLASS. The inspector also evaluates whether the director qualifies for a non-expiring director’s certificate if the director has an expiring one.

If there are any changes in how the director qualifies since the last inspection, the inspector documents how the director meets the qualifications by selecting the appropriate option in the How DC Director Qualified field on the Governing Body Designation page in CLASS and issues a new director certificate that indicates how the director now meets the qualifications.

When the Director Is Not Present for an Annual Review of Qualifications

If the designated director is not present during at least one unannounced monitoring inspection, within a 12-month period, the inspector meets with the director at the center as outlined in the following chart:

Deficiency Cited at the Last Monitoring Inspection?

Complete the Annual Review of Director Qualifications During…

Yes

an unannounced follow-up inspection conducted no later than 15 days after the latest compliance date for any deficiency noted in CLASS Form 2936 Child-Care Facility Inspection at the last monitoring inspection

No

an announced or unannounced follow-up inspection conducted no later than 15 days after the last monitoring inspection.

If the director is not present during an unannounced follow-up inspection, the inspector schedules a meeting with the director. The meeting must be held at the operation.

If the director does not respond to a request to meet, the inspector cites the facility for a violation of minimum standards and follows up as appropriate.

When the Annual Review of Qualifications Is Late

If the director’s qualifications cannot be reviewed within the required 12-month period, the inspector:

  •  obtains the supervisor’s approval to conduct the inspection at a later date; and

  •  documents the supervisor’s approval in CLASS, in the Chronology/Monitoring Category.

Tracking How Frequently a Director Is Present During Inspections

The inspector evaluates how frequently or infrequently the director is not present by reviewing how often the Director Present check box in CLASS has been checked in the past year. If the director is frequently not present, the inspector determines a plan of action, which may include contacting the permit holder to acquire the director’s work schedule.

4131.4 Health and Safety Audits for Licensed Child Day Care Operations

LPPH November 2017

Policy

Licensing must conduct at least one health and safety audit during an unannounced monitoring inspection each year for licensed child care centers, before- or after-school programs, school-age programs, and licensed child care homes.

45 Code of Federal Regulations §98.41

Procedure

A health and safety audit is a review of core measures related to health and safety, conducted during a monitoring inspection. The inspector completes a health and safety audit by completing the appropriate Health and Safety Audit Checklist or conducting a standard-by-standard monitoringinspection.

Selecting Subchapters on the Inspection Form

The Licensing inspector selects a minimum standard subchapter on CLASS Form 2936 Child-Care Facility Inspection when:

  •  the inspector plans to evaluate the entire subchapter, not just a core measure within the subchapter; or

  •  the operation is deficient with two or more core measures within a content area that requires a review of an entire subchapter.

See:

4161.1 Creating a Draft CLASS Form 2936

4166 Documenting a Health and Safety Audit in CLASS

 

4132 Minimum Requirements for Registered Child-Care Homes

LPPH December 2016

First 12 Months After Issuance of a Registration

Policy

During the first 12 months following the issuance of the registration, the inspector conducts an unannounced monitoring inspection to evaluate compliance with all minimum standards.

Additional monitoring inspections are based on an assessment of risk to children and are scheduled in the CLASS system.

DFPS Rules, 40 TAC §745.8407(2)

45 Code of Federal Regulations §98.41

Subsequent Years After Issuance of a Registration

The inspector conducts unannounced inspections for compliance with all minimum standards at least every two years, unless the home has an agreement to receive a subsidy from the Texas Workforce Commission (TWC).

The inspector measures a two-year period by beginning with the first day of the month in which Licensing issued the registration and counting in two-year increments. For example, if a registration was issued on September 10, the two-year period would begin on September 1 and end on August 31 two years later.

Registered Child Care Homes With a TWC Subsidy Agreement

For a registered child care home that has entered into a subsidy agreement with TWC, the inspector conducts an unannounced inspection and evaluates all minimum standards annually.

The inspector conducts the inspection within 12 months from the date the operation’s subsidy status changed in CLASS, or two years from the date of the last monitoring inspection, whichever comes sooner.

See also:

4166 Documenting a Health and Safety Audit in CLASS

4133 Operations That Are Not Regularly Inspected

LPPH August 2012

Policy

Listed Family Homes

Licensing staff inspect listed family homes only as part of an investigation.

See 6221.3 Reports Received for Listed Homes.

Texas Human Resources Code §§42.044(b), 42.044(c-1)(1)

DFPS Rules, 40 TAC §745.8407(1)

Small Employer-Based Child Care and Temporary Shelter Programs

Licensing staff do not conduct regular monitoring inspections on small employer-based child care. However, Licensing staff may need to conduct any of the other types of inspections listed below:

a.   Application Inspections

b.   Follow-up Inspections

c.   Investigation Inspections

d.   Other

See:

4121 Application Inspections

4123 Follow-Up Inspections

4125 Investigation Inspections

4128 Other Types of Inspections

Texas Human Resources Code §§42.153, 42.162, 42.203, 42.209

DFPS Rules, 40 TAC §§745.8407(5), 745.8407(6)

4140 Preparing for Inspections

4141 Preparing for Application, Initial, and Monitoring Inspections

LPPH December 2015

Policy

Licensing staff prepare for each application, initial, or monitoring inspection by reviewing the:

  •  operation’s record;

  •  last enforcement action recommended for the operation;

  •  frequency of inspections of the operation;

  •  operation’s compliance history, as documented in the CLASS system;

  •  operation’s fee payment history;

  •  operation’s background check records, as documented in the CLASS system;

  •  operation’s controlling person list, as documented in the CLASS system;

  •  recommendations from enforcement team conferences (for inspections of residential operations except independent foster homes); and

  •  results of random-sampling inspections of CPA foster homes (for inspections of CPAs only).

Licensing staff use the information obtained during the review to determine which minimum standards to evaluate during the planned inspection.

If deficiencies with standards that pose a risk to the health and safety of children were cited during a previous inspection, Licensing staff must reevaluate the same and related standards at the inspection.

Draft Form 2936 Child-Care Facility Inspection

Staff must create and save the initial draft of Form 2936 Child-Care Facility Inspection in CLASS before conducting the inspection. See 4161 Completing CLASS Form 2936 Child-Care Facility Inspection.

For information on preparing for investigation inspections, see 4142 Preparing for Investigation Inspections.

Procedure

Reviewing Background Materials

To prepare for an inspection, Licensing staff review all of the following:

a.   The most recent information in the CLASS system on enforcement recommendations for the operation, including the recommendation, the enforcement actions taken by other Licensing staff, and the operation’s recommended monitoring frequency

b.   The capacity of the operation, the ages of the children served, the hours of operation (including days and months), and the services provided

c.   The operation’s address, including the Location Address Validation Status and Mailing Address Validation Status, to determine whether either status is set to Not Validated

d.   The directions to the operation

e.   The name of the designated director, operator, or licensed administrator

f.    The qualifications of the designated director or operator

g.   The last renewal date of the license of a designated director or licensed administrator, if applicable

h.   A history of the operation, including all of the following:

  •  Prior investigations, including investigation and inspection findings and technical assistance provided

  •  Prior inspections, including findings and technical assistance provided

  •  Minimum standard rules that may need to be reevaluated for compliance

  •  Conditions and expiration dates of any waivers, variances, and risk evaluations

  •  Results of random-sampling inspections for CPA foster homes (for inspections of child-placing agencies only; see 4431 Using Random-Sampling Inspections to Regulate a Child-Placing Agency)

i.    The operation’s fee payment history to determine whether the operation is current on all applicable fees, unless the operation is exempt from paying all fees (see 5260 Verification of Fee Payment)

j.    The operation’s background check records in CLASS to verify that the operation has complied with all background check requirements (see 5300 Central Registry and Criminal History Searches)

k.   The operation’s controlling person list in CLASS to determine whether any person on the list has a status of Review (see 7773.4 Reviewing the Status of a Sustained Controlling Person in CLASS for procedures to follow when a person has a status of Review)

l.    Recommendations from enforcement team conferences (for inspections of CPAs and RTCs; see 4441 Enforcement Team Conferences for Child-Placing Agencies and General Residential Operations)

m.  Optional checklists, forms, reading guides, and applicable technical assistance materials

Create a Draft Inspection Form in CLASS

After reviewing the background materials related to an operation but before conducting the inspection, Licensing staff:

  •  complete a draft inspection Form 2936 Child-Care Facility Inspection, located in CLASS; and

  •  upload the draft Form 2936 to CLASSMate.

See 4161 Completing CLASS Form 2936 Child-Care Facility Inspection.

4141.1 Monitoring Inspections During an Investigation

LPPH December 2015

Policy

If an operation is under investigation, inspectors consult with the Licensing supervisor while preparing for the inspection to determine whether an inspection will interfere with the investigation. Licensing staff do not conduct an inspection if it would interfere with an ongoing investigation.

4142 Preparing for Investigation Inspections

LPPH August 2012

Policy

Licensing staff prepare for an investigation inspection by reviewing:

a.   the intake report;

b.   the operation’s record;

c.   the last enforcement action recommended for the operation;

d.   the frequency of inspections made of the operation;

e.   the operation’s compliance history, as documented in the CLASS system; and

f.    the operation’s background check records, as documented in the CLASS system.

Draft Form 2936 Child-Care Facility Inspection

After reviewing the information listed above, but before conducting the inspection, Licensing staff create and save the initial draft of Form 2936 Child-Care Facility Inspection in CLASS. See 4161 Completing CLASS Form 2936 Child-Care Facility Inspection.

For information on preparing for other types of inspections, see 4141 Preparing for Application, Initial, and Monitoring Inspections.

Procedure

Reviewing Background Materials

To prepare for an inspection, Licensing staff review all of the following:

a.   The most recent information in CLASS on enforcement recommendations for the operation, including the recommendation, and the enforcement actions taken by other Licensing staff;

b.   The capacity of the operation, the ages of the children served, the hours of operation (including days and months), and the services provided;

c.   The operation’s address and the directions to the operation;

d.   The name of the designated director, operator, or the name of the licensed administrator;

f.    A history of the operation, including all of the following:

  •  Prior investigations

  •  Previous deficiencies

  •  Conditions and expiration dates of any waivers or variances and risk evaluations, if included as part of the allegations

g.   The operation’s background check records in the CLASS system to verify that the operation has complied with all background check requirements (see 5300 Central Registry and Criminal History Searches)

h.   Optional checklists, forms, reading guides, and applicable technical assistance materials

Create a Draft Inspection Form in CLASS

After reviewing the background materials related to an operation but before conducting the inspection, Licensing staff:

  •  complete a draft inspection Form 2936 Child-Care Facility Inspection, in CLASS; and

  •  download the draft Form 2936 to CLASSMate.

See 4161 Completing CLASS Form 2936 Child-Care Facility Inspection.

4150 Conducting Inspections

LPPH June 2015

Policy

When conducting any type of inspection, Licensing staff must:

a.   identify themselves as DFPS Licensing staff and state the specific purpose of the inspection upon arrival at the site;

b.   assess the risk to children;

c.   terminate the inspection if the safety of Licensing staff is threatened;

d.   document the inspection results in the CLASS system (see 4160 Documenting the Results of an Inspection);

e.   conduct an exit interview at the end of the inspection; and

f.    offer technical assistance to help the permit holder identify problems that contribute to deficiencies with the minimum standard rules and understand how to comply with the rules.

DFPS Rules, 40 TAC §745.8401

General Procedures

Procedure

Licensing staff must observe the following requirements when conducting any type of inspection on an operation:

a.   Carry a valid DFPS identification card and present it to the person in charge.

b.   Explain to the person in charge, upon arrival:

1.   the purpose of the inspection;

2.   the law, administrative rules, or minimum standards by which compliance will be evaluated;

3.   that compliance with additional minimum standards may be evaluated as the situation demands; and

4.   that photographs and video may be taken during the inspection.

c.   Obtain written consent before interviewing biological or adopted children, even when the owner’s or operator’s children are in care at the operation. Children in care may be interviewed, provided the child’s parent has not previously refused to allow Licensing to interview his or her children. See 6000 Investigations.

d.   Terminate the inspection at any time when Licensing staff feel unsafe. Staff must not be placed at risk. Report termination of an inspection to the supervisor. If the danger arises from the caregiver’s resistance to the inspection, follow the procedures in 4159 Handling Resistance or Refusal to Allow Inspection.

e.   Follow the procedures in 7200 Handling Immediate Danger to Children, if children are at risk.

f.    Follow the procedures in 4155 When An Inspection is Attempted, if there is no one at the operation or no children are in care.

g.   Follow the procedures in 6210 Receipt of Intake Reports From Statewide Intake, if abuse or neglect is reported or is observed during the inspection.

4150.1 Additional Requirements for All Inspections on Licensed Child Care Centers

LPPH November 2017

At least once per year, inspectors must meet with the designated director of a licensed child care center during an unannounced monitoring inspection, as outlined in 4131.3 Child Day Care: Annual Meeting With the Designated Director at a Licensed Child Care Center.

4150.2 Additional Requirements for All Inspections on Registered Child-Care Homes

LPPH August 2012

Procedure

If Licensing staff find the following conditions when inspecting a registered child-care home that participates in the Child and Adult Care Food Program (CACFP) of the Texas Department of Agriculture, staff send a letter to the contract manager for the CACFP, using Form 2874 Report of Provider Contact:

a.   The operator is not caring for children.

b.   No children are in care when meals are served.

c.   The operator has a full-time job outside of the home.

d.   Meals are served, but child care is not provided.

e.   Only the operator’s own children are in care.

f.    The home has exceeded its capacity (serves more children than it is approved to serve).

g.   The children in care are older or younger than the home is approved to serve.

4150.3 Additional Requirements for Monitoring Inspections on Residential Child-Care Facilities

LPPH August 2012

Procedure

Licensing staff inspecting residential child care operations also perform the following tasks during each inspection:

  •  Read a sampling of serious incident reports.

  •  Conduct a subsequent inspection the following business day, if one is necessary to complete the monitoring inspection.

See:

4420 Monitoring Child-Placing Agencies

4430 Random-Sample Monitoring of CPA Foster Homes

4150.4 Additional Requirements for Investigation Inspections

LPPH June 2015

Policy

The investigator conducts an unannounced investigation inspection at an operation that is the subject of the investigation according to the timeframes in 6000 Investigations.

The first investigation inspection to the operation may be announced if the investigator has:

a.   attempted one or more unannounced inspections;

b.   obtained supervisory approval to conduct an announced inspection; and

c.   documented the following in the Observations Made During Inspection narrative box on the Investigation Conclusion page in the CLASS system:

  •   The reason for an unannounced inspection could not be conducted

  •   The dates supervisory approval was requested and obtained.

Subsequent investigation inspections may be announced or unannounced.

Inspection Not Required

An investigation inspection is not required when the investigation was assigned:

  •   a priority of 5 (P5); or

  •   a priority of 3 (P3) to process a sex offender proximity report.

See 6000 Investigations.

DFPS Rules, 40 TAC §745.8407

4151 Operation Walk-Throughs

LPPH June 2015

Policy

Any time Licensing staff visit an operation other than a child placing agency, staff perform an operation walk-through and cite any deficiencies observed during the walk-through.

Licensing staff walk through all of the following areas in the operation:

a.   Indoor and outdoor activity areas

b.   Areas where meals are prepared and served

c.   Restrooms accessible to children

d.   Sleeping areas

Procedure

During all inspections, Licensing staff walk through the operation and assesses the risk to children related to obvious violations of the Licensing statutes, administrative rules, or minimum standards related to:

a.   supervision of children;

b.   child/caregiver ratio;

c.   swimming pools and transportation safety, if applicable;

d.   fire, safety, and sanitation requirements; and

e.   responsibilities of the director, administrator, staff, or caregivers.

4151.1 Exceptions for an Investigation Inspection

LPPH June 2015

Policy

If Licensing staff has conducted previous investigations at the operation and a supervisor determines that Licensing staff is sufficiently familiar with the operation’s compliance and investigation history, the supervisor may grant an exception that allows Licensing staff to conduct a condensed operation walk-through.

However, at minimum, Licensing staff must walk through:

a.   the sleeping area of the alleged victim, if applicable;

b.   the restrooms accessible to the alleged victim, if applicable; and

c.   the specific area where the incident being investigated is alleged to have occurred.

When granting approval, the supervisor explains to Licensing staff which areas of the operation that Licensing staff is required to conduct a walk-through.

Licensing staff documents the exception approved by the supervisor in CLASS.

Procedure

For investigation inspections, Licensing staff is responsible for:

a.   obtaining approval from the supervisor before conducting a condensed operation walk-through;

b.   checking for and citing any obvious plain-view violations observed during the operation walk-through; and

c.   inspecting the specific area where the incident being investigated is alleged to have occurred and citing any necessary deficiencies.

For an investigation inspection, Licensing staff documents the exception to conducting a full walk-through in the Observations Made During the Inspection section of the Investigation Conclusion page in CLASS. Documentation must include:

  •   the areas included in the walk-through; and

  •   the date the supervisor approved the exception.

4151.2 Exceptions for a Follow-Up Inspection

LPPH June 2015

Policy

If a follow-up inspection is conducted within the timeframe referenced in 4311 Following Up With an Inspection, Licensing staff may conduct a condensed walk-through limited to the area of the operation relevant to the follow-up inspection.

If a follow-up inspection is not conducted within the timeframes referenced in 4311 When a Follow-Up Inspection Is Required. Licensing staff must conduct a full walk-through.

4152 Reviewing Restrictions, Conditions, Waivers, and Variances

LPPH June 2016

At each initial or monitoring inspection, Licensing staff review:

  •  any restrictions on a permit;

  •  any conditions on a permit;

  •  any conditions related to a waiver or variance still in effect;

  •  any conditions related to a risk evaluation still in effect;

  •  any conditions related to a corrective action still in effect; and

  •  any waivers or variances that have expired since the last monitoring inspection.

During an investigation or follow-up inspection, Licensing staff review and evaluate the operation’s compliance with any restrictions or conditions if they are relevant to the investigation or follow-up being conducted.

4152.1 Documenting Deficiencies Related to Restrictions and Conditions

LPPH June 2016

Policy

After reviewing the restrictions and conditions, Licensing staff document an operation’s deficiencies in the CLASS system.

Procedure

For each inspection in which restrictions or conditions are reviewed, Licensing staff document any violations of restrictions or conditions on CLASS Form 2936 Child Care Facility Inspection by:

  •  citing the Licensing statute, administrative rule, or minimum standard that has been violated;

  •  describing the restriction or condition that was violated. If multiple restrictions or conditions were originally referenced using numbers or letters, it is permissible to use numbers or letters to reference each restriction or condition when it is being evaluated;

  •  describing the deficiency observed;

  •  describing how the deficiency was identified, such as whether staff reviewed paperwork, interviewed the operation’s staff or the children, or took photographs; and

  •  documenting the following, depending on whether the deficiency was corrected during the inspection:

  •  If the deficiency was corrected during the inspection, Licensing staff explain how it was corrected.

  •  If the deficiency was not corrected during the inspection, Licensing staff:

  •  explain what correction is needed to either meet the conditions or to comply with the Licensing statute, rule, or minimum standard; and

  •  provide a correction deadline date.

See:

4161 Completing CLASS Form 2936 Child Care Facility Inspection

7425 Inspecting an Operation During a Corrective Action

4152.2 When an Operation Repeatedly Fails to Meet Restrictions or Conditions

LPPH March 2017

If the operation repeatedly fails to meet the restrictions or conditions, Licensing staff consult with the supervisor on what action to take.

See:

3800 Handling Changes in an Operation

5140 Rescinding or Amending a Waiver or Variance

5300 Central Registry and Criminal History Searches

7000 Voluntary Actions and Enforcement Actions

4152.3 Discussing Waivers and Variances

LPPH June 2016

Policy

Licensing staff discuss any waivers or variances that have expired since the last monitoring inspection with the operation to assess the outcome of the waiver or variance and document the outcome in CLASS. Licensing staff also discuss any waivers or variances that are still in effect to determine if any are no longer needed.

See 5121 Documenting Outcomes for Waivers and Variances.

4153 Reviewing Records at an Operation

LPPH November 2017

Policy

Licensing staff review the records of licensed, registered, and certified operations to evaluate compliance with Licensing statutes, administrative rules, and minimum standards.

Licensing staff must review a minimum number of records based on the operation’s type and its capacity. 

The records are reviewed at the operation or at a central administrative location. Licensing staff may make copies of documents, as needed; but they do not remove original records from the operation.

DFPS Rules, 40 TAC §§745.8415; 745.8417

After evaluating records, Licensing staff document the type and number of records evaluated on CLASS Form 2936 Child-Care Facility Inspection.

See 4161 Completing CLASS Form 2936 Child-Care Facility Inspection.

4153.1 Selecting a Sample of Records For a Monitoring Inspection or Two-Year Period

LPPH November 2017

Procedure

Types of Records to Read

Types of records that Licensing staff must read include those that relate to:

a.   enrolled in or admitted to the operation;

b.   employees;

c.   verified foster homes

d.   approved adoptive homes, for child-placing agencies (CPAs);

e.   birth parents who have applied for services (for CPAs that do private adoptions); and

f.    serious incident reports (for residential operations).

Licensing staff do not sample background check records. For policies on reviewing background check records, see 4153.2 Reviewing Background Check Records During Inspections.

Determining the Number of Records to Read at a Residential Child Care Operation for Each Monitoring Inspection

At each monitoring inspection, Licensing staff read the minimum number of each type of record based on:

  •   the operation’s capacity, if the operation is a general residential operation or independent foster family or group home; or

  •   the total number of verified foster homes and/or approved adoptive homes, if the operation is a child-placing agency.

At each monitoring inspection, Licensing staff read the minimum number of records for each type of record according to the operation’s capacity or number of homes in the following chart:

Capacity/Number of Homes

Minimum Number of Each Type of Record to Review During Each Inspection

44 or less

2

45-74

3

75-94

4

95 or more

5

**Exception to the chart: If the operation is on evaluation or probation, Licensing staff are only required to read two of each type of record at each monitoring inspection during the corrective action period.

Licensing staff may read more than the minimum number of records, if necessary, based on the risk identified at the operation or patterns of deficiencies observed.

Determining the Number of Records to Read at a Child Day Care Operation In Each Two-Year Period

During at least one monitoring inspection during the operation’s two-year compliance period as indicated on the Minimum Standards Evaluated Details page in CLASS, Licensing staff read the minimum number of each type of record, according to the following chart:

Capacity

Minimum Number of Each Type of Record In Each Two-Year Period

44 or less

4

45-74

6

75-94

8

95 or more

10

Licensing staff may read more than the minimum number of records, if necessary, based on the risk identified at the operation or patterns of deficiencies observed.

Records That Are Not Eligible for Sample

When selecting records to read, Licensing staffmust not select records of children who are no longer clients of the operation or staff who are no longer employed by the operation, unless Licensing is evaluating standards related to discharge requirements or the availability of records.

4153.11 Sampling Additional Records During a Follow-Up Inspection

LPPH November 2017

During a follow-up inspection conducted to confirm that the operation is now in compliance, Licensing staff may sample additional records to ensure compliance. See 4300 Conducting a Follow-Up With an Operation.

4153.2 Reviewing Background Check Records During Inspections

LPPH June 2015

During each application, initial, and monitoring inspection, Licensing staff review background check records on all persons required to have a background check to determine whether the operation is in compliance with all background check requirements.

During each investigation inspection, Licensing staff ensures the operation has complied with background check requirements concerning the persons involved in the investigations, including principals and any collaterals interviewed. For follow-up inspections, Licensing staff review any background check records relevant to the follow-up being conducted.

See 4140 Preparing for Inspections and 5380 Determining Compliance with Background Check Requirements.

4153.3 Reviewing Information on Controlling Persons

LPPH June 2015

Procedure

During inspections with a category of Application, Initial, or Monitoring, the inspector reviews the list of controlling persons with the person in charge to determine if:

a.   the list accurately reflects the status of all controlling persons for the operation;

b.   the information entered on each controlling person on the Controlling Person Detail page in CLASS is accurate; and

c.   the operation has complied with all requirements on controlling person in statute, administrative rules, and minimum standards.

Controlling Person With a Status of Review

If any controlling person on the list has a status of Review, the inspector follows the procedures in 7773.4 Reviewing the Status of a Sustained Controlling Person in CLASS.

List of Controlling Persons in CLASS Is Inaccurate

If the list of controlling persons in CLASS is inaccurate, the inspector:

a.   documents the changes in a Chronology (category, Controlling Persons);

b.   directs the operation to submit updated information according to the procedures in 5420 When and How Applicants and Operations Submit Information on Controlling Persons; and

c.   cites a deficiency of the appropriate minimum standard, if the operation did not notify Licensing within two days of when a person became or ceased to be a controlling person.

4153.4 Reviewing Records at a Central Administrative Location

LPPH June 2015

When reviewing records at a central administrative location that does not have an operation number, Licensing staff:

  •   document deficiencies as an assessment in CLASS for the applicable operation; and

  •   follow-up on deficiencies with the operation that was cited or with the person who maintains records at the central administrative location.

4154 Technical Assistance

4154.1 Providing Technical Assistance

LPPH August 2012

Policy

Licensing staff provide technical assistance as needed to help applicants, permit holders, and operation employees understand and comply with Licensing statutes, administrative rules, and minimum standards.

Technical assistance supplements Licensing's regulatory requirements by providing additional information or clarification. Technical assistance does not repeat the language as written in the minimum standard, rule, or statute.

All technical assistance provided by Licensing staff must be documented in the CLASS system. See 4154.2 Documenting Technical Assistance.

Procedure

Licensing staff provide technical assistance by giving applicants, permit holders, and operation employees additional guidance and information to help them understand and comply with requirements in a specific minimum standard, administrative rule, or statute.

Technical assistance can be provided during inspections or through communications such as telephone and email.

Distributing Documents as Part of Providing Technical Assistance

Any documents Licensing staff distribute as part of providing technical assistance must:

  •  come from the Technical Assistance Library (TA Library); or

  •  be an approved DFPS form.

Licensing staff may print or email documents from the TA Library to applicants, permit holders, or operation employees.

4154.2 Documenting Technical Assistance

LPPH August 2012

Policy

Licensing staff document all technical assistance provided to an applicant, permit holder, or operation employee in the CLASS system, including the:

  •  name of any technical assistance resource or document given; and

  •  details of discussions regarding how to achieve or maintain compliance.

Documenting Technical Assistance Provided During an Inspection

Procedure

To document technical assistance provided during the course of an inspection, Licensing staff enter the following information on the Standards Detail page of the inspection in CLASSMate or CLASS:

a.   Select an individual Licensing statute, administrative rule, or minimum standard and choose the appropriate finding.

b.   Mark the Technical Assistance checkbox.

c.   Document in the CLASS or CLASSMate Technical Assistance Documentation narrative box:

  •  a summary of the information provided to the operation, and

  •  the documents that were shared with the operation. See 4154.1 Providing Technical Assistance.

Documenting Technical Assistance Provided Outside of an Inspection

Procedure

If Licensing staff provide technical assistance (TA) outside the course of an inspection, staff document the TA in the operation's record in CLASS as follows:

a.   Create a new chronology, selecting Operation General for the type of chronology.

b.   List which minimum standard, administrative rule, or statute the assistance was related to.

c.   Summarize the information provided.

d.   List which documents were shared with the operation. See 4154.1 Providing Technical Assistance.

4155 When a Deficiency Can Be Corrected at Inspection

LPPH November 2017

Policy

Licensing staff evaluate certain criteria to determine whether a deficiency may be corrected at inspection or whether Licensing staff must follow up on a deficiency with or without an inspection. Licensing staff consider the following criteria:

  •   the risk to children;

  •   the scope and severity of the deficiency;

  •   the time and expense needed to correct the deficiency;

  •   the provider’s previous compliance history, including previous enforcement actions;

  •   the provider’s willingness and ability to comply; and

  •   action taken by the operation to comply.

Procedure

Licensing staff may indicate that the operation corrected the deficiency at the inspection if Licensing staff determines that:

  •   the operation has the ability to correct the deficiency at the time of the inspection; and

  •   no follow-up action is needed to further evaluate compliance with the minimum standard.

Before concluding the investigation, Licensing staff documents that the operation corrected the deficiency at inspection. On the CLASS Form 2936 Child-Care Facility Inspection Licensing staff:

  •   selects the Corrected at Inspection checkbox associated with the deficiency that was corrected; and

  •   documents how the operation corrected the deficiency at inspection in the Narrative section associated with the deficiency.

4156 When an Inspection Is Attempted

LPPH August 2012

Policy

For all inspections, except follow-up inspections on operations with a suspended, revoked, or denied permit, when there is no contact person at the operation when Licensing staff arrives to conduct the inspection, Licensing staff:

  •  document in CLASSMate and in the CLASS system that the inspection was not carried out for lack of a contact at the operation; and

  •  establish contact with the operation to determine whether the operation is providing child care services, unless contacting the operation would impede an ongoing investigation. Licensing staff document all contacts or attempted contacts in CLASS as a Chronology with a category of Monitoring or Investigation, as appropriate.

For instructions on attempted inspections related to a follow-up inspection on an operation with a suspended, revoked, or denied permit, see 7636 Follow-Up to Suspension, Revocation, or Denial.

Procedure

Licensed, Certified, Registered, or Listed Operations

Licensing staff document an attempt to inspect a licensed, certified, registered, or listed operation as follows:

a.   Complete CLASS Form 2936 Child-Care Facility Inspection, documenting the attempted inspection and cite any observed deficiencies of Licensing statutes, administrative rules, or minimum standards, if appropriate.

b.   If mailing the form would not impede an ongoing investigation, Licensing staff:

include in the form:

  •  a request that the operation contact Licensing staff within 10 days of receiving the form or letter, and

  •  a warning that failure to respond may be interpreted by Licensing as an indication that the operation has voluntarily closed.

c.   Mail a copy of the form to the operator, applicant, or designee by regular mail;

d.   If mailing the form would impede an ongoing investigation, Licensing staff consult with the supervisor on when to mail the form to the operator, applicant, or designee.

If Licensing staff mail Form 2936 after the attempted inspection, Licensing staff follow the procedures in the chart below, based upon the operation’s response to receiving Form 2936:

If …

then …

the operation does not respond on or before the first workday after 13 calendar days from the date Form 2936 was mailed (10 days after the date that the operation is presumed to receive the notification by regular mail) …

re-inspect to ensure the operation has closed.

If there is no staff at the operation during the second attempt to inspect:

  •  enter the inspection in CLASS as Attempted (see 7340 Voluntary Closure); and

  •  close the operation in CLASS.

the operation notifies Licensing that it is still in business but has no children in care …

notify the operation that it must be open to inspection and maintain compliance with licensing statute, administrative rules, or minimum standards, unless the person in charge chooses to close temporarily. See 7330 Voluntary Suspension.

the operation responds and notifies Licensing that it is still in business and children are in care …

conduct an inspection, and continue to conduct inspections, thereafter, as appropriate. See 4140 Preparing for Inspections.

CPA Foster Homes – Attempted Investigation Inspections

To document an attempt to conduct an investigation inspection of a foster home verified by a child-placing agency (CPA), Licensing staff do as follows:

a.   Complete CLASS Form 2936 Child-Care Facility Inspection, documenting the attempted inspection and cite any observed deficiencies of Licensing statutes, administrative rules, or minimum standards, if appropriate.

b.   If mailing the form would not impede an ongoing investigation, Licensing staff:

include in the form:

  •  a request that the CPA contact Licensing staff within 10 days of receiving the form or letter, and

  •  a warning that failure to respond may be interpreted by Licensing as an indication that the foster home is no longer verified by the CPA.

c.   Mail a copy of the form to the CPA by regular mail.

d.   If mailing the form would impede an ongoing investigation, Licensing staff consult with the supervisor on when to mail the form to the CPA.

After completing Form 2936, Licensing staff:

  •  consult with the supervisor on how to proceed with the investigation; and

  •  document the supervisor’s guidance in the CLASS system as a Chronology with the type of Investigation.

CPA Foster Homes – Attempted Random-Sampling Inspections

If the inspector attempts a random-sampling inspection of a foster home that is verified by a child-placing agency (CPA), the inspector follows procedures in 4435.3 Attempted Random-Sampling Inspections.

4157 Visiting an Operation to Conduct an Investigation Interview When the Operation Is Not the Subject of the Investigation

LPPH August 2012

Policy

When Licensing staff visit an operation as part of an investigation to interview a child or a person of interest and the operation is not involved in the allegations, Licensing staff:

a.   Document the inspection on Form 2936 Child-Care Facility Inspection as Other. See 4161 Completing Form 2936 Child-Care Facility Inspection.

b.   Do not conduct a walk-through inspection, but do cite any obvious, plain-view deficiency seen or heard.

c.   Do not evaluate background check requirements.

d.   Do not evaluate the operation’s compliance with minimum standards.

4158 Avoiding Duplication of Child Day Care Inspections by State Agencies

LPPH November 2017

Policy

To eliminate redundancy, Licensing uses forms generated in the CLASS system to coordinate with other state agencies that inspect the same operations as Licensing.

Licensing staff do not monitor an operation for compliance with minimum standards when another state agency has inspected it for compliance with equivalent standards.

Licensing staff always investigate reports of alleged violations of minimum standards, regardless of whether another state agency has inspected the operation.

Texas Human Resources Code §42.044(a)

Procedure

The entities that inspect child day care operations for compliance with standards that are equivalent to Licensing’s minimum standards are:

  •  the Immunization Branch of the Texas Department of State Health Services (DSHS);

  •  the State Fire Marshal’s Office (SFMO);

  •  the Child and Adult Care Food Program (CACFP) of the Texas Department of Agriculture; and

  •  the child care management services (CCS) contractor for the Texas Workforce Commission’s local workforce development boards.

No Action by Licensing

Licensing staff do not inspect an operation if another agency:

  •  inspected the operation for compliance with equivalent minimum standards within a year before the Licensing inspection; and

  •  found the operation to be in compliance, or the operation provides documentation showing that it has corrected deficiencies to the satisfaction of the other agency.

Actions Required by Licensing

If a state agency other than Licensing finds that an operation is not in compliance with licensing law, administrative rules, or minimum standards and the operation does not correct the deficiencies, Licensing staff:

  •  evaluate the operation’s compliance with applicable DFPS minimum standards to ensure protection of the children;

  •  document any compliance or correction issues; and

  •  obtain a copy of the other agency’s report for the hard copy record, if possible.

In All Cases

In all cases, during each inspection of an operation, Licensing staff:

  •  evaluate the operation for obvious fire, sanitation, and safety hazards; and

  •  cite in CLASS on Form 2936p2a or Form 2936p2b the deficiencies observed.

When Political Subdivisions Inspect Child Day Care Operations

Licensing staff do not inspect a licensed child-care center or a licensed or registered child-care home for the minimum standards related to fire safety or health practices, when all of the following are true:

  a.  The operation has been inspected by a political subdivision of the state. (A political subdivision may include any city, county, school district, junior college district, or public health district.)

  b.  The operation has documentation from the political subdivision regarding the most recent inspection, and the documentation was provided in the correct format (that is, on the appropriate form, as a letter, or as a checklist)

  c.  The documentation states that the operation complies with the applicable standards of the political subdivision.

  d.  Licensing determines that the operation is complying with any corrective action required by the political subdivision.

  e.  Licensing determines that the operation is complying with any restrictions or conditions placed on it by the political subdivision.

Texas Human Resources Code §42.0443

Civil Practices and Remedies Code §101.001(3)(B)

Required During All Licensing Inspections

During each inspection, Licensing staff:

  a.  assess obvious risk to children each time children are present in an operation (see 4150 Conducting the Inspection);

  b.  cite as deficiencies any obvious violations of the minimum standards for fire safety or health practices observed during an inspection; and

  c.  report violations to the appropriate political subdivision.

Procedure

Licensing staff take the following actions during each inspection:

  a.  Determine whether the operation has complied with the restrictions or conditions placed on it by a political subdivision or has corrected the deficiencies noted by the political subdivision.

  b.  Evaluate the operation’s compliance with the minimum standards for fire safety or health practices, or both, if the operation:

  •  does not have documentation from the applicable political subdivision confirming that an inspection was conducted within the required timeframe;

  •  has not corrected the deficiencies cited by the applicable political subdivision on the inspection documentation; or

  •  has not complied with the restrictions or conditions required by the applicable political subdivision as a result of the inspection.

  c.  Notify the political subdivision about any deficiency observed.

  d.  Document all actions in the CLASS system and make appropriate notations on CLASS Form 2936 Child-Care Facility Inspection.

When Not to Evaluate for Compliance With Fire and Health Standards

Licensed Centers

Licensing staff do not inspect licensed centers for compliance with the minimum standards related to fire safety or health practices if:

  •  the operation was inspected by the relevant political subdivision within the timeframe outlined in minimum standards; and

  •  no deficiencies were cited during that inspection, as explained below.

If …

then …

a licensed child-care center has documentation showing that the political subdivision:

  •  conducted a fire inspection within the timeframe outlined in the minimum standards; and

  •  did not cite any deficiencies …

Licensing does not evaluate the center for compliance with minimum standards §§746.801(13), 746.5101 – 746.5105, and 746.5205 – 5501.

a licensed child-care center has documentation showing that the political subdivision:

  •  conducted a health inspection within the timeframe outlined in the minimum standards; and

  •  did not cite any deficiencies …

Licensing does not evaluate the center for compliance with minimum standards §§746.3401 – 746.3433.

a school-age program or a before or after-school program has documentation showing that the political subdivision:

  •  conducted a fire inspection within the timeframe outlined in the minimum standards; and

  •  did not cite any deficiencies …

Licensing does not evaluate the program for compliance with minimum standards §§744.801(12), 744.3501 – 744.3505, and 744.3559 – 744.3701.

a school-age program or a before or after-school program has documentation showing that the political subdivision:

  •  conducted a health inspection within the timeframe outlined in the minimum standards; and

  •  did not cite any deficiencies …

Licensing does not evaluate the program for compliance with minimum standards §§744.2501 – 744.2531.

Licensed and Registered Homes

Although Licensing minimum standards do not require licensed or registered child-care homes to obtain fire or health inspections, a home may have obtained one or both types of inspections from a political subdivision.

If the home was inspected by a political subdivision within the last 12 months and no deficiencies were cited during that inspection, Licensing staff do not evaluate the home for compliance with the relevant minimum standards, as explained below.

If …

then …

a licensed or registered child-care home has documentation showing that the political subdivision:

  •  conducted a fire inspection within the last 12 months; and

  •  did not cite any deficiencies …

Licensing does not evaluate the home for compliance with minimum standards §747.801(8), §747.4901, and 747.5005 – §747.5301.

a licensed or registered child-care home has documentation showing that the political subdivision:

  •  conducted a health inspection within the last 12 months; and

  •  did not cite any deficiencies …

Licensing does not evaluate the home for compliance with minimum standards §747.3201 – §747.3229.

4159 Handling Resistance or Refusal to Allow Inspection

LPPH March 2017

Policy

An operation’s employees must admit Licensing staff and not delay or obstruct Licensing staff from making inspections during hours of operation.

Texas Human Resources Code §§42.044(a) and 42.04412

DFPS Rules, 40 TAC §§745.8413, 745.8415, 745.8419

Procedure

If the employees of an operation delay or obstruct Licensing from making an inspection during the operation’s business hours, Licensing staff follow the procedures outlined below.

If …

then …

the operation’s employees:

  •  refuse to admit Licensing staff to the operation;

  •  attempt to delay or obstruct Licensing staff from inspecting the operation during business hours;

  •  refuse to allow Licensing staff to inspect an area of the operation that affects or could affect the children’s health, safety, or well-being; or

  •  delay or obstruct an attempt to inspect or investigate, so that Licensing staff cannot carry out their responsibilities …

Licensing staff:

a.   advise the person in charge of the operation that:

  •  the inspection or investigation is authorized by Texas Human Resources Code §§42.044(a) and 42.04412, and

  •  DFPS may take enforcement action against the operation’s permit if the resistance continues.

b.   obtain the name of the person in charge at the operation, if possible;

c.   cite obstruction of the inspection or investigation and violation of DFPS rules using Form 2936 Child-Care Facility Inspection in the CLASS system. Include documentation on the form that, if Licensing inspections are further denied, obstructed, or delayed, DFPS may take enforcement action against the operation’s permit under Texas Human Resources Code §§42.071 and 42.072;

d.   consult with the Licensing supervisor about the necessary follow-up actions;

e.   see 7200 Handling Immediate Danger to Children, if children are in immediate danger;

f.   take one or more of the following actions, depending on the circumstances:

  •  Schedule an appointment with the permit holder or applicant

  •  Make an unannounced inspection of the operation

See also 7600 Adverse Actions.

4160 Documenting the Results of an Inspection

LPPH August 2012

Policy

When documenting the results of an inspection, Licensing staff:

a.   documents deficiencies clearly and concisely;

b.   cites the specific Licensing statutes, administrative rules, or minimum standards for which compliance was evaluated and describes the deficiencies observed;

c.   documents the technical assistance given for each Licensing statute, administrative rule, or minimum standard, if applicable;

d.   states the dates by which corrections must be made. Compliance dates must be reasonable and based on the risk to children. See 4500 Evaluating Risk to Children; and

e.   provides the inspection results to the operation at the conclusion of the inspection, on the same day that the inspection took place.

Inspection results are documented on CLASS Form 2936 Child-Care Facility Inspection on the same day as the inspection. If inspection results are left pending or if corrections need to be made to the original Form 2936, Licensing staff create a supplemental Form 2936.

See:

4161 Completing CLASS Form 2936 Child-Care Facility Inspection

4162 Finalizing Form 2936 and Sychronizing CLASSMate with CLASS

4163 Final Determination of Findings Left Pending During an Inspection

4165 Completing a Supplemental Inspection Form

Citing Deficiencies Unrelated to an Inspection

If deficiencies unrelated to an inspection must be cited, Licensing staff use CLASS Form 2939 Child Care Facility Assessment. See 4200 Citing Deficiencies With an Assessment.

4161 Completing CLASS Form 2936 Child-Care Facility Inspection

LPPH August 2012

Policy

After reviewing the background materials related to the operation (see 4140 Preparing for Inspections), Licensing staff create a draft of CLASS Form 2936 in the CLASS system.

On the same day as the inspection, after the inspection is completed, Licensing staff complete CLASS Form 2936 Child-Care Facility Inspection in the CLASS system to document inspection results.

Documenting a Possible Deficiency as Pending on Form 2936

If staff need to conduct further investigation or consult with the supervisor before determining compliance with a specific Licensing statute, administrative rule, or minimum standard, each item requiring further action is documented as Pending on CLASS Form 2936. Licensing staff use the Pending status only if staff cannot determine an operation’s compliance with a statute, rule, or standard before leaving the operation.

Licensing staff must determine whether issues related to an inspection that were documented as pending are deficient or compliant within 10 days after an inspection is completed. See 4163 Final Determination of Findings Left Pending During an Inspection.

Signing and Providing a Copy of Form 2936

Licensing staff provide a copy of Form 2936 to the person in charge after Licensing staff conduct the exit conference. See 4172 Signing and Providing a Copy of Form 2936 Child-Care Facility Inspection

4161.1 Creating a Draft CLASS Form 2936

LPPH November 2017

Procedure

Licensing staff follow the procedures below to create a draft version of CLASS Form 2936 Child-Care Facility Inspection.

Enter the Details

To enter the inspection details in CLASS, on Form 2936 Child-Care Facility Inspection, Licensing staff take the following steps:

  1.  On the Operation main page, select the Monitoring tab.

  2.  On the Inspection/Assessment List page, select Add New Inspection.

  3.  On the Inspection Details page in the General section, select the appropriate Inspection Type (see 4120 Types of Inspections).

  4.  Choose the investigation numbers, if the inspection type is Investigation or Monitoring and Investigation.

  5.  Choose the appropriate Follow Up to Inspections IDs (select up to three IDs), if the inspection type is Follow Up.

  6.  Enter the Inspection Start Date (The inspection start date may be updated after the inspection, if necessary).

  7.  If the licensed child care center, school-age program, before- or after-school program, or licensed child care home is receiving a health and safety audit, document this in the Narrative section.

  8.  Complete other applicable fields and select Save.

Add Standards

Add any applicable statutes, administrative rules, or minimum standards for which compliance must be evaluated:

  1.  On the Inspection Summary page, select Add New.

  2.  On the Standard Details page, in the Standard Information section, click the Search button found next to the terms Standard/Rule/Law to conduct a search of the minimum standards, administrative rules, or statutes applicable to the inspection.

  3.  On the Standards Search page, enter a keyword or select the appropriate option from the Section drop-down list and select Go. (The minimum standard, administrative rule, or statute number can be used as a keyword to perform the search function.)

  4.  Select the appropriate statute, administrative rule, or minimum standard.

  5.  Select Choose from the Finding drop-down menu, and select Save.

Save and Download

  1.  Save the draft form.

  2.  Download the saved draft to CLASSMate before conducting the inspection.

4161.2 Documenting Inspection Results on CLASS Form 2936

LPPH November 2017

Procedure

Licensing staff use CLASS Form 2936 Child Care Facility Inspection to document inspection.

All Inspections

Licensing staff documents:

  1. the finding (non-compliant, compliant, or pending) for each Licensing statute, administrative rule, or minimum standard that was evaluated during the inspection (see 4161.21 Documentation of the Findings Evaluated From the Inspection);

  2. technical assistance provided, if any (see 4154.2 Documenting Technical Assistance); and

  3. a list of any hazards that the operation must correct immediately.

If conducting an inspection at a licensed child care center, before- or after-school program, or school-age program, and the designated director is present during the inspection, Licensing staff selects the Director Present checkbox. See 4131 Minimum Requirements for Licensed Operations.

If conducting an inspection at a licensed child care center and the inspector evaluated the director’s qualifications during the inspection, Licensing staff selects the Dir Qual Eval checkbox. See 3331 Evaluating Director and Primary Caregiver Qualifications for Licensed Child Day Care Operations).

Initial and Monitoring Inspections

Licensing staff documents the review of restrictions and conditions by checking the …items regarding risk to children… checkbox (for initial and monitoring inspections only; see 4152 Reviewing Restrictions, Conditions, Waivers, and Variances);

Application, Initial, and Monitoring Inspections

Licensing staff documents whether Licensing staff assessed risk to children as required during the operation walk-through by checking the …items regarding risk to children…checkbox. Licensing staff check the …items regarding risk to children… checkbox for all application, initial, and monitoring inspections.

See:

4151 Operation Walk-Throughs

4157 Visiting an Operation to Conduct an Investigation Interview When the Operation Is Not the Subject of the Investigation

Background Check Requirements During an Application, Initial, or Monitoring Inspection

If conducting an application, initial, or monitoring inspection, Licensing staff documents information to indicate whether Licensing staff has ensured the operation has complied with background check requirements by selecting the Background Checks have been Verified/Evaluated checkbox (see 5380 Determining Compliance with Background Check Requirements).

Background Check Requirements During an Investigation Inspection

If conducting an investigation inspection, Licensing staff documents information to indicate whether Licensing staff has ensured the operation has complied with background check requirements for principals and collaterals known at time of the inspection by selecting the Background Checks have been Verified/Evaluated checkbox (see 5380 Determining Compliance with Background Check Requirements).

Controlling Persons Verified During an Application, Initial, or Monitoring Inspection

If conducting an application, initial, or monitoring inspection, Licensing staff documents information to indicate that the inspector has discussed the list of controlling persons, as documented in CLASS, with the person in charge. If appropriate, the inspector checks the Controlling Persons Have Been Verified checkbox.

See:

4153.3 Reviewing Information on Controlling Persons

4171 Discussing the Results of an Inspection

5400 Controlling Person

Follow-Up Inspection

If conducting a follow-up inspection, Licensing staff document:

  •  a list of all of the deficiencies or conditions being followed-up on and a finding of NC (deficient) or CO (compliant); and

  •  a narrative explaining how the operation is compliant or the efforts the operation has made toward compliance.

4161.21 Documentation of the Findings Evaluated From the Inspection

LPPH June 2015

If documenting a deficiency, Licensing staff document the following in the Narrative field in CLASSMate or CLASS:

  •   Explain how the operation is deficient. (Describe observations in detail. Do not merely repeat the requirement in the statute, rule, or minimum standard.)

  •   Describe how the deficiency was corrected during the inspection, if applicable.

If further investigation or consultation with the supervisor is needed before determining whether the operation is in compliance with a statute, rule, or minimum standard, Licensing staff document the finding as Pending. If Form 2936 is completed in CLASS, rather than in CLASSMate, Licensing staff must type the following statement on the form for all pending deficiencies (the statement automatically prefills in CLASSMate). This possible standard violation is under further review. Final notification will be sent at a later time.

If documenting an inspection being conducted as part of an investigation, investigators also:

  •   code any citations for plain-view violations observed during the walk-through as Monitoring (MN); and

  •   add appropriate minimum standards with a code of Investigation (IV), if the investigator obtains information regarding a violation related to the allegation being investigated that was not previously identified.

4161.22 Limits to Documenting Names of Children

LPPH June 2015

When documenting inspection results, Licensing staff do not include the names of children when entering information that could be published on the DFPS public website. See 8230 Confidential Information Not to Be Released to the Public.

Licensing staff use only a child’s first name and last initial on hard copy forms (such as inspection guides) and in sections of CLASS that are not published on the DFPS public website, such as the Chronology and Contact fields.

4161.23 Limits to Documenting Names of Operation Employees

LPPH June 2015

When documenting inspection results, Licensing staff do not include the names of operation employees in documentation that is published on the DFPS public website. See 8230 Confidential Information Not to Be Released to the Public.

Licensing staff may use staff names on paper copies of forms, such as inspection guides, and in sections of CLASS that are not published on the DFPS public website, such as the Chronology and Contact fields.

4161.24 Technical Assistance for High Risk Violations

LPPH September 2015

When citing a high risk violation which may result in an administrative penalty, staff:

  •  provides technical assistance on how to comply with the minimum standard or rule, and

  •  advises the operation that another violation of the high risk minimum standard previously cited could result in an administrative penalty.

Staff documents, in the Technical Assistance narrative box in CLASS, as outlined in the Guidelines for Assessing Admin Penalties Related to BGC Deficiencies job aid, that:

  •  the technical assistance on compliance was provided; and

  •  the operation was advised of the risk of incurring an administrative penalty.

4161.3 Leaving an Operation Temporarily to Document Inspection Results

LPPH August 2012

Procedure

If Licensing staff leave the operation to record the results of the inspection on Form 2936 Child-Care Facility Inspection in CLASSMate, staff document in the Narrative field:

  •  the time leaving the operation; and

  •  the time returning to the operation to conduct the exit conference.

For example:

Left operation at (insert time) and returned at (insert time).

CLASSMate captures the time the inspection ended when Licensing staff click the Lock button on the form.

4161.4 Documenting an Inspection Continued on the Following Day

LPPH August 2012

Procedure

If an inspection must be continued on the following day, staff complete a new CLASS Form 2936 Child-Care Facility Inspection.

4162 Finalizing Form 2936 and Synchronizing CLASSMate With CLASS

LPPH August 2012

Finalizing Form 2936

Procedure

Before finalizing the form, Licensing staff:

a.   conduct the exit interview to discuss the results of the inspection with the person in charge at the operation;

b.   sign Form 2936;

c.   have the person in charge at the operation sign Form 2936.

See:

4170 Conducting the Exit Conference

4171 Discussing the Results of the Inspection

4172 Signing and Providing a Copy of Form 2936 Child Care Facility Inspection

After conducting the exit interview and signing the form, Licensing staff finalize Form 2936 Child-Care Facility Inspection in CLASSMate by clicking:

  •  Save Final; and

  •  Lock.

After finalizing the form, Licensing staff provide a copy of Form 2936 to the person in charge. See 4172 Signing and Providing a Copy of Form 2936 Child Care Facility Inspection

Synchronizing CLASSMate With CLASS

Policy

On the same day Form 2936 is completed, when possible, Licensing staff synchronize with CLASS in order to upload the inspection into the CLASS system.

4163 Final Determination of Findings Left Pending During an Inspection

LPPH December 2015

Policy

Within 10 days after completing an inspection, Licensing staff must:

  •  determine whether the operation is deficient or compliant regarding any pending inspection findings coded as Monitoring; and

  •  document the final determinations on a supplemental Form 2936 Child-Care Facility Inspection and mail or email it to the operation. See 4165 Creating a Supplemental Inspection Form.

DFPS Rules, 40 TAC §§745.8447(1); 745.8445

4164 Procedures When the Operation’s List of Controlling Persons Cannot Be Verified During the Inspection

LPPH March 2013

Procedure

If during an Initial or Monitoring inspection the inspector cannot verify whether the operation’s list of controlling persons in the CLASS system is accurate, the inspector does all of the following within 10 days of the inspection:

a.   Contacts the operation’s governing body to verify whether an operation’s list of controlling persons list in CLASS is accurate

b.   Follows the procedures in 7773.4 Reviewing the Status of a Sustained Controlling Person in CLASS, if any controlling person on the list has a status of Review

c.   Documents the contact with and information obtained from the governing body as a Chronology (category, Controlling Persons)

d.   Does as follows, if the controlling persons has changed:

i.   Documents the changes in a Chronology (category, Controlling Persons);

ii.   Directs the operation to submit updated information according to the procedures in 5420 When and How Applicants and Operations Submit Information on Controlling Persons

iii.   Cites a deficiency of the appropriate minimum standard by completing a supplemental CLASS Form 2936 Child Care Facility Inspection, if the operation did not notify Licensing within two days of when a person became or ceased to be a controlling person. See 4165 Completing a Supplemental Inspection Form.

4165 Completing a Supplemental Inspection Form

LPPH November 2017

Policy

Staff create a supplemental Form 2936 Child Care Facility Inspection in the CLASS system only to:

  •  document the final determination about an operation’s compliance with Licensing statutes, administrative rules, or minimum standards that were left pending during an inspection; or

  •  correct errors in spelling, grammar, or content on the original CLASS Form 2936 Child Care Facility Inspection.

If deficiencies unrelated to an inspection must be cited, Licensing staff use CLASS Form 2939 Child-Care Facility Assessment. See 4200 Citing Deficiencies With an Assessment.

Procedure

To complete a supplemental Form 2936 Child Care Facility Inspection, Licensing staff follow these steps:

  1.  Select the appropriate inspection in CLASS.

  2.  Update pending findings to NC (deficient) or CO (compliant).

  3.  Enter the all of the following information in the Narrative field on the supplemental Form 2936:

  a.  Description of the change that is being made.

  b.  Statement that the supplemental Form 2936 replaces the original Form 2936 Child-Care Facility Inspection that was left at the operation on the date of the inspection.

  c.  The date of the previous inspection.

  d.  The posting requirements, if any apply. See 4173 Posting the Day Care Inspection Form or Assessment Form.

  4.  Change the date of notification in the CLASS system to the date the supplemental Form 2936 is created.

  5.  Save and finalize the second version of CLASS Form 2936 by selecting Save Final and Lock.

4165.1 Contacting the Permit Holder

LPPH September 2012

Before mailing the supplemental Form 2936, Licensing staff contact the permit holder to:

a.   discuss the determination made on findings left pending during the inspection, if any;

b.   discuss other changes to the inspection findings, if any; and

c.   inform the permit holder of his or her right to an administrative review. See 7710 Administrative Reviews.

4166 Documenting a Health and Safety Audit in CLASS

LPPH December 2016

Procedure

After a health and safety audit is conducted, the Licensing inspector includes the following statement the Comments box in the Operation Information section on the operation’s Main page in CLASS:

Health and Safety Audit: [date of inspection]

For the date of inspection, use the format MM/DD/YY.

For a registered child care home, the Licensing inspector also enters a manual to-do under the Operation To Do List to conduct an inspection the following year.

 

4170 Conducting the Exit Conference

LPPH December 2015

Policy

After completing an inspection, Licensing staff conduct an exit conference with the person in charge at the operation. During the conference, staff:

  •  discuss the results of the inspection, including the reason for any deficiency issued;

  •  review, but do not provide copies of, all photographs that were taken during the inspection that relate to deficiencies;

  •  provide any technical assistance that may assist the operation in addressing issues that have been identified and documented;

  •  review the requirements and time frames to request an administrative review, if any deficiencies were issued; and

  •  provide a copy of CLASS Form 2936 Child Care Facility Inspection to the person in charge.

See:

7711.3 Explaining the Right to an Administrative Review

8230 Confidential Information Not for Release to the Public

Texas Human Resources Code §42.0441

DFPS Rules, 40 TAC §§745.8495; 745.8801 – 8811

When conducting the exit conference for an initial or monitoring inspection, Licensing staff also:

  •  verify the operation’s contact information; and

  •  review the operation’s compliance history, including concerns or patterns, with the person in charge.

4171 Discussing the Results of an Inspection

LPPH March 2017

Procedure

During each exit conference, Licensing staff do as follows:

  •  Allow the person in charge an opportunity to discuss the findings

  •  Provide the person in charge with the following, if applicable:

a.   Any technical assistance needed to address issues that were identified and documented during the inspection, if applicable. (See 4154 Technical Assistance.)

b.   Information about how high-risk deficiencies or a pattern of deficiencies may affect the frequency of inspections

c.   Information about how failure to comply within specified deadlines or repeated deficiencies may result in enforcement action without further opportunity to correct the deficiencies

d.   Information about how to comment on the inspection by completing the CCL Inspection Feedback Survey. (The Web address for the survey is printed on CLASS Form 2936 Child-Care Inspection Form, which Licensing staff provide before leaving the operation.)

e.   Information about how the operation may request an administrative review in writing within 15 days of receiving the results of the inspection and information on what the request must include to be considered complete. (See 7713 Receiving a Request for an Administrative Review.)

Additional Requirements for Initial and Monitoring Inspections

During each exit conference for an inspection with a category of Initial or Monitoring, Licensing staff also:

  •  review with the person in charge the operation’s compliance history since the previous monitoring inspection, including any concerns or patterns of deficiencies; and

  •  verify the accuracy of the information entered on the Operation Main page in CLASS.

If either the Location Address Validation Status or Mailing Address Validation Status is set to Not Validated, Licensing staff must review the address with the person in charge. If the person in charge indicates that either the location or mailing address in CLASS is inaccurate, the inspector:

  •  documents the correct information in a Chronology (category, Operation General); and

  •  enters the corrected address in CLASS and attempts to validate the address according to the procedures in 1600 Validating an Address in CLASS following the inspection.

4171.1 Discussing Pending Results

LPPH September 2012

Except for inspection findings coded as Investigation, if a determination cannot be made on any aspect of an inspection, Licensing staff explain to the person in charge that Licensing:

  •  will mail a final determination, in the form of a supplemental inspection form, within 10 days; and

  •  may include additional information on the supplemental inspection form that was not included on the original CLASS Form 2936 Child Care Facility Inspection.

See:

4161 Completing CLASS Form 2936 Child Care Facility Inspection

4165 Completing a Supplemental Inspection Form

4171.2 Addressing an Operation’s Concerns About Inspection Findings

LPPH September 2012

Licensing staff work with the person in charge to address any concerns relating to:

  •  minor changes to a deficiency narrative, if the change does not impact the meaning of the citation and does not minimize the scope or severity of the violation; and

  •  compliance dates, if the person in charge has a valid reason for not being able to come into compliance sooner than the proposed date, as long as the change does not compromise the health or safety of children in care.

Immediately after changing any documentation on CLASS Form 2936 Child Care Facility Inspection as a result of feedback from the person in charge, Licensing staff enter a Chronology in the CLASS system that includes:

a.   the CLASS inspection number;

b.   a description of the changes requested by the person in charge; and

c.   a description of what changes were made.

4172 Signing and Providing a Copy of Form 2936 Child Care Facility Inspection

LPPH December 2015

Procedure

At the end of the exit conference, Licensing staff ask the person in charge to sign CLASS Form 2936 Child Care Facility Inspection, even if the findings are left pending. Licensing staff explain that signing Form 2936 does not indicate that the person signing agrees with the inspection results. It is only an acknowledgment that Licensing conducted an inspection at the operation and does not waive the operation’s right to an administrative review.

Both the Licensing staff and the person in charge at the operation sign Form 2936. If the person in charge refuses to sign Form 2936, Licensing staff note on the inspection form the person’s name and his or her decision not to sign.

After Form 2936 is signed by Licensing staff and the person in charge, Licensing staff provide the person in charge with a printed or emailed copy of the completed form before leaving the operation.

If the operation is required to post Form 2936 in a prominent place where it may be viewed by staff, parents, and others, Licensing staff must explain this to the person in charge before leaving the operation.

See:

4160 Documenting the Results of an Inspection

4161 Completing CLASS Form 2936 Child Care Facility Inspection

4173 Posting the Day Care Inspection Form or Assessment Form

4173 Posting the Day Care Inspection Form or Assessment Form

LPPH August 2012

Policy

A licensed child care center, a school-age program, a before or after-school program, a licensed child care home, and a registered child care home must display the most recent CLASS Form 2936 Child Care Facility Inspection or CLASS Form 2939 Child Care Facility Assessment in a prominent place where it may be viewed by staff, parents, and others; however, confidential information may not be posted.

DFPS Rules, 40 TAC §§744.403; 746.403; 747.401

If the operation disagrees with a Licensing decision or action and requests an administrative review, the operation may delay posting Form 2936 or Form 2939 until the administrative review is complete.

DFPS Rules, 40 TAC §745.8801

See:

4200 Citing Deficiencies With an Assessment

7710 Administrative Reviews

Procedure

Licensing staff explain to the person in charge of the operation that CLASS Form 2936 Child Care Facility Inspection or CLASS Form 2939 Child Care Facility Assessment, and any supplemental inspection forms, must be posted in a prominent place where it may be viewed by staff, parents, and other persons.

If Licensing staff document part of the inspection on Form 2936 and document the rest of the inspection on a supplemental inspection form, Licensing staff attach the original CLASS Form 2936 to the supplemental form so that both will be posted.

The person in charge of the operation may note the date a correction was made on the posted form.

The operation is not required to publicly post findings of abuse or neglect.

The names of children and staff:

  •  must not appear on any forms or letters that require posting in a prominent place for viewing by staff, parents, and others (see 8230 Confidential Information Not to Be Released and 4160 Documenting the Results of an Inspection); and

  •  must not be documented in the areas of the CLASS system that appear on the DFPS public website.

Children and staff names may be documented in the hard copy record or in the areas of CLASS that are not published on the DFPS public website.

See 6631 Notifying the Operation of the Results of an Investigation.

4200 Citing Deficiencies With an Assessment

LPPH January 2012

Policy

Licensing staff may learn about a deficiency at a child care operation from a variety of sources. In such cases, Licensing staff may assess the facts provided by the source and write a citation without making an inspection of the operation.

Only deficiencies may be cited based on an assessment. An assessment must not be used for an investigation. See 6430 Conducting Inspections.

Examples of situations in which deficiencies may be identified without making an inspection include the following:

a.   The permit holder informs Licensing that the operation continues to be deficient after the deadline for correction and Licensing staff decide to re-cite the deficiency.

b.   The information entered on a background check form indicates that the request for a background check was not submitted on time.

c.   The information entered into the People List in the CLASS system shows that the operation is not requesting background checks on staff every two years, as required.

d.   Licensing staff cite a child placing agency (CPA) for deficiencies after conducting a sampling inspection on one of the CPA’s foster homes.

e.   Licensing staff cite a CPA for deficiencies after an enforcement team conference. See 4421 Enforcement Team Conferences for Child-Placing Agencies.

f.    Licensing staff become aware of a deficiency at one operation while interviewing children at a different operation. (For example, if residential licensing staff become aware of deficiencies while interviewing children at a day care facility, the residential staff must report the deficiencies to the assigned DFPS day care inspector.)

Citing a deficiency without an inspection does not replace a required inspection.

Procedures

When Licensing staff become aware of a deficiency without making an inspection, staff:

a.   obtain approval from a supervisor, district director, or manager to issue a citation by assessment;

b.   document the approval in the Chronology field in CLASS;

c.   complete CLASS Form 2939 Child Care Facility Assessment within 10 days after becoming aware of the deficiency and document:

  •  each deficiency cited; the reason for each deficiency; and 

  •  the date by which the operation needs to correct each deficiency.

Before mailing Form 2939, staff contact the permit holder or designee to:

  •  discuss the deficiency; and

  •  inform the permit holder or designee that he or she has a right to request an administrative review within 15 days from the date he or she receives Form 2939 (see 4170 Conducting the Exit Conference and 7710 Administrative Reviews).

An assessment may not be used for an investigation. See 6430 Conducting Inspections.

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