Azleway Valley View

During a heightened monitoring visit to the operation on 08/14/2025, some donuts, with a best if used by date of 08/04/25, located on the counter in the kitchen were observed to have mold on them.

Roughhousing between two residents escalated. One resident placed the other in a headlock and transitioned to placing hands around the neck and choking. The caregiver delayed to de-escalate and intervene.

One of the facility vans had a protruding wire sticking out of the second seat and a sliding door that came off the hinges when the door was opened. This was corrected at the initial inspection, but residents were transported in this vehicle for several weeks before the issues were fixed.

The residents and staff witnessed a caregiver threatening placements and inappropriate discipline at the operation.

An employee at the operation was using profanity towards the residents and in the presence of direct care staff.

During a walk-through of the operation, it was observed that conditions of a cabin were not clean. The boy's rooms were observed to be cluttered, the bathroom toilet dispenser was broken off, dirty dishes were observed in the kitchen sink and a liquid was observed on one of the bedroom floors.

A child in care reported seeing a caregiver sleeping while on night duty. The child called out to the caregiver while getting a drink of water and initially received no response until being woken. One caregiver reported observing the same caregiver sleeping on duty when coming on shift. This occurred on two separate occasions. One caregiver also reported observing a separate caregiver sleeping in the office.

A preliminary service plan was not provided for the victim child in this case.

During the investigation, I observed one child's medication log contained an entry for which no time of administration was recorded.

During the investigation, I observed a child's service plan failed to record when the plan was provided to the child's parent entity.

During the investigation, I observed the medication logs for one child's medication failed to document an administration of this medication on 12/21/24.

During the investigation, I observed six child service plans lacked specific goals in multiple areas.

During the investigation, I observed a child's service plan lacking the results of the most recent Psychological Evaluation or attempts to schedule a new one.

During the investigation, I observed the service plans for three children did not include available CAN's results and accurate recommendations.

During the investigation, I observed the service plan for one child did not include his signature or documentation of refusal.

During the investigation, I observed two staff failed to take Trauma Informed Care training in 2024.

One child's medication log did not include the reason the medication was prescribed.

The medication count for one of the residents did not match the medication documentation log

During the walk through of the operation it was found that there were no towels at the sinks in the one of the bathrooms.

During the inspection, I observed a medication log for a child included documentation of one medication administration on 9/30/24 that staff confirmed did not occur as the medication did not return with the child from his last visit and the operation was not in posession of the medication at the time of this inspection.

During the inspection, I observed the operation last administered a prescription nasal spray on 9/27/24 prior to the child's visit. The medication was not administered again following that date as it did not return to the operation from the visit. As of the date of the inspection, the operation was not in posession of this prescription medication and the child has not received an administration since 9/27/24

A child was seriously injured on 9/22/24, and the parent was not notified until 9/23/24, a day after the child was verified safe.

During the monitoring inspection, the operation was not able to provide all documents when requested such as discharge summaries for two children.

During the monitoring inspection, the operation did not provide documents, when requested. Copies of the admissions assessments were provided after the conclusion of the inspection, but discharge summaries were never produced.

During a walk through of the operation one bathroom was found not to have hand towels at the sink. Staff corrected this issue at the time of the inspection.

The investigation revealed that a child in care suffered an injury which was not promptly addressed. The child, having injured his hand, was seen by a doctor who recommended an X-ray. However, the X-ray was not performed until two weeks following this recommendation.

The investigation revealed that the operation did not inform the permanency specialist/conservator of a child in care's fractured hand. The permanency specialist/conservator remained unaware until the inspector brought it to her attention.

During the monitoring inspection, there was one medication record that did not have documentation of the medication (Escitalopram 10mg) administered to the child on the evening of 4/27/2024.

During the monitoring inspection, there was rotten fruit observed in the refrigerator.

During the ANE Investigation, it was reported the operation staff permitted a child to go into the staff office, close, and lock the door, behind him. At that time, the child had access to child records that are stored in the staff office.

During the investigation, it was learned that a post discussion with the child was not held after he was restrained.

During the investigation, it was learned that no one was monitoring the child while he was being restrained.

During the investigation, it was found that a child in care restrained another child in care. The child in care who conducted the restraint does not have the necessary training in restraints.

During the investigation, it was found that the staff member on duty did not intervene when two children began physically fighting. This resulted in a child in care having to intervene in order to stop the altercation. The staff member lacked prudent judgement in not trying to stop the altercation between the two children.

During the investigation, it was learned that the caregiver for the children did not try to intervene in anyway when the altercation started including the verbal altercation.

The operation failed to comply with the safety plan implemented during the ANE investigation.

During the monitoring inspection, a package of spinash that was found rotten, expired, and almost liquified in the refrigerator.

During the monitoring inspection, the first aid kit was missing tweezers.

During the monitoring inspection, a bottle of Pine-Sol was observed to be in the common area and accessible to a child in care.

During the monitoring inspection, one child's medication records was missing the reason medication was prescribed.

During the monitoring inspection, a window located next to the front door was observed to have a crack. There was also a toilet in the home that was observed to be dirty and needing to be cleaned.

During the investigation inspection, medication records were reviewed, and it was observed that one child's medication record was inaccurate. The record indicated the medication had 26 doses remaining, while the package only contained 25 doses. It was also observed that the balance on the medication record was wrong and there was not a deduction after each dose provided. This was previously cited at the monitoring inspection completed in May of this year.

During the investigation inspection, there was a bowl of food (corn) uncovered and stored in the refrigerator.

During the investigation inspection, two of the three bathrooms had empty paper towel dispensers and no personal towels or hand dryers for use. This was previously citated at the last inspection completed earlier this month.

Upon reviewing documents, it is noticed that the operation did not have documentation or had conducted a severe weather drill. This was also corrected at the inspection by having a severe weather drill conducted by the operation.

During the walk through of the operation, it is noticed that 2 of the restrooms did not have toilet paper in the bathrooms. This was corrected during the inspection by rolls of toilet paper being added to those bathrooms.

During the walk through of the operation, it is noticed that 2 of the boys bedrooms did not have pillow cases on the pillow. This was corrected at the inspection by one pillow being removed from the room and a pillow case being added to the other pillow.

During the walk through of the inspection, it is noticed that the pantry door had a hole and the ledge of it was coming off.

Upon reviewing fire inspections, it is noticed that their most recent fire drill was done outside of the 6 months on 4/2/2023. This was corrected at the inspection by the operation conducting a fire drill.

Four beds in use had no mattress protectors.

There were 4 tomatoes with mold in the refrigerator and several packets of snack sandwiches covered in mold. Also, a large bag of shredded cheese was completely opened in the same drawer.

Two of the children's beds (in use) had no pillowcases.

The kids' bathroom on the right side of the facility had mold in the shower floor and doors. There were soiled walls and baseboards around the large trash can, and the vents were covered with dust.

There was nothing written on a child's medication record for "reason the medication was prescribed".

A caregiver argued with children in care, and then she commented "at least I have a home to go home to" - which was demeaning to the boys in the facility.

During the inspection, I observed a hole in the surround of a shower stall, and the operation did not show a maintenance request on file for the damage.

During the unannounced after hours inspection, it was observed that a child's medication record and actual medication count did not match. The medication record reflected there were 24 doses remaining while the package only contained 23 doses.

During the inspection, I observed the curtains in one bedroom to be suspended in such a way that the curtains did not adequately cover the window to provide requisite privacy or sufficiently block light for rest.

During the inspection, I observed a sink a cottage bathroom with a broken hot water knob preventing its use. The operation repaired the knob while I was there for the inspection.

In reviewing the documentation, I observed that the resident's service plan did discuss or assess documented behaviors that resulted in increased supervision levels as documented in the operation's corrective actions to a previous investigation.

During the course of this investigation, evidence indicates that a staff failed to properly supervise children in care, resulting in a resident having inappropriate contact with a minor online and several residents being able to congregate, contact this same minor, and call the police without the staff's awareness.

During the inspection, I observed no thermometer in the refrigerator. The operation replaced the thermometer during the inspection.

The operation is equipped with an electric smoke detection system, and the operation was not able to produce documentation of annual testing of the system by an approved party.

During the inspection, I observed pillow cases and sheets missing from a number of the children's beds.

In three of the four records reviewed, there was either no date for a copy of the service plan being provided to the children, no child's signature, or no documentation that a copy was provided to the child.

There were over 5 places found where a staff failed to sign when medicatoins were given. The timeframe ranged from late 2021 to May of 2022.

There were several medication sheets for two boys that did not state the reason the medications were prescribed.

The facility did not have any record of severe weather drills.

A young man with a history of sexual abuse and a pre-occupation with pornography did not receive adequate supervision. This resulted in sexually inappropriate behaviors and solicitation of younger kids.

The one first aid kit at the operation was missing a thermometer - as required by minimum standards.

There was one first aid kit in the house, but none in the vehicles to transport the boys. There should always be one available for the vehicle that is taking the kids on an outing. There should be a minimum of two at the Valley View Cottage.

Two beds did not have protective convers separating the mattress and the sheet. There was also one pillow case missing.

In one of the child's records reviewed, the name used in the service plan is not the child who the plan is being completed for.

In the child's records reviewed, an evaluation of the strategies and techniques used were not included in the Service Plan Review. The information documented in the service plans reviewed is cut and pasted from the previous service plan, with no changes.

There was a report of a staff testing positive for COVID. This was reported to the hotline, but there was no documentation available for review during this inspection.

The service plan reviewed is not signed by the child or agency supervisor.

In one of the staff records reviewed the staff completed 32 annual training hours for 2020.

In one of the Admission Assessments reviewed it was not signed or dated by professional level service provider who completed the assessment.