Revision 23-3, Effective Sept. 22, 2023

CCR uses an assessment as a regulatory tool to do the following when CCR is not required to conduct an inspection or investigation:

  • cite and notify an operation of a deficiency when an inspector learns about a violation unrelated to an inspection or investigation; or
  • document findings from a follow-up without an inspection when the operation is being re-cited (see 4330 Following Up Without an Inspection).

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

CCR staff follow up on deficiencies cited by assessment according to 4220 Documenting an Assessment and Notifying the Operation, or 4300 Conducting a Follow-up with an Operation.

Procedure

When an inspector determines a monitoring assessment is needed to cite a deficiency, the inspector has 10 days from the date CCR learned about the violation to complete all the following tasks:

  1. consult with a supervisor, program administrator or regional director to discuss the inspector’s recommendation to cite a deficiency by assessment;
  2. document the decision in a Chronology in CLASS; and
  3. if the supervisor, program administrator or regional director approves citing the deficiency, complete the procedures in 4220 Documenting an Assessment and Notifying the Operation. 

The inspector documents photos or other records received in support of the assessment according to 1430 Documenting and Storing Photographs, Video, Audio, Scanned Documents and Other Digital Files and the associated subsections.

4210 Assessment Types

Revision 23-1, Effective Apr. 21, 2023

When citing by assessment, inspectors choose from two types of assessments. Inspectors refer to the following table when deciding which assessment type to use:

Assessment TypeUse to Cite a Deficiency when:See CCRH Section(s):
Monitoring Assessment
  1. DFPS reported a monitoring violation related to:
    • a DFPS investigation (see 6940 Citing Deficiencies for a DFPS Investigation), or
    • Heightened Monitoring visit;
  2. CCR identified a violation during CCR activities other than an inspection or investigation. Examples:
    • enforcement team conference (see 4441 Enforcement Team Conferences for Child-Placing Agencies and General Residential Operations);
    • random-sampling inspection of a CPA’s foster homes (see 4431 Using Random-Sampling Inspections to Regulate a Child-Placing Agency);
    • background check(s) not submitted as required (see 10110 Overview of Background Checks and 10120 Background Check Requests); or
    • an inspection or investigation that reveals a deficiency at a different operation (for example: during an interview);
  3. Another agency (other than DFPS) or a political subdivision reported a violation; or
  4. The operation self-reports a violation (see 6275 Incidents Reported by an Operation (Self-Reports).
4211 Citing a Deficiency with a Monitoring Assessment
Follow-up AssessmentFollowing up on deficiencies from a previous inspection, assessment or investigation without conducting an inspection to re-cite the operation for one or more deficiencies that were not corrected as required.4212 Follow-Up Assessments, 4300 Conducting a Follow-Up with an Operation, and 4330 Following Up Without an Inspection

4211 Citing a Deficiency with a Monitoring Assessment

Revision 23-1, Effective Apr. 21, 2023

Procedure

When an inspector determines a monitoring assessment is needed to cite a deficiency, the inspector has 10 days from the date CCR learned about the violation to complete all the following tasks:

  1. consult with a supervisor, program administrator or regional director to discuss the inspector’s recommendation to cite a deficiency by assessment;
  2. document the decision in a Chronology in CLASS; and
  3. if the supervisor, program administrator or regional director approves citing the deficiency, complete the procedures in 4220 Documenting an Assessment and Notifying the Operation.

4212 Follow-Up Assessments

Revision 23-1, Effective Apr. 21, 2023

Procedure

When an inspector re-cites a deficiency during a follow-up without an inspection, the inspector documents the outcome of the follow-up using an assessment (type Follow-up) in CLASS.

See also: 

4220 Documenting an Assessment and Notifying the Operation       
4310 Time Frames for Conducting a Follow-Up       
4330 Following Up Without an Inspection

4220 Documenting an Assessment and Notifying the Operation

Revision 23-1, Effective Apr. 21, 2023

Procedure

The inspector:

  • documents assessment results on CLASS Form 2939 Child-Care Facility Assessment;
  • notifies the operation; and
  • sends a copy of CLASS Form 2939 to the operation.

Corrections

If the inspector needs to correct the original CLASS Form 2939, the inspector creates a supplemental CLASS Form 2939 according to 4223 Completing a Supplemental Assessment Form.

See also:

4210 Assessment Types       
4211 Citing a Deficiency with a Monitoring Assessment        
4212 Follow-Up Assessments

4221 Documenting an Assessment Using CLASS Form 2939 Child-Care Facility Assessment

Revision 23-4, Effective Nov. 30, 2023

Procedure

When creating a monitoring assessment or follow-up assessment, the inspector chooses the assessment type from the Assessment Type field in the General section of the Assessment Details page (see 4210 Assessment Types).

For both types of assessments, on CLASS Form 2939 Child-Care Facility Assessment, the inspector:

  1. documents compliance with the evaluated CCR statutes, administrative rules and minimum standards; 
  2. documents any technical assistance given; and
  3. for each deficiency cited, documents:
    • the deficiency clearly and concisely; and
    • the compliance date.

The inspector ensures compliance dates are reasonable and based on the risk to children (see 4500 Evaluating Risk to Children and Handling Immediate Danger).

The inspector documents photographs and other records related to the deficiency according to 1431 Documenting Photographs, Video, Audio, Scanned Documents and Other Digital Files.

4221.1 Additional Requirements for Documenting Follow-Up Assessments

Revision 23-1, Effective Apr. 21, 2023

Procedure

When creating a follow-up assessment, the inspector completes the following additional steps:

  • if the purpose of the follow-up assessment is for a Heightened Monitoring (HM) inspector to document a follow-up on a HM-related deficiency, the HM inspector completes the Heightened Monitoring section;
  • links the follow-up assessment to the appropriate previous inspection(s), investigation(s) without an inspection, assessment(s) or a combination of these activities;
  • deletes any linked deficiencies that automatically prefill on the Inspection Summary page if:
    • the deficiency is not evaluated during the current follow-up assessment; or
    • the operation requested an extension during the current follow-up assessment, and CCR granted an extension (Note: the inspector documents the extension in the original inspection or assessment in CLASS. See 4350 Granting an Operation Additional Time to Comply with a Requirement Cited as a Deficiency); and
  • consults the table below for remaining linked deficiencies:
If...Then...
the operation is in compliance…

the inspector:

  • selects Compliance in the Finding field;
  • deletes the date in the Compliance Date field; and
  • deletes the text in the Narrative text box and replaces it with a statement outlining how the operation corrected the deficiency.
the operation is still deficient…

the inspector:

  • selects Deficiency in the Finding field;
  • enters the new compliance date in the Compliance Date field; and
  • deletes the text in the Narrative text box and replaces it with information about how the operation continues to be deficient.  
     

CLASS Updates the Follow Up Information section for the Original Deficiency

For each deficiency linked to the follow-up assessment and documented as Compliance or Deficiency, CLASS automatically updates the Follow Up Information section on the Standard Details page for the original inspection, investigation or assessment. Therefore, the inspector does not take any further steps to update the Follow Up Information section for the linked deficiency.

4222 Notifying the Permit Holder or Designee

Revision 23-3, Effective Sept. 22, 2023

Procedure

Before mailing CLASS Form 2939 Child-Care Facility Assessment, the inspector contacts the permit holder or designee to:

  • discuss the assessment findings; and
  • inform the permit holder or designee of the right to request an administrative review within 15 days from the date of receiving CLASS Form 2939 (see 4170 Conducting the Exit Conference and 5600 Administrative Reviews).

4223 Completing a Supplemental Assessment Form

Revision 23-1, Effective Apr. 21, 2023

The CCR inspector creates a supplemental assessment form to correct errors in spelling, grammar or content on the original CLASS Form 2939 Child-Care Facility Assessment.

Procedure

To complete a supplemental CLASS Form 2939, the inspector:

  1. selects the appropriate assessment in CLASS.
  2. makes the corrections.
  3. enters all the following information in the Narrative field on the supplemental CLASS Form 2939:
    1. description of the change that the inspector is making.
    2. statement that the supplemental CLASS Form 2939 replaces the original CLASS Form 2939.
    3. the date the previous CLASS Form 2939 was sent to the operation.
  4. changes the date in the Date Notification Sent field to the date the supplemental CLASS Form 2939 is created.
  5. saves and finalizes the supplemental CLASS Form 2939.