4200, Citing Deficiencies with an Assessment

May 2020

Child Care Regulation (CCR) staff may learn about a deficiency at a child care operation from a variety of sources. In such cases, CCR 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 HHSC investigation. See 6430 Conducting Inspections.

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

  1. The permit holder informs CCR that the operation continues to be deficient after the deadline for correction and CCR staff decide to re-cite the deficiency.
  2. The information entered on a background check form indicates that the request for a background check was not submitted on time.
  3. The information entered into the People List in CLASS shows that the operation is not requesting background checks on staff every two years, as required.
  4. CCR staff cite a child placing agency (CPA) for deficiencies after conducting a sampling inspection on one of the CPA’s foster homes.
  5. CCR staff cite a CPA for deficiencies after an enforcement team conference. See 4441 Enforcement Team Conferences for Child-Placing Agencies and General Residential Operations.
  6. CCR staff become aware of a deficiency at one operation while interviewing children at a different operation. (For example, if residential CCR staff become aware of deficiencies while interviewing children at a day care facility, the residential staff must report the deficiencies to the assigned day care inspector.)
  7. CCR staff are notified of a monitoring violation during a DFPS investigation.

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


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

  1. obtain approval from a supervisor, district director, or manager to issue a citation by assessment;
  2. document the approval in the Chronology field in CLASS;
  3. select the corresponding investigation number from the Abuse/Neglect Investigation Number drop-down when the violation is related to a DFPS investigation; and
  4. 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).