Licensed Center
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Corrective action means HHSC requires steps to address compliance concerns; see the official HHSC record for details.
Adverse action means HHSC has taken enforcement action affecting an operation’s permit or ability to operate; see the official HHSC record for details.
Texas HHSC records list 8 inspections dated between October 10, 2023 and October 10, 2026.
The most recent inspection in these records is dated September 22, 2026.
The same records list 8 cited deficiencies dated October 18, 2023 to September 26, 2025 (HHSC risk levels: 3 High, 3 Medium High, 2 Medium).
Correction status recorded by HHSC: 0 corrected at inspection, 8 with a correction date recorded, 0 with no correction date recorded.
HHSC lists a verified correction date for 8 of these citations.
The official HHSC record has the full inspection history and the latest information.
Generated from Texas HHSC state records. Counts and dates come directly from the published state data; no descriptions were written by a model.
View the official state record · Report an issue with this page
This summary is generated automatically from public HHSC records. It restates the official record and may lag behind it. The official state record is the authoritative source: official HHSC record.
Texas Health and Human Services records list 8 cited deficiencies for Birnham Woods Elementary YMCA in the 3 years before October 10, 2026 (3 High, 3 Medium High, 2 Medium).
Records list 8 inspections in this window. Most recent inspection: 2026-09-22.
| Risk weight | Citations |
|---|---|
| High | 3 |
| Medium High | 3 |
| Medium | 2 |
| Medium Low | 0 |
| Low | 0 |
| Unknown | 0 |
HHSC assigns each standard a risk weight from Low to High. A deficiency is a finding that a minimum standard was not met.
2025-09-26 · 744.303(4) · Medium High
Report Change in Director
The site director present at todays inspection is not the designated site director CCR has on file. No notification or submission of a new site director has been provided to CCR and the previously designated site director is no longer serving in that role.
Correction date recorded: 2025-10-10
2023-11-17 · 744.1205(a)(4) · High
Supervision ensures each child?s safety, well-being, including physical proximity and auditory or visual awareness of each child?s on going activity
During the follow-up inspection, the site director was observed greeting parents with their children which is outside of the gym area to sign their child out for the day. Licensing was waiting outside with the parent when the site director arrived with the children. Upon…
Correction date recorded: 2023-11-17
2023-11-01 · 744.1601 · Medium High
Child/ Caregiver Ratio
Upon arrival, two caregivers were observed with a total of 42 children, 5-9 years of age. The children were observed in an open gym area, and outdoor area. At 4:13PM, a total of 33 children were observed in care with two staff. At 4:18PM, a total of 29 children, 5-9 years of age…
Correction date recorded: 2023-11-03
2025-09-26 · 744.303(4) · Medium High
Report Change in Director
Corrected at inspection: No. Correction date: 2025-10-10. Correction verified: 2025-10-24.
The site director present at todays inspection is not the designated site director CCR has on file. No notification or submission of a new site director has been provided to CCR and the previously designated site director is no longer serving in that role.
2023-11-17 · 744.1205(a)(4) · High
Supervision ensures each child?s safety, well-being, including physical proximity and auditory or visual awareness of each child?s on going activity
Corrected at inspection: No. Correction date: 2023-11-17. Correction verified: 2023-12-05.
During the follow-up inspection, the site director was observed greeting parents with their children which is outside of the gym area to sign their child out for the day. Licensing was waiting outside with the parent when the site director arrived with the children. Upon entrance of the gym 9 children ages 5 -10 years old were observed unsupervised engaged in various activities. A second caregiver was outside with a group of children on the playground.
2023-11-01 · 744.1205(a)(4) · High
Supervision ensures each child?s safety, well-being, including physical proximity and auditory or visual awareness of each child?s on going activity
Corrected at inspection: No. Correction date: 2023-11-02. Correction verified: 2023-11-17.
Two staff were observed during the follow-up inspection with a total of 42 children. Staff A was observed retrieving children from outdoors for parent pick-up, leaving the children indoors unattended. Staff A walked out of the gym area to the entry door in order for parents/guardians to sign their child out for the day. A total of 23 children were left unattended while Staff B was outside. Staff B was observed walking into the gym area/building, leaving two children outdoors unattended to finish their snack. Licensing staff witnessed several supervision incidents during the follow-up inspection.
2023-11-01 · 744.1309(a)(2) · Medium
Documented Annual Training-15 Hours Required Site Director
Corrected at inspection: No. Correction date: 2023-12-04. Correction verified: 2023-12-05.
During the follow-up inspection, the training topics were not available for Licensing. A total of 8 out of the required 15 training hours were observed for the Site Director. The Site Director did not obtain training topics related to the Health and Safety audit. The Site Director lacked training topics related to emergency preparedness, administering medication, and/or handling, storing, and disposing of hazardous materials.
2023-11-01 · 744.1601 · Medium High
Child/ Caregiver Ratio
Corrected at inspection: No. Correction date: 2023-11-03. Correction verified: 2023-11-17.
Upon arrival, two caregivers were observed with a total of 42 children, 5-9 years of age. The children were observed in an open gym area, and outdoor area. At 4:13PM, a total of 33 children were observed in care with two staff. At 4:18PM, a total of 29 children, 5-9 years of age were observed with Staff B.
2023-10-18 · 744.1309(a)(2) · Medium
Documented Annual Training-15 Hours Required Site Director
Corrected at inspection: No. Correction date: 2023-10-27. Correction verified: 2023-11-01.
A total of 8 out of the required 15 training hours were observed for the Site Director. The Site Director did not obtain training topics related to the Health and Safety audit. The Site Director lacked training topics related to emergency preparedness, administering medication, and/or handling, storing, and disposing of hazardous materials.
2023-10-18 · 744.1601 · Medium High
Child/ Caregiver Ratio
Corrected at inspection: No. Correction date: 2023-10-20. Correction verified: 2023-11-01.
Upon arrival, two caregivers were observed with a total of 41 children, 5-9 years of age. The children were observed in an open gym. At 4:36 PM, a total of 36 children were observed. At 5:11PM, a total of 20 children were observed.
2023-10-18 · 745.641 · High
AP Background check results - Must receive notification prior to allowing subject to be present at your operation
Corrected at inspection: No. Correction date: 2023-10-18. Correction verified: 2023-10-19.
One staff observed in care did not have an active background check in the CLASS system.
2022-10-18 · 744.603(a) · Medium
Children's Records Maintained
Corrected at inspection: No. Correction date: 2022-10-25. Correction verified: 2022-11-01.
I evaluated the enrollment records for 6 children. I observed the following: 1. Two records were missing an address for the emergency contact person. 2. Two files were missing complete contact information for the child's physician.
2022-07-21 · 744.1203(4) · High
Responsibilities of Caregivers- Supervision of Children
Corrected at inspection: No. Correction date: 2022-07-21. Correction verified: 2022-07-22.
During the follow-up inspection to evaluate supervision of children, school-age children were observed entering the gymnasium without caregivers present. The children were in the gym for approximately 5 minutes before a caregiver came into the building.
2022-07-08 · 745.641 · High
AP Background check results - Must receive notification prior to allowing subject to be present at your operation
Corrected at inspection: No. Correction date: 2022-07-08. Correction verified: 2022-07-08.
I observed a caregiver working with children whose background check results is still pending.
2022-06-24 · 744.307(b)(4) · Medium High
Parental Communication - Situation that Placed a Child at Risk
Corrected at inspection: No. Correction date: 2022-07-18. Correction verified: 2022-07-18.
Interviews were conducted. It was determined that the parents were not notified of an incident involving their child until the day after the incident.
2022-06-24 · 744.1203(4) · High
Responsibilities of Caregivers- Supervision of Children
Corrected at inspection: No. Correction date: 2022-07-18. Correction verified: 2022-07-21.
Interviews were conducted and procedures were evaluated. It was determined that school-age children were unsupervised in the restroom.
2021-10-19 · 744.1203(4) · High
Responsibilities of Caregivers- Supervision of Children
Corrected at inspection: No. Correction date: 2021-10-19. Correction verified: 2021-10-27.
During the inspection, I observed three different instances where children were not properly supervised while playing on the playground.
2021-10-19 · 744.2753(a) · Medium
First Aid Kit - Incomplete Kit
Corrected at inspection: No. Correction date: 2021-10-26. Correction verified: 2021-10-27.
I observed that the first aid kit did not contain tweezers.
2021-10-19 · 744.3113(b) · Medium
Maintenance Procedures for Active Play - Monthly Maintenance Checklist
Corrected at inspection: No. Correction date: 2021-10-26. Correction verified: 2021-10-27.
I did not observe documentation of a playground maintenance checklist having been completed for the month of September.
Source: Texas HHSC Child Care Regulation, via data.texas.gov (CC0). See the official record: https://childcare.hhs.texas.gov/Public/InspectionAndComplianceHistory?operationId=528008
Records reflect only deficiencies published by the state after due process. This page does not rate or rank providers. Check the official record for the latest information.
Provider data fetched: October 10, 2026.