State assisted-living licensing record · Texas HHSC · record as pulled September 11, 2026· Not the federal nursing home survey

Retreat at Carrollton, LLC

4010 Nazarene Drive, Carrollton, TX 75010 · Denton County · 122 licensed beds

HHSC licence number 311995 · licensed through June 20, 2027 · first licensed June 2024

The licence

Licensed by HHSC · Assisted Living Facility, Type A · Limited Liability Company (LLC) · managed by 12 Oaks Management Services, INC

Certifications and programs, as listed by HHSC

Alzheimer's certification: No
Accepts Medicaid: No

Citations on file

Since September 2021

HHSC visits

1 routine inspection

Life safety and building

Life safety · physical plant · emergency

Position within Texas

33 citations — more than 99% of the 1,995 licensed assisted living facilities in Texas. Compared only within Texas: a citation from HHSC means what it means in Texas, and there is no national assisted living record to compare to. Counted over 5 years, which holds two or three routine inspections. How this is calculated

Not in this record

Scope and severity, and enforcement. HHSC rates each finding on a scope-and-severity scale but does not publish the rating per facility, and it records fines and enforcement actions separately; neither is republished here. What is here is unusual among states: HHSC inspects fire and life safety itself and publishes those findings per facility, so this record carries a real life safety section.

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Life safety and building citations

The citations about the building itself — fire and life safety, physical plant and emergency management. Usually the maintenance side’s to fix.

The facility failed to conduct required fire drills and document fire drills on the required form.March 25, 2026
The facility failed to ensure that all alarm initiating devices would automatically activate an audible or visual alarm at the facility.March 5, 2024 · corrected April 29, 2024
The facility failed to provide smoke compartmentation where required.March 5, 2024 · corrected April 29, 2024
The facility failed to keep floors in good condition and regularly cleaned.March 5, 2024 · corrected April 29, 2024
The facility failed to ensure that, if laundry was co-mingled and processed in a single central location in the facility, the laundry facility provided all the required fire protection and sanitization features.March 5, 2024 · corrected April 29, 2024
The facility failed to ensure corridors met the Life Safety Code.March 5, 2024 · corrected April 29, 2024
The facility failed to provide the minimum levels of illumination required in the facility.March 5, 2024 · corrected April 29, 2024
The facility failed to ensure means of egress met the referenced codes and standards.March 5, 2024 · corrected April 29, 2024
The facility failed to provide a communication system when resident bedrooms or living units were located on two or more floors or in multiple buildings.March 5, 2024 · corrected April 29, 2024
The facility failed to provide smoke detectors in the required locations.March 5, 2024 · corrected April 29, 2024
The facility failed to provide a staff area on each floor and in each separate building containing resident bedrooms with all the required features.March 5, 2024 · corrected April 29, 2024
The facility failed to provide smoke compartmentation where required.December 14, 2023 · corrected March 5, 2024
The facility failed to protect hazardous areas as required by the referenced codes and standards.December 14, 2023 · corrected March 5, 2024
The facility failed provide the minimum fire-resistant construction based on the height of the building.December 14, 2023 · corrected March 5, 2024
The facility failed to ensure corridors met the Life Safety Code.December 14, 2023 · corrected March 5, 2024
The facility failed to ensure openings between floors were protected to prevent the spread of fire and smoke from one floor to another.December 14, 2023 · corrected March 5, 2024
The facility failed to ensure that interior wall and ceiling finishes met required surface burning characteristics.December 14, 2023 · corrected March 5, 2024
The facility failed to provide the minimum levels of illumination required in the facility.December 14, 2023 · corrected March 5, 2024
The facility failed to ensure means of egress met the referenced codes and standards.December 14, 2023 · corrected March 5, 2024
The facility failed to provide a manual fire alarm system that met the referenced codes and standards.December 14, 2023 · corrected March 5, 2024
The facility failed to provide required emergency lighting.December 14, 2023 · corrected March 5, 2024
The facility failed to provide portable fire extinguishers that met the referenced codes and standards.December 14, 2023 · corrected March 5, 2024
The facility failed to provide at least two separate stairs between the ground floor and other floors and that all stairs used as a means of egress meet the Life Safety Code.December 14, 2023 · corrected March 5, 2024
The facility failed to ensure a bedroom had a floor area of at least 100 square feet for a single-occupancy bedroom or at least 80 square feet per resident in bedrooms occupied by more than one resident.December 14, 2023 · corrected March 5, 2024
The facility failed to provide additional smoke detectors and heat detectors in living units with ranges or stoves.December 14, 2023 · corrected March 5, 2024
The facility failed to ensure doors to resident rooms and living units could be closed by the occupants.December 14, 2023 · corrected March 5, 2024
The facility failed to ensure the fire alarm system automatically notified emergency forces.December 14, 2023 · corrected March 5, 2024
The facility failed to ensure equipment using natural gas or propane met the referenced codes and standards.December 14, 2023 · corrected March 5, 2024
The facility failed to ensure a generator that provided emergency power for required emergency systems met the referenced codes and standards.December 14, 2023 · corrected March 5, 2024

How that compares

Citations on file over 5 years

Compared with the median licensed assisted living facility in Texas. Within-state only.

Citations on file over 5 years, compared
Measure	Citations
This facility	33
Median facility in Texas	2

Visit history

Citations at each HHSC visit

Citations at each HHSC visit
Visit	Type	Citations
December 14, 2023	life safety code inspection	20
March 5, 2024	life safety code inspection	11
March 25, 2026	health inspection	2
March 25, 2026	comprehensive inspection	0

What the citations cover

Citations by category (TagProof's grouping)

Life safety 23
Physical plant 6
Food service 2
Staffing and training 2

Citations by category
Category	Citations
Life safety	23
Physical plant	6
Food service	2
Staffing and training	2

Every visit on file since September 2021

As published by HHSC, newest first, including visits that cited nothing. The wording is HHSC’s own.

March 25, 2026 — health inspection, 2 citations

Citations from the health inspection on March 25, 2026
What HHSC found	Corrected
The facility failed to conduct required fire drills and document fire drills on the required form.	—
The facility failed to ensure that all employees providing services were screened for tuberculosis within two weeks of employment and annually.	—

March 25, 2026 — comprehensive inspection, nothing cited

March 5, 2024 — life safety code inspection, 11 citations

Citations from the life safety code inspection on March 5, 2024
What HHSC found	Corrected
The facility failed to ensure that all alarm initiating devices would automatically activate an audible or visual alarm at the facility.	April 29, 2024
The facility failed to provide smoke compartmentation where required.	April 29, 2024
The facility failed to keep floors in good condition and regularly cleaned.	April 29, 2024
The facility failed to ensure that, if laundry was co-mingled and processed in a single central location in the facility, the laundry facility provided all the required fire protection and sanitization features.	April 29, 2024
The facility failed to ensure corridors met the Life Safety Code.	April 29, 2024
The facility failed to provide the minimum levels of illumination required in the facility.	April 29, 2024
The facility failed to ensure means of egress met the referenced codes and standards.	April 29, 2024
The facility failed to provide a communication system when resident bedrooms or living units were located on two or more floors or in multiple buildings.	April 29, 2024
The facility failed to provide a janitorial facility in the kitchen area and exclusively for the kitchen and failed to provide a can or cart washing area with hot and cold water.	April 29, 2024
The facility failed to provide smoke detectors in the required locations.	April 29, 2024
The facility failed to provide a staff area on each floor and in each separate building containing resident bedrooms with all the required features.	April 29, 2024

December 14, 2023 — life safety code inspection, 20 citations

Citations from the life safety code inspection on December 14, 2023
What HHSC found	Corrected
The facility failed to provide smoke compartmentation where required.	March 5, 2024
The facility failed to protect hazardous areas as required by the referenced codes and standards.	March 5, 2024
The facility failed provide the minimum fire-resistant construction based on the height of the building.	March 5, 2024
The facility failed to ensure corridors met the Life Safety Code.	March 5, 2024
The facility failed to ensure openings between floors were protected to prevent the spread of fire and smoke from one floor to another.	March 5, 2024
The facility failed to ensure that interior wall and ceiling finishes met required surface burning characteristics.	March 5, 2024
The facility failed to provide the minimum levels of illumination required in the facility.	March 5, 2024
The facility failed to ensure means of egress met the referenced codes and standards.	March 5, 2024
The facility failed to provide a manual fire alarm system that met the referenced codes and standards.	March 5, 2024
The facility failed to provide required emergency lighting.	March 5, 2024
The facility failed to provide portable fire extinguishers that met the referenced codes and standards.	March 5, 2024
The facility failed to provide at least two separate stairs between the ground floor and other floors and that all stairs used as a means of egress meet the Life Safety Code.	March 5, 2024
The facility failed to ensure a bedroom had a floor area of at least 100 square feet for a single-occupancy bedroom or at least 80 square feet per resident in bedrooms occupied by more than one resident.	March 5, 2024
The facility failed to provide a janitorial facility in the kitchen area and exclusively for the kitchen and failed to provide a can or cart washing area with hot and cold water.	March 5, 2024
The facility failed to provide a telephone for use by residents and staff with emergency telephone numbers posted at or near the telephone.	March 5, 2024
The facility failed to provide additional smoke detectors and heat detectors in living units with ranges or stoves.	March 5, 2024
The facility failed to ensure doors to resident rooms and living units could be closed by the occupants.	March 5, 2024
The facility failed to ensure the fire alarm system automatically notified emergency forces.	March 5, 2024
The facility failed to ensure equipment using natural gas or propane met the referenced codes and standards.	March 5, 2024
The facility failed to ensure a generator that provided emergency power for required emergency systems met the referenced codes and standards.	March 5, 2024

Reflects the HHSC record as pulled September 11, 2026. A recent visit may not appear yet. This is the Texas state licensing record; it is not the federal nursing home survey and the two are never combined.