Great Lakes Recovery Center for Youth

Violation established, special investigation : CCI Rule 400.4158 Intervention standards and prohibitions

The facility is found in noncompliance, as per interviews there was a pattern of concerns verbalized by staff and youth regarding Staff 2 and Staff 3’s use of derogatory or discriminatory language including negative references to a youth's background or appearance or mental state. In regard to the allegation of Staff 3 using the word “tranny” at the facility, based on information learned in the investigation, it appears that youth used this term in a group session where youth wrote a story and shared their story out loud to the group. TECHNICAL ASSISTANCE: The facility needs to update their internal policy to reflect CCI licensing rule 400.4158 and retrain all staff regarding the updated policy and facility expectations.

Violation established, special investigation : CCI Rule 400.4126 Sufficiency of staff

The facility is found in noncompliance as per interviews with youth and staff, Youth A and Youth C engaged in sexual activity while at the facility as Youth C snuck into Youth A’s bedroom for a few minutes while Staff 4 was working. In regard to the allegations regarding Youth A giving Youth B a “hand job”, there was no information provided in the investigation that would suggest this occurred. In regards to the allegations regarding staff allowing youth to go into areas of the building where there are no cameras in order to engage in sexual activity, there was insufficient information to suggest this occurred, however, per interviews, Staff 1 reported Youth A and Youth B left the gym area while Staff 1 was supervising and Staff 1 did not follow Youth A and Youth B as there were other youth who remained in the gym resulting in Youth A and Youth B to not be supervised. Staff 1 did not call other staff to address Youth A and Youth B leaving the gym to have staff provide supervision. TECHNICAL ASSISTANCE: • The facility update internal policy to ensure staff are effectively supervising youth at all times to include sufficient staff being present to ensure staff are able to supervise appropriately. • The facility train staff to be aware at all times and not completing other tasks when in ratio. 17 • The facility ensure when all youth are moving as a group there are more than one staff to ensure if youth leave an area there is a staff available to follow and provide supervision.

Repeat violation established, special investigation : CCI Rule 400.4112 Criminal history check, subject to requirements; staff qualifications

The facility is found in noncompliance as per interviews Staff 1 did allow youth to use her cellphone to access social media including TikTok and Facebook. In regard to the allegation of Staff 1 bringing in vapes to the facility and/or providing youth with vapes, based on youth and staff interviews there is insufficient information to conclude this occurred. In regard to Staff 1’s boundaries with Youth D, the facility is found in noncompliance as Staff 1 admitted to providing Youth D with her Cash App card to purchase gas as well as plucked his eyebrows. In regard to Staff 1 bringing in items for youth at the facility, the facility is found in compliance as per most interviews Staff 1 brought in items for all the youth. In regard to allegations of Staff 3 suggesting and looking at vibrators with Youth A, the facility is found in noncompliance as Staff 3 never returned calls for an interview and Youth A reported the incident occurred. It was further found based on interviews, that Staff 1 was speeding in order to keep up with Youth D while driving youth to an AA/NA meeting. Based on the interviews and information received, Staff 1 and Staff 3 do not have the ability to perform duties of the position assigned. TECHNICAL ASSISTANCE: • The facility updates the internal policy regarding staff cellphones during shift and retrains staff regarding the expectations of staff cellphones to include youth are not allowed to utilize staff’s cell phones. • The facility updates the internal ...

Repeat violation established, special investigation : 722.120

The facility is found in noncompliance. Per interviews, Staff 1, Staff 4, Staff 5, and Staff 11 all reported Children’s Services Director informed them to initial indicating they had completed the walkthroughs of the facility per the variance even if they had not. Staff 12 reported she was informed by Staff 4 that Children’s Services Director informed her to initial the document indicating the walkthroughs had been completed even if they had not. Staff 10 reported she is not always able to complete the walkthroughs and has left the documentation log blank when unable to do so.

Violation established, special investigation : CCI Rule 400.4126 Sufficiency of staff

The facility is found in noncompliance as the facility has had times where they are not sufficiently staffed resulting in youth not being able to eat breakfast as there has only been one staff working and not all youth wanted to go to the cafeteria for breakfast. TECHNICAL ASSISTANCE: The facility needs to update their internal policy to address staff to youth ratio as the facility does not currently have a policy specific to staff to youth ratio.

Violation established, special investigation : CCI Rule 400.4112 Criminal history check, subject to requirements; staff qualifications

The facility is found in noncompliance as per staff and youth interviews, Staff 1 did allow youths to hit his nicotine vape and purchased and provided two nicotine vapes and a THC cartridge to Youth A.

Violation established, special investigation : CCI Rule 400.4109 Program statement

Allegation One: The facility is found in non-compliance as per staff and youth interviews, Youth A was not searched at intake allowing Youth A to have money and a joint in his wallet. Allegation Two: The facility is found in compliance as there was not enough information to support a rule violation that staff were making racist comments. Youth C reported Staff 2 made a racist comment and Youth B described Staff 2 passing a note to him with a racist comment. Staff 2, Staff 3, Youth D, Youth E, Youth F, and Youth G denied hearing any staff member make racist comments. Technical Assistance: Technical assistance was offered to retrain staff on professional boundaries and how staff’s interactions with youth should remain professional. 10 Consultation: Consultant spoke with Staff 2 about information being shared about her unseemly behavior when the youth are on phone calls with their family and/or workers. Staff 2 was informed how this behavior is perceived as unprofessional and not appropriate for this setting.

Violation established, special investigation : CCI Rule 400.4127 Staff to resident ratio

The facility is found in noncompliance as per interviews with youth, Administrator, Program Supervisor, and Staff 1 and video review, varying interval checks not to exceed fifteen minutes were not completed overnight from 5/21/2025 to 5/22/2025 and 5/27/2025 to 5/28/2025. TECHNICAL ASSISTANCE: • The facility update their internal policy to align with CCI Rule 400.4127(4). • The facility retrain staff on the updated facility policy.

Violation established, special investigation : 722.120

The facility is found in noncompliance as Staff 1 falsified times on the room check log indicating he had completed room checks on the youth however per video footage review, Staff 1 did not complete the room checks he documented for overnights 5/21/2025 to 5/22/2025 and 5/27/2025 to 5/28/2025.

Violation established, special investigation : R 400.4109 Program statement

Staff 1 did not follow Great Lake Recovery Center Policy by maintaining line-of-sight on Youth A, Youth B and Youth C allowing Youth A to give Youth C a hickey on his neck. Youth A and Youth B were in Youth C’s bedroom when Youth A gave Youth C a hickey. Youth are not allowed in each other’s bedroom.