Severe reports

The most serious findings in the state inspection reports we hold: deaths, sexual and physical abuse, restraints that injured a child, suicide attempts, medical neglect and hospitalisations. Every quote below is the licensing agency's own wording, and each one was read against its report by a person before it was listed here.

Sundown M Ranch WA

Inspected February 25, 2025 Death Hospitalisation Police involvement

At 4:12 AM, the patient was found unresponsive. [...] Staff called Emergency Medical Services (EMS), and they arrived around 2:50 AM. EMS took the patient’s vitals, and the patient refused to be transported to the ER. [...] Staff called 911 and administered Narcan to the patient. [...] The document showed that EMS responded and worked on the patient for 15 minutes and got a pulse. The patient was stabilized and transported to the local hospital. [...] Law enforcement responded to the scene and investigated the incident.

Failure to monitor access and egress to the facility can result in a lack of oversight of the facility and poor patient outcomes, including death. [...] The document showed that Emergency Medical Services (EMS) responded and worked on the patient for 15 minutes and got a pulse. The patient was stabilized and transported to the local hospital.

From the state's report. Deficiency cited, complaint investigation. Cited: WAC 246-337-080 – Resident care services (2)(h)(i)(ii) The licensee must address serious illness, medical emergencies, or threat to life; WAC 246-337-075 – Resident rights (2)(g) Each resident has the right to have a safe and clean environment.. "[...]" marks text left out between sentences.

Pearl Youth Residence WA

In plain words: A child in the program reported that a staff member made sexual comments, flirted, and touched them inappropriately. Another staff member reported the allegations to child protective services and law enforcement. The state report notes that the staff member was later charged with two counts of child molestation. Our summary of the state's report. The state's own wording follows.

Review of a facility document titled, “Incident Report”, dated 08/23/23, showed that Staff B, Milieu Manager, contacted CPS to report sexual assault allegations made by Patient #1. [...] It showed that Staff Q captured detailed statements Patient #1 was making to law enforcement about the alleged sexual assault by Staff A. e. [...] 19. Review of an email exchange between Investigator #1, Staff D, Executive Director of Intensive Youth Services, and Individual #2, Detective, on 01/02/24, showed: “[Staff A] has been charged with two counts of Child Molestation in the 3rd Degree”. [...] On or around 08/19/23, Patient #1 disclosed during a “casual conversation” with a milieu staff that Staff A had inappropriately touched them. b. [...] On a second occasion, there was an inappropriate touching event with Staff A in the facility’s laundry room.

Law enforcement determines whether a crime was committed and therefore the facility may not limit or prohibit external reporting activities. [...] 12. During an interview with Staff D, on 09/21/23, they stated that no one from the facility had contacted law enforcement to report the sexual assault allegations made by Patient #1 on 08/18/23. They stated that after a conversation with Staff L, Chief Administrative Officer, they realized that they had the responsibility of reporting allegations of sexual assault to law enforcement.

The documents contained the following information: a. “[Staff A] has been making sexual comments like, “age is just a number” and [they] slap my ass. [They] also been looking down girls' shirts and has been making all of us uncomfortable.” b. “[Staff A] flirts with us kids. [They] tell them age is just a number, winks at them, touches them in places like their butts, gives them flowers, and overall is just really taken. [They] need to not work in a place where people have been sexually assaulted.

From the state's report. Deficiency cited, complaint investigation. Cited: WAC 246-337-075 Resident rights.; WAC 246-337-065 Safety and security.; WAC 246-337-048 Quality improvement program.; WAC 246-337-048 Quality improvement program.. "[...]" marks text left out between sentences.

Pearl Youth Residence WA

In plain words: A child in the program reported that a staff member made sexual comments and touched them inappropriately. Another child made a similar report and called law enforcement, and records showed staff failed to report the first allegation to the police. Our summary of the state's report. The state's own wording follows.

On or around 08/19/23, Patient #1 disclosed during a “casual conversation” with a milieu staff that Staff A had inappropriately touched them. b. [...] The documents contained the following information: a. “[Staff A] has been making sexual comments like, “age is just a number” and [they] slap my ass. [They] also been looking down girls' shirts and has been making all of us uncomfortable.” b. “[Staff A] flirts with us kids. [They] tell them age is just a number, winks at them, touches them in places like their butts, gives them flowers, and overall is just really taken. [They] need to not work in a place where people have been sexually assaulted. [...] On 09/05/23 law enforcement responded to a lewd conduct call [lewd conduct is a type of criminal charge] from Patient #2 after they reported they’d been inappropriately touched by Staff A. b.

12. During an interview with Staff D, on 09/21/23, they stated that no one from the facility had contacted law enforcement to report the sexual assault allegations made by Patient #1 on 08/18/23. They stated that after a conversation with Staff L, Chief Administrative Officer, they realized that they had the responsibility of reporting allegations of sexual assault to law enforcement. [...] 9. A Teams message exchange between Staff D, Executive Director, and Staff E, Counselor, dated 09/28/23, showed Staff D messaging Staff E, saying “The detectives are wanting the documentation around your conversation about the sexual misconduct.

5. During an interview on 09/21/23 at 09:15 AM, Staff D, Executive Director of Intensive Youth Services, stated that an allegation of staff sexual misconduct was made by Patient #1 on or around 8/18/23. [...] 7. Review of law enforcement records and internal facility records showed that Patients #1 and #2 repeatedly reported they were prevented from using the telephone to call 911 and the non-emergency law enforcement number to report sexual misconduct by a staff inside the facility 8.

Staff S wrote:” Did anyone tell [Patient #4] that a DCR [designated crisis responder] would be coming to assess [them] and that due to [their] recent self-harm and blade to [their] neck indicating suicide risk that [they] would be likely detained for 6.5 months? [...] PYR will determine which outside entity needs to be reported to (DOH, Law Enforcement, CPS) and will determine the next steps.

From the state's report. Deficiency cited, complaint investigation. Cited: WAC 246-341-0600 Individual rights.; WAC 246-341-0410 Agency administration—Administrator key responsibilities.; WAC 246-341-0420 Agency policies and procedures.; WAC 246-341-1133 Evaluation and treatment services—Service standards.. "[...]" marks text left out between sentences.

How a report gets on this page

A program reads every inspection report we collect and picks out findings that describe serious harm, using the state's own severity rating or complaint outcome where there is one. A person then reads the report and approves or rejects each one. Only findings the state substantiated are listed: a citation, or a complaint the investigator upheld. A child running away is listed only when it ended in a death or a serious injury. This page is not complete: it covers the states and reports reviewed so far, and a facility's absence here says nothing about its record. Every report we hold, flagged or not, is on the state trackers.