Severe reports

In plain words: A child in the program reported that a staff member pinched and kicked them following a restraint. The state reviewed video and interviews and found evidence that the staff member appeared to kick or try to trip the child. Our summary of the state's report. The state's own wording follows.

Supervisor reports that she was emailed Sunday evening (did not read until on duty Monday) regarding an unauthorized restraint and staff pinching the client. [...] The email stated, "Hi was rounding today by phone [unidentified person] and [Client #3] (A) made an allegation that a staff [Staff #2] pinched him and put him a restraint yesterday. have not given a restrain order this weekend and wanted to pass this along for administration to check on it ... [...] Incident (s): The [Client #3] met with his [therapist] on 3/21/22 and reported that a staff member [Staff #8] kicked him following a restraint on 3/18/2022. [...] Conclusions: Based on interviews with staff, consumer, and review of the video there is evidence to show that staff member [Staff #8] placed her foot out appearing to kick or try to trip the consumer. [...] "[Staff #8] kicked me." Interview on 05/04/2022 with Staff #6 revealed:

From the state's report. Deficiency cited, annual and complaint survey. Cited: V 512} 27D .0304 Client Rights - Harm, Abuse, Neglect. "[...]" marks text left out between sentences.

A caregiver was informed by 16-year-old and 14-year-old child in care that they were sexually assaulted and the caregiver observed blood on the children(s) clothing. The caregiver then failed to immediately seek medical attention or contact law enforcement as related to the incident.

She had the children shower after a sexual assault before returning them to the operation.

From the state's report. Risk level: High; Risk level: Medium High. Cited: 748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation; 748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks.

On August 31, 2021, CCLD received an allegation reporting that on August 29, 2021, Staff member #1 physically assaulted Client #1 causing injuries to [Child 1]'s neck area and possible rib fracture (See LIC811, dated March 29, 2022). [...] It was revealed on August 29, 2021, an incident occurred involving [Child 1] who reportedly displayed behavior outburst resulting in [Child 1] being restrained by Staff member #1 and law enforcement being called. [...] Based on information obtained, the preponderance of the evidence standard has been met, therefore the allegation of physical abuse is Substantiated.

From the state's report. Substantiated. "[...]" marks text left out between sentences. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.

In plain words: A child in the program was found asleep in bed with a staff member outside the door. A deputy later took the child to the hospital for an evaluation after a reported suicide attempt using shoelaces tied to a door. Our summary of the state's report. The state's own wording follows.

8:16 pm: "Consumer assessed for 1:1 at 1950 (7:50 pm) - asleep in bed with staff outside door. [County Sheriff's Deputy] arrived at 2016 (8:16 pm) to transport consumer to [hospital] ED (emergency department) for IVC (involuntarily commitment) evaluation. [...] Reason for admission included self harming behaviors, suicidal ideations, physically and verbally aggressive. [...] As a result of those behaviors and attempted suicide attempt (SA), [Former client 13] was IVC'd. nterview on 3/7/22 [Former client 13]'s MCO Care Coordinator stated: [...] On 12/6/21 he received a call at 7 pm froma acility and told [Former client 13] was being sent to the hospital. [...] He recalled being informed during morning rounds that [Former client 13] attempted to hang herself with some shoe laces tied to a door.

From the state's report. Deficiency cited, annual, complaint, and follow-up survey. Cited: V 314. "[...]" marks text left out between sentences. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.

On June 14, 2021, CCL received an allegation that Client #1 (see LIC811, dated 12/16/2021) was sexually assaulted by Client #2 while in care. [...] Local law enforcement was contacted by the facility.

From the state's report. Substantiated. "[...]" marks text left out between sentences. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.

As [Staff 1] stood by the door, other clients pushed [Staff 1] aside and began to physically assault [Child 1]. [...] [Staff 2] admitted not giving any verbal redirection to clients to de-escalate the incident because [Staff 2] "was in shock." The incident resulted a law enforcement response to the facility. [Child 2] was observed by law enforcement with seven punctures to the right hand, seven punctures to the right wrist, a scratch to the right forearm and a scratch to the right collarbone area. [...] Law enforcement recovered a hair pick on facility property which was identified as the weapon used to stab [Child 2]. [...] [Child 1] was detained at the conclusion of law enforcement's response.

From the state's report. Substantiated. Cited: 80078(a). "[...]" marks text left out between sentences. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.

The letter from DSS notes a Level 1 finding for the allegation of sexual abuse due to the following: Individual 1 remained fairly consistent with the disclosure made to Employee 3 and the Albemarle County Police Department detective regarding the sexual activity between Individual 1 and Employee 1. [...] Employee 4 reported rumors regarding Employee 1's sexual relationship with people at STARS previous to Individual 1's disclosure. [...] There is a preponderance of evidence to show Employee 1 sexually abused Individual 1. [...] Individual 1 had previously told Employee 2 about Individual 1's sexual relationship with Employee 1. [...] Employee 3 reported Individual 1 had told Employee 3 that Individual 1 had previously told Employee 2 about the sexual relationship with Employee 1.

From the state's report. Non-compliance, DBHDS human rights inspection. Cited: 12VAC35-115-50. B. (2) In receiving all services, each individual has the right to: 2. Be protected from harm including abuse, neglect, and exploitation.. "[...]" marks text left out between sentences.

However Supervisor 2 did fail to provide for the safety of Youth A when he was informed on 10/2/21 that Youth A reported being raped and failed to follow up, notify upper management or contact law enforcement.

From the state's report. Repeat violation established, special investigation. Cited: R 400.4112 Criminal history check, subject to requirements; staff.

In plain words: The state investigated a complaint that a staff member failed to properly supervise a fifteen-year-old resident before the child died. The state determined the violation resulted in the resident's death and issued an immediate seven thousand dollar fine to the program. Our summary of the state's report. The state's own wording follows.

On July 23, 2021, the Department concluded a complaint investigation alleging that staff #1 (See the Confidential Names List, LIC 811, dated September 3, 2021) neglected to provide the supervision necessary to meet the needs of fifteen-year-old client #1, prior to [Child 1]'s death. [...] Pursuant to the Enhanced Civil Penalty law, the Health and Safety (H&S) code section 1548 (e)(3)(A) states a violation the Department determines "...resulted in the death of a person receiving care through a Short Term Residential Therapeutic Program," the Department will be issuing an immediate civil penalty of $7,000.00." An exit interview was completed and appeal rights discussed. Copies of this report, the Confidential Names List, Appeal Rights and a Civil Penalty Assessment - Serious Bodily Injury/Physical Abuse (Form 421-D) were provided to the executive director.

From the state's report. Deficiency cited at inspection. "[...]" marks text left out between sentences. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.

Police found the illegally concealed firearm (belonging to [Staff 2]) during a search of the vehicle. Multiple charges were filed against [Staff 1] by police, including assault with a deadly weapon, criminal threats, and cruelty to a child.

From the state's report. Substantiated. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.

In plain words: State officials received a report that a lack of supervision allowed a child in the program to engage in sexual activities with an unknown adult male at the facility. A staff member stated she assumed the child just preferred staying alone in her room instead of socializing. Our summary of the state's report. The state's own wording follows.

On March 31, 2020, Community Care Licensing received claims alleging a lack of supervision contributed to Client #1 engaging in sexual activities with an unidentified male while in the facility. [...] [Staff 1] disclosed that she was under the assumption of knowing [Child 1] "having the habit of staying in the room and not socializing with the residents in the living room." [Staff 1] discovered the unidentified male was present at the facility when a neighbor witnessed the male jump the fence, after the (Continued on LIC9099-C) Los Angeles Sheriff Department (LAPD) arrived at the facility and began questioning staff and residents about the alleged incident.

From the state's report. Substantiated. "[...]" marks text left out between sentences. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.

In plain words: A child in the program reported that another child grabbed her left breast while she was in a facility van and later grabbed her crotch at a YMCA pool. Our summary of the state's report. The state's own wording follows.

Critical Incidents/ as appropriate state body overseemg that Health/ Department of Social and Health (MCO)/ and regional Administrative events when appropriate after consultation (CCO/ CAO/ Risk Manager/ or supervismg below: COMPREHENSIVE HEALTHCARE POLICIES AND PROCEDURES will report and follow-up with the appropriate email/ withm one busmess day any Critical below) or as otherwise specified m the will report to the Department of Health Healthcare s premises/ of any individual of receiving notice of the individuaFs https://fortress.wa.gov/doh/opu'do/s?s=OTPDeathReportmg Director or VP/ or designee of Residential of Health and other appropriate agencies incidents that involve serious or undesirable inpatient hospital stay; and through internal or external emergency or BHA Critical Incident Reporting webpage: https://forti'ess.wa.gov/doh/opmio/s?s=ComplamtFormHPF Director or VP/ or designee of Residential notify DSHS/Residential Care Service suicide/ relocation to a hospital or other or designee in an Assisted Living resident s physician/ and other individual(s) is a significant change in the resident's health care facility; or the resident dies.

1.Review of police report, titled “Supplemental Narrative”, dated 10/23/19, showed that Patient #1 reported sexual assault and harassment to the police. “TPatient #1] confirmed that there have been several incidents and |] asked [Patient #1]to tell me [Police Detective] about the first time that something happened. [Patient #1] told me they were in a facility van coming back from an outing...[Patient #2] reached through a ‘crease’ in the and he grabbed van the left side of her body, under her shirt... [Patient #1] told me [Patient #2}] grabbed her left breast when he reached through her shirt’.” “I [Police Officer] told [Patient #1] | heard about something happening at the YMCA pool... [Patient#1] told me that she was swimming back and forth and [Patient #2] grabbed her crotch...[Patient #2] placed his hand down the back of her pants and then got out of the pool...” 2.

From the state's report. Deficiency cited, complaint investigation. Cited: WAC 246-341-1126(l)(b) Mentai health inpatient services - Policies and procedures "Adult.; WAC 246-341-1126(1}(b) Metal health inpatient services Policies and procedures Adult..

Critical h-icidents/ as appropriate state body overseeing that Health/ Department of Social and Health (MCO)/ and regional Administrative events when appropriate after consultation (CCO/ CAO/ Risk Manager/ or supervising below: COMPREHENSIVE HEALTHCARE POLICIES AND PROCEDURES will report and follow-up with the appropriate email/ within one business day any Critical below) or as otherwise specified in the will report to the Department of Health Healfchcare s premises/ of any mdividual of receiving notice of the individuals https://forti'ess.wa.gov/doh/opuTio/s?s=OTPDeathReportmg Director or VP/ or designee of Residential of Health and other appropriate agencies incidents that mvolve serious or undesirable mpatient hospital stay; and through internal or external emergency or BHA Critical Incident Reporting webpage: https://forh'ess.wa.gov/doh/opuuo/s?s=Con'iplaintFormHPF Director or VP/ or designee of Residential notify DSHS/Residential Care Service suicide/ relocation to a hospital or other or designee m ai\ Assisted Living resident's physician/ and other individual(s) is a significant change in the resident's health care facility; or the resident dies.

From the state's report. Deficiency cited, complaint investigation. Cited: WAC 246-337-075(2)(a) Resident Rights..

Additionally, as had one hospitalization for self-harm and suicidal ideation prior to placement in a therapeutic foster home as placed in a therapeutic foster home after she was discharged from American Children’s Home abruptly, June 2018. [...] Additionally, HB hes had one hospitalization for self-harm and suicidal ideation prior to placement in a therapeutic foster home. was placed in a therapeutic foster home after she was discharged from American Children's Home abruptly, June Initially, ME cclimated well to her foster family. [...] For recipients identified as high risk for dangerous é or self injurious behaviors the discharge/transition fan includes admission to the appropriate level of care. [...] New behaviors have arisen this month. i had sneaked a railroad spike to the home and started self-harming. [...] 2/19/2019- Recently participated in self-harming behaviors which has led to her be hospitalized.

From the state's report. Deficiency cited, complaint and follow-up survey, Type A1 violation. Cited: V 296 anything management staff will be asked to put. "[...]" marks text left out between sentences.

In plain words: A client said a former staff member forced him to perform oral sex and sexually abused him on two dates after earlier inappropriate touching. The client told a staff member, who reported the abuse to a qualified professional and the program’s licensee. Our summary of the state's report. The state's own wording follows.

"[Client #2] further stated that he was forced to perform oral sex on [Former staff 11] on May 19, 2019 around 9 pm while at the facility. [Client #2] stated that [Former staff 11] stood up and told [client #2] to come over to where he was standing and grabbed his head and pulled his head down to his penis area." [...] He was sexually abused by [Former staff 11] on 5/17/19 and 5/19/19. Three to four weeks prior to 5/17/19 and 5/19/19 sexual assaults, [Former staff 11] had touched his butt "like four times before." [...] Denied that he ever told [Former staff 11] about his past or that he was sexually abused. [...] Client #2 made her aware that [Former staff 11] sexually abused him and she contacted the QP, the Licensee #1 and an unknown staff. [...] On 5/20/19 at approximately 12:27 a.m. he received a call from the QP that [Former staff 11] has allegedly sexually abused client #2. [...] And he said the guy eventually molested him.

From the state's report. Deficiency cited, complaint survey, Type A1 violation. Cited: V 512. "[...]" marks text left out between sentences. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.

The MP had built a program for boys "that a [North Carolina (NC) law enforcement association] could model statewide;" [...] 2/12/17 Juvenile Petition: physically abused and injured or sexually abused by parents Interview on 6/25/18 with Client #1 revealed: [...] Staff #14 "had put him (Client #6) on the floor on his stomach because he started punching stuff and being violent;" [...] Staff #14 and Staff #13 told him he had no rights and then had slammed him on the floor trying to restrain him; [...] Staff #14 had left Client #2 at the "temple" or "mud dog"( public baseball field with concrete/rock stairs) to work out running up the stairs and around the ball field because Client #2 had said he was going to run away; [...] Staff #14 had worked for the local Sheriff's Department for 2 % years; [...] Staff #14 walked back to the client's room and Client #5 was kicking the bed and thumping the wall;

From the state's report. Deficiency cited, annual and complaint survey, Type A1 violation. Cited: V 514. "[...]" marks text left out between sentences.

In plain words: Due to a failure to provide proper staffing and supervision, young people in the program were sexually abused and exploited by a van driver and another man from the community. Our summary of the state's report. The state's own wording follows.

An admission assessment dated 3/9/18 noting “was admitted from a crisis center, Full Scale 1Q of 92, victim of physical, sexual and emotional abuse, witnessed her father being shot and killed by the police, held client and her mom hostage in a standoff, situational drug related incidents such as seizures, mini strokes, panic attacks and blacking out, self-injurious behaviors (picks skin), prior inpatient and outpatient treatment, verbal altercations, issues with being disrespectful and not following rules, destroys property, got high off of Xanax and overdosed (took 21 pills), sniffing cleaning products, AWOL from previous placements, poly-substance abuse (marijuana, alcohol, methamphetamines, over the counter drugs, crack/cocaine, opiates, hallucinogens, barbiturates and inhalants)."

Because of the failure to provide appropriate staffing and supervision, clients were sexually abused and exploited by the Church van driver (CVD) and another non-staff adult male in the community.

From the state's report. Deficiency cited, complaint and follow-up survey. Cited: V 295 27G .1703 Residential Tx. Child/Adol - Reg. for A; V 293.

In plain words: A child in the program stole a school laptop from the office to contact men and then ran away from the group home. Staff found her, talked to her about the dangers of contacting older men, and she agreed to follow safety rules before running away later that shift. Our summary of the state's report. The state's own wording follows.

One elopement noted in September 2017. [...] Due to hospitalization between 03/06/18 and 03/21/18, client #8 was not able to be interviewed. [...] 02/25/18, client had been caught inappropriately using her alternative school laptop...client had stolen her school laptop from the staff's office and was attempting to utilize in her bedroom to facetime men...staff discovered Cc client using the laptop during a routine check and retained the tablet..staff educated the client on the dangers of seeking older men, giving out her personal information such as the residential placement's address and attempting to link up with men to be sexually active... client was able to contract for safety and agreed not to steal electronics, utilize face book again to contact men and to really focus on her school work...later in the shift, client eloped from the group home. [...] She was hospitalized in that area.

From the state's report. Deficiency cited, complaint survey. Cited: V 296] 27G .1704 Residential Tx. Child/Adol - Min.. "[...]" marks text left out between sentences.

Onor about February 8, 2023, the Program received a second complaint alleging a counselor (Stowe) employed at DYS Brush Prairie was arrested for having — a sexual relationship with Patient #10.

The notice explained that the Program would comply with the conditions in Part 2 to protect covered records and information obtained from DYS Brush Prairie. — The records request letter explained that the investigation had to do with allegations of staff sexual misconduct with patients and with a failure of facility systems to ensure patient safety.

Swope also engaged in nonconsensual sexual contact with Patient #11 during an outing from DYS Brush Prairie.

2023-2056) the Program became aware of allegations that another counselor at DYS Brush Prairie (Swope) had engaged in sexual contact with Patient #11 within — DYS Brush Prairie’s facility and while Patient #11 was admitted to DYS Brush —- — Prairie.

Further, Patient #9 reported to the Program and DYS Brush Prairie that the incidents — with Reinmuth resembled how they felt when they were raped by a teacher.

During this phone call, Patient #9 reported they had been in communication with Reinmuth since being discharged, and that Reinmuth had been communicating with another patient of DYS Brush Prairie outside of the facility. — Patient #9 reported the conduct of Reinmuth had triggered a manic episode due to past trauma when Patient #9 had been raped by a teacher.

While admitted to DYS Brush Prairie, Patient #9 had frequent contact — with Reinmuth, including disclosing to Reinmuth that Patient #9 was raped by a teacher.

From the state's report. Findings of fact, notice of intent.

In plain words: A staff member punched a child in the face multiple times and cursed at them while multiple staff members held and carried the child. The facility also failed to report the assault to the department and contracting agency within twenty-four hours as required. Our summary of the state's report. The state's own wording follows.

Child #1 was restrained and physically escorted by Staff members A, 8, C, D, E, F, G, H, During (he escort, Staff person A was observed punching Child #4 In the face multiple (Imes and repeatedly told Child #4 to “shut the {_k up.” Stalf person A Was also observed on a video of the event continulng fo punch Ihe chitd in the face while the child was carted dovm the hallway by Stalf members B, 0,D,€,F,G,H In a continual restraint, Child #4 sustalned mutiple tnfurles as a result of the ascault by StaffA. [...] Tho Spectal Victlms Unit was contacted and résponded by assigning a detective (Datectiva Danlel OMalley #895} tothe case.

On BE chiia #1 was assaulted by Staff A. ‘The facllly failed lo complete a written reportable incident report on a form prescribed by the Department; send it_fo the approprlate Departmental office and contracting agency within 24 hours. —

From the state's report. Citation, complaint inspection. Cited: 55 Pa. Code § 3800.32.b; 55 Pa. Code § 3800.18.c. "[...]" marks text left out between sentences.

In plain words: A sixteen-year-old resident sexually assaulted an eleven-year-old resident in their shared bedroom. A staff member later took the younger resident to the hospital, and the older resident was charged with rape and other crimes. Our summary of the state's report. The state's own wording follows.

On 8/7/15 al approximately 2:30 PM, Staff Member B transported Resident #2 to a hospital's emergency room due to the resident belng sexually assaulted by Resident #1 on the evening of 8/6/16, The jocal police department responded {o the hospital at approximately 3:68 PM to investigate (he sexual assault.

On the evening of 8/6/15, Resident #1, a 16 year-old, sexually assavited Resident #2, an 11 year-old, in the residents' shared bedroom #4, Ag a fesullt of the Incident on 8/6/15, Residen! #1 was charged with rape, Involuntary deviate sexual assaull, stalutory sexual assault, aggravated indecent assault, ‘and indecent assault, . [...] Immediate Action: At approximately 12:35 pm on August 7, 2015 Staff B approached Director EEE to inform her that resident 2 had reported 1o SB that he had been sexually assaulted during the previous night (8/6/15). [...] At approximately 1:15 pm, Director HE otified BCCYS regarding the incid ied to [Resident 2]'s agency, Butler County CYS, that he had been transported to the ER,.

Resident #1's-heallh and safely assessment dated 6/6/15 indicates, "Any concems of the child being a perpetrator of sexual abuse? [...] Whiie not within any staff person's eyesight on the evening of 8/6/15, Resident #1, a 16 year-old, sexually assaulted Resident #2, an 11 year-otd, in the residents‘ shared bedioom #4. As a resull of the Incldent on 8/6/15, Resident #1 was charged with rape, involuntary deviate sexual assault, statutory sexual assaull, aggravated indecent assault, and indecent assault,

Resident #1's health and safety assessment daled 6/5/15 indicates, "Any concerns of the child.being a perpetrator of sexual abuse? [...] While not within any staff person's eyesight on the evening of 8/5/15, Resident #1, a 18 year-old, sexually assaulted Resident #2, an 11 year-old, In the residents! shared bedroom #4, As a result of the incident on 8/6/15, Resident #1 was charged with rape, involuntary deviate sexual assaull, statutory sexual assault, aggravated indecent assault, and indecent assault, “ .

A child may not be abused, mistreated, threatened, harassed or subject to corporal punishment, On the eveniig of 8/6/16, Resident #1, a 18 year-old, sexually assaulled Resident #2, an 11 year-old, in the residents’ shared bedroom erere 4 harged with rapa, Involuntary deviate sexual assault, statutory sexual ee a monitoring process will be documented for each child, Repeat Violation: No

From the state's report. Citation, licence action taken. Cited: 55 Pa. Code § 3800.16.c; 55 Pa. Code § 3800.32.b; 55 Pa. Code § 3800.142; 55 Pa. Code § 3800.142; 55 Pa. Code § 3800.32.b. "[...]" marks text left out between sentences. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.

Law enforcement did a search warrant on [the staff person]’s phone and did not see any indication that [the staff person] was friends with clients on Snapchat but said that may have been because none of the clients “accepted” [the staff person]’s friend request. [...] Regarding Sexual Abuse Given the information provided by [Child 1] and [Child 8] that [the staff person] “patted” them and other clients on the buttocks over their clothing and also made comments about “smacking” [Child 1]’s “butt,” that [the staff person] was a staff person in authority who intentionally touched their buttocks, which was an intimate part, and making comments that were in appropriate and sexual in nature, there was a preponderance of the evidence that [the staff person]’s conduct included statements and overt acts that represented a substantial risk of sexual abuse to [Child 1] and [Child 8].

From the state's report. Maltreatment determined/substantiated as to sexual abuse of two alleged victims and neglect of twelve alleged .... "[...]" marks text left out between sentences. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.

On or about February 8, 2023, the Program received a second complaint alleging a counselor (Stowe) employed at DYS Brush Prairie was arrested for having — a sexual relationship with Patient #10.

From the state's report. Findings of fact, notice of intent.