state: OR

facility_name: Native American Rehabilitation Association of the Northwest, Inc. (NARA)

summary: Unannounced - 8 findings

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Licensee: Native American Rehabilitation Association of the
Northwest (NARA)
Executive Director: Jacqueline Mercer
Program Director: Luci LaDue
Date of Unannounced: September 23, 2021
Licensing Coordinator: Robin DuVal
Other Regulatory or Accrediting Agencies: Oregon Health Authority
Purpose: Per OAR 413-215-0101 (1) (b) Children’s Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings: Repeat Findings Comments
Unannounced Site Visit 10/13/2020 Further Action Needed
413-215-0541(D) staff participating; (G) problems encountered: “The evacuation Yes No☐ The form was updated to included (D)
drill log forms were missing elements (D) and (G). Within the last two years, two and (G), however drills were missing for
months of drills were missed. The agency shall update the log forms to contain all two months. The agency shall ensure
required elements and the agency shall ensure that monthly drills occur and are monthly drills are conducted and
documented. This is a REPEAT FINDING (03/14/18).” documentation retained.
No evacuation drill was completed in September 2020. The log forms were missing
elements (D) and (G). This is a REPEAT FINDING 2020.
413-215-0061(4): New Employee Orientation – Umbrella Requirements (30 days): Yes☐ No
(b) Ethical and professional guidelines:
(c) Organizational lines of authority:
(d) Attributes of population served:
(e) & (5)(a) to (c) Mandatory reporting
(f) Privacy laws
(g) Emergency procedures
“These required trainings did not occur within the first 30 days. The agency shall
implement a systematic procedure to ensure trainings are conducted within 30 days
and appropriately documented. This is a REPEAT FINDING (03/14/18).”
1
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 200115)
There was a lack of documentation the following trainings were completed by staff
within 30 days of hire. This is a REPEAT FINDING 2020.
(c) Organizational lines of authority
(d) Attributes of population served
(e) & (5)(a) to (c) Mandatory reporting
(g) Emergency procedures
413-215-0556(1)(a) Discipline and behavior management including de- Yes☐ No
escalation, crisis prevention, positive behavior management, and disciplinary
techniques that are non-punitive in nature: “Discipline and behavior management
training did not occur within the first 30 days. The agency shall implement a
systematic procedure to ensure trainings are conducted and documented. This is a
REPEAT FINDING (03/14/18).”
There was no documentation these trainings were completed by staff. This is a
REPEAT FINDING 2020.
Ongoing Training: Yes☐ No
413-215-0556(2)(a) Environmental emergencies
413-215-0556(2)(b) Universal Precautions
413-215-0556(2)(c) Discipline and Behavior Management
413-215-0061(5) Mandatory reporting (annually)
“Documentation of these trainings was missing from personnel files. The agency
shall implement a systematic procedure to ensure trainings are conducted and
documented.”
There was a lack of documentation the following trainings were completed on an
ongoing basis.
(2)(a) Environmental emergencies
(2)(c) Discipline and Behavior Management
413-215-0511 (2)(c) Residential Care Agencies: Physical Plant Requirements. (2) Yes☐ No
A residential care agency must be kept clean and in good repair.
The male unit had two couches with ripped cushions; one couch had a broken arm;
and one bathroom was dirty and odorous.
New Findings from Site Visit Comments
The residential floor has the current license posted; however, the old license is posted in the main entrance downstairs. The agency shall ensure the current
license is posted at this main entrance.
2 of 3
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 200115)
Interview Summary
Nathan Perry, Clinical Supervisor, provided the tour with the assistance of Heather Taylor, Residential Assistant Supervisor. The current census is 7.
Youth J is 16 years old and has been in the program almost 2 months. Likes it here, is allowed more freedoms than prior two programs, and feels safe. Staff are
trusting. Talks to people outside of the program, has Zoom time with family and time isn’t limited. The food is good, has a variety with vegetarian options, and
gets enough. Provides input into treatment plan and feels listened to. No issues with receiving prescribed medications. Has online school and is going well.
Favorite thing about this program is staff are nice and understanding. Least favorite is Zoom calls instead of being in person. The program does well at
understanding the youth and letting the youth have a voice. This is a no touching program with no inappropriate topics (between staff or youth) and staff have
appropriate boundaries. Staff are good at monitoring and giving positive redirection. The program offers activities like painting, beading, making bracelets,
appropriate movies, reading books, growing butterflies, cultural projects, walks, educational outings, and visits to outdoor places like parks, water park, and
native gardens.
Staff S has worked here approximately 5 months and it’s their first time in this line of work. Described all the onboarding and ongoing training and how it’s tracked
in Relias. Knows to report suspected abuse or neglect to the Oregon Child Abuse Hotline first and then a supervisor. Described the “red flags” training and staff
boundaries include no touching, hugging, no client special treatment and signs to watch out for. Has weekly staff meetings and daily contact with immediate
supervisor. Feels free to express concerns or suggestions and management is responsive to those. Feels the program is adequately staffed for the current
census. Described the daily recreation the youth get. Feels the food is healthy and plentiful. When a youth enters the program, there’s a client books with all
details for the staff to read. No physical interventions with youth here. The program does well at blended cultural groups and being inclusive and has good
COVID protocols.
Observations
The program is clean, in good repair and has a thorough COVID screening protocol for visitors upon entering. A maintenance person was observed painting
walls on the Cedar House side (males). The bedrooms and bathrooms were clean and tidy. The kitchen and dining area was observed to be clean, with available
drinking water and snacks and plenty of food stored in the pantry, refrigerators, and freezers. The exercise room has been updated with new equipment. The
group room on the Sage House side has a lot of craft choices. The space designated for a new youth upon admission (until cleared with a negative COVID test)
is clean with their own designated bedroom and bathroom, a TV and other independent activities.
Corrective Actions and Timeframes:
Please submit the following to verify compliance.
Within 45 days of receipt of this report Native American Rehabilitation Association of the Northwest (NARA) must submit a letter of verification
indicating the agency is in compliance with the specific rules cited above and describing how compliance will be maintained going forward. Along
with the letter of verification, the agency must submit any and all specific documentation requested in the body of this report. The letter of verification
and any additional requested documents are to be emailed directly to Robin DuVal, ROBIN.M.DuVal@dhsoha.state.or.us.
10/20/2021
Licensing Coordinator’s Signature: ________________________ Date: ___________________
10-20-2021
Manager Review: ______________________________________ Date: __________________
3 of 3
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program_name: Youth Residential Treatment Center (YRTC)

program_type: (RC) Residential Care Programs

report_type: Unannounced

view_code: RC

executive_director: Jacqueline Mercer

program_director: Luci LaDue

visit_date: September 23, 2021

licensing_coordinator: Robin DuVal

other_regulatory_agencies: Oregon Health Authority

purpose:
Per OAR 413-215-0101 (1) (b) Children's Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings: Repeat Findings Comments
Unannounced Site Visit 10/13/2020 Further Action Needed
413-215-0541(D) staff participating; (G) problems encountered: "The evacuation Yes No[ ] The form was updated to included (D)
drill log forms were missing elements (D) and (G). Within the last two years, two and (G), however drills were missing for
months of drills were missed. The agency shall update the log forms to contain all two months. The agency shall ensure
required elements and the agency shall ensure that monthly drills occur and are monthly drills are conducted and
documented. This is a REPEAT FINDING (03/14/18)." documentation retained.
No evacuation drill was completed in September 2020. The log forms were missing
elements (D) and (G). This is a REPEAT FINDING 2020.
413-215-0061(4): New Employee Orientation - Umbrella Requirements (30 days): Yes[ ] No
(b) Ethical and professional guidelines:
(c) Organizational lines of authority:
(d) Attributes of population served:
(e) & (5)(a) to (c) Mandatory reporting
(f) Privacy laws
(g) Emergency procedures
"These required trainings did not occur within the first 30 days. The agency shall
implement a systematic procedure to ensure trainings are conducted within 30 days
and appropriately documented. This is a REPEAT FINDING (03/14/18)."
1

There was a lack of documentation the following trainings were completed by staff
within 30 days of hire. This is a REPEAT FINDING 2020.
(c) Organizational lines of authority
(d) Attributes of population served
(e) & (5)(a) to (c) Mandatory reporting
(g) Emergency procedures
413-215-0556(1)(a) Discipline and behavior management including de- Yes[ ] No
escalation, crisis prevention, positive behavior management, and disciplinary
techniques that are non-punitive in nature: "Discipline and behavior management
training did not occur within the first 30 days. The agency shall implement a
systematic procedure to ensure trainings are conducted and documented. This is a
REPEAT FINDING (03/14/18)."
There was no documentation these trainings were completed by staff. This is a
REPEAT FINDING 2020.
Ongoing Training: Yes[ ] No
413-215-0556(2)(a) Environmental emergencies
413-215-0556(2)(b) Universal Precautions
413-215-0556(2)(c) Discipline and Behavior Management
413-215-0061(5) Mandatory reporting (annually)
"Documentation of these trainings was missing from personnel files. The agency
shall implement a systematic procedure to ensure trainings are conducted and
documented."
There was a lack of documentation the following trainings were completed on an
ongoing basis.
(2)(a) Environmental emergencies
(2)(c) Discipline and Behavior Management
413-215-0511 (2)(c) Residential Care Agencies: Physical Plant Requirements. (2) Yes[ ] No
A residential care agency must be kept clean and in good repair.
The male unit had two couches with ripped cushions; one couch had a broken arm;
and one bathroom was dirty and odorous.
New Findings from Site Visit Comments
The residential floor has the current license posted; however, the old license is posted in the main entrance downstairs. The agency shall ensure the current
license is posted at this main entrance.
2 of 3

Interview Summary
Nathan Perry, Clinical Supervisor, provided the tour with the assistance of Heather Taylor, Residential Assistant Supervisor. The current census is 7.
Youth J is 16 years old and has been in the program almost 2 months. Likes it here, is allowed more freedoms than prior two programs, and feels safe. Staff are
trusting. Talks to people outside of the program, has Zoom time with family and time isn't limited. The food is good, has a variety with vegetarian options, and
gets enough. Provides input into treatment plan and feels listened to. No issues with receiving prescribed medications. Has online school and is going well.
Favorite thing about this program is staff are nice and understanding. Least favorite is Zoom calls instead of being in person. The program does well at
understanding the youth and letting the youth have a voice. This is a no touching program with no inappropriate topics (between staff or youth) and staff have
appropriate boundaries. Staff are good at monitoring and giving positive redirection. The program offers activities like painting, beading, making bracelets,
appropriate movies, reading books, growing butterflies, cultural projects, walks, educational outings, and visits to outdoor places like parks, water park, and
native gardens.
Staff S has worked here approximately 5 months and it's their first time in this line of work. Described all the onboarding and ongoing training and how it's tracked
in Relias. Knows to report suspected abuse or neglect to the Oregon Child Abuse Hotline first and then a supervisor. Described the "red flags" training and staff
boundaries include no touching, hugging, no client special treatment and signs to watch out for. Has weekly staff meetings and daily contact with immediate
supervisor. Feels free to express concerns or suggestions and management is responsive to those. Feels the program is adequately staffed for the current
census. Described the daily recreation the youth get. Feels the food is healthy and plentiful. When a youth enters the program, there's a client books with all
details for the staff to read. No physical interventions with youth here. The program does well at blended cultural groups and being inclusive and has good
COVID protocols.
Observations
The program is clean, in good repair and has a thorough COVID screening protocol for visitors upon entering. A maintenance person was observed painting
walls on the Cedar House side (males). The bedrooms and bathrooms were clean and tidy. The kitchen and dining area was observed to be clean, with available
drinking water and snacks and plenty of food stored in the pantry, refrigerators, and freezers. The exercise room has been updated with new equipment. The
group room on the Sage House side has a lot of craft choices. The space designated for a new youth upon admission (until cleared with a negative COVID test)
is clean with their own designated bedroom and bathroom, a TV and other independent activities.

excerpt:
413-215-0511 (2)(c) Residential Care Agencies: Physical Plant Requirements. (2) Yes[ ] No
A residential care agency must be kept clean and in good repair.
The male unit had two couches with ripped cushions; one couch had a broken arm;
and one bathroom was dirty and odorous.
New Findings from Site Visit Comments
The residential floor has the current license posted; however, the old license is posted in the main entrance downstairs. The agency shall ensure the current
license is posted at this main entrance.
2 of 3
The residential floor has the current license posted; however, the old license is posted in the main entrance downstairs. The agency shall ensure the current
license is posted at this main entrance.
2 of 3


summary: License Renewals - 13 findings

raw_content:
Licensed Child Caring Agency Site Visit Report
Residential Care
Licensee: Native American Rehabilitation Association of the
Northwest, Inc. (NARA)
Executive Director: Jacqueline Mercer Date of site visit: February 18, 2022
Program Manager: Luci LaDue Licensing Coordinator: Robin DuVal
Board Chairperson: Jack Cranford
Other Regulatory or Accrediting Agencies: Oregon Health Authority (OHA); Indian Health Service (IHS)
Program Compliance: The program was found to be compliant or will be compliant with OAR 413-215-0001 to 413-215-0131, Licensing Umbrella
Rules, and OAR 413-215-0501 to 413-215-0586, Licensing Residential Care Agencies Rules. Personnel records were reviewed and compliance with
required background checks was documented for employees in all programs.
Program description, type and services: Youth residential treatment center (YRTC) providing 24-hour residential services for youth including
Alcohol & Drug, Mental Health, Medical and Dental services on-site. The service approach is collaborative and strengths-based, including individual
and group therapy, mental health, medical, and on-site dental services. Services include Dialectical Behavioral Therapy (DBT), Cognitive Behavioral
Therapy (CBT), Seeking Safety groups, Trauma informed art, Red Road, telehealth, group and family counseling, peer support, conflict resolution
and communication skill building activities, and medication management. An on-line accredited education program provides continuing education.
Certified by White Bison to provide culturally appropriate treatment. NARA promotes and provides youth with access to traditional spiritual and cultural
activities such as sweat lodge, fire circle, smudging, prayer, and other culturally specific activities. All cultural and spiritual beliefs are honored and
allow youth to participate in the spiritual practice of their choice. The treatment model is based on the Medicine Wheel, integrating Health (wellness),
Mental Health, Sobriety and Culture. Evidence-based practices and new developments in the treatment field drives their services. Staff include
master’s level counselors, clinical supervisors, certified alcohol & drug counselors, and certified recovery mentors. The mental health staff include a
Doctor of Psychology, licensed clinical social workers, licensed professional counselors, and an additional psychiatrist. Medical staff includes
physicians, family nurse practitioners, general nurse practitioners and registered nurses. NARA’s goal is to help individuals and families overcome
their addictions and move forward to enjoy a substance-free life.
Capacity and Age Range: capacity 24, ages 12-17
Funding sources: IHS, OHA, Oregon Department of Human Services (ODHS), Health Resources and Services Administration (HRSA).
Contracts: Roots and Beats; Forward Stride (equine therapy).
Referral sources: 9 Federally Recognized Tribes of Oregon; Oregon Department of Corrections; Oregon Department of Human Services; Oregon
Health Authority; school counselors; other Child Caring Agencies (CCAs); Native organizations.
Average length of stay: 4 months
Average daily population served: 8
Number of children served annually: 46
Use of seclusion or restraint: No
Youth Interviews: Two youth were interviewed over Zoom, individually and privately.
 Youth D. is 17 years old, has been in the program 118 days and is graduating from the program with a discharge plan. Staff are very welcoming
and respectful. Reports feeling safe, food is amazing and gets more than enough, has regular phone calls that aren’t limited or restricted, no
issues receiving medications as ordered, graduated High School while in program, and has regular extracurricular activities. Works with mental
health team regularly each week, feels supported and together developed personal goals and is very active in their own treatment plan. Their
favorite thing about NARA is the supportive staff and the positive, good energy. Reports NARA does well at being flexible, getting needs met,
teaching healthy boundaries and good communication. Stated there was nothing they would change about the program if they could.
 Youth A. is 15 years old and has been in the program approximately 1 ½ months. Reports feeling safe, food is good and provides alternatives,
has private phone calls with family and keeps in contact with prior therapist, working online towards credit recovery for school and expresses
teacher is really nice and helpful, goes on walks and some outings, and enjoys painting. Works with Mental Health team weekly and is involved
in making personal goals. Feels NARA is helping with recovery, living sober and being on a routine with sleep and meal schedule. Reports
outings is their favorite thing and least favorite is some of the groups. NARA does well at taking care of Mental Health needs and is careful
with triggers and what to watch for. Stated there was nothing they would change about the program if they could.
Staff Interviews: Three staff were interviewed over Zoom, individually and privately.
 Staff J. has worked here almost one year. Described initial and ongoing training, including mandatory abuse reporting, healthy boundaries.
Has daily contact with supervisor and feels heard when bringing up concerns or ideas. Staffing has been somewhat challenging due to COVID,
but always has enough to cover. Very much a team environment. Described the various extracurricular activities youth have. At intake, staff
are expected to read the youths information, safety plan, etc. Youth goals are regularly discussed during staff meetings. States NARA does
Page 2 of 16
well at listening to the needs and wants of each youth to complete the program. Two improvement areas are: tighten up the communication
between counselors and RAs; and create or improve a daily structure for the weekends.
 Staff C. has worked here approximately 9 months and shared their background and education. Has weekly contact with their supervisor.
Favorite things about NARA are multi-cultural approach to care; family-oriented environment even those who are not native; and feels
respected and heard. Staffing ratios are good and everyone steps up to fill in when needed.
 Staff N. has worked here 3 years. Reported the various ongoing trainings and ongoing policy and procedure review in weekly meetings.
Supervisor is supportive, open door for communication, very open and provides feedback. Described the recreation and extracurricular
activities the youth participate in. NARA does well at ability to engage with youth, have fun, trust, compassionate staff, building connections.
The only change would be to move physical locations to out of the city. Staff have stepped up to pick up extra shifts and staff are communicative
when feeling burnt out. Reports being proud of this program, and they continue to get stronger every day.
Observations: During the review, the walkthrough consisted of the youth bedrooms, common areas, bathrooms, classroom, recreation room, and
medication room. The kitchen and dining room was observed to be clean with adequate food supply in pantry, refrigerators, and freezers. The program
was clean and in good repair. The milieus are painted in warm colors, as well as youth bedrooms, and comfortable couches to make the living space
more homelike. Staff wore face masks, as mandated statewide due to the COVID-19 pandemic and there was an entry health screening protocol.
Staff were welcoming and accommodating.
Program Strengths, directly quoted by the agency:
We have managed to remain open to serve individuals in need during the pandemic. Addressing the pandemic has been challenging, i.e.,
implementation of greatly increased PPE, social distancing, adding staff to specifically sanitize the facility, and instituting specific visiting protocols for
residents. We modified the use of the building to adapt to continuing changes during the pandemic. We utilized targeted funds and reduced census
to improve our staff trainings, especially crisis response and advanced clinical interventions. We began providing dental services on site, prior to the
beginning of the pandemic. We were able to increase our success rate during this challenging time, as we had 1 out of every 3 clients successfully
graduate our program the last 2 years.
Program Challenges, directly quoted by the agency:
As typical of many residential facilities during the COVID-19 pandemic, we have had significant barriers to our services due to complex and changing
infection control procedures, and responses to staff and client exposures to and diagnoses of COVID-19 in the past 20 months. It is not an exaggeration
to say that COVID-19 has taken up a majority of our efforts, and we are grateful that we have managed to stay open at all during this challenging
time, as many of our colleagues’ programs have been forced to close temporarily or permanently. Unfortunately, we have much more demand for our
services and people are waiting longer times for admission under these conditions.
NARA would have, of course, wanted to continue our services at the same level of census as before the pandemic, but physical space issues to
accommodate social distancing within the facility did not allow that to happen. We did redesign our working space accommodations rapidly to maintain
a census at the highest possible level. In addition, we rapidly developed admission policies and procedures to quarantine new admissions and plan
entry into the milieu, and modified those procedures when vaccines became available. These modifications were developed in close conjunction with
our COVID-19 medical response team, who in turn consulted with the state and examined health guidelines published by the CDC. We also developed
Page 3 of 16
criteria for temporary exclusion from the milieu when exposures or illness was detected, with follow up and bridging services for those clients who
could rejoin us after they were well.
Changes that have occurred in the last 2 years, directly quoted by the agency:
Program structure had been changed to allow physical and spatial accommodations in response to the pandemic. Quarantine protocols were added
in response to the pandemic. Multiple policies were revised, and protocols were created to address issues surrounding the pandemic. Added
Telehealth services to allow resident appointments with ancillary service providers. We have implemented a COVID-19/social distancing monitor
during this pandemic.
Lawsuits, directly quoted by the agency: None
Grievances and complaints filed in the last two years, directly quoted by the agency: None
Exceptions: None
Changes in License: None
Recommendations:
 Compare the youth financial form to what is required by rule OAR 413-215-0581(4) and make any desired changes.
 Add a footer to forms with the date and ensure staff are utilizing the most updated forms.
 For the next renewal period in 2024, utilize the spreadsheet provided by Licensing to prepare personnel records and ensure all required
documentations are available at the time of review.
 Ensure NARA policies are updated when needed to align with changes to ODHS licensing rules for child-caring agencies.
Corrective Actions and Timeframes: Please submit the following to verify compliance.
Within 45 days of receipt of this report, NARA must submit a letter of verification indicating the agency is in compliance with the specific
rules cited below and describe how compliance will be maintained going forward. Along with the letter of verification, the agency must
submit any and all specific documentation requested in the body of this report. The letter of verification and any additional requested
documents are to be emailed directly to Robin DuVal at robin.m.duval@dhsoha.state.or.us.
Page 4 of 16
Summary of Review
Program and Services 413-215-0011(2) Yes No N/A
Program and services are in scope of license X
Governance of the Agency Corrective Action
Yes No N/A Corrective Actions
413-215-0021 Completed
(1)(a) Minimum of 5 board members X
(2)(f) Formally evaluate the exec. Director’s X Performance evaluations were not conducted for 2020 nor
performance annually 2021, however one is scheduled to occur at the upcoming
(2)(g) Approves annual budget X Board meeting and the agency shall submit once completed.
(2)(h) Obtain and review an annual The agency shall ensure a formal performance evaluation of
independent financial review or audit of the Executive Director’s is conducted annually.
financial records.
(2)(k) Written quality improvement program X
(2)(l) Meeting minutes X
Executive Director or Program Director
Yes No N/A
413-215-0021
(3)(a) knowledge of requirements for X
providing care and treatment appropriate to
programs
(3)(g) Approval from BCU X
Discipline, Behavior Management, and
Yes No N/A
Suicide Prevention 413-215-0076
(3) Agency uses appropriate and positive
methods of behavior management and
X
nationally recognized non-violent crisis
intervention
(3)(b)(C) Agency does not use chemical and
mechanical restraint (excluding medically X
necessary devices/prescriptions)
(3)(c) Agency uses appropriate time-out
rooms (adequate space, heat, light and
ventilation and is not capable of locking) and X
documents use in child’s record when
applicable
(3)(e) Agency uses seclusion
X
appropriately/consistent with policy
(4) Agency has adequate plan in place to
X
respond to suicidal behavior/warning signs
Contractors (if applicable) 413-215-0061(6) N/A
(a) Agency ensures the contractor meets the
requirements of this rule and Chapter 413 division X
215
Page 5 of 16
(b)(B) Contract includes the following:
(i) Services provided
(ii) Contractor fees
(iii) Disclosure of information from contractor to
agency
X
(iv) Lines of authority
(v) Adherence to rules, including background check
(vi) Any liability of the agency for acts of the
contractor, rights of indemnity and limitations on
liability
Supplemental Information Provided by Corrective Action
Yes No Corrective Actions
CCA Completed
Documents as indicated on the form titled
“Renewal Licensing Required Documents” X
Documents as indicated on form titled
“Required Financial Documents and X
The agency shall submit the Tax Compliance Certificate once
Information”
received.
All required policies and procedures as The agency shall update the following policies and procedures
identified in the “Umbrella Rules” pursuant to each OAR:
 Rights of Children to include all rights in OAR 413-215-
0046(1)(a-j)
 Grievance Procedures in OAR 413-215-0046(2)
 Personnel in OAR 413-215-0061
X
 Privacy in OAR 413-215-0066
 Discipline, Behavior Management & Training, and Suicide
Prevention in OAR 413-215-0076: Documents titled Non-
Seclusion and Restraint; Suicide Prevention and Precautions
(shows draft); Positive Discipline and Behavior Management.
All required policies and procedures as
identified in “Residential Care Rules” X
SB710 Requirements: Policy and
The agency shall submit the policy and procedures, and notifications
Procedures; notifications to guardian and
required to clients and guardians utilizing the resources provided by
children in care.
this licensor.
OAR 413-215-0077(8)(e), (11)(e) and
X
OAR 413-215-0078(1)
The agency shall ensure clients and guardians receive the notification
at intake and twice yearly thereafter, and document having provided
it.
Page 6 of 16
Physical Plant
Yes No N/A
413-215-0046(3)(a) Foster Rights Posted (if X
children in DHS custody)
413-215-0051(1) Sufficient safe space, X
equipment, and office equipment
413-215-0091(12) License is posted in X
common area at each facility
413-215-0001(5)(d), 0516(4(a)(I) & 0521(1) X
Adequate furnishings and personal items
413-215-0511(2)(a) &(c) Buildings are X
smoke free, clean and in good repair
413-215-0511(2)(d) Rooms are free of X
harmful drafts, odors, and excessive noise
413-215-0511(2)(e) Rooms are adequate in X
size and arrangement
413-215-0511(2)(f) System provides a X
continuous supply of hot and cold water to
taps located throughout the facility
413-215-0511(2)(h) Building is well X
ventilated and room temperature is within a
normal comfort range
413-215-0516(1) All parts of the facility X
ensure the safety of children
Room and Space Requirements
Yes No N/A
Bedrooms 413-215-0516(3)
(a) Adequate furnishings and personal items X
(b) Separate from rooms used for dining, X
living, laundry, kitchen, and storage
(c) Outside room with window allowing X
egress from building
(d) Ceiling at least 90 inches X
(e) Minimum 60 SF per bed X
(f) No more than 25 if dorm style X
(g) Permanently wired fixtures X
(h) Window covering X
(i) Beds are 3 feet apart and maintained to X
ensure safety
Room and Space Requirements
Yes No N/A
Bathrooms 413-215-0516(4)
(a)(A)&(B) 1:8 ratio for toilets and sinks X
(a)(D) Hot and cold running water, soap, and X
approved hand drying options
(a)(E) 1:10 ratio for shower or bathtub X
Page 7 of 16
(a)(E) Individual privacy X
(a)(F) Window covering X
(a)(G) Permanently wired fixtures X
(a)(H) Adequate ventilation X
(b)&(c) Wooden racks on floors are X
prohibited and impervious shower mats are
disinfected & dried daily
Room and Space Requirements
Yes No N/A
Kitchen 413-215-0516(6)
(a) Used exclusively for storage, food X
preparation, dish washing and activities
related to eating
(b) Walls, floors are easily cleanable X
(c) Equipment and utensils are easily X
cleanable, durable, nontoxic, and kept clean
(e) Equipment is easy to clean beneath, X
between and behind
Room and Space Requirements
Yes No N/A
413-215-0516
(2) There is a separate living room or lounge X
area – 15 SF minimum per child
(5) There is a separate dining room with X
capacity for ½ of children in care and 15 SF
per child in care
(7) Laundry is separate from living areas, X
kitchen and dining
(8) Separate storage areas are provided for X
food, kitchen supplies, utensils, clean linens,
soiled linens and clothing, cleaning supplies
and equip, poisons, chemicals, outdoor
recreational and maintenance equipment
(9) Outdoor activity area is protected from X
vehicles and other hazards and of a size and
availability appropriate to the age and needs
of children in care
(11) & 413-215-0076(3)(c)(C)Time out rooms X
have adequate space, heat, light and
ventilation and is not capable of locking
Furnishings and Personal Items
Yes No N/A
413-215-0521
(1) There is a bed with frame, clean mattress X
and pillow and personal storage (dresser,
closet)
Page 8 of 16
(2) Linens are in good repair. There is a X
waterproof mattress cover or mattress.
Linens are appropriate and towels and
washcloths are provided
(3) Bedding is changed weekly or when X
soiled
(4)&(5) Personal hygiene supplies and X
appropriate clothing are provided
Food Services
Yes No N/A
413-215-0536(1)&(2)
(1)(a) Meals are arranged daily, consistent X
with normal mealtimes that occur during the
hours of operation
(1)(b) Menus are prepared in advance in X
accordance with USDA guidelines, provide a
variety of foods and are adjusted for
seasonal changes.
(1)(b) Menus are kept for at least 6 months X
(1)(c) Drinking water is freely available X
(2)(a) Food is stored, prepared & served in a X
sanitary manner
(2)(c) & (d) Food products are obtained from X
commercial suppliers (exception of fruits &
vegetables), unpasteurized juice is
prohibited, and only Grade A pasteurized
and fortified milk in appropriate container.
Safety 413-215-0541 Yes No N/A
(2)(a) Written emergency plan X
(2)(b) Telephone numbers for local police X
and fire are posted near all telephones
(2)(c) Operative flashlights sufficient in X
number are readily available to staff
(3)(a) Evacuation drill occurs monthly under X
varying conditions, is retained 2 yrs and
contains;
(A) identify of person conducting drill
(B) date & time
(C) notification method
(D) staff participating
(E) # of children & staff evacuated
(F) special conditions simulated
(G) problems encountered
(H) time to complete
Safety – Transportation 413-215-0541 Yes No N/A
Page 9 of 16
(5)(b) Vehicle has insurance policy, is smoke X
free, safe operating condition, and has first
aid kit and fire extinguisher 2-A:10-BC
Medication 413-215-0551 Yes No N/A
(3)&(7)(e) Medications have a prescription X
and are stored in the original container with
prescription label
(4)&(5) Herbal supplements and remedies, X
medical treatments, special diets, physical
therapy, physical aides or limitations have a
written order signed by a physician or
qualified medical professional.
(7)(c) Medications are inaccessible to X
children
(8) Medications are disposed in accordance X
with state and federal law
(9) Written record of the disposal of X
medications is maintained and includes:
(a) description and amount
(b) name
(c) reason
(d) method
(e) staff & witness signature
(10) Written record of the administration of X
medication includes:
(a) name
(b) description
(c) dates and times
(d) missed doses
(e) medication disposed
(f) method of administration
(g) ID of person administering
(h) possible adverse reactions
(i) medication taken outside facility
Extracurricular, Enrichment, Cultural &
Social Activities Yes No N/A
413-215-0554
(2) Children have ongoing opportunities to X
participate in at least one age-appropriate or
developmentally appropriate activity
Minimum Staffing Requirements
Yes No N/A
413-215-0561
Page 10 of 16
(1)&(2) Supervision is adequate for the type X
of program, location, age and type of
children, ability of supervisor to respond,
electronic back-up systems.
Minimum ratios are maintained:
Under 30 months of age: 1:4
30 months to ˃ 6 yrs or non-ambulatory: 1:6
Ages 6 and older: 1:7
Overnight (staff awake) 1:10
(4)(a) When one staff on duty, there is X
additional staff immediately available with
max response time of 30 minutes
(5) There is at least one on-site employee X
authorized to apply the reasonable and
prudent parent standard
Separation of Residents
Yes No N/A
413-215-0566
(1) Children are in separate bedrooms than X
adults, unless parent and child, or there is
written approval from guardian/parent and
licensing coordinator
(2) There is adequate supervision of children X
if both males and females are served by the
program
Personnel Files Corrective Action
Yes No N/A Corrective Actions
413-215-0061 Completed
Staff Name/Position X
(3)(g) Date of Hire X
(3)(a) record of education, training and
X
previous employment
(1)(b) & (3)(b) reference checks completed
X The agency shall ensure background checks are completed
and documented
upon hire and at position changes; and retain documentation
(1)(a) & (3)(c) Background check completed in the employee personnel file.
X
and documented
(3)(d) Annual performance evaluations X The agency shall ensure annual performance evaluations are
conducted and documented in the employee personnel file.
(3)(f) Record of personnel actions X
Page 11 of 16
(3)(g) Termination date, reason for
X
termination
(3)(h) Current job description (1)(c)
Employee meets minimum qualifications X
stated in current job description
New Employee Orientation – Umbrella
Corrective Action
Requirements (30 days) Yes No N/A Corrective Actions
Completed
413-215-0061(4)
(a) Agency policies and procedures X
(b) Ethical and professional guidelines X
(c) Organizational lines of authority X
(d) Attributes of population served X
(e) & (5)(a) to (c) Mandatory reporting that
includes:
(a) legal definition of child abuse ORS
419B.005, Oregon Laws 2016, chapter 106,
X The agency shall ensure mandatory abuse reporting training
section 36
occurs within 30 days of hire.
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to
the employee
(f) Privacy laws X
(g) Emergency procedures X
New Employee Orientation – Residential
(30 days) Yes No N/A
413-215-0556
(1)(a) Discipline and behavior management
including de-escalation, crisis prevention,
positive behavior management, and X
disciplinary techniques that are non-punitive
in nature
(1)(b) Restraint and seclusion (if applicable) X
Ongoing Training Corrective Action
Yes No N/A Corrective Actions/Comments
Completed
413-215-0536(2)(b) Employees who handle X
food served to children have a valid food
handler’s card
413-215-0541(5)(a) Employees transporting
children have: current driver’s license,
insurance, trained in emergency procedures X
and behavior management, and training for
15+ passenger vans if applicable)
Page 12 of 16
413-215-0556(2)(a) Environmental
X
emergencies
413-215-0556(2)(b) Universal Precautions X
413-215-0556(2)(c) Discipline and Behavior
X
Management
413-215-0556(3) Staff providing direct care
must maintain current CPR/First Aid X
certification
413-215-0556(4) Designated staff authorized
to apply reasonable and prudent parent
X
standard are trained in application of the
standard
413-215-0061(5) Mandatory reporting
(annually) that includes:
(a) legal definition of child abuse ORS
419B.005, Oregon Laws 2016, chapter 106,
X
section 36
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to
the employee
Children’s Records Yes No N/A
Health Services
413-215-0546
(2) Medical history obtained within 30 days
(significant findings, current immunizations,
history of surgical procedures-health issues- X
injuries, allergies, dental, vision, hearing,
behavioral health, and physician orders)
(2)(e) Documentation of age appropriate
instruction – pregnancy prevention, nutrition,
prevention of HIV & AIDS, and prevention X
and treatment of sexually transmitted
disease
(4)(a) to (f) Medical exams (3 in first year of
life, 2,4,6,9,14) X
Consents Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0576(1) Completed
(a) Provide routine and emergency medical
X
care
Page 13 of 16
(b) Use the discipline and behavior
X
management system
(c) Use restraint or seclusion (if applicable).
Must specify the reasons for the intervention X
and how staff are trained and supervised
(d) Restrict contact with persons outside of
X
the agency
The agency shall add the consent to allow access on the
(e) Allow access as defined in 413-215-0091 “consent and acknowledgement” form already in use and
X
& 0101 utilize the updated form in new admission materials going
forward.
(f) Impose a dress code X
(g) Apply the reasonable and prudent parent
X
standard
Disclosures
413-215-0576(2) Parent/guardian has Yes No N/A
acknowledged in writing:
(a) Information regarding personal or room
searches and protocols for confiscation of X
contraband
(b) Statement of Rights of Children and
X
Parents/Guardians
(c) Any policies and procedures upon
X
request
Authorizations
Yes No N/A
413-215-0576(3)
(a) Disclose or exchange information with
X
others
(b) Child specific visitors X
(c) Visitation resources are pre-approved X
(d) Activity specific authorizations are pre-
approved to allow children to participate in
potentially hazardous activities, including but X
not limited to using motorized yard
equipment, swimming, and horseback riding.
Information about Children in Care
Corrective Action
413-215-0581(1) Summary sheet contains Yes No N/A Corrective Actions
Completed
the following:
(a)The name, gender, date of birth, religious Religious preference was not consistently documented on
X
preference, and previous address the summary sheet. The agency shall ensure an entry is
(b) Name and location of previous and noted for religious preference.
X
current school
(c) Date of admission X
Page 14 of 16
(d) Legal custody X
(e) The name, address, and telephone
number of:
(A) The child in care's parents.
(B) The child in care's legal guardian, if
different than the parents, and a copy of
X
the document that provides for his or her
authority over the child in care.
(C) Other persons significant to child
(D) Other professionals to be involved in
service planning (if applicable)
Service Planning
Yes No N/A
413-215-0581(2)
(b) Intake document is completed the date
child accepted into care (emergency X
placement 48 hours)
(d) Assessment is completed within 30 days
and contains relevant historical info., current
behavioral observations, identified need for X
services, and how agency will provide
services
(e) (A)&(B) Service plan within 60 days
(parent, guardian and child actively
involved). Describes how child’s issues will X
be addressed, anticipated outcomes and
reviewed by child and guardian/parent.
(e)(C)&(D) Service plan is reviewed quarterly
and revised when information indicates other X
services should be provided
Case Management Corrective Action
Yes No N/A Corrective Actions
413-215-0581(3) Completed
(a) Services are documented, progress
X
toward achieving goals is tracked
(b)-(d) discharge planning and instructions X
Incident Reports are completed and stored electronically in a
shared drive, although not organized by youth nor retained in
(f) Incident Reports X each youth file. The agency shall ensure completed incident
reports are retained in each youth record.
Page 15 of 16
Financial Records Corrective Action
Yes No N/A Corrective Actions
413-215-0581(4) Completed
Youth signatures are inconsistently captured on the form.
Records contain date, amount, source,
X The agency shall ensure the form is completed for each
purpose, signatures
transaction and signatures obtained per entry.
Personal Possessions Records
Yes No N/A
413-215-0581(5)
Individual written inventory of all personal
possessions is maintained and updated as X
needed
Records and Documentation Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0071 Completed
(1) Stored safely X
(2) Permanent, legible, dated, and signed X
(3)&(4) Uniform in organization, readily
identifiable and accessible, current, and
Personnel and youth records are incomplete missing items
X
complete, containing all required info. No
noted above.
eraser tape or white out.
(7) Permanent registry for each child
includes:
Name
Gender
X
Birth date
Names, addresses of parents or guardians
Dates of admission
Placement upon discharge
Licensing Coordinator’s Signature: ________________________ Date: _3_/7_/_2_0_2_2_ ___________
Manager Review: ______________________________________ Date: _ _ _0_3_-_0_7_-_2_0_2_2_ _____
Page 16 of 16

report_type: License Renewals

facility_type: Residential Care

board_chairperson: Jack Cranford

capacity_age_range: capacity 24, ages 12-17

average_length_of_stay: 4 months

use_of_seclusion_or_restraint: No Youth Interviews: Two youth were interviewed over Zoom, individually and privately. - Youth D. is 17 years old, has been in the program 118 days and is graduating from the program with a discharge plan. Staff are very welcoming and respectful. Reports feeling safe, food is amazing and gets more than enough, has regular phone calls that aren't limited or restricted, no issues receiving medications as ordered, graduated High School while in program, and has regular extracurricular activities. Works with mental health team regularly each week, feels supported and together developed personal goals and is very active in their own treatment plan. Their favorite thing about NARA is the supportive staff and the positive, good energy. Reports NARA does well at being flexible, getting needs met, teaching healthy boundaries and good communication. Stated there was nothing they would change about the program if they could. - Youth A. is 15 years old and has been in the program approximately 1 ½ months. Reports feeling safe, food is good and provides alternatives, has private phone calls with family and keeps in contact with prior therapist, working online towards credit recovery for school and expresses teacher is really nice and helpful, goes on walks and some outings, and enjoys painting. Works with Mental Health team weekly and is involved in making personal goals. Feels NARA is helping with recovery, living sober and being on a routine with sleep and meal schedule. Reports outings is their favorite thing and least favorite is some of the groups. NARA does well at taking care of Mental Health needs and is careful with triggers and what to watch for. Stated there was nothing they would change about the program if they could. Staff Interviews: Three staff were interviewed over Zoom, individually and privately. - Staff J. has worked here almost one year. Described initial and ongoing training, including mandatory abuse reporting, healthy boundaries. Has daily contact with supervisor and feels heard when bringing up concerns or ideas. Staffing has been somewhat challenging due to COVID, but always has enough to cover. Very much a team environment. Described the various extracurricular activities youth have. At intake, staff are expected to read the youths information, safety plan, etc. Youth goals are regularly discussed during staff meetings. States NARA does Page 2 of 16 well at listening to the needs and wants of each youth to complete the program. Two improvement areas are: tighten up the communication between counselors and RAs; and create or improve a daily structure for the weekends. - Staff C. has worked here approximately 9 months and shared their background and education. Has weekly contact with their supervisor. Favorite things about NARA are multi-cultural approach to care; family-oriented environment even those who are not native; and feels respected and heard. Staffing ratios are good and everyone steps up to fill in when needed. - Staff N. has worked here 3 years. Reported the various ongoing trainings and ongoing policy and procedure review in weekly meetings. Supervisor is supportive, open door for communication, very open and provides feedback. Described the recreation and extracurricular activities the youth participate in. NARA does well at ability to engage with youth, have fun, trust, compassionate staff, building connections. The only change would be to move physical locations to out of the city. Staff have stepped up to pick up extra shifts and staff are communicative when feeling burnt out. Reports being proud of this program, and they continue to get stronger every day. Observations: During the review, the walkthrough consisted of the youth bedrooms, common areas, bathrooms, classroom, recreation room, and medication room. The kitchen and dining room was observed to be clean with adequate food supply in pantry, refrigerators, and freezers. The program was clean and in good repair. The milieus are painted in warm colors, as well as youth bedrooms, and comfortable couches to make the living space more homelike. Staff wore face masks, as mandated statewide due to the COVID-19 pandemic and there was an entry health screening protocol. Staff were welcoming and accommodating.

recommendations:
Compare the youth financial form to what is required by rule OAR 413-215-0581(4) and make any desired changes.
- Add a footer to forms with the date and ensure staff are utilizing the most updated forms.
- For the next renewal period in 2024, utilize the spreadsheet provided by Licensing to prepare personnel records and ensure all required
documentations are available at the time of review.
- Ensure NARA policies are updated when needed to align with changes to ODHS licensing rules for child-caring agencies.

excerpt:
(2)(f) Formally evaluate the exec. Director’s
performance annually

excerpt:
(a) Agency ensures the contractor meets the
requirements of this rule and Chapter 413 division
215

excerpt:
Documents as indicated on form titled
“Required Financial Documents and
Information”

excerpt:
All required policies and procedures as
identified in the “Umbrella Rules”

excerpt:
SB710 Requirements: Policy and
Procedures; notifications to guardian and
children in care.
OAR 413-215-0077(8)(e), (11)(e) and
OAR 413-215-0078(1)

excerpt:
(1)(a) & (3)(c) Background check completed
and documented

excerpt: (3)(d) Annual performance evaluations

excerpt:
(e) & (5)(a) to (c) Mandatory reporting that
includes:
(a) legal definition of child abuse ORS
419B.005, Oregon Laws 2016, chapter 106,
section 36
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to
the employee

excerpt:
(e) Allow access as defined in 413-215-0091
& 0101

excerpt:
(a)The name, gender, date of birth, religious
preference, and previous address

excerpt: (f) Incident Reports

excerpt:
Records contain date, amount, source,
purpose, signatures Youth signatures are inconsistently captured on the form.
The agency shall ensure the form is completed for each
transaction and signatures obtained per entry.

excerpt:
(3)&(4) Uniform in organization, readily
identifiable and accessible, current, and
complete, containing all required info. No
eraser tape or white out.


summary: Unannounced - 17 findings

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Residential Care
Licensee: Native American Rehabilitation Association of the Northwest, Inc. (NARA) Date of Unannounced: November 4, 2022
Executive Director: Jacqueline Mercer Licensing Coordinator: Robin DuVal
Program Manager: Luci LaDue
Board Chairperson: Jack Cranford
Other Regulatory or Accrediting Agencies: Oregon Health Authority (OHA); Indian Health Service (IHS)
Purpose: Per OAR 413-215-0101 (1) (b) Children’s Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings: License Renewal 02/18/2022 Repeat Findings Comments
Further Action
Needed?
Governance of the Agency 413-215-0021(2)(f) Formally evaluate the Executive Yes☐ No This violation has been corrected.
Director’s performance annually. No further action needed.
Performance evaluations were not conducted for 2020 nor 2021, however one is
scheduled to occur at the upcoming Board meeting and the agency shall submit once
completed. The agency shall ensure a formal performance evaluation of the Executive
Director’s is conducted annually.
Supplemental Information Provided by CCA: Documents as indicated on form titled Yes☐ No This violation has been corrected.
“Required Financial Documents and Information” No further action needed.
The agency shall submit the Tax Compliance Certificate once received.
Supplemental Information Provided by CCA: All required policies and procedures as Yes☐ No This violation has been corrected.
identified in the “Umbrella Rules”. No further action needed.
The agency shall update the following policies and procedures pursuant to each OAR:
 Rights of Children to include all rights in OAR 413-215-0046(1)(a-j)
 Grievance Procedures in OAR 413-215-0046(2)
 Personnel in OAR 413-215-0061
Page 1 of 4
 Privacy in OAR 413-215-0066
 Discipline, Behavior Management & Training, and Suicide Prevention in OAR
413-215-0076: Documents titled Non-Seclusion and Restraint; Suicide
Prevention and Precautions (shows draft); Positive Discipline and Behavior
Management.
Supplemental Information Provided by CCA: SB710 Requirements: Policy and Yes☐ No This violation has been corrected.
Procedures; notifications to guardian and children in care. No further action needed.
OAR 413-215-0077(8)(e), (11)(e) and OAR 413-215-0078(1).
The agency shall submit the policy and procedures, and notifications required to clients
and guardians utilizing the resources provided by this licensor.
The agency shall ensure clients and guardians receive the notification at intake and
twice yearly thereafter, and document having provided it.
Personnel Files 413-215-0061(1)(a) & (3)(c) Background check completed and Yes☐ No Records were reviewed and this
documented. requirement was met. No further action
needed.
The agency shall ensure background checks are completed upon hire and at position
changes; and retain documentation in the employee personnel file.
Personnel Files 413-215-0061(3)(d) Annual performance evaluations. Yes☐ No Records were reviewed and this
requirement was met. No further action
The agency shall ensure annual performance evaluations are conducted and needed.
documented in the employee personnel file.
New Employee Orientation – Umbrella Requirements (30 days) 413-215-0061(4) Yes☐ No Records were reviewed and this
(e) & (5)(a) to (c) Mandatory reporting that includes: requirement was met. No further action
(a) legal definition of child abuse ORS 419B.005, Oregon Laws 2016, chapter 106, needed.
section 36
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to the employee
The agency shall ensure mandatory abuse reporting training occurs within 30 days of
hire.
Consents 413-215-0576(1)(e) Allow access as defined in 413-215-0091 & 0101. Yes☐ No Records were reviewed and this
requirement was met. No further action
The agency shall add the consent to allow access on the “consent and needed.
acknowledgement” form already in use and utilize the updated form in new admission
materials going forward.
Information about Children in Care 413-215-0581(1)(a) Summary sheet contains the Yes☐ No Records were reviewed and this
following: The name, gender, date of birth, religious preference, and previous address. requirement was met. No further action
needed.
Page 2 of 4
Religious preference was not consistently documented on the summary sheet. The
agency shall ensure an entry is noted for religious preference.
Case Management 413-215-0581(3)(f) Incident Reports. Yes☐ No Records were reviewed and this
requirement was met. No further action
Incident Reports are completed and stored electronically in a shared drive, although not needed.
organized by youth nor retained in each youth file. The agency shall ensure completed
incident reports are retained in each youth record.
Financial Records 413-215-0581(4) Records contain date, amount, source, purpose, Yes No☐ Youth and staff signatures are
signatures. consistently captured; however
transactions are not thoroughly
documented. The agency shall ensure
Youth signatures are inconsistently captured on the form. The agency shall ensure the
each transaction is thoroughly
form is completed for each transaction and signatures obtained per entry.
completed. Repeat finding.
 This requirement is unmet and
further corrective action is
needed.
Records and Documentation 413-215-0071(3)&(4) Uniform in organization, readily Yes☐ No This violation has been corrected.
identifiable and accessible, current, and complete, containing all required info. No No further action needed.
eraser tape or white out.
Personnel and youth records are incomplete missing items noted above.
New Findings from Site Visit
None
Interview Summary
Two youth, ages 17, who have been in program approximately 2 months, were individually interviewed. Both reported feeling safe and gave personal examples
of how this program is benefiting them. The food is good and plentiful. They described various activities and outings the agency provides. They receive
medications as prescribed. Peer relationships are average. The school program is great. They have regular contact with people on their approved contact list.
Staff are trusting and model healthy recovery tools. They meet regularly with their therapist. Both reported liking the program and how they take care of people,
find solutions to problems, provide second chances to try again and provide an overall sense of community. One youth reported the agency could improve on
staff consistency of what’s allowed and not allowed because it makes it confusing to youth sometimes.
During the review, I spoke with agency management, and they shared that the census is increasing since pre-COVID, wages were increased including shift
differentials and bonuses, and personnel records will be changing to electronic records soon.
Page 3 of 4
Observations
Upon entrance, COVID protocols were in place with temperature checks, questionnaire, and sign-in sheets as well as face masks. Youth were observed in the
milieu and later in the classroom and appeared to be comfortable and on task. The environment was welcoming, in good condition and clean. The kitchen and
dining room were clean, and plenty of food was observed in the refrigerators, freezers, and pantry. Bedrooms were clean with individualized décor.
Corrective Actions and Timeframes: Please submit the following to verify compliance.
Within 45 days of receipt of this report NARA must submit a letter of verification indicating the agency is in compliance with the specific rules cited
above and describing how compliance will be maintained going forward. Along with the letter of verification, the agency must submit any and all
specific documentation requested in the body of this report. The letter of verification and any additional requested documents are to be emailed directly
to ROBIN.M.DuVal@dhsoha.state.or.us.
Licensing Coordinator’s Signature: ________________________ Date: _1_1_/_2_9_/2_0_2__2_________
Manager Review: ______________________________________ Date: _1_1_-_2_9_-_2_0_2_2_ _______
Page 4 of 4

visit_date: November 4, 2022

licensing_coordinator: Robin DuVal Program Manager: Luci LaDue

purpose:
Per OAR 413-215-0101 (1) (b) Children's Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings: License Renewal 02/18/2022 Repeat Findings Comments
Further Action
Needed?
Governance of the Agency 413-215-0021(2)(f) Formally evaluate the Executive Yes[ ] No This violation has been corrected.
Director's performance annually. No further action needed.
Performance evaluations were not conducted for 2020 nor 2021, however one is
scheduled to occur at the upcoming Board meeting and the agency shall submit once
completed. The agency shall ensure a formal performance evaluation of the Executive
Director's is conducted annually.
Supplemental Information Provided by CCA: Documents as indicated on form titled Yes[ ] No This violation has been corrected.
"Required Financial Documents and Information" No further action needed.
The agency shall submit the Tax Compliance Certificate once received.
Supplemental Information Provided by CCA: All required policies and procedures as Yes[ ] No This violation has been corrected.
identified in the "Umbrella Rules". No further action needed.
The agency shall update the following policies and procedures pursuant to each OAR:
- Rights of Children to include all rights in OAR 413-215-0046(1)(a-j)
- Grievance Procedures in OAR 413-215-0046(2)
- Personnel in OAR 413-215-0061
Page 1 of 4
- Privacy in OAR 413-215-0066
- Discipline, Behavior Management & Training, and Suicide Prevention in OAR
413-215-0076: Documents titled Non-Seclusion and Restraint; Suicide
Prevention and Precautions (shows draft); Positive Discipline and Behavior
Management.
Supplemental Information Provided by CCA: SB710 Requirements: Policy and Yes[ ] No This violation has been corrected.
Procedures; notifications to guardian and children in care. No further action needed.
OAR 413-215-0077(8)(e), (11)(e) and OAR 413-215-0078(1).
The agency shall submit the policy and procedures, and notifications required to clients
and guardians utilizing the resources provided by this licensor.
The agency shall ensure clients and guardians receive the notification at intake and
twice yearly thereafter, and document having provided it.
Personnel Files 413-215-0061(1)(a) & (3)(c) Background check completed and Yes[ ] No Records were reviewed and this
documented. requirement was met. No further action
needed.
The agency shall ensure background checks are completed upon hire and at position
changes; and retain documentation in the employee personnel file.
Personnel Files 413-215-0061(3)(d) Annual performance evaluations. Yes[ ] No Records were reviewed and this
requirement was met. No further action
The agency shall ensure annual performance evaluations are conducted and needed.
documented in the employee personnel file.
New Employee Orientation - Umbrella Requirements (30 days) 413-215-0061(4) Yes[ ] No Records were reviewed and this
(e) & (5)(a) to (c) Mandatory reporting that includes: requirement was met. No further action
(a) legal definition of child abuse ORS 419B.005, Oregon Laws 2016, chapter 106, needed.
section 36
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to the employee
The agency shall ensure mandatory abuse reporting training occurs within 30 days of
hire.
Consents 413-215-0576(1)(e) Allow access as defined in 413-215-0091 & 0101. Yes[ ] No Records were reviewed and this
requirement was met. No further action
The agency shall add the consent to allow access on the "consent and needed.
acknowledgement" form already in use and utilize the updated form in new admission
materials going forward.
Information about Children in Care 413-215-0581(1)(a) Summary sheet contains the Yes[ ] No Records were reviewed and this
following: The name, gender, date of birth, religious preference, and previous address. requirement was met. No further action
needed.
Page 2 of 4
Religious preference was not consistently documented on the summary sheet. The
agency shall ensure an entry is noted for religious preference.
Case Management 413-215-0581(3)(f) Incident Reports. Yes[ ] No Records were reviewed and this
requirement was met. No further action
Incident Reports are completed and stored electronically in a shared drive, although not needed.
organized by youth nor retained in each youth file. The agency shall ensure completed
incident reports are retained in each youth record.
Financial Records 413-215-0581(4) Records contain date, amount, source,

interview_summary:
Two youth, ages 17, who have been in program approximately 2 months, were individually interviewed. Both reported feeling safe and gave personal examples
of how this program is benefiting them. The food is good and plentiful. They described various activities and outings the agency provides. They receive
medications as prescribed. Peer relationships are average. The school program is great. They have regular contact with people on their approved contact list.
Staff are trusting and model healthy recovery tools. They meet regularly with their therapist. Both reported liking the program and how they take care of people,
find solutions to problems, provide second chances to try again and provide an overall sense of community. One youth reported the agency could improve on
staff consistency of what's allowed and not allowed because it makes it confusing to youth sometimes.
During the review, I spoke with agency management, and they shared that the census is increasing since pre-COVID, wages were increased including shift
differentials and bonuses, and personnel records will be changing to electronic records soon.
Page 3 of 4

previous_findings:
License Renewal 02/18/2022 Repeat Findings Comments
Further Action
Needed?
Governance of the Agency 413-215-0021(2)(f) Formally evaluate the Executive Yes[ ] No This violation has been corrected.
Director's performance annually. No further action needed.
Performance evaluations were not conducted for 2020 nor 2021, however one is
scheduled to occur at the upcoming Board meeting and the agency shall submit once
completed. The agency shall ensure a formal performance evaluation of the Executive
Director's is conducted annually.
Supplemental Information Provided by CCA: Documents as indicated on form titled Yes[ ] No This violation has been corrected.
"Required Financial Documents and Information" No further action needed.
The agency shall submit the Tax Compliance Certificate once received.
Supplemental Information Provided by CCA: All required policies and procedures as Yes[ ] No This violation has been corrected.
identified in the "Umbrella Rules". No further action needed.
The agency shall update the following policies and procedures pursuant to each OAR:
- Rights of Children to include all rights in OAR 413-215-0046(1)(a-j)
- Grievance Procedures in OAR 413-215-0046(2)
- Personnel in OAR 413-215-0061
Page 1 of 4
- Privacy in OAR 413-215-0066
- Discipline, Behavior Management & Training, and Suicide Prevention in OAR
413-215-0076: Documents titled Non-Seclusion and Restraint; Suicide
Prevention and Precautions (shows draft); Positive Discipline and Behavior
Management.
Supplemental Information Provided by CCA: SB710 Requirements: Policy and Yes[ ] No This violation has been corrected.
Procedures; notifications to guardian and children in care. No further action needed.
OAR 413-215-0077(8)(e), (11)(e) and OAR 413-215-0078(1).
The agency shall submit the policy and procedures, and notifications required to clients
and guardians utilizing the resources provided by this licensor.
The agency shall ensure clients and guardians receive the notification at intake and
twice yearly thereafter, and document having provided it.
Personnel Files 413-215-0061(1)(a) & (3)(c) Background check completed and Yes[ ] No Records were reviewed and this
documented. requirement was met. No further action
needed.
The agency shall ensure background checks are completed upon hire and at position
changes; and retain documentation in the employee personnel file.
Personnel Files 413-215-0061(3)(d) Annual performance evaluations. Yes[ ] No Records were reviewed and this
requirement was met. No further action
The agency shall ensure annual performance evaluations are conducted and needed.
documented in the employee personnel file.
New Employee Orientation - Umbrella Requirements (30 days) 413-215-0061(4) Yes[ ] No Records were reviewed and this
(e) & (5)(a) to (c) Mandatory reporting that includes: requirement was met. No further action
(a) legal definition of child abuse ORS 419B.005, Oregon Laws 2016, chapter 106, needed.
section 36
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to the employee
The agency shall ensure mandatory abuse reporting training occurs within 30 days of
hire.
Consents 413-215-0576(1)(e) Allow access as defined in 413-215-0091 & 0101. Yes[ ] No Records were reviewed and this
requirement was met. No further action
The agency shall add the consent to allow access on the "consent and needed.
acknowledgement" form already in use and utilize the updated form in new admission
materials going forward.
Information about Children in Care 413-215-0581(1)(a) Summary sheet contains the Yes[ ] No Records were reviewed and this
following: The name, gender, date of birth, religious preference, and previous address. requirement was met. No further action
needed.
Page 2 of 4
Religious preference was not consistently documented on the summary sheet. The
agency shall ensure an entry is noted for religious preference.
Case Management 413-215-0581(3)(f) Incident Reports. Yes[ ] No Records were reviewed and this
requirement was met. No further action
Incident Reports are completed and stored electronically in a shared drive, although not needed.
organized by youth nor retained in each youth file. The agency shall ensure completed
incident reports are retained in each youth record.
Financial Records 413-215-0581(4) Records contain date, amount, source, purpose, Yes No[ ] Youth and staff signatures are
signatures. consistently captured; however
transactions are not thoroughly
documented. The agency shall ensure
Youth signatures are inconsistently captured on the form. The agency shall ensure the
each transaction is thoroughly
form is completed for each transaction and signatures obtained per entry.
completed. Repeat finding.
- This requirement is unmet and
further corrective action is
needed.
Records and Documentation 413-215-0071(3)&(4) Uniform in organization, readily Yes[ ] No This violation has been corrected.
identifiable and accessible, current, and complete, containing all required info. No No further action needed.
eraser tape or white out.
Personnel and youth records are incomplete missing items noted above.
New Findings from Site Visit
None


summary: Unannounced - 1 finding

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Residential Care
Licensee: Native American Rehabilitation Association of the
Northwest, Inc. (NARA)
Executive Director: Jacqueline Mercer Date of Unannounced: August 8, 2023
Program Manager: Luci LaDue Licensing Coordinator: Robin DuVal
Board Chairperson: Jack Cranford
Other Regulatory or Accrediting Agencies: Oregon Health Authority (OHA); Indian Health Service (IHS)
Purpose: Per OAR 419-400-0240 (1)(b) Children’s Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Findings
Comments
 Unannounced Site Visit 11/04/2022 Further Action Needed
Financial Records 419-470-0170 (4) Records contain date, amount,
source, purpose, signatures. Yes☐ No Financial records were reviewed, and
requirements were met.
Youth signatures are inconsistently captured on the form. The agency shall  No further corrective action needed at
ensure the form is completed for each transaction and signatures obtained this time.
per entry.
Youth and staff signatures are consistently captured; however, transactions
are not thoroughly documented. The agency shall ensure each transaction
is thoroughly completed. Repeat finding.
 This requirement is unmet and further corrective action is
needed.
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Form Rev. 01/23/2023
New Findings from Site Visit
None
Interview Summary
Two youth, ages 16, who have been in the program approximately 3 months and 2 months respectfully, were individually interviewed. Both reported feeling
safe, staff are trusting, food is good and plentiful, peer relationships are going ok, and they get medications as ordered. One reports the staff feel like family
and that they’ve demonstrated what a healthy family could look like. The program does well at having caring staff, being considerate, and taking care of the
youth’s needs. When asked if the agency could improve or change anything, neither had anything to report.
During the visit, I spoke with various levels of management, and reminded them to notify this licensing coordinator of any positive COVID cases. With
assistance of various grants, they’ll be purchasing new dressers, wardrobes, desks, couches, etc. They report the current census is around 18 and the census
has been increasing. This licensor reminded the program of the required ratios of toilets, sinks, and showers to children in care. In addition to the bathrooms
and shower rooms within the milieu and bedroom area, there are two working bathrooms down another hallway within the residential portion of the program for
use. It was reported that, for the first time since opening this program, the current population of youth has gang related ties and among the current youth, the
ties are to opposing gangs. The program purchased and replaced clothing items of certain gang related colors with neutral colored clothing, shoes, and
accessories. Parents, guardians, and youth were informed of the rationale, and this licensor recommended that agency review their dress code policy and
update as necessary.
Observations
Soon after arriving in the building, it was disclosed that two youth were COVID positive, and the agency instituted face coverings program wide. These youth
were in quarantine together in a room separate from the milieu rooms which has a bathroom and shower room within the room, beds, dressers, their
belongings, TV with gaming, etc. to make their quarantine time more tolerable. Meals were brought to them. Staff check on them every 15 minutes. Youth and
staff have walkie-talkies in the event they need to reach them urgently. The therapist met with each youth prior to sharing this space to ensure they felt safe
and comfortable to do so.
Youth were observed wearing face masks and relaxing and interacting with staff in the milieu. The environment was welcoming, in good condition and clean.
The kitchen and dining room were clean, and plenty of food was observed in the refrigerators, freezers, and pantry. Bedrooms and bathrooms were clean.
The classroom was a clean, calming space, and it was reported that the teacher incorporates education and culture in outings.
The medication carts in the locked medication room were observed. Upon review of the medication administration records, it appears the youth is initialing
one side of the log at the time of receiving their medication, and the staff initials the flip side of the log. This licensor will follow-up and review their policy and
procedures to ensure licensing requirements are being met.
Across the street from the program building, the agency installed a fenced area of the large lot which is called the “Healing Garden” with areas to sit, graveled
pathways, traditional healing plants, and an area slated for a traditional sweat lodge. Youth and staff were observed in this space, and it appeared to be a
comforting place to be.
As a side note, it was observed that the OHA license posted at the reception area was not the current active license. This licensor requested they post the
current license.
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Form Rev. 01/23/2023
Corrective Actions and Timeframes: Please submit the following to verify compliance.
Within 45 days of receipt of this report Native American Rehabilitation Association of the Northwest, Inc. (NARA) must submit a letter of
verification indicating the agency is in compliance with the specific rules cited above and describing how compliance will be maintained going forward.
Along with the letter of verification, the agency must submit any and all specific documentation requested in the body of this report. The letter of
verification and any additional requested documents can be emailed directly to robin.m.duval@odhsoha.oregon.gov.
Licensing Coordinator’s Signature: ________________________ Date: _8_/2_2_/_2_0_2_3_ __________
Manager Review: ______________________________________ Date: _8_-_2_2_-2__0_2_3_ ________
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Form Rev. 01/23/2023

purpose:
Per OAR 419-400-0240 (1)(b) Children's Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Findings
Comments
- Unannounced Site Visit 11/04/2022 Further Action Needed
Financial Records 419-470-0170 (4) Records contain date, amount,
source,

interview_summary:
Two youth, ages 16, who have been in the program approximately 3 months and 2 months respectfully, were individually interviewed. Both reported feeling
safe, staff are trusting, food is good and plentiful, peer relationships are going ok, and they get medications as ordered. One reports the staff feel like family
and that they've demonstrated what a healthy family could look like. The program does well at having caring staff, being considerate, and taking care of the
youth's needs. When asked if the agency could improve or change anything, neither had anything to report.
During the visit, I spoke with various levels of management, and reminded them to notify this licensing coordinator of any positive COVID cases. With
assistance of various grants, they'll be purchasing new dressers, wardrobes, desks, couches, etc. They report the current census is around 18 and the census
has been increasing. This licensor reminded the program of the required ratios of toilets, sinks, and showers to children in care. In addition to the bathrooms
and shower rooms within the milieu and bedroom area, there are two working bathrooms down another hallway within the residential portion of the program for
use. It was reported that, for the first time since opening this program, the current population of youth has gang related ties and among the current youth, the
ties are to opposing gangs. The program purchased and replaced clothing items of certain gang related colors with neutral colored clothing, shoes, and
accessories. Parents, guardians, and youth were informed of the rationale, and this licensor recommended that agency review their dress code policy and
update as necessary.

observations:
Soon after arriving in the building, it was disclosed that two youth were COVID positive, and the agency instituted face coverings program wide. These youth
were in quarantine together in a room separate from the milieu rooms which has a bathroom and shower room within the room, beds, dressers, their
belongings, TV with gaming, etc. to make their quarantine time more tolerable. Meals were brought to them. Staff check on them every 15 minutes. Youth and
staff have walkie-talkies in the event they need to reach them urgently. The therapist met with each youth prior to sharing this space to ensure they felt safe
and comfortable to do so.
Youth were observed wearing face masks and relaxing and interacting with staff in the milieu. The environment was welcoming, in good condition and clean.
The kitchen and dining room were clean, and plenty of food was observed in the refrigerators, freezers, and pantry. Bedrooms and bathrooms were clean.
The classroom was a clean, calming space, and it was reported that the teacher incorporates education and culture in outings.
The medication carts in the locked medication room were observed. Upon review of the medication administration records, it appears the youth is initialing
one side of the log at the time of receiving their medication, and the staff initials the flip side of the log. This licensor will follow-up and review their policy and
procedures to ensure licensing requirements are being met.
Across the street from the program building, the agency installed a fenced area of the large lot which is called the "Healing Garden" with areas to sit, graveled
pathways, traditional healing plants, and an area slated for a traditional sweat lodge. Youth and staff were observed in this space, and it appeared to be a
comforting place to be.
As a side note, it was observed that the OHA license posted at the reception area was not the current active license. This licensor requested they post the
current license.
2 of 3 | P a g e

previous_findings:
Repeat Findings
Comments
- Unannounced Site Visit 11/04/2022 Further Action Needed
Financial Records 419-470-0170 (4) Records contain date, amount,
source, purpose, signatures. Yes[ ] No Financial records were reviewed, and
requirements were met.
Youth signatures are inconsistently captured on the form. The agency shall - No further corrective action needed at
ensure the form is completed for each transaction and signatures obtained this time.
per entry.
Youth and staff signatures are consistently captured; however, transactions
are not thoroughly documented. The agency shall ensure each transaction
is thoroughly completed. Repeat finding.
- This requirement is unmet and further corrective action is
needed.
1 of 3 | P a g e

New Findings from Site Visit
None