summary: Visit conducted on 11/12/2025. Visit covered 6 main areas/topics. No compliance issues identified.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM:  Kids in Crisis-Farm House (Nursery)

TIME OF VISIT (FROM - TO): 10-10:45am					                      DATE: 11/12/2025

AGENCY PERSONNEL WHO PARTICIPATED:

Executive Director, Managing Director, Program Director

List of Areas / Topics covered during visit:

•	Census: 6(4 f, 2m) LBC (8)
•	Program updates: Clinician position was filled. Increase in referrals involving DMST, Length of Stays are increasing, 2current youth have DCF involvement and 1 has NY ACS involvement.  Concerns reported regarding a community partner regarding expertise in DMST services.
•	Staffing vacancies: Three (3) full-time positions (2am, 1pm shifts)
•	Staff/client interactions: 2 youth were home and 4 were attending school.  Youth observed playing video game while the other youth was sitting with staff watching tv.
•	Physical plant observed and clean.

Corrective Actions implemented as a result of previous visit:

•	Not applicable

Areas of regulatory non-compliance identified during this visit:
•	Not applicable

Amita Patel
Regulatory Consultant                                   Date 12/18/25

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|


state: CT

facility_name: NAFI Connecticut, Inc./ Touchstone / RT #29

summary: Visit covered 6 main areas/topics. No compliance issues identified.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM:   Touchstone                   		DATE:  1/22/26

TIME OF VISIT (FROM - TO):       2-2:30pm

 AGENCY PERSONNEL WHO PARTICIPATED: Program Director

List of Areas / Topics covered during visit:

•	Current Census=0, LBC=16
•	Staffing vacancy: Trainer
•	Milieu observation: No youth in the program.  The census is 0.  Last youth discharged on 2/9/25.
•	Staff/client interactions; None, as there are no youth in program.  Staff observed throughout the campus in the school building, dorm building and the main house.
•	Staff report daily for all shifts.  They continue to work on physical maintenance of all 3 buildings; team building and participate in various trainings. PD reports that staff are also practicing mock intakes for new staff in training.
•	Physical Plant: T/W toured the dorm, main house and school buildings. All buildings, bedrooms and bathrooms observed and clean.  Both the dorm and main house buildings can accommodate up to nine (9) youth.

Corrective Actions implemented as a result of previous visit:

•	Not applicable

Areas of regulatory non-compliance identified during this visit:
•	Not applicable

Amita Patel
Regulatory Consultant                                   							Date  4/16/26

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM
Cc: File
      Program Director|

facility_name: Touchstone                   		DATE:  1/22/26


summary: Visit covered 8 main areas/topics. Found 1 compliance issues.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM:   Touchstone                   		DATE: 11/13/25 (Personnel File Review)
									          11/14/25 (Physical plant)
TIME OF VISIT (FROM - TO):       9:30-11:00am

 AGENCY PERSONNEL WHO PARTICIPATED: Program Director, Assistant Program Director

List of Areas / Topics covered during visit:

•	Current Census=0, LBC=9
•	Staffing: Direct Care-3rd shift -two (2) full time, Trainer, ORR approved the lead medical coordinator position to be combined with program nurse.  New nurse program started on 10/22/25.  Prevention Sexual Abuse compliance officer is still vacant and is being covered by Assistant Program Director until the position is filled.
•	Milieu observation: No youth in the program.  The census is 0.  Last youth discharged on 2/9/25.
•	Staff/client interactions; None, as there are no youth in program.  Staff observed throughout the campus in the school building, dorm building and the main house.
•	Staff report daily for all shifts.  They continue to work on physical maintenance of all 3 buildings; team building and participate in various trainings. PD reports that staff are also practicing mock intakes for new staff in training.
•	Physical Plant: T/W toured the dorm, main house and school buildings. All buildings, bedrooms and bathrooms observed and clean.  Both the dorm and main house buildings can accommodate up to nine (9) youth.

Corrective Actions implemented as a result of previous visit:

•	Not applicable

Areas of regulatory non-compliance identified during this visit:

Section 17a-145-64:  Personnel policies and procedures:
There is one (1) file (LSD) in which staff did not have a current physical in the record indicating that a physical was conducted within 90 days prior to hire as it was completed approximately six (6) months prior to hire.

Section 17a-145-74:  Lavatory facilities:  Toilet articles and linens
•	Toilet seat needs to be replaced in the first-floor student bathroom in the school building

Amita Patel
Regulatory Consultant                                   							Date  11/21/25

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM
Cc: File
      Program Director|

description: Section 17a-145-74:


state: OR

facility_name: ADAPT - Deer Creek Board Chairperson: Kelsey Wood

summary: Unannounced - 05/19/2022

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Licensee: Adapt – Deer Creek
Executive Director: Dr. Gregory Brigham
Program Director(s): Ronald Farley
Date of Unannounced: 5/19/2022
Licensing Coordinator: Mary Torres
Other Regulatory or Accrediting Agencies: Oregon Health Authority (OHA)
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 Comments
Findings
Further Action
Needed
Program had no previous findings from the Yes☐ No☐
last Licensing site visit
Yes☐ No☐
Yes☐ No☐
1
(rev. 200115)
New Findings from Site Visit Comments
Program had no findings from this Licensing
site visit.
Interview Summary
Individual conversations were held with Deer Creek’s Program’s Director, Lead Counselor, Intake Coordinator and current residents.
The program’s current census includes three, male residents. The second floor of the program where female residents are housed has been unoccupied for
the past 5 months as the program does not have enough staff to supervised both floors. During COVID, the average population was 6 youth. Current referrals
are reflecting high acuity and the program is unable to serve the majority of the youth being referred. Primary referral sources continue to be from Adapt
outpatient services, Linn and Curry Counties and parents. Despite low census, there are no external pressures to increase population from the larger parent
company.
School continues to take place on campus. The program’s school contract is scheduled to be renegotiated soon. The program will be asking for cameras to be
installed on the back side of the school. This would allow the monitoring of the gazebo and garden area.
Family visits are still occurring on site. Families are able to visit their child for an hour at a time.
The Adapt parent program is still working towards the development of a “recovery campus”. This 40 acre campus will provide detox services to adults and
youth. Two to four beds will be earmarked for adolescents.
In speaking to the residents, all youth report only positive things about the program. All youth express liking their current placement and find staff to be helpful
and supportive. Strengths for the program include helping youth become clean and sober, that staff are willing to help youth when struggling, the program
helps youth establish and use good coping skills and staff seeing potential in all youth. No areas of weakness for the program were identified.
2
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 200115)
Observations
COVID precautions are still in place with staff masking.
The facility characteristically was found clean and well maintained.
Youth were in school during the tour of the facility and then were observed working in the program’s garden under the supervision of staff. Youth were
positively engaged with each other and the counselor working alongside them.
Corrective Actions and Timeframes:
Please submit the following to verify compliance.
Within 45 days of receipt of this report Adapt Deer Creek 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 Licensing Coordinator email address or sent by regular mail to the following address:
Department of Human Services
Children’s Care Licensing Program
Attn: Mary Torres
201 High St. SE Suite 500
Salem, OR 97301
Licensing Coordinator’s Signature: ________________________ Date: _ _ _ _6_/1_0_/_2_0_2_2_ _______
Manager Review: ______________________________________ Date: _ _6_-_8_-2__0_2_2_________
3
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 200115)

agency_name: ADAPT

program_type: (RC) Residential Care Programs

report_type: Unannounced

view_code: RC

licensee: Adapt - Deer Creek

executive_director: Dr. Gregory Brigham

program_director: Ronald Farley

licensing_coordinator: Mary Torres

other_regulatory_agencies: Oregon Health Authority (OHA)

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 Comments
Findings
Further Action
Needed
Program had no previous findings from the Yes[ ] No[ ]
last Licensing site visit
Yes[ ] No[ ]
Yes[ ] No[ ]
1

New Findings from Site Visit Comments
Program had no findings from this Licensing
site visit.
Interview Summary
Individual conversations were held with Deer Creek's Program's Director, Lead Counselor, Intake Coordinator and current residents.
The program's current census includes three, male residents. The second floor of the program where female residents are housed has been unoccupied for
the past 5 months as the program does not have enough staff to supervised both floors. During COVID, the average population was 6 youth. Current referrals
are reflecting high acuity and the program is unable to serve the majority of the youth being referred. Primary referral sources continue to be from Adapt
outpatient services, Linn and Curry Counties and parents. Despite low census, there are no external pressures to increase population from the larger parent
company.
School continues to take place on campus. The program's school contract is scheduled to be renegotiated soon. The program will be asking for cameras to be
installed on the back side of the school. This would allow the monitoring of the gazebo and garden area.
Family visits are still occurring on site. Families are able to visit their child for an hour at a time.
The Adapt parent program is still working towards the development of a "recovery campus". This 40 acre campus will provide detox services to adults and
youth. Two to four beds will be earmarked for adolescents.
In speaking to the residents, all youth report only positive things about the program. All youth express liking their current placement and find staff to be helpful
and supportive. Strengths for the program include helping youth become clean and sober, that staff are willing to help youth when struggling, the program
helps youth establish and use good coping skills and staff seeing potential in all youth. No areas of weakness for the program were identified.
2

Observations
COVID precautions are still in place with staff masking.
The facility characteristically was found clean and well maintained.
Youth were in school during the tour of the facility and then were observed working in the program's garden under the supervision of staff. Youth were
positively engaged with each other and the counselor working alongside them.


summary: License Renewals - 13 findings

raw_content:
Licensed Child Caring Agency Site Visit Report
Residential Care
Licensee: ADAPT – Deer Creek Board Chairperson: Kelsey Wood
Executive Director: Greg Brigham, PhD Date of site visit: 9/24/24
Program Director: Ron Farley Licensing Coordinator: Mary Torres
Other Regulatory or Accrediting Agencies: Oregon Health Authority (OHA). A joint review with OHA was conducted on the same day at the
request of the program.
Program Compliance: The program was found to be compliant or will be compliant with OAR 419-400-0005 to 419-400-0310, Licensing Umbrella
Rules, and OAR 419-470-0010 to 419-470-0180, Licensing Residential Care Agencies Rules. Personnel records were reviewed and compliance
with required background checks was documented for employees in all programs.
Program Description as summarized by the program: Deer Creek is an adolescent treatment center for chemically dependent and co-occurring
adolescents from the ages of 13 to 17. We are licensed for 15 beds and contracted to serve primarily OHP clients through our local CCO. We serve
the entire state of Oregon and each county's respective CCO, receiving referrals from agencies who have assessed teens meeting the ASAM
requirements. Our primary catchment area is Douglas, Coos, and Curry Counties. Our average length of stay is 4.5 months. Deer Creek uses the
Adolescent Community Reinforcement Approach (ACRA) as our primary treatment approach. We provide gender-specific groups and provide a
seeking safety curriculum. We prioritize pregnant teens and injection drug users.
Program type and services as reported by the program: Adapt offers medical services for all clients, and we refer to local providers as needed
for other services. Our clients attend Twelve-Step meetings in the community and have access to church services. We have a family program each
Sunday and recreation each Saturday. We provide classes and life skills, alcohol, and other drug education, as well as school provided by an
accredited education provider. Clients can work towards either a GED or high school diploma depending on what meets their needs.
We have a full-time director of Adolescent Services that overseas both outpatient as well as residential services. We have two full-time counselors,
one of which is the lead counselor and overseas daily activities. The lead counselor is also an LCSW who provides mental health assessments and
treatment. We have an intake coordinator, classroom aide, lead counselor assistant and residential assistants who cover all shifts.
Capacity and Age Range: 15 residents, ages 13 -17 years
Funding sources: Oregon Health Authority (OHA) contracts, program revenue, local Coordinated Care Organizations (CCO) – Umpqua Health
Alliance (UHA), Advanced Health and other third-party payors
P age 1 | 19
Form Rev. 1/2/2024
Contracts and sources for referrals: Department of Human Services (statewide), communities throughout the state, schools within Douglas
County, family referrals
Average length of stay: 4.5 months
Average daily population served: 6 to 10 residents
Number of children served annually: 55 residents
Use of seclusion or restraint: Deer Creek does not use either seclusion or restraint.
Interviews, Observations: Youth and staff were interviewed at the time of this review, and a tour of the facility was completed. Youth report feeling
safe with in the program and report positive experiences during their stay. The number and variety of outings that youth are able to attend was
identified as a strength of the program. One minor change requested was more instruction time with the school’s art teacher. Youth enjoy the food
at the program and appreciate the counselor’s support and involvement in meeting goals. Youth also benefit from daily family contact.
Staff interviews highlighted census; 4 youth currently on site at the time of the review with an increase in numbers over the next few days, staffing
updates, and changes in the program’s educational curriculum as well as changes with a former medical provider. New staff member reports
experiencing good support during transition and how the youth-focused training has prepared them for their role on campus.
A tour of the building resulted in no concerns for the program’s physical plant.
Program Strengths as identified by the program: We have an experienced program director and staff that have been with us for many years.
We have access to mental health and primary care providers through Adapt. We use the YMCA as part of our exercise program four times per
week. We provide opportunities for community support groups. We have a dining area for both upstairs and downstairs to have snacks and other
food readily available. We have lots of open area for clients to have space and recreation—sand volleyball court, fields, and a garden area.
Because we are a smaller program we can do some extra individualized treatment, for example a client attending UCC or visiting Job Corps.
Program Challenges as reported by the program: A significant challenge is the acuity of the mental health needs of clients being referred.
An ongoing challenge is recruiting and maintaining staff. Another challenge, which is very recent, is when CCOs deny requests to complete
treatment. When private insurance does this we bill the parents, but when a CCO denies completion care the families have already met a poverty
level that billing would make an unnecessary hardship.
Changes that have occurred in the last 2 years as reported by the program: The biggest change came last year when we moved to online
schooling from a more traditional classroom setting. The transient nature of our residential assistants. We hired a new counselor, Willie Haaby. We
have added a daily program of counselor led meditation. We have returned to a similar programing we had prior to COVID, including family
P age 2 | 19
Form Rev. 1/2/2024
program, passes and more community involvement. We now have in-house Basic Life Support (BLS) classes through Adapt Integrated Health Care
staff.
Lawsuits: None, according to the program.
Grievances and complaints filed in the last two years: The program received and addressed 10 formal grievances over this last licensing
period. Nine of the grievances were initiated by a resident while one grievance was filed by a parent. All grievances were addressed in a short
amount of time and handled at the lowest level of review and intervention needed.
Corrective Actions and Timeframes: Please submit the following to verify compliance.
Within 45 days of receipt of this report (insert name of agency) 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 (Licensing Coordinator and email address).
Exceptions: The program had no exceptions over this last licensing period.
Changes in License: N/A
Summary of Review
Program and Services
Yes No N/A Corrective Actions/Comments
419-400-0020 (2)
Program and services are in scope of license X
Governance of the Agency
Yes No N/A Corrective Actions/Comments
419-400-0040
(1)(a) Minimum of 5 board members X
(2)(f) Formally evaluate the exec. Director’s Completed annual performances were not provided nor verified at the time of the review.
performance annually
X
CORRECTIVE ACTION: Provide copies of completed annual performance appraisals for
the program’s Exec. Director and/or Program Director.
(2)(g) Approves annual budget X
(2)(h) Obtain and review an annual
independent financial review or audit of X
financial records.
(2)(k) Written quality improvement program X
(2)(l) Meeting minutes X
P age 3 | 19
Form Rev. 1/2/2024
Executive Director or Program Director
Yes No N/A Corrective Actions/Comments
419-400-0040
(3)(a) knowledge of requirements for
providing care and treatment appropriate to X
programs
(3)(g) Approval from BCU Approved background checks for both the Exec. Director and Program Director completed
X
in June of 2024
Installation and Use of Video Equipment
Used to Monitor or Record Children in
Yes No N/A Corrective Actions/Comments
Care
419-400-0145
(1) If a child-caring agency installs video
equipment to monitor or record a child in
care, all employees, volunteers, parents or
X
guardians, and children in care must be
informed about the intended use and
locations of the equipment.
Discipline, Behavior Management, and
Suicide Prevention Yes No N/A Corrective Actions/Comments
419-400-0150
(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 The program does not utilize chemical and mechanical restraint.
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 The program does not utilize time out rooms.
documents use in child’s record when
applicable
(3)(e) Agency uses seclusion
X The program does not utilize seclusion.
appropriately/consistent with policy
(4) Agency has adequate plan in place to
X
respond to suicidal behavior/warning signs
Contractors (if applicable)
Yes No N/A Corrective Actions/Comments
419-400-0120(6)
(a) Agency ensures the contractor meets the
requirements of this rule and Chapter 413 X A contractor’s file was not pulled for audit at the time of the review.
division 215
(b)(B) Contract includes the following:
(i) Services provided A contractor’s file was not pulled for audit at the time of the review. It is requested that the
(ii) Contractor fees X program provide a copy of any existing policy, contract or summary that speaks to the use
(iii) Disclosure of information from contractor of contracted services that meets Licensing Rule. ***Note, this is not a finding.***
to agency
P age 4 | 19
Form Rev. 1/2/2024
(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
Restraints and Involuntary Seclusion
Yes No N/A Corrective Actions/Comments
419-400-0180
(13)(d) Each child caring agency that
submits a report under this section shall The program’s quarterly restraint and seclusion reports can be located on their website at:
make its quarterly report available to the https://adaptoregon.org/wp-content/uploads/2024/10/2024-Q3-Adapt-CCLP-CCA-
X
public upon request at the Child Caring Involuntary-Seclusion-Restraint-Reporting-Review.pdf
Agency’s main office and on the child caring
agency’s website if applicable.
Supplemental Information Provided by
Yes No N/A Corrective Actions/Comments
CCA
Documents as indicated on the form titled
X
“Renewal Licensing Required Documents”
Documents as indicated on form titled A completed Tax Compliance Form that verifies compliance from the Dept. of Revenue
“Required Financial Documents and was not submitted at the time of the review.
Information”
CORRECTIVE ACTION: Submit final document that verifies tax compliance from the
Dept. of Revenue.
X ********
A copy of the program’s 2021/2022 audit was submitted for the review. A complete
financial review can not be completed without a copy of the program’s most current audit
for the 2023 year.
CORRECTIVE ACTION: Submit a copy of the program’s audit for the 2023 fiscal year.
All required policies and procedures as A grievance policy requires an update. Please update mailing address for Licensing
identified in the “Umbrella Rules” Coordinator, Mary Torres to reflect 4600 25th Ave NE Suite 150 Salem, OR 97201.
***Note this is not a finding. The Licensing office recently relocated. ***
********
X
A copy of the program’s Seclusion, Restraint and other Prohibited Types of Discipline
Policy was not submitted at the time of review.
CORRECTIVE ACTION: Submit a copy of the above missing policy to Licensing for
review.
All required policies and procedures as
X
identified in “Agency Type Specific Rules”
Physical Plant
Yes No N/A Corrective Actions/Comments
P age 5 | 19
Form Rev. 1/2/2024
419-400-0090(3)(a) Foster Rights Posted (if
X
children in DHS custody)
419-400-0100(1) Sufficient safe space,
X
equipment, and office equipment
419-400-0230(12) License is posted in
X
common area at each facility
419-470-0020(2)(a) &(c) Buildings are
X
smoke free, clean and in good repair
419-470-0020 (2)(d) Rooms are free of
X
harmful drafts, odors, and excessive noise
419-470-0020 (2)(e) Rooms are adequate in
X
size and arrangement
419-470-0020 (2)(f) System provides a
continuous supply of hot and cold water to X
taps located throughout the facility
419-470-0020 (2)(h) Building is well
ventilated and room temperature is within a X
normal comfort range
419-470-0030 (1) All parts of the facility
X
ensure the safety of children
Room and Space Requirements
Yes No N/A Corrective Actions/Comments
419-470-0030
(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, kitchen, X
and dining areas
(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.
(Hazardous materials are properly labeled, in
original container and locked)
(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) Time-out rooms: Rooms used for time X The program does not utilize time out rooms.
out or quiet time must have adequate space,
heat, light, and ventilation and must not be
capable of locking.
P age 6 | 19
Form Rev. 1/2/2024
Room and Space Requirements
Bedrooms Yes No N/A Corrective Actions/Comments
419-470-0030(3)
(a) Adequate furnishings and personal items X
(b) Separate from rooms used for dining,
X
living, laundry, kitchen, and storage
(c) Meet Oregon Fire Code Requirements X
(d) Be an outside room, with a window that
operates as designed. If the window is
modified from its original design, the fire
X
marshal must approve the modification and
indicate this room still meets applicable
Oregon Fire Code.
(d) Ceiling at least 90 inches X
(e) Minimum 60 SF per occupant X
(f) No more than 25 if dorm style X The program does not have the space for large dorm style sleeping areas.
(g) Permanently wired fixtures X
(h) Window covering X
Room and Space Requirements
Bathrooms Yes No N/A Corrective Actions/Comments
419-470-0030(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
(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
prohibited and impervious shower mats are
X Neither wooden racks nor impervious shower mats are used by the program.
disinfected & dried daily be in good condition
and free of mold
Room and Space Requirements
Kitchen Yes No N/A Corrective Actions/Comments
419-470-0030(6)
(a) Used exclusively for storage, food
preparation, dishwashing, and activities
X
related to eating and food preparation
activities
(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
P age 7 | 19
Form Rev. 1/2/2024
Furnishings and Personal Items
Yes No N/A Corrective Actions/Comments
419-470-0040
(1) There is a bed with frame, X
(1)(b) clean mattress in good condition,
X
with a minimum thickness of five inches
(1)(c) a pillow in good condition X
(1)(d) a private dresser, closet, or similar
storage area for personal belongings that X
is readily accessible
(2) Linens are in good repair. There is a
waterproof mattress cover or mattress.
X
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 Corrective Actions/Comments
419-470-0070
(1)(a) Meals are arranged daily, consistent
with normal mealtimes that occur during the
X
hours of operation and provide snacks
between mealtimes
(1)(b) Menus are prepared in advance in
accordance with USDA guidelines, provide a
X
variety of foods and are adjusted for
seasonal changes including snacks
(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
commercial suppliers (exception of fruits &
vegetables), unpasteurized juice is X
prohibited, and only Grade A pasteurized
and fortified milk in appropriate container.
Residential Care Safety
Yes No N/A Corrective Actions/Comments
419-470-0080
(2) Written emergency plan that includes X
(a) Identifying the types of emergencies most
likely to happen where the residential care X
agency is located
(b) Identifying a place to meet for each type
X
of emergency identified
P age 8 | 19
Form Rev. 1/2/2024
(c) Identifying an alternate shelter if
X
necessary
(d) Ensuring access to necessary Current written emergency plan does not speak to ensuring access to necessary
medications or medical equipment medications or medical equipment during or after an emergency and/or evacuation.
X
CORRECTIVE ACTION: Incorporate how necessary medications or medical equipment
during or after an emergency and/or evacuation will be accessed. Submit revised plan to
Licensing for review.
(e) How to help each child in care recover Current written emergency plan does not speak to how the program plans to assist each
after a disaster child in care recover after a disaster.
X
CORRECTIVE ACTION: Incorporate a plan to help each child in care recover after a
disaster. Submit revised plan to Licensing for review.
(3) Telephone numbers for local police, fire
department, poison control, after hours
medical advice and other appropriate X
emergency numbers must be posted near all
telephones.
(4) Operative flashlights sufficient in number
X
are readily available to staff
(5)(a) Evacuation drill occurs monthly under
varying conditions, is retained 2 years, and
contains:
(A) identify of person conducting drill
(B) date & time
(C) notification method X
(D) staff participating
(E) # of children & staff evacuated
(F) special conditions simulated
(G) problems encountered
(H) time to complete
Umbrella Safety
Yes No N/A Corrective Actions/Comments
419-400-0200
(5)(b) Vehicle has insurance policy, is smoke X Although the program’s 15 passenger van is in safe operating condition and has all
free, safe operating condition, and has first required equipment, the van’s back bench seats has been heavily vandalized with racial
aid kit and fire extinguisher 2-A:10-BC symbols and profanity graffiti.
CORRECTIVE ACTION: Remove or cover graffiti areas and implement a process where
the interior of all vehicles are inspected on a regular basis for offensive tagging as it would
appear that the graffiti in the van occurred over a course of time and was not a single
insolated incident.
(1)(b)(A) Each vehicle used to transport a X
child in care must be: properly registered,
covered by an insurance policy in full force
and effect, maintained in safe operating
condition, and smoke-free.
P age 9 | 19
Form Rev. 1/2/2024
(3) If a child-caring agency has a swimming X
pool on the premises that is accessible to
children in care or if a child-caring agency
plans to have children in care engage in
swimming, the child-caring agency must
have and adhere to policies and procedures
that address, at a minimum, providing
disclosures and obtaining consents,
assessing swimming ability of children in
care, and ensuring the safety of pool access.
(4)(a) The program protects children from X
potentially harmful items and materials.
(4)(b) Direct supervision of children who do X Currently, the program does not have a resident that requires this level of supervision.
not have the ability to adjust and control
water temperature
(4)(c) Light fixtures have protective covers X
unless designed to be used without one
Medication
Yes No N/A Corrective Actions/Comments
419-470-0100
(3) &(7)(e) Medications have a prescription
and are stored in the original container with X
prescription label
(4) & (5) Herbal supplements and remedies,
medical treatments, special diets, physical
therapy, physical aides, or limitations have a
written order signed by a physician or
qualified medical professional. A written X
order, signed by a physician or qualified
medical professional, is also required before
a restriction on diet or physical activity is
imposed.
(7)(c) Medications are inaccessible to
children and stored behind at least two
X
locking mechanisms. This does not apply to
Naloxone.
(8) Medications are disposed in accordance
X
with state and federal law
(9) Written record of the disposal of
medications is maintained and includes:
(a) description and amount
(b) name X
(c) reason
(d) method
(e) staff & witness signature
(10) Written record of the administration of
X
medication includes:
P age 10 | 19
Form Rev. 1/2/2024
(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 Corrective Actions/Comments
419-470-0110
(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 Corrective Actions/Comments
419-470-0130
(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 years 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
Sleeping Arrangements
Yes No N/A Corrective Actions/Comments
419-470-0140
(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
when sleeping
P age 11 | 19
Form Rev. 1/2/2024
(3) When assigning bedrooms a residential X
care agency must consider all of the
following:
(a) Chronological age
(b) Developmental age
(c) Gender identity
(d) Personal history, including medical,
mental health, behavioral health, and past
adverse experiences including any physical
or sexual abuse
Personnel Files
Yes No N/A Corrective Actions/Comments
419-400-0120
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
and documented
(1)(a) & (3)(c) Background check completed
X
and documented
(3)(d) Annual performance evaluations X
(3)(f) Record of personnel actions X
(3)(g) Termination date, reason for
X All personnel files audited for this review were of current employees.
termination
(3)(h) Current job description (1)(c)
Employee meets minimum qualifications X
stated in current job description
New Employee Orientation – Umbrella
Requirements (30 days) Yes No N/A Corrective Actions/Comments
419-400-0120(4)
Although it is believed that this information is covered at some point shortly after hire,
current training titles could not pinpoint where and when this specific training was
provided for the new hire whose file was audited at the time of this review.
(a) Agency policies and procedures X
CORRECTIVE ACTION: Clearly title and/or provide a brief summary of what type of
information is being covered during new employee orientation moving forward.
Although it is believed that this information is covered at some point shortly after hire,
current training titles could not pinpoint where and when this specific training was
(b) Ethical and professional guidelines X
provided for the new hire whose file was audited at the time of this review.
P age 12 | 19
Form Rev. 1/2/2024
CORRECTIVE ACTION: Clearly title and/or provide a brief summary of what type of
information is being covered during new employee orientation moving forward.
A newly hired employee’s file did not reflect completion of suicide prevention and
intervention.
(c) Suicide prevention and intervention X
CORRECTIVE ACTION: Ensure that all newly hired employees receive and complete this
required training moving forward.
(d) Attributes of population served X
(e) & (5)(a) to (c) Mandatory reporting that
includes:
(a) legal definition of child abuse in ORS
418.257 and 419B.005 X
(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 (Prior to working alone and
Yes No N/A Corrective Actions/Comments
within 30 days)
419-470-0120(1)
(a) Discipline and behavior management
including de-escalation, crisis prevention,
positive behavior management, and X
disciplinary techniques that are non-punitive
in nature
(b) CPR and First Aid sufficient to retain a
X
current certification
(c) Universal precautions and hygiene X
(d) Application of the reasonable and
X
prudent parent standard
A newly hired employee’s file did not reflect completion of suicide prevention and risk
(e) Training on the agency’s policy on assessment tool training.
suicide prevention and suicide risk X
assessment tool CORRECTIVE ACTION: Ensure that all newly hired employees receive and complete this
required training moving forward.
Crisis Intervention Training Standards
and Certification Yes No N/A Corrective Actions/Comments
419-400-0160(4) (as applicable)
(a)Complete a minimum of 12 hours of initial
training in person from a certified instructor,
including but not limited to a minimum of six Deer Creek staff are trained in de-escalation practices, and the program does not utilize
X
hours of training focused on positive physical restraint techniques.
behavior support, nonviolent crisis
intervention and other methods of
P age 13 | 19
Form Rev. 1/2/2024
nonphysical intervention to support children
in care during a crisis
(d) Receive a certificate that states:
(A) The dates during which the certification
is current
(B) The type of restraint which the individual
is certified to perform if applicable
(C) The type of training the individual is
Deer Creek staff are trained in de-escalation practices, and the program does not utilize
certified to conduct if applicable X
physical restraint techniques.
(D) Any special endorsements earned by the
individual
(E) The level of training
(F) The name of the certified instructor who
conducted the training and administered the
assessment of proficiency.
(e) A certification issued:
(A) Must be personal to the individual
Deer Creek staff are trained in de-escalation practices, and the program does not utilize
certified by the training provider X
physical restraint techniques.
(B) May be valid for no more than two years
with recertification
Ongoing Training Yes No N/A Corrective Actions/Comments
419-470-0070(2)(b) Employees who handle
All meals are prepared off site in an industrial kitchen. Employees in the facility do not
food served to children have a valid food X
prepare or handle food.
handler’s card
419-400-0200 (1) 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)
419-470-0120 (2)(a) Environmental
X
emergencies
419-470-0120 (2)(b) Universal Precautions X
419-470-0120 (2)(c) Discipline and Behavior
X
Management
419-470-0120 (2)(d) Agency’s policy on
X
suicide prevention and risk assessment tool
419-470-0120 (3) Staff providing direct care
must maintain current CPR/First Aid X
certification
419-470-0120 (4) Designated staff
X
authorized to apply reasonable and prudent
P age 14 | 19
Form Rev. 1/2/2024
parent standard are trained in application of
the standard
419-400-0120(5) Mandatory reporting
(annually) that includes:
(a) legal definition of child abuse in ORS
418.257 and 419B.005 X
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to
the employee
419-400-0160(4)(b) Receive continuing
education (as applicable on crisis
X
intervention training) from a certified
instructor on an annual basis
Comments:
Children’s Records Yes No N/A Corrective Actions/Comments
Health Services
419-470-0090
(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)
(4)(a) to (f) Medical exams (3 in first year of
life, 2,4,6,9,14) X
(g) Have a physical examination within the
first 60 days after admission of a child in
care. Documentation of a physical X
examination having occurred within the
calendar year will meet this requirement.
Consents
Yes No N/A Corrective Actions/Comments
419-470-0160(1)
(a) Provide routine and emergency medical
X
care
P age 15 | 19
Form Rev. 1/2/2024
(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
(e) Allow access as defined in 419-400-0230
X
& 0240
(f) Impose a dress code X
(g) Apply the reasonable and prudent parent
X
standard
Disclosures
419-470-0160(2) Yes No N/A Corrective Actions/Comments
Parent/guardian has 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 request X
Authorizations
Yes No N/A Corrective Actions/Comments
419-470-0160(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
419-400-0190(1) Yes No N/A Corrective Actions/Comments
Summary sheet contains the following:
(a)The name, gender, date of birth, religious
X
preference, and previous address
(b) Name and location of previous and
X
current school
(c) Date of admission X
(d) Legal custody X
(e) The name, address, and telephone
number of: X
(A) The child in care's parents.
P age 16 | 19
Form Rev. 1/2/2024
(B) The child in care's legal guardian, if
different than the parents, and a copy of
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 Corrective Actions/Comments
419-470-0170(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 be X
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
Yes No N/A Corrective Actions/Comments
419-470-0170(3)
(a) Services are documented, progress
X
toward achieving goals is tracked
(c) Discharge summary must include:
(A)Current medications
(B)Name of the physician or qualified medical
professional who prescribed each medication
(C)Any outstanding medical or other
appointments X
(D)Summary of the child’s participation in the
program and progress achieved
(E)Results of evaluations
(F)Recommendations regarding services
(G)Discharge destination
(e) Follow up services X
(f) Incident Reports X
Records Relating to Restraint &
Yes No N/A Corrective Actions/Comments
Involuntary Seclusion
P age 17 | 19
Form Rev. 1/2/2024
419-400-0180 (12) Records X
419-400-0180(13)(e) Each child caring The program does not currently have a process in place where notice is given to parents
agency shall provide notice regarding how to or guardians about how to access quarterly reports.
access the quarterly reports to the parents or
guardians of children in care in the program. X CORRECTIVE ACTION: Create and implement a process where parents/guardians of
The child caring agency shall provide the children in care are provided notice regarding how to access the program’s quarterly
notice upon the child in care’s admission and restraint and seclusion. These notices must occur at the time of admission and at least
at least two times each year thereafter. twice, each year thereafter.
The program does not currently have a process for providing information to children in
care about how a child in care may report suspected inappropriate use of restraint or
seclusion.
CORRECTIVE ACTION: Create and implement a process where children in care are
419-400-0190(1) Information provided to provided information about how to report suspected inappropriate use of restraint or
children in care relating to Restraint & X seclusion. This information must contain assurance that a child in care will not
Involuntary Seclusion experience retaliation for reporting, the telephone number for the toll-free child abuse
hotline (885-503-7233), contact information for the program’s Licensing Coordinator
(Mary Torres, 503-798-5300, mary.torres@odhsoha.oregon.gov,) and the phone
numbers and email addresses for the child in care’s respective caseworker, attorney, and
court appointed special advocate (CASA), if applicable and for the Disability Rights
Oregon (503-245-2081, welcome@droregon.org).
Financial Records
Yes No N/A Corrective Actions/Comments
419-470-0170(4)
Records contain date, amount, source, Youth are not allowed to have money within the program as the program meets all their
X
purpose, signatures needs during their stay.
Personal Possessions Records
Yes No N/A Corrective Actions/Comments
419-470-0170 (5)
One youth’s file did not reflect a completed inventory of all personal possessions
Individual written inventory of all personal
possessions is maintained and updated as X CORRECTIVE ACTION: Ensure a process where all personal possessions are
needed inventoried in writing, and the inventory record is maintained and updated moving
forward.
Records and Documentation
Yes No N/A Corrective Actions/Comments
419-400-0140
(1) Stored safely X Files electronically stored.
(2) Permanent, legible, dated, and signed X
(3) & (4) Uniform in organization, readily
identifiable and accessible, current, and
X
complete, containing all required info. No
eraser tape or white out.
(7) Permanent registry for each child
includes:
Name X
Gender
Birth date
P age 18 | 19
Form Rev. 1/2/2024
Names, addresses of parents or guardians
Dates of admission
Placement upon discharge
Comments:
Licensing Coordinator’s Signature: ________________________ Date: _ _1_1_/1_5_/_2_4___________
Manager Review: ______________________________________ Date: ___1_1_-_1_5_-_2_0_2_4______
P age 19 | 19
Form Rev. 1/2/2024

report_type: License Renewals

facility_type: Residential Care

licensee: ADAPT - Deer Creek Board Chairperson: Kelsey Wood

board_chairperson: Kelsey Wood

capacity_age_range: 15 residents, ages 13 -17 years

funding_sources: Oregon Health Authority (OHA) contracts, program revenue, local Coordinated Care Organizations (CCO) - Umpqua Health Alliance (UHA), Advanced Health and other third-party payors P age 1 | 19

average_length_of_stay: 4.5 months

average_daily_population_served: 6 to 10 residents

number_of_children_served_annually: 55 residents

interviews_observations:
Youth and staff were interviewed at the time of this review, and a tour of the facility was completed. Youth report feeling
safe with in the program and report positive experiences during their stay. The number and variety of outings that youth are able to attend was
identified as a strength of the program. One minor change requested was more instruction time with the school's art teacher. Youth enjoy the food
at the program and appreciate the counselor's support and involvement in meeting goals. Youth also benefit from daily family contact.
Staff interviews highlighted census; 4 youth currently on site at the time of the review with an increase in numbers over the next few days, staffing
updates, and changes in the program's educational curriculum as well as changes with a former medical provider. New staff member reports
experiencing good support during transition and how the youth-focused training has prepared them for their role on campus.
A tour of the building resulted in no concerns for the program's physical plant.

lawsuits: None, according to the program.

excerpt:
(2)(f) Formally evaluate the exec. Director’s
performance annually Completed annual performances were not provided nor verified at the time of the review.
CORRECTIVE ACTION: Provide copies of completed annual performance appraisals for
the program’s Exec. Director and/or Program Director.

excerpt:
Documents as indicated on form titled
“Required Financial Documents and
Information” A completed Tax Compliance Form that verifies compliance from the Dept. of Revenue
was not submitted at the time of the review.
CORRECTIVE ACTION: Submit final document that verifies tax compliance from the
Dept. of Revenue.
********
A copy of the program’s 2021/2022 audit was submitted for the review. A complete
financial review can not be completed without a copy of the program’s most current audit
for the 2023 year.
CORRECTIVE ACTION: Submit a copy of the program’s audit for the 2023 fiscal year.

excerpt:
All required policies and procedures as
identified in the “Umbrella Rules” A copy of the program’s Seclusion, Restraint and other Prohibited Types of Discipline
Policy was not submitted at the time of review.
CORRECTIVE ACTION: Submit a copy of the above missing policy to Licensing for
review.

excerpt:
(d) Ensuring access to necessary
medications or medical equipment Current written emergency plan does not speak to ensuring access to necessary
medications or medical equipment during or after an emergency and/or evacuation.
CORRECTIVE ACTION: Incorporate how necessary medications or medical equipment
during or after an emergency and/or evacuation will be accessed. Submit revised plan to
Licensing for review.

excerpt:
(e) How to help each child in care recover
after a disaster Current written emergency plan does not speak to how the program plans to assist each
child in care recover after a disaster.
CORRECTIVE ACTION: Incorporate a plan to help each child in care recover after a
disaster. Submit revised plan to Licensing for review.

excerpt:
(5)(b) Vehicle has insurance policy, is smoke
free, safe operating condition, and has first
aid kit and fire extinguisher 2-A:10-BC Although the program’s 15 passenger van is in safe operating condition and has all
required equipment, the van’s back bench seats has been heavily vandalized with racial
symbols and profanity graffiti.
CORRECTIVE ACTION: Remove or cover graffiti areas and implement a process where
the interior of all vehicles are inspected on a regular basis for offensive tagging as it would
appear that the graffiti in the van occurred over a course of time and was not a single
insolated incident.

excerpt:
(a) Agency policies and procedures Although it is believed that this information is covered at some point shortly after hire,
current training titles could not pinpoint where and when this specific training was
provided for the new hire whose file was audited at the time of this review.
CORRECTIVE ACTION: Clearly title and/or provide a brief summary of what type of
information is being covered during new employee orientation moving forward.

excerpt:
(b) Ethical and professional guidelines Although it is believed that this information is covered at some point shortly after hire,
current training titles could not pinpoint where and when this specific training was
provided for the new hire whose file was audited at the time of this review. CORRECTIVE ACTION: Clearly title and/or provide a brief summary of what type of
information is being covered during new employee orientation moving forward.

excerpt:
(c) Suicide prevention and intervention A newly hired employee’s file did not reflect completion of suicide prevention and
intervention.
CORRECTIVE ACTION: Ensure that all newly hired employees receive and complete this
required training moving forward.

excerpt:
(e) Training on the agency’s policy on
suicide prevention and suicide risk
assessment tool A newly hired employee’s file did not reflect completion of suicide prevention and risk
assessment tool training.
CORRECTIVE ACTION: Ensure that all newly hired employees receive and complete this
required training moving forward.

excerpt:
Each child caring
agency shall provide notice regarding how to
access the quarterly reports to the parents or
guardians of children in care in the program.
The child caring agency shall provide the
notice upon the child in care’s admission and
at least two times each year thereafter. The program does not currently have a process in place where notice is given to parents
or guardians about how to access quarterly reports.
CORRECTIVE ACTION: Create and implement a process where parents/guardians of
children in care are provided notice regarding how to access the program’s quarterly
restraint and seclusion. These notices must occur at the time of admission and at least
twice, each year thereafter.

excerpt:
Information provided to
children in care relating to Restraint &
Involuntary Seclusion The program does not currently have a process for providing information to children in
care about how a child in care may report suspected inappropriate use of restraint or
seclusion.
CORRECTIVE ACTION: Create and implement a process where children in care are
provided information about how to report suspected inappropriate use of restraint or
seclusion. This information must contain assurance that a child in care will not
experience retaliation for reporting, the telephone number for the toll-free child abuse
hotline (885-503-7233), contact information for the program’s Licensing Coordinator
(Mary Torres, 503-798-5300, mary.torres@odhsoha.oregon.gov,) and the phone
numbers and email addresses for the child in care’s respective caseworker, attorney, and
court appointed special advocate (CASA), if applicable and for the Disability Rights
Oregon (503-245-2081, welcome@droregon.org).

excerpt:
Individual written inventory of all personal
possessions is maintained and updated as
needed One youth’s file did not reflect a completed inventory of all personal possessions
CORRECTIVE ACTION: Ensure a process where all personal possessions are
inventoried in writing, and the inventory record is maintained and updated moving
forward.


facility_name: Affect Youth Services Date of site visit: March 11 & 12, 2025

summary: License Renewals - 11 findings

raw_content:
Licensed Child Caring Agency Site Visit Report
Residential Care
Licensee: Affect Youth Services, Inc. Date of site visit: March 31, 2021
Executive Director: Mandy Augsburger Licensing Coordinator: Robin DuVal
Board Chairperson: Mandy Straus
Other Regulatory or Accrediting Agencies: Oregon Department of Human Services (ODHS) Child Welfare Treatment Services.
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(s): The program offers an extended family care model where youth with higher needs can still be placed within a family setting
allowing for a family experience with additional staff for extra support. The program is contracted with CW Treatment Services and is a non-BRS
provider. Youth are assisted in taking personal responsibility and accountability for their actions and using positive behavior support to model
appropriate responses. Youth will have more positive outcomes when they know they are being supported in their plan to transition out of the program.
Program type and services: Practical application of life skills, modifying negative behaviors through “do-overs”, building trusting relationships,
positive peer culture. These are accomplished through discussion and modeling. Other services such as therapy, drug and alcohol treatment,
mentoring and skills training are outsourced by referral of the caseworker.
Capacity and Age Range: capacity 15; ages 10-17
Funding sources: ODHS Child Welfare
Contracts and sources for referrals: ODHS Child Welfare
Average length of stay: 5.5 months
Average daily population served: 11.5
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 03/25/2021)
Number of children served annually: 38.5
Use of seclusion or restraint: No seclusion. Restraint utilizing “Right Response” methods as their nationally recognized nonviolent crisis intervention
program.
Youth J. Interview: Youth J. is 17 years old and has been in the program for about 2.5 years, and reports this program is helping with goals; staff
are trusting; likes it here and feels safe. Likes the people here and the relationships built. The program does well at working on one’s self. Described
things they do for fun on-site and off-site. Food is good and gets enough. Has online school and gets help if needed. Wishes to have more freedoms,
like a job and driver’s license, and to get out in the community more often.
Youth W. Interview: Youth W. is 15 years old and has been in the program for about 6 months, and reports this program is helping with goals; staff
are trusting; likes it here and feels safe. Described things they do for fun, on-site and off-site. The food is “excellent” and gets enough. Has online
school and gets help if needed. Feels that the rules have a purpose with a learning opportunity and likes that the program works on integrity.
Staff Interviews: Two staff were interviewed separately; Staff C. here since the program opened in 2016, and Staff M. for about 3.5 years. Both
described ongoing trainings and described the correct process to report suspected child abuse or neglect. Due to the homelike setting, formal staff
meetings are seldom. However, daily information is shared in person or through a staff messaging app called “Slack”, as well as contact with their
immediate supervisor is daily. Management is responsive to concerns made by staff and staff feel free to express concerns or suggestions. When a
youth enters the program, information about supervision and other specifics is provided verbally by the Executive Director. The food provided to the
youth is good, plentiful, and dinner is usually a home-made meal, and adjustments are made for “picky eaters” or allergies. COVID-19 presented
challenges with a lot of adjustments in their day-to-day routine from school, appointments, outings, etc.
Observations: Staff were wearing face masks, except those who live on-site, as mandated statewide due to the COVID-19 pandemic. House
renovations look nice and provides extra kitchen space, addition of a conference room and office, and new flooring and shelving in the youth dorm
room. The driveway has an electric gate to enter/exit the property. Adequate food supply in pantry, refrigerators, and freezers. Youth have on-site
distance learning for school, due to the COVID-19 pandemic.
Program Strengths: The program reports the following.
 Staff Team has strong communication, are flexible with schedules and duties. We have a good team camaraderie like a family due to the
grace and support all staff and youth receive. A divide and conquer attitude to accommodate staffs’ strengths and weaknesses. Strength based
annual reviews.
 Staff ability to recognize youth's weaknesses and work on turning them into a strength.
 Provides a stable family environment even though it is a program.
 Do overs and grace abound. Youth are given multiple opportunities to start over each day and every new day begins with a fresh start.
 De-escalation of youth, providing a sounding board for youth.
 Vigilant of youth sensitivity, tolerance, minimizing / recognizing potential triggers
2
Program Challenges: The program reports the following.
 Staff Team struggles to complete assigned trainings without multiple reminders, although there has been improvement with the use of the new
Slack App.
 Keeping prohibited items and substances away from the premises.
 Stopping growing dissention one youth or multiple youth spread throughout the program. Taking in youth with defiance issues who know that
we cannot do anything to stop their behaviors (a learned trait of being in the system).
Changes that have occurred in the last 2 years: The program reports the following.
 Major renovation of property - increased square footage by 1,148, including the addition of a conference room and office as well as extending
the kitchen by 8 feet, new siding, new roof, made larger parking area for staff w/ retaining wall, new flooring in youth dorm.
 Implemented the use of Right Response for last resort, emergency restraint.
 Implemented use of Slack App for streamlined communication / training between all staff.
 New trainings covering gender identity, cultural identity, trauma informed care, etc.
 Staff Team has grown in the area of giving more grace on a regular basis and identifying their own optimal performance range of stress. When
staff recognize their own stress, they can ask another staff to assist if needed when working with escalated youth.
Lawsuits: None
Grievances and complaints filed in the last two years: None
Corrective Actions and Timeframes: Please submit the following to verify compliance.
Within 45 days of receipt of this report Affect Youth Services, Inc. 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 will
be emailed directly to Robin DuVal at robin.m.duval@dhsoha.state.or.us.
Exceptions: 1) overnight awake staff ratio; and 2) use of cameras in the shared open space of the dorm rooms, living areas, and outdoor areas.
Recommendations: Create disclosures for the guardians and youth regarding religious activities; personnel possessions; and the use of cameras.
Changes in License: None.
3
Summary of Review
Program and Services Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0011(2) Completed
Program and services are in scope of license X
Governance of the Agency Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0021 Completed
(1)(a) Minimum of 5 board members X
(2)(f) Formally evaluate the exec. Director’s X Performance evaluations of the Executive Director are
performance annually conducted annually, however not signed by the board
(2)(g) Approves annual budget X chairperson as required by OAR 413-215-0021(2)(f). The
(2)(h) Obtain and review an annual X agency shall ensure the board chairperson is involved in the
independent financial review or audit of annual performance evaluation and signed by the board
financial records. chairperson.
(2)(k) Written quality improvement program X
(2)(l) Meeting minutes X
Executive Director or Program Director Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0021 Completed
(3)(a) knowledge of requirements for X
providing care and treatment appropriate to
programs
(3)(g) Approval from BCU X
Discipline, Behavior Management, and Corrective Action
Yes No N/A Corrective Actions/Comments
Suicide Prevention 413-215-0076 Completed
(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) Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0061(6) Completed
4
(a) Agency ensures the contractor meets the
requirements of this rule and Chapter 413 X
division 215
(b)(B) Contract includes the following:
(i) Services provided
(ii) Contractor fees
(iii) Disclosure of information from contractor
to agency
(iv) Lines of authority X
(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 N/A Corrective Actions/Comments
CCA Completed
Documents as indicated on the form titled
X
“Renewal Licensing Required Documents”
Documents as indicated on form titled
“Required Financial Documents and X
Information”
All required policies and procedures as Note: The Mandatory Abuse Reporting Policy and Procedure,
identified in the “Umbrella Rules” and Suicide Prevention Policy is under review by the
X
licensing coordinator, and recommendations will be provided
for necessary any updates.
All required policies and procedures as
X
identified in “Agency Type Specific Rules”
Physical Plant Corrective Action
Yes No N/A Corrective Actions/Comments
Completed
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
5
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 Corrective Action
Yes No N/A Corrective Actions/Comments
Bedrooms 413-215-0516(3) Completed
(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 Corrective Action
Yes No N/A Corrective Actions/Comments
Bathrooms 413-215-0516(4) Completed
(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
(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 Corrective Action
Yes No N/A Corrective Actions/Comments
Kitchen 413-215-0516(6) Completed
(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
6
(e) Equipment is easy to clean beneath, X
between and behind
Room and Space Requirements Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0516 Completed
(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 Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0521 Completed
(1) There is a bed with frame, clean mattress X
and pillow and personal storage (dresser,
closet)
(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 Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0536(1)&(2) Completed
(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.
7
(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 Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0541 Completed
(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 years 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 Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0541 Completed
(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 Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0551 Completed
(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
(8) Medications are disposed in accordance X 413-215-0551(8): Unused medications were being stored in a
with state and federal law separate container from current medications in the locked
(9) Written record of the disposal of X medication closet, to be given to the youth’s guardian when
medications is maintained and includes: available.
(a) description and amount  The agency shall ensure all unused medications be
(b) name disposed of and in a manner that ensures that they
(c) reason cannot be retrieved.
(d) method
(e) staff & witness signature
(10) Written record of the administration of X 413-215-0551(9): Unused medications were not documented
medication includes: on a written disposal record as required. The agency shall
(a) name ensure all unused medications are documented utilizing the
(b) description already established medication disposal form, capturing all
(c) dates and times required elements (a-e). The written disposal record shall be
(d) missed doses thoroughly completed and maintained.
(e) medication disposed
(f) method of administration
(g) ID of person administering 413-215-0551(10): The Medication Administration Record
(h) possible adverse reactions (MAR) form was missing required elements. The agency
(i) medication taken outside facility shall update the MAR form to include (e) and (i), and
document appropriately going forward. The written MAR shall
be thoroughly completed and maintained.
The agency shall ensure all staff are retrained on the above
noted requirements.
Extracurricular, Enrichment, Cultural &
Corrective Action
Social Activities Yes No N/A Corrective Actions/Comments
Completed
413-215-0554
(2) Children have ongoing opportunities to X
participate in at least one age-appropriate or
developmentally appropriate activity
Minimum Staffing Requirements Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0561 Completed
(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
9
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 Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0566 Completed
(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/Comments
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
and documented
(1)(a) & (3)(c) Background check completed
X
and documented
(3)(d) Annual performance evaluations X
Records of personnel actions were missing from personnel
(3)(f) Record of personnel actions X
files. The agency shall develop and implement a personnel
(3)(g) Termination date, reason for action form for all employees to be utilized when there is a
X
termination personnel action to be recorded or requires payroll action.
(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/Comments
Completed
413-215-0061(4)
(a) Agency policies and procedures X
10
(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
section 36
(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
Corrective Action
(30 days) Yes No N/A Corrective Actions/Comments
Completed
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
Two staff have not received restraint training to date. The
agency shall ensure:
1) All current untrained employees are trained utilizing
(1)(b) Restraint and seclusion (if applicable) X “Right Response” methods as their nationally
recognized crisis intervention model.
2) Provide documentation when completed.
3) All new employees are trained within 30 days of hire.
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)
413-215-0556(2)(a) Environmental
X
emergencies
413-215-0556(2)(b) Universal Precautions X
11
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 Corrective Action
Yes No N/A Corrective Actions/Comments
Completed
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
12
(b) Use the discipline and behavior
X
management system
The consent form was missing the agency’s use of restraint.
(c) Use restraint or seclusion (if applicable).
The agency had previously updated their restraint and
Must specify the reasons for the intervention X
behavior consent form. However, it wasn’t updated in the
and how staff are trained and supervised
intake packet, therefore the program is using the old form.
(d) Restrict contact with persons outside of
The agency shall ensure the updated restraint consent is:
X
the agency
1) Included in all future intakes and retained in the
(e) Allow access as defined in 413-215-0091 youths file, and
X
& 0101 2) Provided to and signed by all current youth
guardians.
(f) Impose a dress code X
(g) Apply the reasonable and prudent parent
X
standard
Disclosures
Corrective Action
413-215-0576(2) Parent/guardian has Yes No N/A Corrective Actions/Comments
Completed
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 Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0576(3) Completed
(a) Disclose or exchange information with Authorization to disclose or exchange information was
X
others missing from youth records. The agency shall:
1) Develop and implement an authorization document
(b) Child specific visitors X
to disclose or exchange information with others, and
(c) Visitation resources are pre-approved X 2) Ensure this authorization is included in all future
(d) Activity specific authorizations are pre- intakes and retained in the youth’s record.
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/Comments
Completed
the following:
(a)The name, gender, date of birth, Previous address was missing from the summary sheet. The
religious preference, and previous X agency shall ensure:
address 1) The form is updated to include previous address.
(b) Name and location of previous and 2) The previous address is documented on the
X
current school summary sheet.
13
(c) Date of admission X
(d) Legal custody X Religious preference was not consistently documented on
(e) The name, address, and telephone the summary sheet. The agency shall ensure an entry is
number of: noted for religious preference.
(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 Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0581(2) Completed
(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/Comments
413-215-0581(3) Completed
(a) Services are documented, progress
X
toward achieving goals is tracked
(b)-(d) discharge planning and instructions X
(f) Incident Reports X
Financial Records Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0581(4) Completed
Records contain date, amount, source, The financial form was missing required elements. The
X
purpose, signatures agency shall:
14
1) Update the form to include the source, purpose, and
signatures (not initials).
2) Utilize the form when youth have any money, gift
cards, etc. that are received or dispersed.
Personal Possessions Records Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0581(5) Completed
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
Personnel and youth records are incomplete missing items
(3)&(4) Uniform in organization, readily
noted above.
identifiable and accessible, current, and
X
complete, containing all required info. No
The agency shall ensure the revised date is noted on
eraser tape or white out.
documents (forms, policies, procedures, etc.) when revised.
(7) Permanent registry for each child
includes:
Name
Gender
X
Birth date
Names, addresses of parents or guardians
Dates of admission
Placement upon discharge
4/19/2021
Licensing Coordinator’s Signature: ________________________ Date: ___________________
Manager Review: ______________________________________ Date: _____4_-_1_9_-_2_0__2_1_ ___
15

agency_name: Affect Youth Services, Inc. (AYS)

board_chairperson: Mandy Straus

licensing_coordinator: Robin DuVal

program_services:
Practical application of life skills, modifying negative behaviors through "do-overs", building trusting relationships,
positive peer culture. These are accomplished through discussion and modeling. Other services such as therapy, drug and alcohol treatment,
mentoring and skills training are outsourced by referral of the caseworker.

capacity_age_range: capacity 15; ages 10-17

funding_sources: ODHS Child Welfare

contracts_and_referrals: ODHS Child Welfare

average_length_of_stay: 5.5 months

use_of_seclusion_or_restraint: No seclusion. Restraint utilizing "Right Response" methods as their nationally recognized nonviolent crisis intervention program. Youth J. Interview: Youth J. is 17 years old and has been in the program for about 2.5 years, and reports this program is helping with goals; staff are trusting; likes it here and feels safe. Likes the people here and the relationships built. The program does well at working on one's self. Described things they do for fun on-site and off-site. Food is good and gets enough. Has online school and gets help if needed. Wishes to have more freedoms, like a job and driver's license, and to get out in the community more often. Youth W. Interview: Youth W. is 15 years old and has been in the program for about 6 months, and reports this program is helping with goals; staff are trusting; likes it here and feels safe. Described things they do for fun, on-site and off-site. The food is "excellent" and gets enough. Has online school and gets help if needed. Feels that the rules have a purpose with a learning opportunity and likes that the program works on integrity. Staff Interviews: Two staff were interviewed separately; Staff C. here since the program opened in 2016, and Staff M. for about 3.5 years. Both described ongoing trainings and described the correct process to report suspected child abuse or neglect. Due to the homelike setting, formal staff meetings are seldom. However, daily information is shared in person or through a staff messaging app called "Slack", as well as contact with their immediate supervisor is daily. Management is responsive to concerns made by staff and staff feel free to express concerns or suggestions. When a youth enters the program, information about supervision and other specifics is provided verbally by the Executive Director. The food provided to the youth is good, plentiful, and dinner is usually a home-made meal, and adjustments are made for "picky eaters" or allergies. COVID-19 presented challenges with a lot of adjustments in their day-to-day routine from school, appointments, outings, etc. Observations: Staff were wearing face masks, except those who live on-site, as mandated statewide due to the COVID-19 pandemic. House renovations look nice and provides extra kitchen space, addition of a conference room and office, and new flooring and shelving in the youth dorm room. The driveway has an electric gate to enter/exit the property. Adequate food supply in pantry, refrigerators, and freezers. Youth have on-site distance learning for school, due to the COVID-19 pandemic.

program_strengths:
The program reports the following.
- Staff Team has strong communication, are flexible with schedules and duties. We have a good team camaraderie like a family due to the
grace and support all staff and youth receive. A divide and conquer attitude to accommodate staffs' strengths and weaknesses. Strength based
annual reviews.
- Staff ability to recognize youth's weaknesses and work on turning them into a strength.
- Provides a stable family environment even though it is a program.
- Do overs and grace abound. Youth are given multiple opportunities to start over each day and every new day begins with a fresh start.
- De-escalation of youth, providing a sounding board for youth.
- Vigilant of youth sensitivity, tolerance, minimizing / recognizing potential triggers
2

program_challenges:
The program reports the following.
- Staff Team struggles to complete assigned trainings without multiple reminders, although there has been improvement with the use of the new
Slack App.
- Keeping prohibited items and substances away from the premises.
- Stopping growing dissention one youth or multiple youth spread throughout the program. Taking in youth with defiance issues who know that
we cannot do anything to stop their behaviors (a learned trait of being in the system).

changes_in_last_two_years:
The program reports the following.
- Major renovation of property - increased square footage by 1,148, including the addition of a conference room and office as well as extending
the kitchen by 8 feet, new siding, new roof, made larger parking area for staff w/ retaining wall, new flooring in youth dorm.
- Implemented the use of Right Response for last resort, emergency restraint.
- Implemented use of Slack App for streamlined communication / training between all staff.
- New trainings covering gender identity, cultural identity, trauma informed care, etc.
- Staff Team has grown in the area of giving more grace on a regular basis and identifying their own optimal performance range of stress. When
staff recognize their own stress, they can ask another staff to assist if needed when working with escalated youth.

changes_in_license:
None.
3

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

excerpt:
(8) Medications are disposed in accordance
with state and federal law 413-215-0551(8): Unused medications were being stored in a
separate container from current medications in the locked
medication closet, to be given to the youth’s guardian when
available.
 The agency shall ensure all unused medications be
disposed of and in a manner that ensures that they
cannot be retrieved.
413-215-0551(9): Unused medications were not documented
on a written disposal record as required. The agency shall
ensure all unused medications are documented utilizing the
already established medication disposal form, capturing all
required elements (a-e). The written disposal record shall be
thoroughly completed and maintained.
413-215-0551(10): The Medication Administration Record
(MAR) form was missing required elements. The agency
shall update the MAR form to include (e) and (i), and
document appropriately going forward. The written MAR shall
be thoroughly completed and maintained.
The agency shall ensure all staff are retrained on the above
noted requirements.

excerpt:
(9) Written record of the disposal of
medications is maintained and includes:
(a) description and amount
(b) name
(c) reason
(d) method
(e) staff & witness signature

excerpt:
(10) Written record of the administration of
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

excerpt: (3)(f) Record of personnel actions

excerpt:
(c) Use restraint or seclusion (if applicable).
Must specify the reasons for the intervention
and how staff are trained and supervised

excerpt:
(a) Disclose or exchange information with
others Authorization to disclose or exchange information was
missing from youth records. The agency shall:
1) Develop and implement an authorization document
to disclose or exchange information with others, and
2) Ensure this authorization is included in all future
intakes and retained in the youth’s record.

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

excerpt:
Records contain date, amount, source,
purpose, signatures The financial form was missing required elements. The
agency shall: 1) Update the form to include the source, purpose, and
signatures (not initials).
2) Utilize the form when youth have any money, gift
cards, etc. that are received or dispersed.

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