summary: Visit conducted on 12/18/25. No compliance issues identified. Implemented 1 corrective actions.

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:           Silver Hill Therapeutic Services-Klingenstein House Residential

TIME OF VISIT (FROM - TO):  10:30am to 11:15am 	 DATE: 12/18/25

AGENCY PERSONNEL WHO PARTICIPATED:
Job Titles:
Unit Supervisor and nurse

List of Areas / Topics covered during visit: This was an unannounced quarterly Licensing visit to obtain a program update and tour the physical plant.

A meeting was held with the Director of Quality and Experience and Unit Supervisor. Topics discussed included:

•	Current LBC is 10.  Current census is 8. One intake scheduled this afternoon.
•	No Exceptional Circumstances filed during the quarter.
•	Discussed current residents and milieu. All female residents and getting along well.
•	Currently there are two second shift positions open.  All shifts being covered with per diem and full-time staff.
•	Discussed educational programming.  Met with the teacher and one resident in the classroom.
•	Met with other residents in the dayroom, playing games and finishing their snack.
•	New furniture in place in the dayroom. New area carpet as well.
•	Discussed clinical programming.  The residents are cooperative. Discussed discharges and where the residents are referred to following their stay.

Milieu Observation:
•	Residents in the dayroom with one in school.

Physical Plant:
•	Toured the home with the unit supervisor.  No safety concerns observed.  The home is very clean and maintained very well.

Corrective Actions implemented as a result of previous visit:
NA

Areas of regulatory non-compliance identified during this visit:
NA

Please submit a regulation compliance plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The Regulation Compliance Plan must be submitted to the attention of the undersigned at the address listed above. No Regulation Compliance Plan is required for this Licensing visit.

James Funaro  				Date:    12/18/25
Regulatory Consultant

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


state: CT

facility_name: Silver Hill Therapeutic Services, LLC.

summary: Visit conducted on 6/20/25. No compliance issues identified. Implemented 1 corrective actions.

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:           Silver Hill Therapeutic Services-Klingenstein House Residential

TIME OF VISIT (FROM - TO):  9:00am to 10:00am   	 DATE: 6/20/25

AGENCY PERSONNEL WHO PARTICIPATED:
Job Titles:
Program Director, Unit Supervisor

List of Areas / Topics covered during visit: This was a scheduled quarterly Licensing visit to obtain a program update and tour the physical plant.

A meeting was held with the Program Director and Unit Supervisor. Topics discussed included:

•	Current LBC is 10.  Current census is 7. Discussed 3 pending referrals.
•	No calls to emergency services, exceptional circumstances or restraints.
•	Discussed current residents and recent discharges. Average length of stay is 35 days.
•	Currently fully staffed with no vacancies.
•	Discussed summer educational programming.
•	Met residents in the dayroom who were involved with a pet therapy program.
•	Met with a security officer who was doing the monthly unit check.  Ensuring there is no safety concerns with the bedrooms or physical plant.

Milieu Observation:
•	Residents were in dayroom during the visit.

Physical Plant:
•	Toured the home with the unit supervisor.  No safety concerns observed.  The home is very clean and maintained very well.

Corrective Actions implemented as a result of previous visit:
NA

Areas of regulatory non-compliance identified during this visit:
NA

Please submit a regulation compliance plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The Regulation Compliance Plan must be submitted to the attention of the undersigned at the address listed above. No Regulation Compliance Plan is required for this Licensing visit.

James Funaro  				Date:    6/20/25
Regulatory Consultant

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


summary: Visit conducted on 1/30/25. No compliance issues identified. Implemented 1 corrective actions.

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:           Silver Hill Therapeutic Services-Klingenstein House Residential

TIME OF VISIT (FROM - TO):  10:30am to 12:00pm   	 DATE: 1/30/25

AGENCY PERSONNEL WHO PARTICIPATED:
Job Titles:
Program Director, Quality Director, Director of Nursing, DCF Nurse

List of Areas / Topics covered during visit: This was a scheduled quarterly Licensing visit to obtain a program update and tour the physical plant.

A meeting was held with the Program Director and Quality Director. Topics discussed included:

•	Current LBC is 10.  Current census is 3. Discussed pending referrals.
•	No calls to emergency services or exceptional circumstances.
•	Discussed current residents and recent discharges.
•	Reviewed recent restraint/incident report.
•	Discussed staffing and out of state background checks.
•	DCF nurse reviewed med-room and current nursing practices.
•	Discussed recreation in the community and community outreach.

Milieu Observation:
•	Residents were in school during the visit.

Physical Plant:
•	Toured the home with the Quality Director.  No safety concerns observed.  The home is very clean and maintained very well.

Corrective Actions implemented as a result of previous visit:
NA

Areas of regulatory non-compliance identified during this visit:
NA

Please submit a regulation compliance plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The Regulation Compliance Plan must be submitted to the attention of the undersigned at the address listed above. No Regulation Compliance Plan is required for this Licensing visit.

James Funaro  				Date:    1/31/25
Regulatory Consultant

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


summary: Visit conducted on 10/21/24. No compliance issues identified. Implemented 1 corrective actions.

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:           Silver Hill Therapeutic Services-Klingenstein House Residential

TIME OF VISIT (FROM - TO):  10:45am to 12:30pm   	 DATE: 10/21/24

AGENCY PERSONNEL WHO PARTICIPATED:
Job Titles:
Program Director, Quality Director, Nursing

List of Areas / Topics covered during visit: This was a scheduled quarterly Licensing visit to obtain a program update and tour the physical plant.

A meeting was held with the Program Director and Quality Director. Topics discussed included:

•	Current LBC is 5.  Current census is 3.
•	No calls to emergency services or exceptional circumstances
•	Discussed current residents and milieu.  No incident reports completed since last visit.
•	Discussed staffing.
•	Reviewed personnel files for most recent hires.
•	Reviewed case record information for a current resident
•	Reviewed discharge information for a recently discharged resident.
•	Discussed clinical and recreational activities for the residents.

Milieu Observation:
•	Residents were in school during the visit.

Physical Plant:
•	Toured the home with the Quality Director.  No safety concerns observed.  The home is very clean and maintained well.

Corrective Actions implemented as a result of previous visit:
NA

Areas of regulatory non-compliance identified during this visit:
NA

Please submit a service development plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The Regulation Compliance Plan must be submitted to the attention of the undersigned at the address listed above. No Regulation Compliance Plan is required for this Licensing visit.

James Funaro  				Date:    10/24/24
Regulatory Consultant

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


facility_name: Wellspring Foundation, Inc. / RT #26

summary: Visit conducted on 12/15/25_. 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: Wellspring RT

 TIME OF VISIT (FROM - TO):       First shift____                                     DATE: 12/15/25_

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:
Assistant Director of Operations

List of Areas / Topics covered during visit:
Youth in the program, the physical plant and staffing. There were a total of 15 youth residing in Beauvais House. Two of the youth were staying at home until they were no longer sick. All youth were upstairs in their bedrooms. On duty was the program director, a clinician, 4 staff and a nurse. There were 2 per diem staff positions available.

In Shiloah House there were 2 youth residing in the home and they were sitting at the kitchen table conversing with staff. On duty were 2 staff, with another staff shadowing, the program director. There was one staff position available at the facility but it was recently filled.

Corrective Actions implemented as a result of previous visit:
None

Areas of regulatory non-compliance identified during this visit:
None

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Keith Bryan                                                12/15/25
Regulatory Consultant                                   Date

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

facility_name: Wellspring RT

visit_time: First


summary: Visit conducted on 09/25/25_. 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: Wellspring RT

 TIME OF VISIT (FROM - TO):       First shift____                                     DATE: 09/25/25_

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:
Coordinator of Organizational Excellence

List of Areas / Topics covered during visit:
Youth in the program, the physical plant and staffing. There were a total of 13 youth residing in Beauvais House. One girl was currently at home visit, 1 was at a doctor's appointment, some were attending a group session and some were in their bedrooms. The program director, 5 therapists, 3 staff and a nurse were on duty in Beauvais House.

In Shiloah House there was 1 youth residing in the home and she was sitting at the table in the kitchen. Two staff were on duty and the program director. There were currently no staff positions available at the facility.

Corrective Actions implemented as a result of previous visit:
None

Areas of regulatory non-compliance identified during this visit:
None

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Keith Bryan                                               09/25/25
Regulatory Consultant                                   Date

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


summary: Visit conducted on 06/12/25_. 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: Wellspring RT

 TIME OF VISIT (FROM - TO):       First shift____                                     DATE: 06/12/25_

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:
Coordinator of Organizational Excellence

List of Areas / Topics covered during visit:
Youth in the program, the physical plant and staffing. There were a total of 15 youth residing in Beauvais House and they were all at school. The program director, 5 therapists, 4 staff, the psychiatrist and a nurse were on duty in Beauvais House.

In Shiloah House there were 5 youth residing in the home and they were all at school. Three staff were on duty, a clinician and the program director. There were currently no staff positions available at the facility.

Corrective Actions implemented as a result of previous visit:
None

Areas of regulatory non-compliance identified during this visit:
None

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Keith Bryan                                               06/12/25
Regulatory Consultant                                   Date

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


summary: Visit conducted on 01/10/25_. 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: Wellspring RT

 TIME OF VISIT (FROM - TO):       First shift____                                     DATE: 01/10/25_

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:
Executive Director
Coordinator of Organizational Excellence

List of Areas / Topics covered during visit:
Youth in the program, the physical plant and staffing. There were a total of 9 youth residing in Beauvais House and they were all in school. The program director, 3 therapists, 3 staff, the psychiatrist and a nurse were on duty in Beauvais House.

In Shiloah House there were 5 youth residing in the home and they were all in school. Three staff were on duty and a clinician.

Corrective Actions implemented as a result of previous visit:
None

Areas of regulatory non-compliance identified during this visit:
None

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Keith Bryan                                               01/10/25
Regulatory Consultant                                   Date

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


raw_content:
November 18, 2024

Wellspring Foundation, Inc.
21 Arch Bridge Road
Bethlehem, CT 06751
Attention: Daniel Murray, Ph.D.

Licensing Inspection for Wellspring Foundation, Inc. Residential Treatment Facility
Inspectors Keith Bryan, James Funaro and Patrick Hughes

Dear Dr. Murray
On 11/7/24 and 11/8/24, a biennial licensing inspection was conducted at your facility. This inspection was conducted to determine the compliance of this facility with the Regulations for Operation of Child Caring Agencies and Facilities 17a-145-48 through 17a-151-98, as well as the DCF Guidelines for the Administration of Medication for Certified Staff. DCF has determined that the program is in compliance with applicable regulatory provisions except those itemized below.  Please review the sections identified and submit a plan of correction to address each area. The plan must be submitted within 30 days of receipt of this letter and should identify: 1. the steps to be taken to correct the areas of non-compliance; 2. the date correction(s) will be completed; and 3. steps to be taken to prevent recurrence of the citation. Also included in the report are recommendations. Recommendations are meant to highlight areas that are not currently areas of non-compliance but may become non-complaint if actions aren’t taken. Recommendations are made in order to enhance program functioning. Recommendations do not require the submission of a service development plan.
Section 17a-145-63. Chief administrative officer
There shall be a chief administrative officer who shall be in charge of the overall management of the facility and carry out the policies of the governing board. Each facility shall provide the staff and complementary services to enhance the physical and emotional well-being and ensure the safety of the children.
•	One out of 19 current employee personnel files reviewed contained a state police background check for criminal convictions that was conducted a few days after the employee's hire date.

•	Two out of 16 terminated employee personnel files reviewed contained state police background checks for criminal convictions that were conducted a few days after the employees' hire dates.
•	One out of 16 terminated employee personnel files reviewed contained a DCF child protective services check for abuse and neglect that was conducted a few days after the employee's hire date.

•	One of 19 current personnel files reviewed did not contain documentation of restraint training as required.

•	Two out of 19 current personnel files reviewed did not contain documentation of CPR training as required.

Once a finding is made that your agency has satisfactorily addressed the regulatory compliance issues DCF will be prepared to renew your agency’s license.

Please take note that failure to submit an acceptable plan of correction or to successfully implement a plan will result in a licensing action being taken against your agency, including but not limited to suspension and / or non-renewal.

Any questions, comments or concerns you have regarding these findings should be addressed to this Department. Your response will become part of the permanent record of your organization.

Sincerely,

Keith Bryan
DCF Regulatory Consultant
Department of Children and Families
505 Hudson Street
Hartford, CT 06106
Phone: 860-560-5050
Mobile: 959-255-0617
Fax: 860-550-6665
keith.bryan@ct.gov
cc: Kathleen DiTuccio, Licensing Program Supervisor, TSS
file|

report_type: unstructured


summary: Visit conducted on 09/26/24_. 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: Wellspring RT

 TIME OF VISIT (FROM - TO):       First shift____                                     DATE: 09/26/24_

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:
Executive Director
Coordinator of Organizational Excellence

List of Areas / Topics covered during visit:
Youth in the program, the physical plant, and staffing. There were a total of 10 youth residing in Beauvais House and they were all were in school. The program director, 2 therapists, 2 staff and a nurse was on duty in Beauvais House.

In Shiloah House there were 4 youth residing in the home and they were all in school. The program director and 1 staff were on duty, with another staff due in at 11am.

One full time and 1 part time second shift position was available in both programs.

Corrective Actions implemented as a result of previous visit:
None

Areas of regulatory non-compliance identified during this visit:
None

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Keith Bryan                                               09/26/24
Regulatory Consultant                                   Date

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


summary: Visit conducted on 06/25/24_. Found 5 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: Wellspring RT

 TIME OF VISIT (FROM - TO):       First shift____                                     DATE: 06/25/24_

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:
Executive Director
Coordinator of Organizational Excellence

List of Areas / Topics covered during visit:
A review of 11 personnel files were conducted at the facility.

Corrective Actions implemented as a result of previous visit:
None

Areas of regulatory non-compliance identified during this visit:
Section 17a-145-63. Chief administrative officer
There shall be a chief administrative officer who shall be in charge of the overall management of the facility and carry out the policies of the governing board. Each facility shall provide the staff and complementary services to enhance the physical and emotional well-being and ensure the safety of the children.
•	Out of 11 personnel files reviewed 4 presented with state police background checks that were conducted after the employees' hire dates.
•	One out of 11 personnel files reviewed presented with a DCF child protective services check that was conducted after the employee's hire date.
•	Three out of the 11 personnel files reviewed did not contain documentation of CPR training as required.
•	Out of 11 personnel files reviewed 1 did not present with documentation of mandated reporter training as required. Two of the 11 personnel files reviewed presented with documentation of mandated reporter training that was conducted 8 months after the employees' hire dates.

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Keith Bryan                                               06/25/24
Regulatory Consultant                                   Date

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

type: general


summary: Visit conducted on 04/01/24_. 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: Wellspring RT

 TIME OF VISIT (FROM - TO):       First shift____                                     DATE: 04/01/24_

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:
Executive Director
Coordinator of Organizational Excellence

List of Areas / Topics covered during visit:
Youth in the program, the physical plant, and staffing. There were a total of 13 youth residing in Beauvais House and they were all upstairs in their bedrooms. The results of the review of personnel of files will be attached to this report on a later date.

In Shiloah House there were 4 youth residing in the home and they were all sitting at the kitchen table talking and one was playing an acoustic guitar.

There was a clinical director, 3 clinicians and 4 direct care staff, including the cook on duty in Beauvais House. There was a Program director, 1 clinician and 3 direct care staff on duty In Shiloah. There was also 1 nurse on duty to cover the campus.

Corrective Actions implemented as a result of previous visit:
None

Areas of regulatory non-compliance identified during this visit:
None

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Keith Bryan                                               04/01/24
Regulatory Consultant                                   Date

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


summary: Visit conducted on 12/19/23_. 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: Wellspring RT

 TIME OF VISIT (FROM - TO):       First shift____                                     DATE: 12/19/23_

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:
Executive Director
Coordinator of Organizational Excellence

List of Areas / Topics covered during visit:
Youth in the program, the physical plant, and staffing. There were a total of 10 youth residing in Beauvais House. One youth was at home sick and 1 was off grounds on vacation. Two youth were in individual sessions and 3 youth were in a group session.

In Shiloah House there were 4 youth residing in the home and they were in various areas of the home.

There was a clinical director, 3 clinicians and 4 direct care staff, including the cook on duty in Beauvais House. There was a clinical director, 1 clinician and 2 direct care staff on duty In Shiloah. There were also 2 nurses on duty to cover the campus.

Corrective Actions implemented as a result of previous visit:
None

Areas of regulatory non-compliance identified during this visit:
None

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Keith Bryan                                               12/19/23
Regulatory Consultant                                   Date

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


summary: Visit conducted on 09/27/23_. 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: Wellspring RT

 TIME OF VISIT (FROM - TO):       First shift____                                     DATE: 09/27/23_

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:
Executive Director

List of Areas / Topics covered during visit:
Youth in the program, the physical plant, and staffing. There were a total of 9 youth residing in Beauvais House. There were 2 youth residing in Shiloah House. There were 2 confirmed cases of covid on campus and the 2 youth were quarantined. Due to cases of covid on campus this writer did not inspect the physical plant.

There were 3 clinicians and 3 direct care staff, including the cook on duty in Beauvais House. There were 2 clinicians and 2 direct care staff on duty In Shiloah. There were also 2 nurses on duty to cover the campus.

Corrective Actions implemented as a result of previous visit:
None

Areas of regulatory non-compliance identified during this visit:
None

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Keith Bryan                                               9/27/23
Regulatory Consultant                                   Date

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


summary: Visit conducted on 06/26/23_. No compliance issues identified. Implemented 1 corrective actions.

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: Wellspring RT

 TIME OF VISIT (FROM - TO):       First shift____                                     DATE: 06/26/23_

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:
Assistant Executive Director
Quality Assurance Manager

List of Areas / Topics covered during visit:
Youth in the program, the physical plant, and staffing. There were total of 5 youth in Beauvais House. Five youth were on home visits and 3 recently graduated. There were 2 youth in Shiloah House and 2 more were on home visits.

There were 3 clinicians and 3 direct care staff, including the cook were on duty in Beauvais House. There were 2 clinicians and 2 direct care staff on duty In Shiloah. There were also 2 nurses on duty to cover the campus.

Corrective Actions implemented as a result of previous visit:
Section 17a-145-68. Heating, ventilation, lighting, was responded to satisfactorily.

Areas of regulatory non-compliance identified during this visit:
None

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Keith Bryan                                               7/20/23
Regulatory Consultant                                   Date

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


summary: Visit conducted on 1/10/23_. Found 2 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: Wellspring RT

 TIME OF VISIT (FROM - TO):       First shift____                                     DATE: 1/10/23_

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:
Executive Director
Shiloah House Program Director
Maintenance Person

List of Areas / Topics covered during visit:
Youth in the program, the physical plant, and staffing. There were total of 12 youth in Beauvais House and 5 youth in Shiloah House. One youth from Shiloah was home sick and 2 others were on weekend passes.

There were 2 clinicians on duty including the program director. There were 2 direct care staff on duty and the cook that also teaches in the kitchen.

Corrective Actions implemented as a result of previous visit:
None

Areas of regulatory non-compliance identified during this visit:
Section 17a-145-68. Heating, ventilation, lighting
Comfortable heating, sufficient ventilation, and both natural and artificial lighting shall be provided.
•	One emergency light tester was not functioning in Shiloah House.

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Keith Bryan                                               2/22/23
Regulatory Consultant                                   Date

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


facility_name: Boys&Girls Village/Kraft House #176

summary: Visit conducted on 2-4-26. No compliance issues identified.

raw_content:
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:  Boys & Girls Village, Inc. - Kraft House PRTF

TIME OF VISIT (FROM - TO):    11:30am-1:45pm	    DATE:  2-4-26

AGENCY PERSONNEL WHO PARTICIPATED:
Job Titles:
•	VP of Administrative Operations

List of Areas / Topics covered during visit: This was a scheduled quarterly Licensing visit to obtain an update on the program and tour the physical plant.

A meeting was held with the VP of Administrative Operations who facilitated a tour of the residence. Topics discussed included:
•	Census: 13 males.
•	Staff vacancies: two full time and one part time awake shift direct care positions; one clinician on medical leave; new Clinical Director hired.
•	Incident data from previous three months.
•	Video monitoring system: review process, access.
•	Quality assurance activities, PQI monthly meetings.
•	Holiday activities.
•	DPH investigation.
•	Nursing documentation improvements.
•	Street power outage during the quarter - no impact to campus due to generators.

Physical Plant:
•	All areas of the residence appeared very clean and organized.
•	Exit door alarms; delayed opening crash bars.

Milieu Observation:
•	Clients observed in residence Community room with numerous staff.

Corrective Actions implemented as a result of previous visit: N/A

Areas of regulatory non-compliance identified during this visit: None.

Please submit a regulation compliance plan to address the above referenced areas of non-compliance within 30 days of receipt of this report. The regulation compliance plan must be submitted to the attention of the undersigned at the address listed above. - No regulation compliance plan is required following this Licensing visit.

Kathleen Forsythe, LCSW				                     Date:  2-5-26
Regulatory Consultant

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

Cc: 	VP of Administrative Operations, File|


summary: Visit conducted on 11-4-25. No compliance issues identified.

raw_content:
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:  Boys & Girls Village, Inc. - Kraft House PRTF

TIME OF VISIT (FROM - TO):    9:30am-2:30pm		    DATE:  11-4-25

AGENCY PERSONNEL WHO PARTICIPATED:
Job Titles:
•	VP of Human Resources
•	VP of Administrative Operations

List of Areas / Topics covered during visit:  This was a scheduled Licensing visit to conduct a semi annual personnel file review, obtain an update on the program, and tour the physical plant.

Personnel File Review: A personnel file review was conducted with the VP of Human Resources for new staff hired for the Safe Haven program.
•	Seven personnel files were reviewed. No regulatory issues identified.

Physical Plant: A meeting was held with the VP of Administrative Operations who facilitated tour of the residence. Topics discussed included:
•	Census: 13
•	Staff vacancies: three full time mental health workers and two Milieu Supervisors for the campus; New Milieu Coordinator hired.
•	Incident data.
•	Clients on enhanced supervision status: process, definitions, email communication to staff.
•	Incident data.
•	All areas of the residence appeared very clean and organized.
•	Bathrooms: Monitoring logs; new hand dryers have been installed.

Milieu Observation: One client resting in bed with staff positioned outside door in hallway. Second shift staff reporting for work.

Corrective Actions implemented as a result of previous visit: N/A

Areas of regulatory non-compliance identified during this visit: None.

Please submit a regulation compliance plan to address the above referenced areas of non-compliance within 30 days of receipt of this report. The regulation compliance plan must be submitted to the attention of the undersigned at the address listed above. - No regulation compliance plan is required following this Licensing visit.

Kathleen Forsythe, LCSW				                           Date:  11-7-25
Regulatory Consultant

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

Cc: 	VP of Administrative Operations
       File|


summary: Visit conducted on 8-6-25. No compliance issues identified.

raw_content:
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:  Boys & Girls Village, Inc. - Kraft House PRTF

TIME OF VISIT (FROM - TO):     10:00am-12:00pm             		DATE:  8-6-25

AGENCY PERSONNEL WHO PARTICIPATED:
Job Titles:
•	VP of Operations
•	Director of Residency Services

List of Areas / Topics covered during visit:  This was a scheduled Licensing visit to introduce the new Regulatory Consultant, obtain an update on the program, and tour the physical plant.

A meeting was held with the VP of Operations. Topics discussed included:
•	Overview of PRTF program.
•	Census= 13, over capacity waiver in place; Licensing application submitted to increase LBC pending written authorization from Fire Marshal and Health Inspector.
•	Staff vacancies: 1 full time and 1 part time direct care slot.; perdiem pool available.
•	Incident data for the quarter.
•	Client/Staff supervision ratios.
•	Restraint ordering procedures.
•	Data collection; utilizing data analysis in clinical work, PQI process.
•	Motivational interviewing; consultant; staff training/coaching.
•	Recent upgraded hardware for video surveillance system.
•	Request to review program policies & procedures.
•	On-campus recreation, certified ROPES course.
•	Weekly generator testing, power back-up.
•	Brief introductions to CEO, HR Director, Director of Residency Services, Clinician.
•	Agency vehicles.
•	Monthly Family Night.
•	Summer program schedule.

Physical Plant: VP of Operations and Milieu Coordinator facilitated tour of the residence.
•	All areas appeared very clean and organized.
•	Bathrooms: Ligature resistant equipment; No hand soap or single use paper towels present in all client bathrooms - Staff reportedly provide items when clients use restrooms.
•	Windows in several bedrooms only contain one curtain panel - additional curtains have been ordered.
•	Discussed headcount procedures, frequency, documentation; staff supervision stations; delayed openings on emergency exits; bathroom/shower supervision procedures, individual hygiene baskets.
•	Food services.
•	Barber Shop: Located in another residence; licensed barber visits weekly, staff/client supervision procedures during haircuts.
•	Food storage procedures for dry goods.
•	School expansion project nearly complete for Fall opening.

Milieu observation:
•	Clients observed in Community room with staff present participating in Life Skills group.
•	Program nurse observed in Nursing office.

Corrective Actions implemented as a result of previous visit: N/A

Areas of regulatory non-compliance identified during this visit: None.

Please submit a regulation compliance plan to address the above referenced areas of non-compliance within 30 days of receipt of this report. The regulation compliance plan must be submitted to the attention of the undersigned at the address listed above. - No regulation compliance plan is required following this Licensing visit.

Kathleen Forsythe, LCSW				                      Date:  8-8-25
Regulatory Consultant

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

Cc: 	VP of Operations
      Director of Residency Services
      File|


summary: Visit conducted on 5/29/2025. Visit covered 6 main areas/topics. Found 1 compliance issues. Implemented 1 corrective actions.

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: Boys and Girls Village / Kraft House

 TIME OF VISIT (FROM - TO):       __9am to 2:30pm_______     DATE: 5/29/2025

 AGENCY PERSONNEL WHO PARTICIPATED:

	Job Title
	VP of Administrative Operations

	Supervisor
	VP of Residential Services

List of Areas / Topics covered during visit:

•	Announced visit to Kraft House.
•	Census 13.  LBC 12. One over capacity waiver approved this quarter.
•	Physical plant inspection was conducted. No concern.
•	Discussed the programing, resident safety, etc.
•	Discussed staffing of shifts.
•	Youth were in school at the time of visit.

Corrective Actions implemented as a result of previous visit: Completed.
No Regulatory Compliance Plan required.

Areas of regulatory non-compliance identified during this visit:
No Regulatory Compliance Plan required.

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Thomas S. Cuchara                           __6/24/2025__
Regulatory Consultant                                   Date

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

description: No Regulatory Compliance Plan required.

facility_name: Boys and Girls Village / Kraft House


raw_content:
Kim Shaunesey, PhD.							                2/4/2025
Executive Director
Boys & Girls Village Inc.
528 Wheelers Farm Rd.
Milford, CT 06461

RE: CCF/PRTF- 176 Kraft House

Dear Dr. Shaunesey,

On January 13, 14, 15, 2025, a biennial licensing inspection was conducted at your facility. This inspection was conducted to determine the compliance of this facility with the Regulations for Operation of Child-Caring Agencies and Facilities 17a-145-48 through 17a-145-98, the Psychiatric Residential Treatment Facilities Guidelines, and the DCF Guidelines for the Administration of Medication by Certified Staff.

Please review the areas identified and submit the regulatory compliance plan of correction to address each area. The plan must be submitted within 30 days of receipt of this letter and should identify: 1. the steps to be taken to correct the non-compliance and 2. the date correction(s) will be completed. The areas of non-compliance are as follows:

Regulations for the Operation of Child-Caring Agencies and Facilities
Section 17a-145-96. Discharge of child.
Evidence: Four discharge files were reviewed. At the time of the inspection, one youth was discharged to Yale New Haven Hospital and admitted to the child/adolescent psychiatric unit.  The record did not have documentation of the name of the staff or job title of the person who admitted youth.  The parent was notified by the facility their child was being discharged from BGV PRTF and transported to Yale New Haven Hospital. When youth are discharged from a program and subsequently admitted to the Hospital, the name and/or job title of responsible to admit the youth should be documented in the case record.  The program reviewed the discharge procedure and made corrections to include the name and job title of the admitting staff.  The agency' provided a written response which is accepted by licensing. No further action required.

Sec. 17a-16.  Rights of children and youths under the supervision of the Commissioner of Children and Families.

Evidence: 6 client files were reviewed.  At the time of the inspection, files reviewed found that staff created an approved call list by using the document found in the electronic file system, CareLogic,  However, the Policy & Procedure clearly states an approved call list cannot be established, but a restricted call list is allowed. The program reviewed and revised the Policy & Procedure to include training staff on documenting calls and removed and updated the old document found in the electronic health record.  The agency provided a written response which is accepted by licensing. No further action required.

Psychiatric Residential Treatment Facilities Guidelines

No citations.

Sincerely,

Thomas S. Cuchara,
Regulatory Consultant-DCF Licensing Unit
860-550-6310p 203-675-6975c
tom.cuchara@ct.gov|


summary: Visit conducted on 12/12/24. Visit covered 6 main areas/topics. Found 1 compliance issues. Implemented 1 corrective actions.

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: Boys and Girls Village / Kraft House

 TIME OF VISIT (FROM - TO):       __9:45am to 11:30am_______     DATE: 12/12/24

 AGENCY PERSONNEL WHO PARTICIPATED:

	Job Title
	VP of Administrative Operations

List of Areas / Topics covered during visit:

•	Announced visit to Kraft House.
•	Census 13.  LBC 12. Two 'over capacity waivers' approved this quarter and one remains at the time of the licensing visit.
•	Physical plant inspection was conducted. No concern.
•	Discussed the programing, resident safety, etc.
•	Discussed staffing of shifts.
•	One case record reviewed and found to reviewed two restraint incidents.

Corrective Actions implemented as a result of previous visit: Completed.
No Regulatory Compliance Plan required.

Areas of regulatory non-compliance identified during this visit:
No Regulatory Compliance Plan required.

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Thomas S. Cuchara                           __12/21/24__
Regulatory Consultant                                   Date

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

description: No Regulatory Compliance Plan required.


summary: Visit conducted on 9/13/24. Visit covered 6 main areas/topics. Found 1 compliance issues. Implemented 1 corrective actions.

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: Boys and Girls Village / Kraft House

 TIME OF VISIT (FROM - TO):       __10:30 to 11:30am_______     DATE: 9/13/24

 AGENCY PERSONNEL WHO PARTICIPATED:

	Job Title
	VP of Administrative Operations

	VP Residential Services
	Milieu Manager

List of Areas / Topics covered during visit:

•	Announced visit to Kraft House.
•	Census 10.
•	Physical plant inspection was conducted.
•	Discussed the programing, resident safety, etc.
•	Discussed staffing of shifts.
•	One case record reviewed and found to be in compliance.

Corrective Actions implemented as a result of previous visit: Completed.

Section 17a-145-73. Sleeping accommodations. Room # 515: Blood found on the wall.

Areas of regulatory non-compliance identified during this visit:
No Regulatory Compliance Plan required.

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Thomas S. Cuchara                           __9/17/24__
Regulatory Consultant                                   Date

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

description: No Regulatory Compliance Plan required.


summary: Visit conducted on 5/28/24. Visit covered 6 main areas/topics. Found 1 compliance issues. Implemented 1 corrective actions.

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: Boys and Girls Village / Kraft House

 TIME OF VISIT (FROM - TO):       __10am to 3pm__________      DATE: 5/28/24

 AGENCY PERSONNEL WHO PARTICIPATED:

	Job Title
	VP of Administrative Operations

	VP- Human Resources

List of Areas / Topics covered during visit:

•	Announced visit to Kraft House.
•	Physical plant inspection was conducted. No residents were in the unit.  See below.
•	Discussed the programing, resident safety, etc.
•	Discussed staffing of shifts.
•	One case record reviewed and found to be in compliance.
•	Reviewed personnel files of school staff that work in Safe Haven and Kraft House.

Corrective Actions implemented as a result of previous visit:
No SDP from last visit.

Areas of regulatory non-compliance identified during this visit:
Section 17a-145-73. Sleeping accommodations.
Room # 515: Blood found on the wall.

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Thomas S. Cuchara                           __6/28/24____
Regulatory Consultant                                   Date

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


summary: Visit conducted on 3/27/24. Visit covered 5 main areas/topics. Found 1 compliance issues. Implemented 1 corrective actions.

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: Boys and Girls Village / Kraft House

 TIME OF VISIT (FROM - TO):       __10am to 12pm__________      DATE: 3/27/24

 AGENCY PERSONNEL WHO PARTICIPATED:

	Job Title
	VP of Administrative Operations

List of Areas / Topics covered during visit:

•	Unannounced visit to Kraft House.
•	Physical plant inspection was conducted. Blood found on wall, but maintenance will clean and remove.
•	Discussed the programing, resident safety, etc.
•	Discussed staffing of shifts.
•	One case record reviewed and found to be in compliance.

Corrective Actions implemented as a result of previous visit: Completed.
No SDP from last visit.

Areas of regulatory non-compliance identified during this visit:
No Regulatory Compliance Plan required.

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Thomas S. Cuchara                           __7/25/24____
Regulatory Consultant                                   Date

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

description: No Regulatory Compliance Plan required.


summary: Visit conducted on 11/2/23. Visit covered 9 main areas/topics. Found 3 compliance issues. Implemented 1 corrective actions.

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: Boys and Girls Village / Kraft House

 TIME OF VISIT (FROM - TO):       __9am to 1pm__________               DATE: 11/2/23

 AGENCY PERSONNEL WHO PARTICIPATED:

	Job Title
	VP of Administrative Operations
	VP of Human Resources
	RN

List of Areas / Topics covered during visit:

•	Census is 12. LBC 12.
•	Kraft House remains on a 4th Provisional License (60 days).
•	All youth were at school at the time of the visit.
•	Physical plant inspection was conducted. See below.
•	Fire drills reviewed and in compliance.
•	Reviewed Personnel files. (6) No concerns.
•	Discussed the programing, resident safety, etc.
•	Discussed staffing of shifts. The Director of Nursing is on maternity leave, but her position is being covered by a full time RN.
•	One open and 2 discharge files reviewed and found to be in compliance.

Corrective Actions implemented as a result of previous visit:
No SDP from last visit.

Areas of regulatory non-compliance identified during this visit:
At the time of the visit the following citations were documented.  The program completed the areas cited on 11/3/23 as evidence of photos via email. No further action required.

Section 17a-145-73.  Sleeping accommodations.
•	RM 217. The youth a vulgar message written on paper found taped to bedroom wall.
•	RM 218.  The wall next to client's bed has evidence of blood splatter due to resident smearing blood from bleeding nose.  Maintenance removed the blood from the wall and a behavior plan was created and implemented.

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Thomas S. Cuchara                           __11/15/23_______
Regulatory Consultant                                   Date

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

description: 73. Sleeping accommodations.


summary: Visit conducted on 7/7/23. 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: Boys and Girls Village / Kraft House

 TIME OF VISIT (FROM - TO):       __9am to 12pm__________               DATE: 7/7/23

 AGENCY PERSONNEL WHO PARTICIPATED:

	Job Title
	VP of Administrative Operations

List of Areas / Topics covered during visit:

•	Census is 8. LBC 8.
•	Kraft House is on a 2nd Provisional License (60 days).  The License expires 7/22/23.
•	All youth were at school at the time of the visit. One youth, 11 years old is on census and a waiver was approved.
•	Physical plant inspection was conducted and in compliance. See below.
•	Discussed the programing, resident safety, etc.
•	Discussed staffing of shifts. The Director of Nursing recently resigned, but the program was able to hire another Director of Nursing that will begin duties 7/10/23.
•	Reviewed fire drills and found to be incompliance
•	One case record reviewed.

Corrective Actions implemented as a result of previous visit: n/a

Areas of regulatory non-compliance identified during this visit:
Physical Plant:  At the time of the visit, the exit door 'safety' glass was found broken.  One youth escalated in the milieu hallway and broke the window on two exit doors.  Maintenance was able to use durable plexiglass to cover the affected area until a replace window is purchased.  Although this is a temporary repair, please identify in the Service Development Plan an approximate date the exits doors will be restored to their original condition.

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Thomas S. Cuchara                           __8/1/23_______
Regulatory Consultant                                   Date

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

area_type: Physical Plant


summary: Visit conducted on 4/28/23. Visit covered 8 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: Boys and Girls Village / Kraft House

 TIME OF VISIT (FROM - TO):       __9am to 12pm__________               DATE: 4/28/23

 AGENCY PERSONNEL WHO PARTICIPATED:

	Job Title
	VP of Administrative Operations

List of Areas / Topics covered during visit:

•	Census is 4. LBC 4.
•	This the first visit to the Kraft House since receiving the 1st Provisional License (60 days).  The License expires 5/23/23.
•	At the time of the visit there was one youth in the program and the other youth in school.
•	Physical plant inspection was conducted and in compliance.
•	Discussed the programing, resident safety, etc.
•	Discussed staffing of shifts.
•	Reviewed medication.
•	One case record reviewed.

Corrective Actions implemented as a result of previous visit: n/a

Areas of regulatory non-compliance identified during this visit:
  N/A

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Thomas S. Cuchara                           __5/4/23_______
Regulatory Consultant                                   Date

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


facility_name: Children's Center of Hamden (The) / START / RT #73

summary: Visit covered 14 main areas/topics. No compliance issues identified.

raw_content:
DCF-3034
1/2013 (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: The Children's Center of Hamden-START (PRTF) Program

 TIME OF VISIT (FROM - TO) 11:30 am to 12:40pm:      DATE: December 5, 2025

AGENCY PERSONNEL WHO PARTICIPATED:

Job Title
Clinical Director
VP, Residential Services
Program Director

Areas / Topics covered during visit:

•	Census: The residential program census was twenty-two (9 males and 13 females) at the time of the scheduled quarterly visit.
•	Admissions: In the last quarter the program reported that there were fourteen new admissions.
•	Discharges: The program confirmed that in the last quarter there were nine planned discharges and one unplanned discharge.
•	Staffing: It was reported by the program that the residential staffing included thirty-five full-time employees and three part-time employees.
•	Staff vacancies: The program confirmed that there were fourteen staff vacancies in the last quarter.
•	Staff hires: The program reported that there were three new hires in the last quarter.
•	Physical plant: A walkthrough of Heaton, Marcy and Brewster Units was conducted with the Director of Clinical Services, the Program Director, and the VP of Residential Services and the purpose was to identify potential regulatory issues ahead of the upcoming inspection.
•	Medication: The residential program continues to depend on nurses to administer medication to clients across all three shifts.
•	Personnel files: An audit of personnel records was not conducted in this quarter.
•	SIU Reports: There were no reports in this quarter.

Corrections implemented as a result of previous visit:
N/A

Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning)
N/A

Areas of regulatory non-compliance identified during this visit:
N/A

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Penny Woodward, LCSW                          December 15, 2025
Regulatory Consultant                                              Date

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


summary: Visit covered 11 main areas/topics. No compliance issues identified.

raw_content:
DCF-3034
1/2013 (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: The Children's Center of Hamden-START (PRTF) Program

TIME OF VISIT (FROM - TO) 11:22am to 12:34pm:                   DATE: August 13, 2025

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Title
VP, Residential Services
Program Director

Areas / Topics covered during visit:

•	Census: The residential program census was twenty-two (9 males and 13 females) at the time of the quarterly inspection visit.
•	Admissions: In the last quarter the program reported that there were nine new admissions.
•	Discharges: The program confirmed that in the last quarter there were 14 planned discharges.
•	Staffing: It was reported that the residential staffing consisted of thirty-eight employees, and they are responsible for shift coverage for all three units.
•	Staff vacancies: The program confirmed that there were fourteen staff vacancies in the last quarter.
•	Staff hires: four new direct care personnel were hired in the last quarter, and a new therapist has been selected to fill the vacant clinical position; her out of state background checks are currently pending.
•	Physical plant: A walkthrough of Heaton, Marcy and Brewster Units was conducted with the VP of Residential Services, and the Program Director to confirm the program's compliance with regulatory requirements.
•	Medication: No new updates were reported during the quarterly inspection visit.
•	Personnel: On 8/19/25, five employee records were reviewed, and all files contained the required background check information.
•	SIU: During the past quarter, licensing responded to one incident report and completed one incident response note. The incident occurred on 7/22/25 and involved allegations that a staff member had struck a resident on two separate occasions.

Corrections implemented as a result of previous visit:
N/A

Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning)
N/A

Areas of regulatory non-compliance identified during this visit:
N/A

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Penny Woodward, LCSW                          August 25, 2025
Regulatory Consultant                                        Date

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


summary: Visit covered 13 main areas/topics. No compliance issues identified.

raw_content:
DCF-3034
1/2013 (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: The Children's Center of Hamden-START (PRTF) Program

TIME OF VISIT (FROM - TO) 11:25 am to 12:40pm:                   DATE: June 10, 2025

AGENCY PERSONNEL WHO PARTICIPATED:

Job Title
Clinical Director
VP, Residential Services
Program Director

Areas / Topics covered during visit:

•	Census: The residential program census was twenty-six (10 males and 16 females) at the time of the scheduled quarterly visit.
•	Admissions: In the last quarter the program reported that there were fifteen new admissions.
•	Discharges: The program confirmed that in the last quarter there were thirteen discharges.
•	Staffing: It was reported that the residential staffing consisted of forty-six employees.
•	Staff vacancies: The program confirmed that there were fourteen staff vacancies in the last quarter.
•	Staff hires: There were two new hires in the last quarter.
•	Physical plant: A walkthrough of Heaton, Marcy and Brewster Units was conducted with the Director of Clinical Services, the Program Director, and the VP of Residential Services to confirm the facility's compliance with regulatory requirements.
•	Medication: The residential program continues to utilize nurses from a temporary staffing agency to cover open shifts. The program employs four full-time RNs, one full-time LPN, and eleven per-diem nurses with RN credentials.

Corrections implemented as a result of previous visit:
N/A

Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning)
N/A

Areas of regulatory non-compliance identified during this visit:
N/A

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Penny Woodward, LCSW                          June 23, 2025
Regulatory Consultant                                        Dat

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


summary: Visit covered 14 main areas/topics. No compliance issues identified. Includes 1 recommendations.

raw_content:
DCF-3034
1/2013 (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: The Children's Center of Hamden-START (PRTF) Program

 TIME OF VISIT (FROM - TO) 11:00 am to 1:00pm:                   DATE: February 24, 2025

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Title
Clinical Director
VP, Residential Services
Program Director

Areas / Topics covered during visit:

•	Census: The residential program census was twenty-three (10 males and 13 females) at the time of the scheduled quarterly visit.
•	Admissions: In the last quarter the program reported that there were fifteen new admissions.
•	Discharges: The program confirmed that in the last quarter there were fourteen discharges.
•	Staffing: It was reported that the residential staffing consisted of forty-four employees
•	Staff vacancies: The program confirmed that there were ten staff vacancies in the last quarter.
•	Staff hires: There were two new hires in the last quarter.
•	Physical plant: A walkthrough of Heaton, Marcy and Brewster Units was conducted with the Director of Clinical Services, the Program Director, and the VP of Residential Services to evaluate the facility's compliance with regulatory requirements.
•	Medication: It was reported that the residential program is currently utilizing nurses from a temporary staffing agency to cover open shifts. The program employs four full-time RNs, one full-time LPN, and seven per-diem nurses with RN credentials.
•	Personnel: On 2/3/25, thirteen employee records were reviewed, and all files contained the required background check information.
•	SIU: During the past quarter, licensing responded to one incident and completed one incident response note.
The incident occurred on 1/7/25, and involved an emergency service call due to a resident's mental health disruption at the program.

Corrections implemented as a result of previous visit:
N/A

Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning)
17a-145-73: Sleeping Accommodations. Upon inspection of residents' bedrooms, it was noted that the furniture was outdated and of poor quality, and the current clothing storage system did not meet the needs of the clients in the program.

Areas of regulatory non-compliance identified during this visit:
N/A

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Penny Woodward, LCSW                          March 4, 2025
Regulatory Consultant                                       Date

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


raw_content:
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: The Children's Center of Hamden-START (PRTF) Program

 TIME OF VISIT (FROM - TO) 11:15 am to 12:38pm:                   DATE: December 3, 2024

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Title
Clinical Director
VP, Residential Services
Program Director

Areas / Topics covered during visit:

•	Census: The residential program census was twenty-two (8 males and 14 females) at the time of the scheduled quarterly visit.
•	Admissions: In the last quarter the program reported that there were nine new admissions.
•	Discharges: The program confirmed that in the last quarter there were eleven discharges.
•	Staffing: It was reported that the residential staffing consisted of thirty-seven full-time employees
•	Staff vacancies: The program confirmed that there were thirteen staff vacancies in the last quarter.
•	Staff hires: There were nine new hires in the last quarter.
•	Physical plant: A walkthrough of the Marcy, Heaton, and Brewster Units was conducted with the Director of Clinical Services, the Program Director, and the VP of Residential Services to assess the facility's compliance with regulatory requirements.
•	Personnel: Employee records and files were not reviewed during the quarterly visit.

During the past quarter, licensing responded to one incident and completed one incident response note. The incident occurred on 9/23/24, and it involved the behavioral disruption of a resident.

Corrections implemented as a result of previous visit:
N/A

Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning)
N/A

Areas of regulatory non-compliance identified during this visit:
N/A

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Penny Woodward, LCSW                          December 13, 2024
Regulatory Consultant                                   Date

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


summary: Visit covered 12 main areas/topics. Found 2 compliance issues.

raw_content:
DCF-3034
1/2013 (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: The Children's Center of Hamden-START (PRTF) Program

 TIME OF VISIT (FROM - TO) 11:00am to 12:15pm:                   DATE: August 22, 2024

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Title
Clinical Director

Areas / Topics covered during visit:

•	Census: The residential program census was twenty-six (8 males and 16 females) at the time of the scheduled quarterly visit.
•	Admissions: In the last quarter the program reported that there were eight new admissions.
•	Discharges: The program confirmed that in the last quarter there were seven discharges.
•	Staffing: It was reported that the residential staffing consisted of twenty-eight full-time employees
•	Staff vacancies: The program confirmed that there were eleven staff vacancies in the last quarter.
•	Staff hires: There were three new hires in the last quarter.
•	Physical plant: A walkthrough of Marcy, Heaton and Brewster Units was conduced with the Director of Clinical Services to determine if the facility was in compliance with regulatory requirements.
•	Personnel: Eight employee records were reviewed on July 16, 2024, and three files did not have the required criminal background checks.  On 8/9/24, the program provided documentation confirming that criminal background checks on all three employees had been completed.
•	SIU Reports: There were no reports in this in this quarter.

Corrections implemented as a result of previous visit:
N/A

Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning)
N/A

Areas of regulatory non-compliance identified during this visit:
Section 17a-145-73: Sleeping accommodations. Upon inspection of bedrooms in all three cottages, furniture was in poor condition and did not meet regulatory standards.

Section 17a-145-77: Dining areas and supervision. Upon inspection of the dining areas in Heaton and Brewster Cottages, food had not been properly stored and was left out in open containers.

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Penny Woodward, LCSW                          September 10, 2024
Regulatory Consultant                                   Date

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

regulation: Sleeping accommodations.

regulation: Dining areas and supervision.


summary: Visit conducted on May 14, 2024. Visit covered 13 main areas/topics. No compliance issues identified.

raw_content:
DCF-3034
1/2013 (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: The Children's Center of Hamden-Start (PRTF) Program

 TIME OF VISIT (FROM - TO): 11:00am to 2:00pm                     DATE: May 14, 2024

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Title
VP, Clinical Services
Program Director
Clinical Director
DCF Nurse

Areas / Topics covered during visit:

•	Census: The residential program census was twenty-six (10 males and 16 females) at the time of the scheduled quarterly visit.
•	Admissions: In the last quarter the program reported that there were eleven new admissions.
•	Discharges: The program confirmed that in the last quarter there were thirteen discharges.
•	Staffing: The residential staffing consists of twenty-eight full-timers, three part-timers and eighteen per-diem employees.
•	Staff vacancies: The facility reported that there were fourteen staff vacancies in the last quarter.
•	Staff hires: The program had six new hires in the last quarter.
•	Physical plant: A walkthrough of Marcy, Heaton and Brewster Units was conduced with the VP of Clinical Services, program director and clinical director. The cottages were being maintained according to regulatory requirements. In the last quarter, Marcy Cottage became a boys' unit and Heaton and Brewster Cottages became girls' units.
•	Personnel: Employee records and files were not reviewed during the quarterly visit.

During the past quarter, licensing responded to two incidents and completed two incident response notes. The first incident occurred on 12/21/23 and involved inappropriate contact between a PRTF Resident and day school client. The second incident occurred on 2/1/24 and involved a lack of supervision of clients while on the milieu.

Corrections implemented as a result of previous visit:
N/A

Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning)
N/A

Areas of regulatory non-compliance identified during this visit:
N/A

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Penny Woodward, LCSW                          May 28, 2024
Regulatory Consultant                                   Date

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


summary: Visit conducted on March 11, 2024. Visit covered 1 main areas/topics. Found 2 compliance issues.

raw_content:
DCF-3034
1/2013 (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: The Children's Center of Hamden-Start (PRTF) Program

 TIME OF VISIT (FROM - TO): 11:00am to 1:30pm                     DATE:  March 11, 2024

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Title
VP, Residential Services

Areas / Topics covered during visit:

On March 11, 2024, a visit was conducted to address an incident that occurred at the facility on December 21, 2023. The incident involved inappropriate sexual contact between a resident from the PRTF Program and a client from the fifth-year day school program that is on the CCOH Campus.

Female PRTF resident (age 14) was working in the kitchen, in the vocational program and requested to use the bathroom. Instead of being escorted to the bathroom that residents use, she was taken to the staff bathroom that is in a remote area next to the kitchen. The resident was left unsupervised in the bathroom and staff returned to the kitchen area. When the female resident did not return to her workstation, a kitchen staff went to check on her and resident stated that she was okay but did not open the door.  The staff left the area and returned to the kitchen. When the resident had not returned to her workstation, a second kitchen staff went to check on her and requested that she open the door.  When the resident opened the door, the staff saw that she was not alone and there was a male client in the bathroom with her.

Cameras are in the dining hall but not in the kitchen or hallway where the staff bathroom is located. Video footage reviewed by the program showed that the male client (age 18) was eating breakfast in the dining hall, around 8:14am he left the area and went to the kitchen.  At 8:17am, a staff in the dining hall noticed that the male client was missing and began searching for him. The male client returned to the dining hall around 8:28am and it was reported that he had been missing for a total of fourteen minutes.

The male client was a participant of the fifth-year day school program that is on campus and it is unclear what prior contact he had with the female resident.  It is suspected by staff that they may have met while during a school activity.  The male client was expelled on the day of the incident.

Physical plant: A walkthrough of Marcy, Heaton and Brewster Units was conducted with the VP of Residential Services. Male residents have been relocated to the Marcy Unit and female residents have been moved to the Brewster and Heaton Units. The cottages were appropriately furnished but the décor was below standard and needs to be addressed.

Corrections implemented as a result of previous visit:
N/A

Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning)
N/A

Areas of regulatory non-compliance identified during this visit:

17a-145-61: Written policies and procedures.
Upon review of program documentation, the female client arrived at the kitchen around 8:07am and supervision of the youth was transferred to kitchen staff. Records show that kitchen staff are not trained on procedures for supervising clients in the residential program or have knowledge about bathroom policy.  Evidence was found that the program failed to follow its own policies and procedures for the supervision of clients.

17a-145-63: Chief administrative officer.
Upon review of program documentation, the bathroom door was opened and unlocked and kitchen staff had not cleared the bathroom before allowing client to use it.  The bathroom was in a remote hallway, staff returned to the kitchen and left the client unsupervised.  Evidence was found that the program failed to ensure the safety of children by allowing untrained staff to supervise a client while participating in an on campus vocational program.

Upon review of program documentation, staff from the day school was supposed to be supervising the male client but information show that staff had not been properly positioned and all areas in the dining hall were not monitored. Evidence was found that the program failed to ensure that adult participants in the fifth-year program do not have contact with clients from the PRTF Program.

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Penny Woodward, LCSW                          March 15, 2023
Regulatory Consultant                                   Date

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

regulation: Chief administrative officer.


summary: Visit conducted on January 30, 2024. Visit covered 9 main areas/topics. No compliance issues identified.

raw_content:
DCF-3034
1/2013 (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: The Children's Center of Hamden-Start (PRTF) Program

TIME OF VISIT (FROM - TO): 11:00am to 12:30pm                     DATE: January 30, 2024

AGENCY PERSONNEL WHO PARTICIPATED:

Job Title
VP, Residential Services
Program Director
Director of Nursing

Areas / Topics covered during visit:
•	Census: The program's bed capacity has not changed and it remains at twenty-eight.
•	Admissions: December data shows that there were three female admissions and one male admission.
•	Discharges: December data shows that there were three youths discharged from the program.
•	Staff vacancies: December data shows that there were ten direct care staff vacancies.
•	Staff hires: December data shows that there were four new staff hired at the facility.
•	Physical plant: A walkthrough of Marcy, Heaton and Brewster Units was conduced with the VP of Residential Services and the program director. The cottages were being maintained according to regulatory requirements.
•	Residential: Plans are being developed to move males to the Marcy Unit and relocated females to the Brewster/Heaton Units.
Policies and procedures are being updated and the final draft will be submitted to the Department on February 1st.
•	Nursing: Medical policies are being updated and the final draft will be submitted to the Department on March 1st.

SIU Report: The program had one SIU report in the last quarter (1/9/24) that required follow-up and please see report in file for additional information.

Corrections implemented as a result of previous visit:
N/A

Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning)
N/A

Areas of regulatory non-compliance identified during this visit:
N/A

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Penny Woodward, LCSW                          February 8, 2023
Regulatory Consultant                                   Date

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

visit_date: January 30, 2024


raw_content:
December 19, 2023

The Children's Center of Hamden, Inc.
1400 Whitney Ave
Hamden, CT. 06517

Re: Bi-annual licensing inspection at the Psychiatric Residential Treatment Facility/Start Program to determine compliance with Regulations for Operation of Child-Caring Agencies and Facilities 17-145-48 through 17A-145-98, as well as the DCF Guidelines for the Administration of Medication by certified staff.

DCF has determined that the program is in compliance with all applicable regulatory provisions except those itemized below. Please review areas identified and submit a service development plan to address each area.

The plan must be submitted within 30 days of receipt of this letter and should identify: 1. Steps to be taken to correct the non-compliance. 2. The date corrections(s) will be completed.

17a-145-61: Written policies and procedures.
(Evidence) Upon review of the agency manual, there was pertinent information missing and policies did not accurately reflect all program procedures.

17a-145-63: Chief administrative officer.
(Evidence) Upon review of all three cottages, common areas and bedrooms contained antiquated and very outdated furniture and they need to be addressed.  Windows in all cottages contained privacy film that were heavily scratched or marked and they need to be addressed.

17a-145-73: Sleeping accommodations.
(Evidence) Upon inspection of Marcy Cottage, bedroom seven's ceiling contained a light fixture cover that was noticeably stained and it needs to be addressed.
Bedroom eight contained a dresser that had multiple scratches and scuff marks and it needs to be addressed.  Bedroom forty-eight contained a wall that had a small hole and it needs to be addressed.

Heaton Cottage - Bedroom nine's carpet contained multiple large stains and it needs to be addressed.

17a-145-74: Lavatory facilities.
(Evidence) Upon inspection of Marcy Cottage, one of the bathrooms contained a metal window frame that had rust and chipping paint and it needs to be addressed. The tub was no longer white and discolored from daily use and it needs to be addressed.

Heaton Cottage - One of the bathrooms, contained a vanity that had chipping paint and it needs to be addressed.

17a-145-75: Health and medical treatment.
(Evidence) Upon review of staff training documentation, emergency medication training was not being conducted by a licensed medical professional as required by regulations.  See nursing guidelines for additional information.

(Evidence) Upon review of medical policies, important information on medical practices and procedures was missing and it needs to be addressed.

17a-145-76: Kitchens, equipment, food handling.
(Evidence) Upon inspection of the kitchen in Marcy Cottage, the oven contained a large amount of grease stains from daily use and it needs to be addressed.

Once a finding is made that your agency has satisfactorily addressed the regulatory compliance issues. And all required supplementary materials have been received, the Department of Children and Families will be prepared to issue a regular license. Failure to submit a plan of correction or successfully implement a plan will result in the refusal to renew the license.  Should you have any questions or comments regarding the contents of this report please do not hesitate to call me at (959) 255-0615.

Sincerely,

Penny Woodward

Penny Woodward, LCSW
Regulatory Consultant|