summary: Visit conducted on 12-21-23. Found 7 compliance issues.

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 Bridge Family Centers- Freymann House STAR program

TIME OF VISIT (FROM - TO):     9:00am-12:00pm                    DATE:  12-21-23

AGENCY PERSONNEL WHO PARTICIPATED:
Job Titles:
•	HR Director

List of Areas / Topics covered during visit:  This was a scheduled Licensing visit to the HR Dept. to conduct a semiannual personnel file review. Eight personnel files were reviewed of identified Bridge staff hired or transferred into the program since August 2023. See 'Areas of Regulatory Noncompliance' below.

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

Areas of regulatory non-compliance identified during this visit:
17a-145-64	 Personnel Policies and Procedures.
•	Five files (KC, NT, JB, SM, KL) reviewed did not contain evidence that the employee received a copy of the agency's personnel policies.

17a-101	Protection of Children from Abuse. Mandated Reporters. Educational and Training Programs. Model Mandated Reporting Policy.
•	Five files (KC, RH, SG, SM, KL) reviewed do not contain evidence of completing the DCF mandatory reporter of abuse/neglect training.

17a-131 	Cardiopulmonary Resuscitation Training Required for Persons Who Directly Supervise Children.
•	Three files (JB, SM, KL) reviewed did not contain evidence of CPR certification.

17a-151 	Investigation. Issuance of license or provisional license. Revocation, suspension or limitation of license. Appeal.
•	One file of a former employee (EB) does not contain evidence that the agency requested a check of the child abuse and neglect registry in any state in which the employee resided in the preceding five years. Documentation in the personnel file indicates the employee resided in Hawaii and Virginia in the five years prior to hire at The Bridge Family Centers.
•	A completed Connecticut state police criminal history check on one employee (KC) does not contain the correct spelling of the last name.

46a-154. Internal monitoring, training and development of policies and procedures required and subject to state agency inspection.
•	Five files (KC, NT, JB, SM, KL) reviewed do not contain evidence of restraint training in the Therapeutic Crisis Intervention/TCI course.

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

Kathleen Forsythe, LCSW                               			Date:  12-28-23
______________________________
Regulatory Consultant

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM.
Cc: HR Director
      Director of Residential Services|

description: 64 Personnel Policies and Procedures.


state: CT

facility_name: Bridge Family Center, Inc /WH STAR/ Freymann House

summary: Visit conducted on 12-6-23. No compliance issues identified. Implemented 1 corrective actions.

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 Bridge Family Centers- Freymann House STAR program

TIME OF VISIT (FROM - TO):      1:15pm-3:30pm                    DATE: 12-6-23

AGENCY PERSONNEL WHO PARTICIPATED:
Job Titles:
•	Program Manager
•	Youth Worker (3)
•	Client (3)

List of Areas / Topics covered during visit:  This was a scheduled Licensing visit to meet with the Program Manager and to tour the physical plant.

A meeting was held with the Program Manager. Discussion included:
•	Census = 6, with two clients currently in detention.
•	One new admission (N.) remains in detention after going AWOL from program shortly after admission.
•	Two staff scheduled to take medication administration certification exam next week; two other staff waiting to complete onsite practicum in order to obtain certification.
•	Staffing schedule for December received.
•	November medication administration records have been reviewed by the nurse.
•	Daily schedule reviewed, including mealtimes and meal prep responsibility.
•	Restorative Justice activities: New daily group each afternoon; Use of 'Circle Forward' manual; Brief visit from Restorative Justice consultant on 12-4-23 to observe the process, with another visit scheduled later this month; social skills group.
•	School plans for clients: Client S. has been discharged from school and will be provided a tutor. Client V. has been discharged from school - had a preplacement visit yesterday for another facility.
•	DCF Licensing semiannual personnel file review scheduled for late December.
•	Confirmed dates for the April 2024 biennial relicensing inspection.
•	CSI consultant activities for Freymann House.
•	Staff vacancies:
?	Program nurse's last day is 12-8-23 and interviews for replacement have occurred;
?	One FT second shift behavior specialist;
?	5 PT bi-weekly weekend slots;
?	New clinician hired with a 1-9-24 start date;
?	Director of Residential Services has resigned, effective next month - interim Director has been identified.

Physical Plant: 	Program Manager facilitated a tour of the physical plant.
•	The first, second and third floors were toured.
•	Common areas (kitchen, living room, library) appeared clean and organized.
•	Bedrooms and bathrooms appeared generally clean and organized.
•	Unoccupied bedrooms are locked.
•	Interior painting on the second and third floors completed, although the lower half of second floor bathroom walls are in need of repainting.
•	Paper towel holders installed in bathrooms.
•	All bedroom windows contain new shades.
•	New beds, mattresses and dressers placed in bedrooms, waiting on one additional mattress delivery.
•	Bedroom doors have been labeled.
•	New exercise bike placed in lower level.
•	Updated daily routine schedules posted in living room.
•	Clients have large amount of personal effects in bedrooms- additional storage containers needed in some rooms.
•	Gap observed at bottom of entrance door - wind guard needed.
•	Medication administration room observed.

Milieu:
•	A client (E.) returned from detention during the Licensing visit.
•	Three clients socializing in a bedroom.
•	Two direct care staff observed supervising clients.
•	Clients eager to participate in afternoon rec activity.

Recreation:
•	Meeting held with direct care worker responsible for creating monthly activity schedule.
•	Clients have input on activity planning.
•	Reviewed the December activity schedule.

Corrective Actions implemented as a result of previous visit: A service development plan was submitted following a November Licensing visit. The plan was accepted by the Department.

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

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

Kathleen Forsythe, LCSW                                                  				Date: 12-11-23
______________________________
Regulatory Consultant

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM.
Cc: Interim Director of Residential Services
      Director of Residential Services
      Program Manager|


raw_content:
DCF Corrective Action Plan – The Bridge – Freymann House STAR Site

Corporate Name:       The Bridge Family Center	Program Name: Freymann House STAR                   Date: 11/7/23

The plan of correction should include specific goals, objectives, and steps that effectively reflect the issues described above. Please submit this plan to the undersigned by the close of business on 1/7/24. We hope to continue an ongoing dialogue with you as you work on the plan of correction. If you have any questions, please feel free to contact Kathleen Dituccio at kathleen.diticco@ct.gov

Area Needing Attention	The Bridge Plan of Correction	Completion Date	Title/Person Responsible to Monitor Plan
1.	Section 17a-145-62. Chief administrative officer (Each facility shall provide the staff and complementary services to enhance the physical and emotional well-being and ensure the safety of the children.
a)	Submit a detailed plan outlining how staff are trained in all policies and practices to perform their job effectively, and documentation of when staff are trained to include the staff’s written acknowledgement.
b)	Submit a plan to empower and model for staff how to engage, and confidently and consistently address issues/incidents with youth that arise in the program. For example, submit a detailed plan to ensure staff engage and intervene in arguments & physical altercations among residents in a timely and appropriate manner.
c)	Submit a plan to ensure that residents receive timely medical attention, care, and support when they are observed under the influence of alcohol or drugs.
d)	Submit a plan and concrete calendar to ensure that there is a consistent activity schedule for the residents.

2.	Supervision:  Section 17a-145-60. Written policies and procedures

a)	Submit a plan to provide adequate and consistent supervision of all residents.
b)	Submit a plan to keep residents safe when there are verbal and physical disputes among residents.
c)	Submit a plan regarding mealtimes and appropriate spaces for youth to eat (i.e., not in bedrooms.) Include a plan for training staff to effectively enforce these procedures.
d)	Submit procedures that outline when and why youth are given community time and include expectations of appropriate community behavior and guidelines around what behaviors would remove privileges. Include a plan to train staff around these procedures.

3.	Section 17a-145-86. Instructions in Safety Procedures. Supervision.

a)	Submit a plan to ensure that nothing is hung by residents on the sprinkler system.
b)	Submit a plan that ensures youth do not have any contraband or paraphernalia (vape, gummies) on their person or in their rooms and a plan to address these infractions when they occur. Also include a plan to train staff regarding these procedures.

4.	Section 17a-145-75.  Health and medical treatment.  Administration of first aid.  Prescription medication.
 Administration of medicine or    treatment.  Written records.  Storage of drugs, medicines, and instruments.  Sick room, telephone.
a)	Submit a detailed plan to ensure the RN checks transcriptions and MARs to identify medication errors/missed medications, trends or recurrent problems for youth, as required.
b)	Submit a detailed plan to ensure RN reviews and signs off on physician's orders transcribed to MAR by medication certified staff and that RN, on a monthly basis, checks that all prescription/ orders are current, correctly transcribed on the medication record, match the pharmacy labels and ensure that the medications are stored properly.
c)	Submit a detailed plan to ensure all mediation certified staff and LPN activities are supervised by RN and that the RN cannot function as an APRN if not hired in said (APRN) role.  Include in the plan that the agency's policy is reinforced through continued in service education to staff by the RN.
d)	Submit a detailed plan to ensure medication certified staff cannot receive verbal orders/directive regarding changes in the youth's medication or treatment therapy over the phone.
e)	Submit revised policy to include directive to program staff on measures to follow when youth AWOL and had medication therapy and indicate how staff will be made aware of the policy and expectations.

5.	Physical Plant
Submit a plan to ensure that the following is rectified:
a)	Replace the 3rd floor fire extinguisher.
b)	Submit a plan to ensure that youth are complying with chores (cleaning rooms and bathrooms, other chores) to include what happens when this does not happen. Also include a plan to train staff regarding these procedures.
c)	Replace broken blinds in the third-floor bathroom and bedroom.|

report_type: unstructured


summary: Visit conducted on 11-2-23. Found 3 compliance issues. Implemented 4 corrective actions.

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 Bridge Family Centers- Freymann House STAR program

TIME OF VISIT (FROM - TO):      12:00pm-2:00pm                    DATE: 11-2-23

AGENCY PERSONNEL WHO PARTICIPATED:
Job Titles:
•	Program Manager
•	Clinical Coordinator
•	Youth Worker (2)
•	Clinical Intern
•	Client (4)
•	Community Solutions, Inc. Consultant

List of Areas / Topics covered during visit:  This was a scheduled Licensing visit to meet with the Program Manager and to tour the physical plant.

A meeting was held with the Program Manager and Clinical Coordinator. Discussion included:
•	Recent 10-31-23 incident in which a client assaulted two staff and a peer. Client involved currently at CCMC; program request to DCF to find another placement for this client.

•	Staff vacancies: Two full-time second shift & five part-time weekend vacancies with one pending hire. Currently one perdiem staff on the roster. Three Harwinton House staff have worked at Freymann in recent weeks; new Behavioral Specialist position has been posted.

•	Second shift management:
o	Program Manager reported that Freymann House had a second shift supervisor in the past but position no longer exists; reported that staff work out division of duties and contact an administrator on-call if needed.

•	Census: Program currently has five residents. LBC = 9 with 6 beds reserved for DCF.

•	Headcount procedures and documentation.

•	Requested Program Manager to follow up and ensure submission of more than a dozen missing Significant Event Reports to DCF Risk Management for incidents from the past few weeks.

•	The Bridge Family Centers partnership with Community Solutions, Inc. (CSI) for recent 3-day TCI restraint training for staff; Bridge Family Centers currently has two TCI instructors on staff; Consultant from CSI providing consultation at Bridge STAR homes.
.
•	Program meeting scheduled on site this date with Program Manager from another facility to follow up on event involving Freymann House client on a pre-placement visit.

•	School attendance: Majority of clients refuse to attend school; follow up needed with assigned DCF workers; one client currently has no school placement assigned; school social worker for one client visited house twice; no academic programming offered in the house for clients refusing to attend school.

•	Clinical Coordinator Schedule: Sixteen (16) hours per week at Freymann House that includes one 'late night' until 7:00pm.

•	Physical Plant updates:
o	Third floor bedrooms (3) and the hallway have been painted by contractors since last Licensing visit in late September; second floor painting is scheduled; whole house interior painting to continue in coming weeks.
o	New furniture has been ordered to include 5 bed frames, seven mattresses, 2 box springs, 5 bed platform boards, 2 dressers and 5 tall chests; furniture delivery is expected 11-9-23. New dining chairs to be ordered mid-November.
o	Bedroom doors to be labeled once painting is complete.

•	Biennial relicensing inspection to be conducted in April 2024.

•	Weekly recreation budget of $250.00; types of activities scheduled; client recreation schedule is displayed each month.

•	How contraband is stored.

•	Incentive planning (individual and group) to encourage client participation in program routine, and to discourage vaping and AWOL behaviors.

•	Meal preparation: Program Manager reported that staff cook dinner;  clients are responsible to prepare their own breakfast and lunch; more than ample supply of food observed in the house; menus posted in kitchen.

Physical Plant: 	See Areas of Regulatory Non-compliance below.
Program Manager and a direct care worker facilitated a tour of the physical plant. The first, second and third floors were toured. Items discussed/observed during tour included:
•	Common areas (kitchen, living room, library) appeared clean and organized.
•	Bedrooms, hallways and stairs in need of vacuuming.
•	Only two of the six bedrooms were organized with beds made; One client bedroom on second floor was extremely messy - client was observed lying on a bed on a cell phone and stated she would begin cleaning the room.
•	Two client bathrooms were messy with toilet paper and paper towels not in holders; large amounts of hair observed on floor; rusty window blinds observed in 2nd floor bathroom, which lacks a toilet paper holder. And paper towels.
•	Two aerosol cans (furniture polish and bathroom cleaner) were observed on a shelf in an open closet inside a bedroom - Program Manager removed cans and locked inside a supply closet.
•	Evidence of patchwork on walls in stairwells in preparation of scheduled painting.
•	'Guts' book utilized for communication with staff.
•	No posted November recreation schedule.
•	Posted daily routine schedule.
•	Board games and books were observed in library room next to kitchen.
•	Cleaning supply closet in kitchen is locked.
•	Hygiene supply cabinet available for client use outside of bathroom.
•	A window in a bedroom off the kitchen does not contain curtains or blinds for privacy. Manager pointed to a blanket on an unmade bed and reported that a blanket is placed over the window at night.

Milieu:
•	One direct staff member, Program Manager, Clinical Coordinator and Clinical intern were present in the house with two clients at start of visit; one client was attending an off-site education program.
•	A second direct care female staff member returned to the house with two clients following a medical appointment.
•	Observation of three clients receiving delivery packages from Program Manager; opening of packages in staff presence to ensure no contraband was received.
•	No lunch preparation or consumption was observed during the Licensing visit.
•	Direct care staff confirmed there is no 'lead' or 'in-charge' staff on second shift; reported the house is "unorganized".

CSI Consultant:
•	A brief meeting was held with consultant from Community Solutions, Inc. Consultant who arrived at the house; started 10-2-23 and is reportedly assisting with training needs, onboarding of new staff, distribution of surveys, etc. Reported conducting one onsite visit per week at each of the four Bridge STAR programs.

Corrective Actions implemented as a result of previous visit:
•	Interior house painting completed on third floor; painting on all floors to be completed by end of the month.
•	New bedroom furniture and mattresses have been ordered - anticipated delivery next week.
•	A completed service development plan following a late September 2023 Licensing visit was received by the Department on 10-23-23.

Areas of regulatory non-compliance identified during this visit:
17a-145-73		Sleeping Accommodations.
•	Several bedrooms are extremely disorganized and in need of a deep clean.
•	A window in one bedroom next to the kitchen does not contain a window covering (blinds, curtains, etc.) for privacy.

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

Kathleen Forsythe, LCSW                                                  				Date: 11-3-23
______________________________
Regulatory Consultant

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM.
Cc: Director of Residential Services
      Program Manager|

type: general

description: 73 Sleeping Accommodations.


summary: Visit conducted on 9-29-23. Visit covered 1 main areas/topics. Found 8 compliance issues.

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 Bridge Family Centers- Freymann House STAR program

TIME OF VISIT (FROM - TO):      11:30am-1:15pm                 DATE: 9-29-23

AGENCY PERSONNEL WHO PARTICIPATED:
Job Titles:
•	Program Director
•	Youth Worker
•	Clinical Intern
•	Client (1)

List of Areas / Topics covered during visit:  This was a scheduled Licensing visit for this newly assigned Regulatory Consultant and the DCF Licensing Unit Manager to meet with the Program Manager and to tour the physical plant.

Tour of the physical plant facilitated by the Program Manager. The first, second and third floors were toured. See Areas of Regulatory Non-compliance below.

Items discussed during tour included:
•	Freezer chest in storage room is in need of defrosting and contains a broken thermometer.
•	Labeling bedrooms for identification.
•	Enhancing client safety in bedrooms.
•	Infection control practices for beds prior to new admissions.
•	Posting emergency phone numbers; lack of house phone on third floor.
•	Menus.
•	Motion sensors on interior staircases; nonfunctioning sensor on front interior staircase.
•	One Bridge maintenance staff member reportedly conducts monthly walk-throughs; maintenance request procedure.

Milieu: Clients were not present in the house at the start of the visit. One client returned to the program during the visit with a community support worker. A new female youth worker was present, as well as a Clinical intern.

A meeting was held with the Program Director and the Regulatory Consultant. Topics discussed included:
•	Census=5. LBC = 9, with seven beds reserved for DCF clients.
•	Staff vacancies: 1 full time 1st shift, 2 full time 2nd shift, 1 part-time biweekly staff.
•	Bridge Family Centers 'hands-off' practice.
•	TCI restraint training for staff of four types of hands-on techniques.
•	Client cell phone practices.
•	Recreation activities.
•	Staffing ratios.
•	DCF Monthly Restraint/Seclusion reporting requirement.
•	Overview/status of five current residents and length of stay (ranges from one week to 6 months).
•	One resident refusing to attend school; efforts of program to engage resident in educational programming.
•	Roster of medication administration certified staff (10).

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

Areas of regulatory non-compliance identified during this visit:

17a-145-73	Sleeping Accommodations.
•	Walls in the six bedrooms contain damage, chipped/peeling paint, and graffiti.
•	Bedrooms contain mattresses that are dirty/stained, some with tears, and lack protective coverings.
•	The window in bedroom # 3 does not contain curtains, blinds, etc. for privacy.
•	Missing mattress in bedroom #4.
•	Exposed wires in a second-floor bedroom.
•	Dressers in bedrooms are damaged.

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

Kathleen Forsythe, LCSW
______________________________             Date: 10-10-23
Regulatory Consultant

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

Cc: Director of Residential Services
      Program Manager|

description: 73 Sleeping Accommodations.

description: Missing mattress in bedroom #4.

description: Exposed wires in a second

description: floor bedroom.

description: Dressers in bedrooms are damaged.


summary: Visit conducted on ___6/12/23. Visit covered 5 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: _Bridge Family Center / Freymann House

 TIME OF VISIT (FROM - TO):       ___11:15am to 1pm_____________________               DATE: ___6/12/23

 AGENCY PERSONNEL WHO PARTICIPATED:

	Job Title
	Program Manager

List of Areas / Topics covered during visit:  .
•	Current Census= 7. LBC 6 DCF and 3 Community beds. Total Bed Capacity 9.
o	One youth is using one of the Community beds.
•	Physical plant inspection of the Group Home. No concern.
•	Discussed the programing challenges and resident's treatment and compliance.
•	Discussed staffing of shifts.  2nd shift has no FTE vacancies, but is looking to fill shifts using parttime and per diem staff.
•	Discussed the length of stay for youth.

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                           ___8/4/23_______
Regulatory Consultant                                   Date

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

facility_name: _Bridge Family Center / Freymann House


summary: Visit conducted on ___3/29/23. Visit covered 6 main areas/topics. No compliance issues identified.

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

Field Visit Reporting Form

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

  NAME OF FACILITY / PROGRAM: _Bridge Family Center / Freymann House

 TIME OF VISIT (FROM - TO):       ___9:45 to 12pm_____________________               DATE: ___3/29/23

 AGENCY PERSONNEL WHO PARTICIPATED:

	Job Title
	Program Manager
	Director of Residential Services
	Youth Worker

List of Areas / Topics covered during visit:  .
•	Current Census= 6. LBC 9- 6 DCF and 3 Community beds.
•	Physical plant inspection of the Group Home.  No concern.
•	Discussed the programing challenges and resident's treatment and compliance.
•	Discussed staffing of shifts. Vacancy one full time youth worker on 1st and 2nd shifts
•	Reviewed controlled medication.  No concern.

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                           ___4/4/23_______
Regulatory Consultant                                   Date

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


summary: Visit conducted on ___9/1/2022. 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: _Bridge Family Center / Freymann House

 TIME OF VISIT (FROM - TO):       ___9:20am_______________________               DATE: ___9/1/2022

 AGENCY PERSONNEL WHO PARTICIPATED:

Name	Job Title
CD	Program Manager
KP	Clinical Director of Residential Services

List of Areas / Topics covered during visit:  .
•	Census. One resident is in school and the other in hospital.
•	Physical plant inspection of the Group Home.  See below.
•	Discussed the programing challenges and resident's treatment and compliance.
•	Discussed staffing of shifts.
•	One case record reviewed and in compliance.

Corrective Actions implemented as a result of previous visit:

Areas of regulatory non-compliance identified during this visit:
Section 17a-145-73.  At the time of the licensing visit one of the bedrooms cloths and numerous items on the floor.  The room was cluttered.  Prior to the end of the visit the room was cleaned and organized.  No further action 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                           ___11/7/2022_______
Regulatory Consultant                                   Date

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


facility_name: Greater Bridgeport Adolescent Prog./Phoenix House

summary: Visit conducted on ___3-18-26_____. Visit covered 7 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: ____GBAPP Phoenix Shelter__________________________________

 TIME OF VISIT (FROM - TO):       __________________________         DATE:___3-18-26_____

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:

SB - Lead Housing Specialist

List of Areas / Topics covered during visit:
•	Current census - 0. The last admission was in December 2025. There have been inquiries about the program and there was a possible pending admission.
•	No new staff have been hired since the last visit.
•	Physical plant tour. Bedrooms, bathrooms and common areas were clean and free from clutter. One bedroom did not have a bed. Staff reported that a bed would be placed in the room.
•	Review of the case record of a resident who was admitted in December 2025. The record did not contain a treatment plan or a nursing assessment. The youth was discharged on 1-1-26 (apartment).
•	Staff indicated that they have been doing outreach in the community and inquiries about the program have increased. The criteria for admission into the shelter was discussed.

Corrective Actions implemented as a result of previous visit: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Areas of regulatory non-compliance identified during this visit:

Section 17a-145-93. Medical, dental and nursing care.
•	Documentation of a nursing assessment done within 72 hours of admission was not provided for the resident admitted in December.

Section 17a-145-94 Written treatment plan.
•	There was no treatment plan in the record that was reviewed.

Please submit a service development plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The service development plan must be submitted to the attention of the undersigned at the address listed above.
     Terri Bohara                                                 3-20-26
______________________________            _________________
Regulatory Consultant                                   Date

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

description: 93. Medical, dental and nursing care.


summary: Visit conducted on __9-3-25______. Visit covered 11 main areas/topics. 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: ____GBAPP - Phoenix House__________________________________

 TIME OF VISIT (FROM - TO):       ____Morning_______           DATE:__9-3-25______

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:
SB - Lead Housing Specialist

List of Areas / Topics covered during visit:
•	Census - 0  The most recent admission was in July.
•	There are currently 2 staff openings.
•	Physical plant tour. No issues. Bedrooms and bathroom were clean.  Common area was clean.
•	There is currently no med certified staff on 3rd shift but staff are available to come in as needed.
•	Review of the case record of a recently admitted youth. DOA -7-8-25/DOD 7-23-25.  Consent for placement signed by parent. Release of information only signed by child.  Staff were informed that as minors, the residents are legally not able to give permission. Bio-psychosocial assessment and nursing assessment were both completed. The treatment plan was reviewed after the visit. The discharge summary was completed. Documentation was comprehensive.
•	Outreach efforts in the community continue.  It was suggested that contact with 2nd shift staff at bus/train stations may be helpful in getting information out to individuals who may benefit from the program.
•	The program is no longer on a provisional license. Quarterly visits will be implemented beginning next quarter.

Corrective Actions implemented as a result of previous visit: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Areas of regulatory non-compliance identified during this visit:

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

___Terri Bohara      ______________________9-15-25______________________
Regulatory Consultant                                   Date

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


summary: Visit conducted on _7-1-25_______. 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: ____GBAPP - Phoenix House shelter__________________________________

 TIME OF VISIT (FROM - TO):       _Un-announced - noon_________________________  DATE:_7-1-25_______

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:
Youth Coach (MJ)

List of Areas / Topics covered during visit:
•	Census - 0. There has only been one admission (March 2025) to the shelter since the initial licensure.
•	Staff continue to be assigned to the shelter but also help out in other GBAPP programs. There is always one person available to take calls.
•	Recruitment in the community continues. It was suggested that at least some of the recruitment occur in the evening when potential clients are more likely to be out at bus and train stations. It was also suggested that outreach be done with police department youth officers and anti human trafficking agencies.
•	The provisional license will continue.
•	Bedrooms and common areas were clean and free of clutter.

Corrective Actions implemented as a result of previous visit: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Areas of regulatory non-compliance identified during this visit:
•	No citations

Please submit a service development plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The service development plan must be submitted to the attention of the undersigned at the address listed above.
   Terri Bohara                                                 7-7-25
______________________________            _________________
Regulatory Consultant                                   Date

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

description: No citations


summary: Visit conducted on __5-7-25______. Visit covered 10 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: ______GBAPP - Phoenix House________________________________

 TIME OF VISIT (FROM - TO):       _____Morning_____________________         DATE:__5-7-25______

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:
MP - Director
SB - Case Manager

List of Areas / Topics covered during visit:
•	Census - 0. There has been one admission into the program (March).
•	Review of one personnel file. There was no documentation of CPR certification.
•	A scheduled visit by the federal agency overseeing the program did not occur as the unit responsible was disbanded.
•	Grants Management (Federal agency) is currently subject to DOGE oversight.  There have been changes in the way access to funds is handled.
•	The program continues to look at ways to improve referrals. Discussed the need to pursue other resources as schools will be closing in approx. a month.
•	Review of case record (DOA 3-10-25/DOD 3-27-25).   Required documentation (Assessments, treatment plan, case notes) was in the record.
•	The discharge summary did not note that the resident was discharged to his legal guardian and the identifying information.

Corrective Actions implemented as a result of previous visit: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Areas of regulatory non-compliance identified during this visit:

Section 17a-145-96 Personnel policies and procedures.
•	One personnel file reviewed did not have documentation of current CPR certification.

Section 17a-145-96 Discharge of child.
•	The discharge summary did not indicate that the child was discharged to his legal guardian.

Please submit a service development plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The service development plan must be submitted to the attention of the undersigned at the address listed above.
    Terri Bohara                                                     5-16-25
______________________________            _________________
Regulatory Consultant                                   Date

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

description: 96 Personnel policies and procedures.

personnel:
MP - Director
SB - Case Manager


summary: Visit conducted on _3-5-25_______. Visit covered 6 main areas/topics. 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: ___GBAPP  Phoenix Shelter___________________________________

 TIME OF VISIT (FROM - TO):       __________________________         DATE:_3-5-25_______

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:
MP - Director

List of Areas / Topics covered during visit:
•	Census - 0  There have been outreach efforts to the community to raise awareness about the program and to let schools and various businesses know that it is an option for homeless youth. The program has received calls but the youth have not been appropriate for the program. Outreach has also been made to the Norwalk and Bridgeport DCF offices.
•	The previous supervisor resigned from her position. There are several part-time openings. (One 24 hr. 2nd shift;1 weekend 1st shift; 1 evening Saturday position; 2 3rd shift staff for Wednesday). The agency does not utilize any third party agency staff. An updated staffing list and schedule was provided.
•	Staff take CPR classes in the community and PMT classes in Middletown. Some staff are in the process of becoming med certified but have not completed the training.  There are currently no med certified staff in the program but there are staff in other programs who reportedly maintain their med admin certification. The program nurse has not yet provided staff with the Epi-Pen training.

Corrective Actions implemented as a result of previous visit: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Areas of regulatory non-compliance identified during this visit:

Please submit a service development plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The service development plan must be submitted to the attention of the undersigned at the address listed above.
     Terri Bohara                                               3-13-25
______________________________            _________________
Regulatory Consultant                                   Date

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


summary: Visit conducted on __1-13-25________________. 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: _____GBAPP - Phoenix House ___________________________________

 TIME OF VISIT (FROM - TO): Morning                     DATE: __1-13-25________________

 AGENCY PERSONNEL WHO PARTICIPATED:

Name	Job Title
TJ	Program Director

List of Areas / Topics covered during visit:
•	Census - 0. There have been no admissions since the program was licensed in November. Outreach to the community is continuing.
•	There are several part-time positions open, There are 2 second shift openings and 1 opening on both first and third shifts. The director indicated that the shifts are currently being covered by her and others in the program.  The nurse is on call as there are no residents. The PD is pursuing her medication administration certificate.
•	The bedrooms and bathroom were clean and well maintained.
•	A second provisional license will be issued.

Corrective Actions implemented as a result of previous visit: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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

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.

___Terri Bohara     ___________________________            ___1-14-25______________
Regulatory Consultant                                   Date

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

visit_time: Morning


facility_name: Kids In Crisis, Inc. / Cottage-Adolescent Shelter

summary: Visit covered 5 main areas/topics. No compliance issues identified.

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

Field Visit Reporting Form

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

NAME OF FACILITY / PROGRAM:        		Kids in Crisis-Cottage (Adolescent Shelter)

 TIME OF VISIT (FROM - TO) 10:40-11:30am                         					DATE:  9/10/25

 AGENCY PERSONNEL WHO PARTICIPATED:

Executive Director, Managing Director, Program Director

List of Areas / Topics covered during visit:

•	Census (2) LBC (10)
•	Program updates:  Length of stay is increasing due to barriers with discharge.
•	Staffing Vacancy: Two (2) day positions and one (1) is an overnight position.
•	Staff/client interactions: Both residents were at the dining table eating lunch. Staff were observed either eating with youth or in the kitchen preparing ands cleaning up lunch.
•	Physical plant was observed to be clean.

Corrective Actions implemented as a result of previous visit:

•	Not applicable

Areas of regulatory non-compliance identified during this visit:

•	None at the time of this quarterly visit.

Amita Patel
Regulatory Consultant                                   Date 9/26/25

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


raw_content:
July 9, 2025

Shari Shapiro, Executive Director
Kids in Crisis
1 Salem Street
Cos Cob, CT 06807

RE: CCF # 5 Cottage/Adolescent Shelter

Dear Ms. Shapiro,
On 5/13/25, a relicensing inspection was conducted at your facility.  This inspection was conducted to determine the compliance of this program with the Regulations for the Licensure of a Child Caring Facility, Sections 17a-145-59  through 17a-145-98.  Listed below are the areas of regulatory non-compliance which were identified during the relicensing inspection.  Please review the areas identified and submit the enclosed service development plan 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:

Section 17a-145-64:  Personnel policies and procedures:
•	One (1) file reviewed was missing employee physical form.
•	One (1) file reviewed was missing dates and results of TB testing.

Section 17a-145-74:  Lavatory facilities:  Toilet articles and linens:
•	The bottom of the bathtub is heavily scoffed.  (The program has been looking into all options to address prior to replacing)

17a-101  Protection of Children from Abuse. Mandated Reporters. Educational and Training Programs. Model Mandated Reporting Policy:
•	Two (2) files reviewed were missing evidence that mandated reporter training was completed by employees.

17a-131 Cardiopulmonary Resuscitation Training Required for Persons Who Directly Supervise Children:
•	-Two (2) files reviewed were missing evidence employees completed CPR training.

17a-151    Investigation. Issuance of license or provisional license. Revocation, suspension or limitation of license. Appeal:
•	One (1) file reviewed was missing out of state CPS background check for NY state.

46a-154. Internal monitoring, training and development of policies and procedures required and subject to state agency inspection.
•	Five files (5) were missing evidence that employees completed Restraint Training in the Therapeutic Crisis Intervention/TCI course.

.
Amita Patel
AMITA PATEL, LMSW
REGULATORY CONSULTANT

505 Hudson Street Hartford, CT 06106
Cell Phone: 860-924-8822 | ?Office Phone: 860-550-6373|


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

Field Visit Reporting Form

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

  NAME OF FACILITY / PROGRAM:        		Kids in Crisis-Cottage (Adolescent Shelter)

 TIME OF VISIT (FROM - TO) 12-12:30pm                         					DATE:  1/9/25

 AGENCY PERSONNEL WHO PARTICIPATED:

Executive Director, Managing Director, Program Director

List of Areas / Topics covered during visit:

•	Census (5) LBC (10)
•	Program updates:  Funding secured for upgraded lighting and new carpeting.
•	Staffing Vacancy: Three (3) youth workers (Full time Day shift (2) and Evening (1)
•	Staff/client interactions:  All residents were at the dining table eating burgers for lunch.
•	Physical plant was observed to be clean.

Corrective Actions implemented as a result of previous visit:

•	Not applicable

Areas of regulatory non-compliance identified during this visit:

•	None at the time of this quarterly visit.

Amita Patel
Regulatory Consultant                                   Date 1/14/25

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


summary: 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:        		Kids in Crisis-Cottage (Adolescent Shelter)

 TIME OF VISIT (FROM - TO) 10:30-11:15am                         				DATE:  10/22/24

 AGENCY PERSONNEL WHO PARTICIPATED:

Executive Director, Managing Director

List of Areas / Topics covered during visit:

•	Census (10) LBC (10)
•	Program updates/ Programming (youth from both KIC programs can co-mingle with supervision)
•	Staffing Vacancy: None
•	Staffing updates: There are two nurses in the program (APRN, RN)
•	Staff/client interactions:  All residents were at the dining table having a snack.
•	Physical plant was observed to be clean.
•	Program has a new outdoor patio.

Corrective Actions implemented as a result of previous visit:

•	Not applicable

Areas of regulatory non-compliance identified during this visit:

•	None at the time of this quarterly visit.

Amita Patel
Regulatory Consultant                                   Date 12/18/24

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


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

Field Visit Reporting Form

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

  NAME OF FACILITY / PROGRAM:        		Kids in Crisis-Adolescent Shelter

 TIME OF VISIT (FROM - TO)  11:15am-12pm                         				DATE:  7/17/24

 AGENCY PERSONNEL WHO PARTICIPATED:

Executive Director

List of Areas / Topics covered during visit:

•	Census (2)  LBC (12)
•	Program updates
•	Staffing Vacancy:  One (1) full time clinician and program director.  Temporary clinical coverage being provided by Teen Talk Counselor.
•	Staff/client interactions:  Two (2) youth were observed in the program getting ready to go on outing with staff.
•	Physical plant was observed to be clean

Corrective Actions implemented as a result of previous visit:

•	Not applicable

Areas of regulatory non-compliance identified during this visit:

•	None at the time of this quarterly visit.

Amita Patel
Regulatory Consultant                                   Date 7/19/24

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

facility_name: Kids in Crisis-Adolescent Shelter


summary: Visit conducted on 5/15/24. Visit covered 5 main areas/topics. No compliance issues identified.

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

Field Visit Reporting Form

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

  NAME OF FACILITY / PROGRAM:        Kids in Crisis-Adolescent Shelter

 TIME OF VISIT (FROM - TO): 11:30-12:30                         DATE:  5/15/24

 AGENCY PERSONNEL WHO PARTICIPATED:

Program Director

List of Areas / Topics covered during visit:

•	Census (4)  LBC (8)
•	Program updates
•	Staffing:  PD position will be vacant in June 2024.
•	Staff/client interactions:  No youth were observed as all youth were attending school in the community.
•	Physical plant was observed to be clean

Corrective Actions implemented as a result of previous visit:

•	Not applicable

Areas of regulatory non-compliance identified during this visit:

•	None at the time of this quarterly visit.

Amita Patel
Regulatory Consultant                                   Date 6/14/24

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


summary: Visit conducted on 3/26/2024. Visit covered 5 main areas/topics. No compliance issues identified.

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

Field Visit Reporting Form

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

  NAME OF FACILITY / PROGRAM:        Kids in Crisis-Adolescent Shelter

 TIME OF VISIT (FROM - TO): 11:30-12:30                         DATE:  3/26/2024

 AGENCY PERSONNEL WHO PARTICIPATED:

Program Director

List of Areas / Topics covered during visit:

•	Census (5)  LBC (8)
•	Program updates
•	Staffing:  There are two (2) vacant full time youth counselor positions (overnight, day shift)
•	Staff/client interactions:  No youth were observed as all youth were attending school in the community.
•	Physical plant was observed to be clean

Corrective Actions implemented as a result of previous visit:

•	Not applicable

Areas of regulatory non-compliance identified during this visit:

•	None at the time of this quarterly visit.

Amita Patel
Regulatory Consultant                                   Date 3/27/24

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


facility_name: Kids In Crisis, Inc. /Farm House Nursery Shelter

summary: Visit conducted on 9/10/25. Visit covered 6 main areas/topics. No compliance issues identified.

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

Field Visit Reporting Form

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

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

TIME OF VISIT (FROM - TO):  12-12:30					                      DATE: 9/10/25

AGENCY PERSONNEL WHO PARTICIPATED:

Executive Director, Managing Director, Program Director

List of Areas / Topics covered during visit:

•	Census: (3 males) LBC (10)
•	Program updates:  New program director
•	Staffing vacancies: Four (4) positions open-Two (2) are day positions and two (2) are overnight positions.
•	Staff/client interactions: no youth were present as they were attending school.
•	Physical plant observed and clean.

Corrective Actions implemented as a result of previous visit:

•	Not applicable

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

Amita Patel
Regulatory Consultant                                   Date 9/26/25

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

facility_name: Kids in Crisis-Farm House (Nursery)

personnel: •	Program updates:  New program director


raw_content:
July 9, 2025

Shari Shapiro, Executive Director
Kids in Crisis
1 Salem Street
Cos Cob, CT 06807

RE: CCF # 10 Farmhouse/Nursery Shelter

Dear Ms. Shapiro,

On 5/13/25, a relicensing inspection was conducted at your facility.  This inspection was conducted to determine the compliance of this program with the Regulations for the Licensure of a Child Caring Facility, Sections 17a-145-59 through 17a-145-98.  Listed below are the areas of regulatory non-compliance which were identified during the relicensing inspection.  Please review the areas identified and submit the enclosed service development plan 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:

Section 17a-145-64:  Personnel policies and procedures:
•	One (1) file reviewed did not have the clinical licensure verification for program clinician.

Section 17a-145-98. Case records. Reports. Confidentiality
•	Three (3) reviewed files did not have evidence of a clinical service delivery or documentation.

Section 17a-145-94  Written Treatment Plan
•	Three (3) reviewed files did not have evidence of documented treatment plans.

Section 17a-145-96  Discharge of child
•	Two (2) reviewed files did not indicate youth was discharged to legal guardian/designee.

17a-101  Protection of Children from Abuse. Mandated Reporters. Educational and Training Programs. Model Mandated Reporting Policy:
•	Two (2) files reviewed were missing evidence that mandated reporter training was completed by employees.

17a-131 Cardiopulmonary Resuscitation Training Required for Persons Who Directly Supervise Children:
•	Four (4) files reviewed were missing evidence employees completed CPR training.

17a-151    Investigation. Issuance of license or provisional license. Revocation, suspension or limitation of license. Appeal:
•	Two (2) files reviewed was missing out of state CPS background check.

46a-154. Internal monitoring, training and development of policies and procedures required and subject to state agency inspection.
•	Five files (5) were missing evidence that employees completed Restraint Training in the Therapeutic Crisis Intervention/TCI course.

Amita Patel
AMITA PATEL, LMSW
REGULATORY CONSULTANT

505 Hudson Street Hartford, CT 06106
Cell Phone: 860-924-8822 | ?Office Phone: 860-550-6373|


summary: Visit conducted on 1/14/25. Visit covered 6 main areas/topics. No compliance issues identified.

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

Field Visit Reporting Form

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

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

TIME OF VISIT (FROM - TO):  12:30-1pm						                      DATE:  1/14/25

AGENCY PERSONNEL WHO PARTICIPATED:

Executive Director, Managing Director, Program Director

List of Areas / Topics covered during visit:

•	Census: (1) LBC (10)
•	Program updates:  Funding secured for upgraded lighting and new carpeting.
•	Staffing;  Five (5) full-time and three (3) part time youth workers. Current vacancies being covered by part time staff and relief staff.
•	Staff/client interactions: One(youth) was present having lunch in dining room with staff.
•	Physical plant observed and clean.

Corrective Actions implemented as a result of previous visit:

•	Not applicable

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

Amita Patel
Regulatory Consultant                                   Date 1/14/25

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


summary: Visit conducted on 10/22/24. Visit covered 7 main areas/topics. No compliance issues identified.

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

Field Visit Reporting Form

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

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

TIME OF VISIT (FROM - TO):  11:15am-12pm		DATE:  10/22/24

AGENCY PERSONNEL WHO PARTICIPATED:

Executive Director, Managing Director, Program Director, Program Clinician

List of Areas / Topics covered during visit:

•	Census: 4 LBC (8)
•	Program updates/ Programming (youth from both KIC programs can co-mingle with supervision)
•	Staffing;  5 full time (3 day and 2 overnight).  Current vacancies being covered by part time staff and relief staff.
•	Staff/client interactions;  Three (3) youth were in school and one (1) youth in hospital due to vaping over the weekend.
•	Physical plant observed and clean
•	Program has a new outdoor patio

Corrective Actions implemented as a result of previous visit:

•	Not applicable

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

Amita Patel
Regulatory Consultant                                   Date 12/17/24

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


summary: Visit conducted on 7/17/24. Visit covered 6 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:  Kids in Crisis-Nursery

TIME OF VISIT (FROM - TO):  10:45-11:15am                         		DATE:  7/17/24

AGENCY PERSONNEL WHO PARTICIPATED:

Executive Director

List of Areas / Topics covered during visit:

•	Census: 7  LBC 8
•	Program updates
•	Staffing
•	Staff/client interactions (Two (2) residents observed having snack at the dining table.
•	Physical plant observed and clean
•	Program will be adding additional cameras in the stairwell/corridor

Corrective Actions implemented as a result of previous visit:

•	Not applicable

Areas of regulatory non-compliance identified during this visit:

•   Section 17a-145-73:  Sleeping Accommodations:
1)	Several Bedrooms (M4, M5, F1, F2, F3) the hardwood floors have deep scratches.
2)	Bedroom (M3) the desk has writing on it.
3)	Bedroom M1 & M2 the electric switch plate is cracked and there is writing on the wall behind the door.

•	Section 17a-145-74. Lavatory facilities. Toilet articles and linens
1)	Resident bathroom on the lower level has a hole in the wall behind the door.

Amita Patel
Regulatory Consultant                                   Date 7/19/24

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

facility_name: Kids in Crisis-Nursery


summary: Visit conducted on 5/15/24. 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:        Kids in Crisis-Nursery

 TIME OF VISIT (FROM - TO):  10:30-11:30am                         DATE:  5/15/24

 AGENCY PERSONNEL WHO PARTICIPATED:

Program Director

List of Areas / Topics covered during visit:

Census: 6  LBC 12
Program updates
Staffing
Staff/client interactions (All residents were attending school on site).  T/W observed youth in their respective classrooms and all youth were smiling and greeted t/w.
Physical plant observed and clean

Corrective Actions implemented as a result of previous visit:

•	Not applicable

Areas of regulatory non-compliance identified during this visit:

•	None at the time of this quarterly visit.

Amita Patel
Regulatory Consultant                                   Date 6/14/24

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


summary: Visit conducted on 3/26/2024. Visit covered 6 main areas/topics. No compliance issues identified.

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

Field Visit Reporting Form

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

  NAME OF FACILITY / PROGRAM:        Kids in Crisis-Nursery

 TIME OF VISIT (FROM - TO):  10:30-11:30am                         DATE:  3/26/2024

 AGENCY PERSONNEL WHO PARTICIPATED:

Program Director

List of Areas / Topics covered during visit:

•	Census: 6  LBC 12
•	Program updates
•	Staffing
•	Staff/client interactions (All residents were attending school on site).  T/W observed youth in their respective classrooms and all youth were smiling and greeted t/w.
•	Physical plant observed and clean
•	New federal regulations regarding enhanced background checks

Corrective Actions implemented as a result of previous visit:

•	Not applicable

Areas of regulatory non-compliance identified during this visit:

•	None at the time of this quarterly visit.

Amita Patel
Regulatory Consultant                                   Date 3/27/24

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


personnel: List of Areas / Topics covered during visit:

personnel: •	Staff/client interactions (All residents were attending school on site).  T/W observed youth in their respective classrooms and all youth were smiling and greeted t/w.

personnel: •	New federal regulations regarding enhanced background checks

personnel: Corrective Actions implemented as a result of previous visit:


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

summary: Visit conducted on 9/15/25. Visit covered 2 main areas/topics. No compliance issues identified.

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

Field Visit Reporting Form

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

  NAME OF FACILITY / PROGRAM:   Touchstone

 TIME OF VISIT (FROM - TO):       12:15-1:30pm 	                 				DATE: 9/15/25

 AGENCY PERSONNEL WHO PARTICIPATED: Program Director

List of Areas / Topics covered during visit:
•	Current Census=0, LBC=9
•	Staffing:  The majority of staff have returned that were previously laid off during the summer.
o	There are many vacancies due to an increase in LBC (16) approval by ORR: Nurse, Direct Care Staff ( Five (5) third shift, two (2) second shift, Assistant Teacher
o	New positions required by ORR include Lead Medical Coordinator, Prevention Sexual Abuse (PSA) compliance officer, Trainer
•	Milieu observation: No youth in the program.  The census is 0.  Last youth discharged on 2/9/25.
•	Staff/client interactions; None no youth in program.  Staff observed in the kitchen of the main house assisting the program chef.
•	Staff report daily for all shifts.  They continue to work on physical maintenance of all 3 buildings; team building and participate in various trainings.
•	Physical Plant: T/W toured the Dorm, Main House and School buildings. Any newly placed youth would reside in the Main House at this time due to fire marshal approval for the dorm building.  Both buildings, bedrooms and bathrooms observed and clean.  Each building once approved can accommodate up to nine (9) youth.

Corrective Actions implemented as a result of previous visit:

•	Not applicable

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

Amita Patel
Regulatory Consultant                                   							Date  9/30/25

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

facility_name: Touchstone


summary: Visit conducted on 4/21/25. Visit covered 7 main areas/topics. No compliance issues identified.

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

Field Visit Reporting Form

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

  NAME OF FACILITY / PROGRAM:   Touchstone

 TIME OF VISIT (FROM - TO):       10-11am 	                 				DATE:  4/21/25

 AGENCY PERSONNEL WHO PARTICIPATED: Program Director

List of Areas / Topics covered during visit:
•	Current Census=0, LBC=9
•	Staffing:  Vacancy (1) Prevention Sexual Abuse (PSA) compliance officer (ORR newly funded position)
•	Milieu observation:  No youth in the program.  Census is 0.  Last youth discharged on 2/9/25.
•	Programming: Application pending with ORR regarding an increase in census up to 16.
•	Staff/client interactions;  None no youth in program.  Staff observed in kitchen of the main house assisting the program chef.
•	Staff report daily for all shifts.  They work on physical maintenance of all 3 buildings, team building and participate in various trainings.
•	Physical Plant: T/W toured the Dorm, Main House and School buildings. Any newly placed youth would reside in the Main House.  The program is awaiting inspection and town approval for use of the generator providing back up power for the sprinkler system in the Dorm Building. Both buildings, bedrooms and bathrooms observed and clean.

Corrective Actions implemented as a result of previous visit:

•	Not applicable

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

Amita Patel
Regulatory Consultant                                   							Date  5/1/25

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


summary: Visit conducted on 1/14/25. Visit covered 7 main areas/topics. No compliance issues identified.

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

Field Visit Reporting Form

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

  NAME OF FACILITY / PROGRAM:   Touchstone

 TIME OF VISIT (FROM - TO):       9:45-10:15am 	                 				DATE:  1/14/25

 AGENCY PERSONNEL WHO PARTICIPATED: Program Director

List of Areas / Topics covered during visit:
•	Current Census=2, LBC=9
•	Staffing:  Vacancy (1) Prevention Sexual Abuse (PSA) compliance officer (ORR newly funded position)
•	Milieu observation:  Youth were observed in their respective classrooms.
•	Programming: Application pending with ORR regarding an increase in census up to 16.
•	Discharge planning: All youth have been discharging quickly from the program.
•	Staff/client interactions;  Two (2) residents were in their respective classroom and both youth were smiling and greeted t/w.
•	Physical Plant: T/W toured the Main House and School buildings. Youth continue to reside in the Main House as the sprinkler system connection to the generator.  The electric work is complete and the program is awaiting inspection and town approval. Both buildings, bedrooms and bathrooms observed and clean.

Corrective Actions implemented as a result of previous visit:

•	Not applicable

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

Amita Patel
Regulatory Consultant                                   							Date  1/14/25

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


summary: Visit conducted on 12/3/24. Visit covered 7 main areas/topics. No compliance issues identified.

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

Field Visit Reporting Form

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

  NAME OF FACILITY / PROGRAM:   Touchstone

 TIME OF VISIT (FROM - TO):       10:45-11:45am 	                 DATE:  12/3/24

 AGENCY PERSONNEL WHO PARTICIPATED: Program Director and Assistant Program Director

List of Areas / Topics covered during visit:
•	Current Census=8, LBC=9
•	Staffing:  Vacancy (1) Prevention Sexual Abuse (PSA) compliance officer (ORR newly funded position.  Current nurse role has been filled by an RN.
•	Milieu observation:  Youth were observed in their respective classrooms.
•	Programming: Application pending with ORR regarding an increase in census up to 16.
•	Discharge planning: All youth have been discharging quickly from the program.
•	Staff/client interactions (All residents were attending school on site).  T/W observed youth in their respective classrooms and all youth were smiling and greeted t/w.
•	Physical Plant: T/W toured the Dorm, Main House and School buildings. Youth continue to reside in the Main House as the sprinkler system connection to the generator is pending the completion of the electrical work/upgrade.  All buildings, bedrooms and bathrooms observed and clean.

Corrective Actions implemented as a result of previous visit:

•	Not applicable

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

Amita Patel
Regulatory Consultant                                   Date  12/3/24

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


summary: Visit conducted on 6/21/24. Visit covered 7 main areas/topics. 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:   Touchstone

 TIME OF VISIT (FROM - TO):       10-11:30am 	                 DATE:  6/21/24

 AGENCY PERSONNEL WHO PARTICIPATED: Regional Director
					       Assistant Program Director

List of Areas / Topics covered during visit:
•	Current Census=9, LBC=9
•	Staffing:  Vacancy-1 Program Director, Overnight Supervisor, Direct Care (2nd and 3rd shift)
•	Program Updates:  added additional cameras on the side of the residence building and rear of the school building, additional Prevention Sexual Abuse (PSA) resource cell phone added to the residence building.
•	Milieu observation:  Youth were observed in their respective classrooms.
•	Staff/client interactions (All residents were attending school on site).  T/W observed youth in their respective classrooms and all youth were smiling and greeted t/w.
•	Physical Plant: Sleeping Accommodations/Residence Building has temporarily relocated to the building that houses the program kitchen and dining room.  All bedrooms and bathrooms observed and clean.

Corrective Actions implemented as a result of previous visit:

•	Not applicable

Areas of regulatory non-compliance identified during this visit:

•	Section 17a-145-73. Sleeping accommodations
One (1) bedroom was missing a window screen.

Amita Patel
Regulatory Consultant                                   Date  6/27/24

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

description: Section 17a


summary: Visit conducted on 2/21/24 (Quarterly Visit) &. Visit covered 8 main areas/topics. Found 1 compliance issues.

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

Field Visit Reporting Form

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

  NAME OF FACILITY / PROGRAM:   Touchstone

 TIME OF VISIT (FROM - TO):       11:00am-12:30pm                 DATE:  2/21/24 (Quarterly Visit) &
  2/22/24 (Personnel Review)

 AGENCY PERSONNEL WHO PARTICIPATED: Program Director
					       Assistant Program Director

List of Areas / Topics covered during visit:
•	Current Census=8, LBC=9
•	Staffing:  Vacancy-1 full-time Nurse
•	Program Updates
•	Milieu observation:  Youth were observed in their respective classroom.
•	Staff/client interactions (All residents were attending school on site).  T/W observed youth in their respective classrooms and all youth were smiling and greeted t/w.
•	Physical Plant observed and clean

Corrective Actions implemented as a result of previous visit:

•	Not applicable

Areas of regulatory non-compliance identified during this visit:

•	Section 17a-145-64:  Personnel policies and procedures:

There is one (1) file (GC) in which staff did not have a current physical in the record indicating that a physical was conducted within 90 days prior to hire.

•	Sec. 46a-154. Internal monitoring, training and development of policies and procedures required and subject to state agency inspection.

16 files (SR, JS, SR, JN, WR, MP, LS, MR, JR, DA, LM, PE, NR, KB, RC, WA) reviewed do not contain evidence of restraint training in the Safe De-escalation & Physical Management.

Amita Patel
Regulatory Consultant                                   Date  4/5/24

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

visit_date: 2/21/24 (Quarterly Visit) &


facility_name: NOANK Community Support Services / Church Hill

summary: Visit conducted on 1-12-26. Visit covered 7 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:     Noank Community Support Services (Church Hill House)

TIME OF VISIT (FROM - TO):  	11:30 am- 12:15 pm                   DATE: 1-12-26

AGENCY PERSONNEL WHO PARTICIPATED: Program Director

List of Areas / Topics covered during visit:

•	Discussed current census (4) and the licensed bed capacity is 5.

•	Discussed staffing vacancies for supervisor position, clinician, residential advisors and restorative coach.

•	During the visit, two residents in the home. Met with OK and SL upstairs with the director.  Resident AC is currently hospitalized, resident EL was at school.

•	Discussed the milieu and current discharge planning.

•	Discussed recent Exceptional Circumstances.

•	Discussed clinical support and currently GF clinician covering CHH.

•	Inspection of the Church Hill House physical plant was completed and discussed. No safety concerns observed.

Corrective Actions implemented as a result of previous visit:

•	Not applicable

Areas of regulatory non-compliance identified during this visit:

•	Not applicable

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:    1/15/26
Regulatory Consultant

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


raw_content:
November 13, 2025

Regina Moller
Executive Director
Noank Community Support Services
479 Gold Star Highway
Groton, CT  06340

Re: Relicensing inspection –License #CCF-167

Dear Ms. Moller,

On October 15-17, 2025, a biennial re-licensing inspection was conducted at the Church Hill House STTAR located at 105 Church Hill Rd, Ledyard, CT. This inspection was conducted to determine the compliance of this program with the DCF Regulations for Operation of Child-Caring Agencies and Facilities 17a-145-48 through 17a-145-124. Additionally, a review was conducted on 10-17-25 by DCF Nurse Consultant Errolee Miller, RN to determine the program’s compliance with the DCF Medication Administration Guidelines and the DCF Nursing Standards. A full standard of compliance was issued.
On November 11, 2025, the licensing unit received, reviewed, and accepted the Regulation Compliance Plan. The Department has made a decision to issue a regular twenty-four month license from the renewal date of January 8, 2026.
On behalf of the Department, I would like to thank you and your staff, for the courtesy and cooperation that was extended to us during our visits.

If you have any questions, please do not hesitate to contact me at (860) 209-3136.

Sincerely,
James Funaro
_____________________________
James Funaro
DCF Regulatory Consultant|


summary: Visit conducted on 7-8-25. Visit covered 7 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:     Noank Community Support Services (Church Hill House)

TIME OF VISIT (FROM - TO):  	10:00 am- 11:00 am                   DATE: 7-8-25

AGENCY PERSONNEL WHO PARTICIPATED: Assistant Program Director and Director of Residential Care

List of Areas / Topics covered during visit:

•	Discussed current census (3) and the licensed bed capacity is 5.

•	Discussed ongoing search for vacant supervisor positions.

•	During the visit, three residents in the home.  Resident JP went to Walmart with a staff to use an incentive gift card she earned. Residents JT and AC were about the house and chatted with this Reg-Consultant.

•	Discussed the milieu and current discharge planning.  STTAR review held, and JP's D/C setting identified.

•	Discussed recent Critical Incident and reviewed video of the incident.  Discussed planning to help enhance safety and deter unwanted visitors.

•	Inspection of the Church Hill House physical plant was completed and discussed. No safety concerns observed.

Corrective Actions implemented as a result of previous visit:

•	Not applicable

Areas of regulatory non-compliance identified during this visit:

•	Not applicable

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:    710/25
Regulatory Consultant

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


summary: Visit conducted on 6-5-25. Visit covered 6 main areas/topics. No compliance issues identified.

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

Field Visit Reporting Form

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

NAME OF FACILITY / PROGRAM:     Noank Community Support Services (Church Hill House)

TIME OF VISIT (FROM - TO):  	9:45 am- 10:45 am                   DATE: 6-5-25

AGENCY PERSONNEL WHO PARTICIPATED: Program Director, Director of Quality Assurance and Restorative Coach

List of Areas / Topics covered during visit:

•	Discussed current census (5) and the licensed bed capacity is 5.

•	Discussed current search and interviews for vacant supervisor positions.

•	During the visit, three residents in the home, and two at school. Met with residents on the 2nd floor.

•	Discussed the milieu and current discharge planning with the Department's assigned workers.

•	Discussed resident's cooperation with clinical services and education.

•	Inspection of the Church Hill House physical plant was completed and discussed. No safety concerns observed.  New replacement windows are still on order. New closet doors and door frames have been installed.

Corrective Actions implemented as a result of previous visit:

•	Not applicable

Areas of regulatory non-compliance identified during this visit:

•	Not applicable

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:    6/6/25
Regulatory Consultant

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


summary: Visit conducted on 5-22-25. Visit covered 7 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:     Noank Community Support Services (Church Hill House)

TIME OF VISIT (FROM - TO):  	10:00 am- 11:00 am                   DATE: 5-22-25

AGENCY PERSONNEL WHO PARTICIPATED: Program Director, Director of Quality Assurance

List of Areas / Topics covered during visit:

•	Discussed current census (5) and the licensed bed capacity is 5.

•	Discussed current staffing levels, coverages and use of per diem staff.

•	During the visit, two residents at in the home, one at a medical appointment, one at school and one hospitalized.

•	Discussed recent med error and SIU investigations.

•	Discussed overall milieu and current discharge plans.

•	Discussed resident's cooperation with education.

•	Inspection of the Church Hill House physical plant was completed and discussed. No safety concerns observed.  New replacement windows have been ordered. The new staff seating area on the second floor as been approved by the Fire Marshal.

Corrective Actions implemented as a result of previous visit:

•	Not applicable

Areas of regulatory non-compliance identified during this visit:

•	Not applicable

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:    5/23/25
Regulatory Consultant

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


summary: Visit conducted on 5-8-25. 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:     Noank Community Support Services (Church Hill House)

TIME OF VISIT (FROM - TO):  	12:00 pm- 12:45 pm                   DATE: 5-8-25

AGENCY PERSONNEL WHO PARTICIPATED: Program Director, Director of Quality Assurance

List of Areas / Topics covered during visit:

•	Discussed current census (5) and the licensed bed capacity is 5.

•	Discussed current staffing levels and staff vacancies.

•	During the visit, two residents at school and one present and two AWOL.

•	Discussed recent AWOLs, 911 calls and Exceptional Circumstances.

•	Discussed clinical programming.

•	Discussed overall milieu.

•	Discussed resident's cooperation with education and incentives.

•	Inspection of the Church Hill House physical plant was completed and discussed. No safety concerns observed.  Overall, the rooms were clean.  There is a new door jamb on order for room 1 as a resident broke the door.  New blinds are being installed in room 4. New closet doors ordered for rooms 1, 3 and 4.  A seating area being made for staff to use on the 2nd floor. In the basement the old utility sink is being replaced. Plans to steam clean all the carpets.

•	During the past quarter licensing responded to one incident and completed one incident response note. The incident occurred on 2-26-25 and involved an investigation completed by SIU.

Corrective Actions implemented as a result of previous visit:

•	Not applicable

Areas of regulatory non-compliance identified during this visit:

•	Not applicable

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:    5/9/25
Regulatory Consultant

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