summary: License Renewals - 76 findings

raw_content:
Licensed Child Caring Agency Site Visit Report
Residential Care - License Renewal
Licensee: Affect Youth Services Date of site visit: March 11 & 12, 2025
Executive Director: Mandy Augsburger Licensing Coordinator: Robin DuVal
Board Chairperson: Ben Putrin
Other Regulatory or Accrediting Agencies: Jennie Walker with Oregon Department of Human Services (ODHS) Child Welfare
Treatment Services participated during this review.
Program compliance: The program was found to be compliant or will be compliant with OAR 419-400-0005 to 419-400-0310, Licensing
Umbrella Rules, and OAR 419-470-0010 to 419-470-0180, Licensing Residential Care Agencies Rules. Personnel records were reviewed
and compliance with required background checks was documented for employees in all programs.
Program description provided by Affect Youth Sevcices: The program offers an extended family care model where youth with higher needs
can still be placed within a family setting allowing for a family experience with additional staff for extra support. The program is contracted with Child
Welfare Treatment Services and is a non-BRS (Behavior Rehabilitation Services) provider. Youth are assisted in taking personal responsibility and
accountability for their actions and using positive behavior support to model appropriate responses. Youth will have more positive outcomes when
they know they are being supported in their plan to transition out of the program. Youth attend public schools.
Program type and services as described by Affect: Practical application of life skills, modifying negative behaviors through “do-overs”,
building trusting relationships, positive peer culture. These are accomplished through discussion and modeling. Other services such as
therapy, drug and alcohol treatment, mentoring and skills training are outsourced by referral of the caseworker.
Capacity and age range: 15, ages 10-17
Funding sources: ODHS Child Welfare
Contracts and sources for referrals: ODHS Child Welfare
Average length of stay: 7 months
Average daily population served: 11.5
Form revised 3/12/2025 Page 1 of 26
Number of children served annually: 20
Use of seclusion or restraint: Restraint only as a last resort utilizing Crisis Prevention Institute (CPI), a non-violent crisis intervention.
Youth Interviews: Four youth were individually interviewed, ages 12-17, with stays in the program ranging 2-12 months. They reported
feeling safe, staff are trusting, get their medications as prescribed, and the program is responsive taking youth to medical appointments
when needed. They described their daily routine, including recreation options in the rec building as well as outings. Youth have regular
phone contact with persons on their approved contact list, and youths listed the places in the program where they can have privacy for
those calls. The food is good, mostly dinners, as those are homemade, and they sit to eat like a big family. Some report wanting more of
a variety for breakfast, other than cereal, and less carbohydrates and more protein. The interaction with peers is going ok, as to be
expected with the amount of youth in one program. When asked if they could change anything about the program, they reported a desire
to go on outings more frequently. They report the program does well at taking care of the youth and providing a safe place to live.
Staff Interviews: Two staff were individually interviewed, one working in the program for approximately 8 months and the other since the
program opened in 2016. Both described the initial and ongoing training, including Mandatory Abuse Reporter requirements. They have
regular daily contact with their supervisor, they feel free to express concerns and management is responsive to those concerns. The
program provides recreation each day, including all the opportunities in the recreation building, as well as daily meals. Youth can
communicate with family members, caseworkers and other people outside the program on their approved contact list, and interviewees
listed the space options for youth to have privacy for a meaningful conversation. They report the program does well at supporting kids,
setting up needed services and appointments, and encouraging the youth to be supportive of one another. They both feel fortunate to
work in this program and with this population of youth.
Observations: The Executive Director accompanied this licensor for the walk-thru which consisted of the dorm rooms, bedrooms,
bathrooms, laundry room, common room, kitchen, conference room. The recreation building, known as the “barn”, was observed to be
spacious and clean with a pool table and other games, an open loft area with multiple TV and gaming set-ups with seating for each, and
corner exercise equipment. A converted room in an outbuilding is used for multiple purposes, such as a visitation room and to house
music equipment.
Program Strengths, as reported by the agency: Adapting to the needs of each individual child involving de-escalation, regulation, and
coping skills. Youth outings, community interaction and experiences. Giving youth a family feel while being placed in a program.
Form revised 3/12/2025 Page 2 of 26
Respecting that these are youth who deserve fun in their life, not just appointments. Youth attend regular public schools. Attempted to
coordinate visits with family outside of ODHS to extend weekend visit time when allowed. Majority of staff are long-term providing
consistency for you.
Program Challenges, as reported by the agency: Coordinating transportation for all youth appointments during the week. Note: OHP
covered transportation services are regularly unreliable. Volunteers to cover board positions. Hiring and staffing as it’s incredibly difficult
to fill positions with quality team members. Getting enough appropriate referrals. Youth team support and understanding, i.e. ongoing
issues with scheduling with CASAs, attorney’s, mentors, Boys & Girls Aid, etc.
Changes that have occurred in the last 2 years, as reported by the agency: Staffing and schedule changes to accommodate staff
needs. No other significant changes were reported.
Lawsuits: none disclosed by the agency.
Grievances and complaints filed in the last two years: none disclosed by the agency.
Exceptions: Financial Audit; and overnight awake staffing ratio.
Changes in License: None
Corrective actions and timeframes: Please submit the following to verify compliance.
Within 45 days of receipt of this report (Affect Youth Services) must submit a letter of verification indicating the agency is in compliance
with the specific rules cited above and describing how compliance will be maintained going forward. Along with the letter of verification,
the agency must submit any and all specific documentation requested in the body of this report. The letter of verification and any additional
requested documents can be emailed directly to (Robin DuVal, robin.m.duval@odhsoha.oregon.gov).
Summary of review
Program and services Yes/No or Corrective actions/comments
419-400-0020 (2) N/A
Program and services are in scope of license yes
Form revised 3/12/2025 Page 3 of 26
Governance of the agency Yes/No or Corrective actions/comments
419-400-0040 N/A
(1)(a) Minimum of 5 board members Yes
(2)(f) Formally evaluate the Executive Director’s Yes
performance annually
(2)(g) Approves annual budget Yes
(2)(h) Obtain and review an annual independent Yes Exception on file
financial review or audit of financial records.
(2)(k) Written quality improvement program Yes
(2)(l) Meeting minutes Yes
Executive Director or Program Director Yes/No or Corrective actions/comments
419-400-0040 N/A
(3)(a) knowledge of requirements for providing care Yes
and treatment appropriate to programs
(3)(g) Approval from BCU Yes
Installation and use of video equipment used to Yes/No Corrective actions/comments
monitor or record children in care or N/A
419-400-0145
(1) If a child-caring agency installs video equipment to No The agency’s policy and procedure must be updated to
monitor or record a child in care, all employees, state:
volunteers, parents or guardians and children in care • “all employees, volunteers, parents or guardians,
must be informed about the intended use and locations and children in care must be informed about the
of the equipment. intended use and locations of the equipment.”
Refer to page 25 of this report for more details.
Form revised 3/12/2025 Page 4 of 26
Discipline, behavior management and suicide Yes/No or Corrective actions/comments
prevention N/A
419-400-0150
(3) Agency uses appropriate and positive methods of Yes
behavior management and nationally recognized non-
violent crisis intervention
(3)(b)(C) Agency does not use chemical and N/A Agency does not utilize chemical or mechanical restraints
mechanical restraint (excluding medically necessary in their programming.
devices/prescriptions)
(3)(c) Agency uses appropriate time-out rooms N/A Agency does not utilize designated time-out rooms
(adequate space, heat, light and ventilation and is not specifically, however there are areas in the program for the
capable of locking) and documents use in child’s child in care to take space.
record when applicable
(3)(e) Agency uses seclusion appropriately/consistent N/A Agency does not utilize seclusion in their programming.
with policy
(4) Agency has adequate plan in place to respond to Yes
suicidal behavior/warning signs
Contractors (if applicable) Yes/No or Corrective actions/comments
419-400-0120(6) N/A
(a) Agency ensures the contractor meets the N/A None were disclosed by the CCA.
requirements of this rule and Chapter 413 division 215
(b)(B) Contract includes the following: N/A None were disclosed by the CCA.
(i) Services provided
(ii) Contractor fees
(iii) Disclosure of information from contractor to agency
(iv) Lines of authority
(v) Adherence to rules, including background check
(vi) Any liability of the agency for acts of the contractor,
rights of indemnity and limitations on liability
Form revised 3/12/2025 Page 5 of 26
Restraints and Involuntary Seclusion Yes/No or Corrective actions/comments
419-400-0180 N/A
(13)(d) Each child caring agency that submits a report Yes Note: No agency website.
under this section shall make its quarterly report
available to the public upon request at the child
caring agency’s main office and on the child caring
agency’s website if applicable.
Supplemental information provided by CCA Yes/No Corrective actions/comments
or N/A
Documents as indicated on the form titled “Renewal Yes
Licensing Required Documents”
Documents as indicated on form titled “Required Yes
Financial Documents and Information”
All required policies and procedures as identified in No The agency shall update the following policies and
the “Umbrella Rules” procedures. Refer to pages 23-25 of this report for specifics.
• Grievance, OAR 419-400-0090
• Incident reporting, OAR 419-400-0110(a)
• Discipline, OAR 419-400-0150
• Transportation safety, OAR 419-400-0200
• Searches, OAR 419-400-0200(2)
• Hazards, OAR 419-400-0200(4)
• Personnel 419-400-0120
• Privacy OAR 419-400-0130
• Use of Video Equipment OAR 419-400-0145
All required policies and procedures as identified in No The agency shall update the following policies and
“Agency Type Specific Rules” procedures. Refer to pages 25 & 26 of this report for
specifics.
• Health Services, OAR 419-470-0090
• Medication, OAR 419-470-0100
Form revised 3/12/2025 Page 6 of 26
Physical plant Yes/No Corrective actions/comments
or N/A
419-400-0090(3)(a) Foster Rights Posted (if children Yes
in ODHS custody)
419-400-0100(1) Sufficient safe space, equipment Yes
and office equipment
419-400-0230(12) License is posted in common Yes
area at each facility
419-470-0020(2)(a) and (c) Buildings are smoke Yes
free, clean and in good repair
419-470-0020 (2)(d) Rooms are free of harmful Yes
drafts, odors and excessive noise
419-470-0020 (2)(e) Rooms are adequate in size Yes
and arrangement
419-470-0020 (2)(f) System provides a continuous Yes
supply of hot and cold water to taps located
throughout the facility
419-470-0020 (2)(h) Building is well ventilated and Yes
room temperature is within a normal comfort range
419-470-0030 (1) All parts of the facility ensure the Yes
safety of children
Room and space requirements Yes/No Corrective actions/comments
419-470-0030 or N/A
(2) There is a separate living room or lounge area – Yes
15 SF minimum per child
(5) There is a separate dining room with capacity for Yes
½ of children in care and 15 SF per child in care
(7) Laundry is separate from living, kitchen and Yes
dining areas
(8) Separate storage areas are provided for food, Yes
kitchen supplies, utensils, clean linens, soiled linens
Form revised 3/12/2025 Page 7 of 26
Room and space requirements Yes/No Corrective actions/comments
419-470-0030 or N/A
and clothing, cleaning supplies and equipment,
poisons, chemicals, outdoor recreational and
maintenance equipment. (Hazardous materials are
properly labeled, in original container and locked)
(9) Outdoor activity area is protected from vehicles Yes
and other hazards and of a size and availability
appropriate to the age and needs of children in care
(11) Time-out rooms: Rooms used for time out or N/A
quiet time must have adequate space, heat, light
and ventilation and must not be capable of locking.
Room and space requirements - bedrooms Yes/No Corrective actions/comments
419-470-0030(3) or N/A
(a) Adequate furnishings and personal items Yes
(b) Separate from rooms used for dining, living, Yes
laundry, kitchen and storage
(c) Meet Oregon Fire Code Requirements Yes
(d) Be an outside room, with a window that operates Yes
as designed. If the window is modified from its
original design, the fire marshal must approve the
modification and indicate this room still meets
applicable Oregon Fire Code.
(d) Ceiling at least 90 inches Yes
(e) Minimum 60 SF per occupant Yes
(f) No more than 25 if dorm style Yes
(g) Permanently wired fixtures Yes
(h) Window covering Yes
Form revised 3/12/2025 Page 8 of 26
Room and space requirements - bathrooms Yes/No Corrective actions/comments
419-470-0030(4) or N/A
(a)(A) and (B) 1:8 ratio for toilets and sinks Yes
(a)(D) Hot and cold running water, soap and Yes
approved hand drying options
(a)(E) 1:10 ratio for shower or bathtub Yes
(a)(E) Individual privacy Yes
(a)(F) Window covering N/A There are no windows in the bathrooms.
(a)(G) Permanently wired fixtures Yes
(a)(H) Adequate ventilation Yes
(b) and (c) Wooden racks on floors are prohibited Yes
and impervious shower mats are disinfected and
dried daily be in good condition and free of mold
Room and space requirements - kitchen Yes/No Corrective actions/comments
419-470-0030(6) or N/A
(a) Used exclusively for storage, food preparation, Yes
dishwashing and activities related to eating and food
preparation activities
(b) Walls, floors are easily cleanable Yes
(c) Equipment and utensils are easily cleanable, Yes
durable, nontoxic and kept clean
(e) Equipment is easy to clean beneath, between Yes
and behind
Furnishings and personal items Yes/No Corrective actions/comments
419-470-0040 or N/A
(1) There is a bed with frame Yes
(1)(b) clean mattress in good condition, with a Yes
minimum thickness of five inches
(1)(c) a pillow in good condition Yes
Form revised 3/12/2025 Page 9 of 26
Furnishings and personal items Yes/No Corrective actions/comments
419-470-0040 or N/A
(1)(d) a private dresser, closet, or similar storage Yes
area for personal belongings that is readily
accessible
(2) Linens are in good repair. There is a waterproof Yes
mattress cover or mattress. Linens are appropriate
and towels and washcloths are provided
(3) Bedding is changed weekly or when soiled Yes
(4) and (5) Personal hygiene supplies and Yes
appropriate clothing are provided
Food services Yes/No Corrective actions/comments
419-470-0070 or N/A
(1)(a) Meals are arranged daily, consistent with No The agency shall be consistent with providing snacks
normal mealtimes that occur during the hours of between mealtimes.
operation and provide snacks between mealtimes Note: The agency has already begun working with this
licensor to ensure compliance.
(1)(b) Menus are prepared in advance in accordance No The agency shall update their menus to be more reflective
with USDA guidelines, provide a variety of foods and of what is being served, including snacks, demonstrating a
are adjusted for seasonal changes including snacks variety of foods in accordance with USDA guidelines.
• Note: The agency has already begun working with
this licensor to ensure compliance.
(1)(b) Menus are kept for at least 6 months Yes
(1)(c) Drinking water is freely available Yes
(2)(a) Food is stored, prepared and served in a Yes
sanitary manner
(2)(c) and (d) Food products are obtained from Yes
commercial suppliers (exception of fruits and
vegetables), unpasteurized juice is prohibited, and
only Grade A pasteurized and fortified milk in
appropriate container.
Form revised 3/12/2025 Page 10 of 26
Residential care safety Yes/No Corrective actions/comments
419-470-0080 or N/A
(2) Written emergency plan that includes: No
(a) Identifying the types of emergencies most likely
to happen where the residential care agency is
located
(b) Identifying a place to meet for each type of
The agency shall update the written emergency plan to
emergency identified
include requirements (b), (c), and (d) and submit for review.
(c) Identifying an alternate shelter if necessary
(d) Ensuring access to necessary medications or
medical equipment
(e) How to help each child in care recover after a
disaster
(3) Telephone numbers for local police, fire Yes
department, poison control, after hours medical
advice and other appropriate emergency numbers
must be posted near all telephones.
(4) Operative flashlights sufficient in number are Yes
readily available to staff
(5)(a) Evacuation drill occurs monthly under varying Yes
conditions, is retained 2 years and contains:
(A) identify of person conducting drill
(B) date and time
(C) notification method
(D) staff participating
(E) number of children and staff evacuated
(F) special conditions simulated
(G) problems encountered
(H) time to complete
Form revised 3/12/2025 Page 11 of 26
Umbrella safety Yes/No Corrective actions/comments
419-400-0200 or N/A
(1)(b) Vehicle has insurance policy, is smoke free, Yes
safe operating condition, and has first aid kit and fire
extinguisher 2-A:10-BC
(1)(b)(A) Each vehicle used to transport a child in Yes
care must be: properly registered,
covered by an insurance policy in full force and
effect, maintained in safe operating condition and
smoke-free.
(3) Water safety. If a child-caring agency has a Yes The agency does not have a swimming pool; however, they
swimming pool on the premises that is accessible to take youth swimming at public pools and discloses this
children in care or if a child-caring agency plans to information to the guardian and obtains their consent.
have children in care engage in swimming, the child-
caring agency must have and adhere to policies and
procedures that address, at a minimum, providing
disclosures and obtaining consents, assessing
swimming ability of children in care and ensuring the
safety of pool access.
(4)(a) The program protects children from potentially Yes
harmful items and materials.
(4)(b) Direct supervision of children who do not have Yes
the ability to adjust and control water temperature
(4)(c) Light fixtures have protective covers unless Yes
designed to be used without one
Medication Yes/No Corrective actions/comments
419-470-0100 or N/A
(3) and (7)(e) Medications have a prescription and are Yes
stored in the original container with prescription label
(4) and (5) Herbal supplements and remedies, Yes
medical treatments, special diets, physical therapy,
Form revised 3/12/2025 Page 12 of 26
Medication Yes/No Corrective actions/comments
419-470-0100 or N/A
physical aides or limitations have a written order
signed by a physician or qualified medical
professional. A written order, signed by a physician or
qualified medical professional, is also required before
a restriction on diet or physical activity is imposed.
(7)(c) Medications are inaccessible to children and Yes
stored behind at least two locking mechanisms. This
does not apply to Naloxone.
(8) Medications are disposed in accordance with Yes
state and federal law
(9) Written record of the disposal of medications is Yes
maintained and includes:
(a) description and amount
(b) name
(c) reason
(d) method
(e) staff and witness signature
(10) Written record of the administration of Yes
medication includes:
(a) name
(b) description
(c) dates and times
(d) missed doses
(e) medication disposed
(f) method of administration
(g) ID of person administering
(h) possible adverse reactions
(i) medication taken outside facility
Form revised 3/12/2025 Page 13 of 26
Extracurricular, enrichment, cultural and social Yes/No Corrective actions/comments
activities or N/A
419-470-0110
(2) Children have ongoing opportunities to Yes
participate in at least one age-appropriate or
developmentally appropriate activity
Minimum staffing requirements Yes/No Corrective actions/comments
419-470-0130 or N/A
(1) and (2) Supervision is adequate for the type of Yes
program, location, age and type of children, ability of
supervisor to respond, electronic back-up systems. Exception on file for overnight staffing ratio.
Minimum ratios are maintained:
-Ages 6 and older: 1:7
-Overnight (staff awake): 1:10
(4)(a) When one staff on duty, there is additional Yes
staff immediately available with max response time
of 30 minutes
(5) There is at least one on-site employee authorized Yes
to apply the reasonable and prudent parent standard
Sleeping arrangements Yes/No Corrective actions/comments
419-470-0140 or N/A
(1) Children are in separate bedrooms than adults, Yes
unless parent and child, or there is written approval
from guardian/parent and licensing coordinator
(2) There is adequate supervision of children when Yes
sleeping
(3) When assigning bedrooms a residential care Yes
agency must consider all of the following:
(a) Chronological age
(b) Developmental age
Form revised 3/12/2025 Page 14 of 26
(c) Gender identity
(d) Personal history, including medical, mental
health, behavioral health and past adverse
experiences including any physical or sexual abuse
Personnel files Yes/No Corrective actions/comments
419-400-0120 or N/A
Staff name/position Yes
(3)(g) Date of hire Yes
(3)(a) record of education, training and previous Yes
employment
(1)(b) and (3)(b) reference checks completed and Yes
documented
(1)(a) and (3)(c) Background check completed and Yes
documented
(3)(d) Annual performance evaluations Yes
(3)(f) Record of personnel actions Yes
(3)(g) Termination date, reason for termination Yes
(3)(h) Current job description (1)(c) Employee meets Yes
minimum qualifications stated in current job
description
New employee orientation – Umbrella Yes/No Corrective actions/comments
Requirements (30 days) or N/A
419-400-0120(4)
(a) Agency policies and procedures Yes
(b) Ethical and professional guidelines Yes
(c) Suicide prevention and intervention Yes
(d) Attributes of population served Yes
(e) and (5)(a) to (c) Mandatory reporting that includes: Yes
(a) legal definition of child abuse in ORS 418.257 and
419B.005
Form revised 3/12/2025 Page 15 of 26
New employee orientation – Umbrella Yes/No Corrective actions/comments
Requirements (30 days) or N/A
419-400-0120(4)
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to the
employee
(f) Privacy laws Yes
(g) Emergency procedures Yes
New employee orientation - residential (prior to Yes/No Corrective actions/comments
working alone and within 30 days) or N/A
419-470-0120(1)
(a) Discipline and behavior management including Yes
de-escalation, crisis prevention, positive behavior
management and disciplinary techniques that are
non-punitive in nature
(b) CPR and First Aid sufficient to retain a current Yes
certification
(c) Universal precautions and hygiene Yes
(d) Application of the reasonable and prudent parent Yes
standard
(e) Training on the agency’s policy on suicide Yes
prevention and suicide risk assessment tool
Crisis intervention training standards and Yes/No Corrective actions/comments
certification or N/A
419-400-0160(4) (as applicable)
(a)Complete a minimum of 12 hours of initial training No Records indicated 9 hours, therefore not meeting the
in person from a certified instructor, including but not minimum of 12 hours. The agency indicated that all staff
limited to a minimum of six hours of training focused will complete training within the next few months.
on positive behavior support, nonviolent crisis
Form revised 3/12/2025 Page 16 of 26
Crisis intervention training standards and Yes/No Corrective actions/comments
certification or N/A
419-400-0160(4) (as applicable)
intervention and other methods of nonphysical Corrective Action: The agency shall ensure this training
intervention to support children in care during a crisis requirement is met.
(d) Receive a certificate that states: No
(A) The dates during which the certification is current Corrective Action: Upon completion of a minimum of 12
(B) The type of restraint which the individual is hours of training, the agency shall ensure a certificate is
certified to perform if applicable documented capturing all required date elements. This
(C) The type of training the individual is certified to licensor provided an example.
conduct if applicable
(D) Any special endorsements earned by the At the completion of above noted training, the agency will
individual complete certifications for each employee and submit those
(E) The level of training for confirmation.
(F) The name of the certified instructor who
conducted the training and administered the
assessment of proficiency.
(e) A certification issued: No Corrective Action: The agency shall ensure a copy of the
(A) Must be personal to the individual certified by the employees CPI blue card shall be kept in the employee
training provider training record.
(B) May be valid for no more than two years with
recertification
Ongoing training Yes/No Corrective actions/comments
or N/A
419-470-0070(2)(b) Employees who handle food Yes
served to children have a valid food handler’s card
419-400-0200 (1) Employees transporting children Yes
have: current driver’s license, insurance, trained in
emergency procedures and behavior management
and training for 15+ passenger vans if applicable)
419-470-0120 (2)(a) Environmental emergencies Yes
Form revised 3/12/2025 Page 17 of 26
Ongoing training Yes/No Corrective actions/comments
or N/A
419-470-0120 (2)(b) Universal precautions Yes
419-470-0120 (2)(c) Discipline and behavior Yes
management
419-470-0120 (2)(d) Agency’s policy on suicide Yes
prevention and risk assessment tool
419-470-0120 (3) Staff providing direct care must No One staff persons certification had expired. Upon this
maintain current CPR/First Aid certification licensor sharing this information, the agency acted promptly
to get the staff person scheduled. All other staff have
current certifications; therefore, all shifts haver someone
certified in CPR/First Aid.
Corrective Action: The agency shall track expiration dates
to ensure certifications are kept current.
419-470-0120 (4) Designated staff authorized to Yes
apply reasonable and prudent parent standard are
trained in application of the standard
419-400-0120(5) Mandatory reporting (annually) that Yes
includes:
(a) legal definition of child abuse in ORS 418.257
and 419B.005
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to the
employee
419-400-0160(4)(b) Receive continuing education Yes
(as applicable on crisis intervention training) from a
certified instructor on an annual basis
Form revised 3/12/2025 Page 18 of 26
Children’s records Yes/No Corrective actions/comments
health services or N/A
419-470-0090
(2) Medical history obtained within 30 days Yes
(significant findings, current immunizations, history
of surgical procedures-health issues-injuries,
allergies, dental, vision, hearing, behavioral health
and physician orders)
(4)(a) to (f) Medical exams (3 in first year of life, Yes
2,4,6,9,14)
(g) Have a physical examination within the first 60 Yes
days after admission of a child in care.
Documentation of a physical examination having
occurred within the calendar year will meet this
requirement.
Consents Yes/No Corrective actions/comments
419-470-0160(1) or N/A
(a) Provide routine and emergency medical care Yes
(b) Use the discipline and behavior management Yes
system
(c) Use restraint or seclusion (if applicable). Must Yes
specify the reasons for the intervention and how
staff are trained and supervised
(d) Restrict contact with persons outside of the Yes
agency
(e) Allow access as defined in 419-400-0230 and Yes
0240
(f) Impose a dress code Yes
(g) Apply the reasonable and prudent parent standard Yes
Form revised 3/12/2025 Page 19 of 26
Disclosures Yes/No Corrective actions/comments
419-470-0160(2) or N/A
Parent/guardian has acknowledged in writing:
(a) Information regarding personal or room searches Yes
and protocols for confiscation of contraband
(b) Statement of Rights of Children and Yes
Parents/Guardians
(c) Any policies and procedures upon request Yes
Authorizations Yes/No Corrective actions/comments
419-470-0160(3) or N/A
(a) Disclose or exchange information with others Yes
(b) Child specific visitors Yes
(c) Visitation resources are pre-approved Yes
(d) Activity specific authorizations are pre-approved Yes
to allow children to participate in potentially
hazardous activities, including but not limited to
using motorized yard equipment, swimming and
horseback riding.
Information about children in care Yes/No Corrective actions/comments
419-400-0190(1) Summary sheet contains the or N/A
following:
(a)The name, gender, date of birth, religious Yes
preference and previous address
(b) Name and location of previous and current school Yes
(c) Date of admission Yes
(d) Legal custody Yes
(e) The name, address and telephone number of: Yes
(A) The child in care's parents.
(B) The child in care's legal guardian, if different
than the parents and a copy of the document that
Form revised 3/12/2025 Page 20 of 26
Information about children in care Yes/No Corrective actions/comments
419-400-0190(1) Summary sheet contains the or N/A
following:
provides for his or her authority over the child in
care.
(C) Other persons significant to child
(D) Other professionals to be involved in service
planning (if applicable)
Service planning Yes/No Corrective actions/comments
419-470-0170(2) or N/A
(b) Intake document is completed the date child Yes
accepted into care (emergency placement 48 hours)
(d) Assessment is completed within 30 days and Yes
contains relevant historical information, current
behavioral observations, identified need for services
and how agency will provide services
(e) (A) and (B) Service plan within 60 days (parent, No Guardian involvement was not clearly documented as being
guardian and child actively involved). Describes how provided to and reviewed by the guardian. While on-site,
child’s issues will be addressed, anticipated suggestions were provided to the agency. This is a repeat
outcomes and reviewed by child and guardian/parent. finding.
Corrective Action: The agency shall ensure
documentation of guardian involvement on service plans.
(e)(C) and (D) Service plan is reviewed quarterly Yes
and revised when information indicates other
services should be provided
Case management Yes/No Corrective actions/comments
419-470-0170(3) or N/A
(a) Services are documented, progress toward Yes
achieving goals is tracked
Form revised 3/12/2025 Page 21 of 26
Case management Yes/No Corrective actions/comments
419-470-0170(3) or N/A
(c) Discharge summary must include: No Discharge summaries were inconsistent not meeting all
(A)Current medications requirements. This is a repeat finding.
(B)Name of the physician or qualified medical
professional who prescribed each medication Corrective Action: The agency shall ensure all discharge
(C)Any outstanding medical or other appointments summaries include all requirements and edit the discharge
(D)Summary of the child’s participation in the form to correlate to the requirements.
program and progress achieved
(E)Results of evaluations
(F)Recommendations regarding services
(G)Discharge destination
(e) Follow up services Yes
(f) Incident reports Yes
Records relating to Restraint and Involuntary Yes/No Corrective actions/comments
Seclusion or N/A
419-400-0180 (12) Records Yes
419-400-0180(13)(e) Each child caring agency shall Yes
provide notice regarding how to access the quarterly
reports to the parents or guardians of children in care
in the program. The child caring agency shall provide
the notice upon the child in care’s admission and at
least two times each year thereafter.
419-400-0190(1) Information provided to children in N/A Comment: Youth served by ODHS, although the agency
care relating to Restraint and Involuntary Seclusion includes this information in their intake packet.
Financial records Yes/No Corrective actions/comments
419-470-0170(4) or N/A
Records contain date, amount, source, purpose, Yes
signatures
Form revised 3/12/2025 Page 22 of 26
Personal possessions records Yes/No Corrective actions/comments
419-470-0170 (5) or N/A
Individual written inventory of all personal possessions Yes
is maintained and updated as needed
Records and documentation Yes/No Corrective actions/comments
419-400-0140 or N/A
(1) Stored safely Yes
(2) Permanent, legible, dated and signed Yes
(3) and (4) Uniform in organization, readily identifiable Yes
and accessible, current and complete, containing all
required info. No eraser tape or white out.
(7) Permanent registry for each child includes: Yes
Name
Gender
Birth date
Names, addresses of parents or guardians
Dates of admission
Placement upon discharge
Policies and procedures to update:
Grievance: add board member contact information in the event the complaint is pertaining to the ED.
Incident reporting: Update this sentence, “Interviews of all involved parties will be conducted to ensure the accuracy of the report,
prior to submission, except reports made to the Child Abuse Hotline to not interfere with the investigation process.
Behavior Management, were prohibited discipline is noted: Add
• (K) Removing or limiting the use of a mobility aid or other assistive device for the purpose of controlling a child in care’s
behavior.
Discipline: recommend combing the Discipline and Behavior management policies and procedures.
• Note: (K) above is included in the discipline P&P.
Form revised 3/12/2025 Page 23 of 26
Transportation: Add information related to the following:
• (A) Each vehicle used to transport a child in care must be: (i) Properly registered.
• A statement regarding (E) The child-caring agency must take reasonable steps to ensure safety when using off-road
vehicles.
• That the fire extinguisher is “properly secured”.
Searches: Add information related to the following:
• (E) The staff member must then pat the clothing of the child in care using only enough contact to conduct an appropriate
search;
• (G) If the child in care refuses to comply, the executive director or designee must be notified immediately and be
responsible to resolve the matter;
• (H) All searches must be documented in writing.
• (f) If the child in care refuses to comply with a requirement of the search, the program must follow established policies to
determine if the child in care can be refused admission to or discharged from the program.
• (g) Information regarding any personal or room searches and protocols for confiscation of contraband items, including the
notification of law enforcement if illegal contraband is discovered. This information will include the procedures and
rationales of the child-caring agency for any program-initiated room or body search.
Hazards: Add
• (b) Direct supervision by staff must be provided for any child in care who does not have the ability to adjust and control
water temperature.
• (c) Each light fixture must have a protective cover unless it is designed to be used without one.
Personnel: Some requirements are referenced in the “Employee Training Manual” document, but missing all requirements set
forth in this rule. The agency shall either update this manual or create a new Personnel Policy and Procedure to capture all
requirements set forth in OAR 419-400-0120.
Privacy:
• Add “audio or video recording: to the sentence where it states, “Youth photos will not be used without a signed media
consent form by the ODHS Caseworker / legal guardian.”
Form revised 3/12/2025 Page 24 of 26
• Update the “Calls & Visitation Policy” where it states, “All calls will be made in a public area, there is no guarantee of
privacy.” This is in conflict with OAR 419-400-0090(1)(b) The child in care’s right to privacy.
• Recommend updating the title or opening sentence that includes privacy, disclosure of camera use, and youth private
communication; or see recommendation below.
Audio Video Monitoring:
• Recommend removing this section from the Privacy policy and procedure document and create a stand-alone for this topic,
which can refer to the privacy policy and procedure.
• Add a statement of: all employees, volunteers, parents or guardians, and children in care must be informed about the
intended use and locations of the equipment
Health Services, “Medical Care”: add information related to the following:
(2) Medical history. Within 30 days of a child in care being placed with a residential care agency, the residential care
agency must obtain available medical history and other health-related information on the child in care, including:
(a) Significant findings of the most current physical examination;
(b) The child in care's current immunizations, history of surgical procedures and significant health issues or injuries, and
past or present communicable diseases;
(c) Any known allergies;
(d) Dental, vision, hearing, and behavioral health; and
(e) Physician or qualified medical professional's orders, including those related to medications, if any.
(3) Health Services. The residential care agency must provide or arrange for the following health services, as applicable:
(a) Medical exams.
(b) Information on maintaining reproductive health and birth control.
(c) Prenatal care.
(d) Well-baby care.
(e) Fetal alcohol syndrome.
(f) Accessing child and infant health insurance programs.
(g) Screening for breast and other common cancers.
(h) Provide all necessary feminine hygiene products.
(i) Access to birth control, vaccinations, and information about preventing sexually transmitted diseases.
(j) Age-appropriate consultation is provided regarding nutrition, pregnancy prevention, prevention of HIV and AIDS and
general information about the prevention and treatment of sexually transmitted illnesses.
Form revised 3/12/2025 Page 25 of 26
Medications:
• Self-administration – add that the physician approval must be in writing.
• Documentation to include: (d) what to do if there is a charting documentation error, if a medication is refused, if a
medication is missed, or any other type of medication error that results in a medication not being administered as
prescribed.
• Storage – add information regarding being stored behind at least two locking mechanisms.
• (a) Prescription medications that are unused and medications that are expired or recalled may not be maintained with
current medication and must be disposed of as described in agency disposal policy.
• Medication Administration Record (MAR) form: dates and times, method of administration; and space to record any
possible adverse reactions to a medication.
• Add the medication record detail to the Medication policy and procedure, to match the MAR form.
Licensing Coordinator’s Signature: ________________________ Date: ______5_/8_/_2_0_2_5_______
Manager Review: ______________________________________ Date: __5_-_8_-_2_0_2_5_________
Form revised 3/12/2025 Page 26 of 26

report_type: License Renewals

report_title: Licensed Child Caring Agency Site Visit Report

facility_type: Residential Care - License Renewal

licensee: Affect Youth Services

board_chairperson: Ben Putrin

funding_sources: ODHS Child Welfare

contracts_and_referrals: ODHS Child Welfare

average_length_of_stay: 7 months

average_daily_population_served: 11.5 Form revised 3/12/2025 Page 1 of 26

lawsuits: none disclosed by the agency.

grievances_and_complaints: none disclosed by the agency.

exceptions: Financial Audit; and overnight awake staffing ratio.

observations:
The Executive Director accompanied this licensor for the walk-thru which consisted of the dorm rooms, bedrooms,
bathrooms, laundry room, common room, kitchen, conference room. The recreation building, known as the "barn", was observed to be
spacious and clean with a pool table and other games, an open loft area with multiple TV and gaming set-ups with seating for each, and
corner exercise equipment. A converted room in an outbuilding is used for multiple purposes, such as a visitation room and to house
music equipment.

excerpt:
419-400-0040 N/A
(1)(a) Minimum of 5 board members Yes
(2)(f) Formally evaluate the Executive Director's Yes
performance annually
(2)(g) Approves annual budget Yes
(2)(h) Obtain and review an annual independent Yes Exception on file
financial review or audit of financial records.
(2)(k) Written quality improvement program Yes
(2)(l) Meeting minutes Yes
Executive Director or Program Director Yes/No or Corrective actions/comments

excerpt:
419-400-0145
(1) If a child-caring agency installs video equipment to No The agency's policy and procedure must be updated to
monitor or record a child in care, all employees, state:
volunteers, parents or guardians and children in care - "all employees, volunteers, parents or guardians,
must be informed about the intended use and locations and children in care must be informed about the
of the equipment. intended use and locations of the equipment."
Refer to page 25 of this report for more details.
Form revised 3/12/2025 Page 4 of 26
Discipline, behavior management and suicide Yes/No or Corrective actions/comments
prevention N/A

excerpt:
419-400-0150
(3) Agency uses appropriate and positive methods of Yes
behavior management and nationally recognized non-
violent crisis intervention
(3)(b)(C) Agency does not use chemical and N/A Agency does not utilize chemical or mechanical restraints
mechanical restraint (excluding medically necessary in their programming.
devices/prescriptions)
(3)(c) Agency uses appropriate time-out rooms N/A Agency does not utilize designated time-out rooms
(adequate space, heat, light and ventilation and is not specifically, however there are areas in the program for the
capable of locking) and documents use in child's child in care to take space.
record when applicable
(3)(e) Agency uses seclusion appropriately/consistent N/A Agency does not utilize seclusion in their programming.
with policy
(4) Agency has adequate plan in place to respond to Yes
suicidal behavior/warning signs
Contractors (if applicable) Yes/No or Corrective actions/comments

excerpt:
419-400-0180 N/A
(13)(d) Each child caring agency that submits a report Yes Note: No agency website.
under this section shall make its quarterly report
available to the public upon request at the child
caring agency's main office and on the child caring
agency's website if applicable.
Supplemental information provided by CCA Yes/No Corrective actions/comments
or N/A
Documents as indicated on the form titled "Renewal Yes
Licensing Required Documents"
Documents as indicated on form titled "Required Yes
Financial Documents and Information"
All required policies and procedures as identified in No The agency shall update the following policies and
the "Umbrella Rules" procedures. Refer to pages 23-25 of this report for specifics.
- Grievance, OAR

excerpt:
419-400-0090
- Incident reporting, OAR

excerpt:
419-400-0150
- Transportation safety, OAR

excerpt:
419-400-0130
- Use of Video Equipment OAR

excerpt:
419-400-0145
All required policies and procedures as identified in No The agency shall update the following policies and
"Agency Type Specific Rules" procedures. Refer to pages 25 & 26 of this report for
specifics.
- Health Services, OAR

excerpt:
419-400-0090(3)(a) Foster Rights Posted (if children Yes
in ODHS custody)

excerpt:
419-400-0100(1) Sufficient safe space, equipment Yes
and office equipment

excerpt:
419-400-0230(12) License is posted in common Yes
area at each facility

excerpt:
419-470-0020(2)(a) and (c) Buildings are smoke Yes
free, clean and in good repair

excerpt:
419-470-0020 (2)(e) Rooms are adequate in size Yes
and arrangement

excerpt:
419-470-0030 or N/A
(2) There is a separate living room or lounge area - Yes
15 SF minimum per child
(5) There is a separate dining room with capacity for Yes
½ of children in care and 15 SF per child in care
(7) Laundry is separate from living, kitchen and Yes
dining areas
(8) Separate storage areas are provided for food, Yes
kitchen supplies, utensils, clean linens, soiled linens
Form revised 3/12/2025 Page 7 of 26
Room and space requirements Yes/No Corrective actions/comments

excerpt:
419-470-0070 or N/A
(1)(a) Meals are arranged daily, consistent with No The agency shall be consistent with providing snacks
normal mealtimes that occur during the hours of between mealtimes.
operation and provide snacks between mealtimes Note: The agency has already begun working with this
licensor to ensure compliance.
(1)(b) Menus are prepared in advance in accordance No The agency shall update their menus to be more reflective
with USDA guidelines, provide a variety of foods and of what is being served, including snacks, demonstrating a
are adjusted for seasonal changes including snacks variety of foods in accordance with USDA guidelines.
- Note: The agency has already begun working with
this licensor to ensure compliance.
(1)(b) Menus are kept for at least 6 months Yes
(1)(c) Drinking water is freely available Yes
(2)(a) Food is stored, prepared and served in a Yes
sanitary manner
(2)(c) and (d) Food products are obtained from Yes
commercial suppliers (exception of fruits and
vegetables), unpasteurized juice is prohibited, and
only Grade A pasteurized and fortified milk in
appropriate container.
Form revised 3/12/2025 Page 10 of 26
Residential care safety Yes/No Corrective actions/comments

excerpt:
419-400-0120 or N/A
Staff name/position Yes
(3)(g) Date of hire Yes
(3)(a) record of education, training and previous Yes
employment
(1)(b) and (3)(b) reference checks completed and Yes
documented
(1)(a) and (3)(c) Background check completed and Yes
documented
(3)(d) Annual performance evaluations Yes
(3)(f) Record of personnel actions Yes
(3)(g) Termination date, reason for termination Yes
(3)(h) Current job description (1)(c) Employee meets Yes
minimum qualifications stated in current job
description
New employee orientation - Umbrella Yes/No Corrective actions/comments
Requirements (30 days) or N/A

excerpt:
419-400-0120(4)
(a) Agency policies and procedures Yes
(b) Ethical and professional guidelines Yes
(c) Suicide prevention and intervention Yes
(d) Attributes of population served Yes
(e) and (5)(a) to (c) Mandatory reporting that includes: Yes
(a) legal definition of child abuse in ORS 418.257 and
419B.005
Form revised 3/12/2025 Page 15 of 26
New employee orientation - Umbrella Yes/No Corrective actions/comments
Requirements (30 days) or N/A

excerpt:
419-470-0120(1)
(a) Discipline and behavior management including Yes
de-escalation, crisis prevention, positive behavior
management and disciplinary techniques that are
non-punitive in nature
(b) CPR and First Aid sufficient to retain a current Yes
certification
(c) Universal precautions and hygiene Yes
(d) Application of the reasonable and prudent parent Yes
standard
(e) Training on the agency's policy on suicide Yes
prevention and suicide risk assessment tool
Crisis intervention training standards and Yes/No Corrective actions/comments
certification or N/A

excerpt:
419-470-0070(2)(b) Employees who handle food Yes
served to children have a valid food handler's card

excerpt:
419-400-0200 (1) Employees transporting children Yes
have: current driver's license, insurance, trained in
emergency procedures and behavior management
and training for 15+ passenger vans if applicable)

excerpt: 419-470-0120 (2)(b) Universal precautions Yes

excerpt:
419-470-0120 (2)(c) Discipline and behavior Yes
management

excerpt:
419-470-0120 (2)(d) Agency's policy on suicide Yes
prevention and risk assessment tool

excerpt:
419-400-0160(4)(b) Receive continuing education Yes
(as applicable on crisis intervention training) from a
certified instructor on an annual basis
Form revised 3/12/2025 Page 18 of 26
Children's records Yes/No Corrective actions/comments
health services or N/A

excerpt:
419-470-0170(2) or N/A
(b) Intake document is completed the date child Yes
accepted into care (emergency placement 48 hours)
(d) Assessment is completed within 30 days and Yes
contains relevant historical information, current
behavioral observations, identified need for services
and how agency will provide services
(e) (A) and (B) Service plan within 60 days (parent, No Guardian involvement was not clearly documented as being
guardian and child actively involved). Describes how provided to and reviewed by the guardian. While on-site,
child's issues will be addressed, anticipated suggestions were provided to the agency. This is a repeat
outcomes and reviewed by child and guardian/parent. finding.
Corrective Action: The agency shall ensure
documentation of guardian involvement on service plans.
(e)(C) and (D) Service plan is reviewed quarterly Yes
and revised when information indicates other
services should be provided
Case management Yes/No Corrective actions/comments

excerpt:
419-470-0170(3) or N/A
(c) Discharge summary must include: No Discharge summaries were inconsistent not meeting all
(A)Current medications requirements. This is a repeat finding.
(B)Name of the physician or qualified medical
professional who prescribed each medication Corrective Action: The agency shall ensure all discharge
(C)Any outstanding medical or other appointments summaries include all requirements and edit the discharge
(D)Summary of the child's participation in the form to correlate to the requirements.
program and progress achieved
(E)Results of evaluations
(F)Recommendations regarding services
(G)Discharge destination
(e) Follow up services Yes
(f) Incident reports Yes
Records relating to Restraint and Involuntary Yes/No Corrective actions/comments
Seclusion or N/A

excerpt:
419-400-0180(13)(e) Each child caring agency shall Yes
provide notice regarding how to access the quarterly
reports to the parents or guardians of children in care
in the program. The child caring agency shall provide
the notice upon the child in care's admission and at
least two times each year thereafter.

excerpt:
419-400-0140 or N/A
(1) Stored safely Yes
(2) Permanent, legible, dated and signed Yes
(3) and (4) Uniform in organization, readily identifiable Yes
and accessible, current and complete, containing all
required info. No eraser tape or white out.
(7) Permanent registry for each child includes: Yes
Name
Gender
Birth date
Names, addresses of parents or guardians
Dates of admission
Placement upon discharge
Policies and procedures to update:
Grievance: add board member contact information in the event the complaint is pertaining to the ED.
Incident reporting: Update this sentence, "Interviews of all involved parties will be conducted to ensure the accuracy of the report,
prior to submission, except reports made to the Child Abuse Hotline to not interfere with the investigation process.
Behavior Management, were prohibited discipline is noted: Add
- (K) Removing or limiting the use of a mobility aid or other assistive device for the purpose of controlling a child in care's
behavior.
Discipline: recommend combing the Discipline and Behavior management policies and procedures.
- Note: (K) above is included in the discipline P&P.
Form revised 3/12/2025 Page 23 of 26
Transportation: Add information related to the following:
- (A) Each vehicle used to transport a child in care must be: (i) Properly registered.
- A statement regarding (E) The child-caring agency must take reasonable steps to ensure safety when using off-road
vehicles.
- That the fire extinguisher is "properly secured".
Searches: Add information related to the following:
- (E) The staff member must then pat the clothing of the child in care using only enough contact to conduct an appropriate
search;
- (G) If the child in care refuses to comply, the executive director or designee must be notified immediately and be
responsible to resolve the matter;
- (H) All searches must be documented in writing.
- (f) If the child in care refuses to comply with a requirement of the search, the program must follow established policies to
determine if the child in care can be refused admission to or discharged from the program.
- (g) Information regarding any personal or room searches and protocols for confiscation of contraband items, including the
notification of law enforcement if illegal contraband is discovered. This information will include the procedures and
rationales of the child-caring agency for any program-initiated room or body search.
Hazards: Add
- (b) Direct supervision by staff must be provided for any child in care who does not have the ability to adjust and control
water temperature.
- (c) Each light fixture must have a protective cover unless it is designed to be used without one.
Personnel: Some requirements are referenced in the "Employee Training Manual" document, but missing all requirements set
forth in this rule. The agency shall either update this manual or create a new Personnel Policy and Procedure to capture all
requirements set forth in OAR

excerpt:
419-400-0120.
Privacy:
- Add "audio or video recording: to the sentence where it states, "Youth photos will not be used without a signed media
consent form by the ODHS Caseworker / legal guardian."
Form revised 3/12/2025 Page 24 of 26
- Update the "Calls & Visitation Policy" where it states, "All calls will be made in a public area, there is no guarantee of
privacy." This is in conflict with OAR

excerpt:
419-400-0090(1)(b) The child in care's right to privacy.
- Recommend updating the title or opening sentence that includes privacy, disclosure of camera use, and youth private
communication; or see recommendation below.
Audio Video Monitoring:
- Recommend removing this section from the Privacy policy and procedure document and create a stand-alone for this topic,
which can refer to the privacy policy and procedure.
- Add a statement of: all employees, volunteers, parents or guardians, and children in care must be informed about the
intended use and locations of the equipment
Health Services, "Medical Care": add information related to the following:
(2) Medical history. Within 30 days of a child in care being placed with a residential care agency, the residential care
agency must obtain available medical history and other health-related information on the child in care, including:
(a) Significant findings of the most current physical examination;
(b) The child in care's current immunizations, history of surgical procedures and significant health issues or injuries, and
past or present communicable diseases;
(c) Any known allergies;
(d) Dental, vision, hearing, and behavioral health; and
(e) Physician or qualified medical professional's orders, including those related to medications, if any.
(3) Health Services. The residential care agency must provide or arrange for the following health services, as applicable:
(a) Medical exams.
(b) Information on maintaining reproductive health and birth control.
(c) Prenatal care.
(d) Well-baby care.
(e) Fetal alcohol syndrome.
(f) Accessing child and infant health insurance programs.
(g) Screening for breast and other common cancers.
(h) Provide all necessary feminine hygiene products.
(i) Access to birth control, vaccinations, and information about preventing sexually transmitted diseases.
(j) Age-appropriate consultation is provided regarding nutrition, pregnancy prevention, prevention of HIV and AIDS and
general information about the prevention and treatment of sexually transmitted illnesses.
Form revised 3/12/2025 Page 25 of 26
Medications:
- Self-administration - add that the physician approval must be in writing.
- Documentation to include: (d) what to do if there is a charting documentation error, if a medication is refused, if a
medication is missed, or any other type of medication error that results in a medication not being administered as
prescribed.
- Storage - add information regarding being stored behind at least two locking mechanisms.
- (a) Prescription medications that are unused and medications that are expired or recalled may not be maintained with
current medication and must be disposed of as described in agency disposal policy.
- Medication Administration Record (MAR) form: dates and times, method of administration; and space to record any
possible adverse reactions to a medication.
- Add the medication record detail to the Medication policy and procedure, to match the MAR form.


state: OR

facility_name: Albertina Kerr - Subacute

summary: Unannounced - 5 findings

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Licensee: Albertina Kerr Sub-Acute
Executive Director: Jeff Carr
Program Director(s): Chuck Haas
Date of Unannounced: June 8th, 2021
Licensing Coordinator: Todd Cooley
Other Regulatory or Accrediting Agencies: OHA
Purpose: Per OAR 413-215-0101 (1) (b) Children’s Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Comments
Findings
Further Action
Needed
Safety 413-215-0541 Yes☐ No  (2020 Site Review) Documentation of 13 drills over the last 24 months. Only two of
(3)(a) Evacuation drill occurs monthly these were in 2019.
 (2020 Site Review) 3 months were missing since February 2020. AKC is
developing a plan for monthly audits to ensure these are being completed.
2021 Unannounced – Fire drill logs were provided, and they have been
completed consistently since the last unannounced review. No further
action necessary.
Minimum Staffing Requirements 413-215- Yes☐ No  (2020 Site Review) There are no staff trained in the reasonable and prudent parent
0561 standard.
(5) There is at least one on-site employee  (2020 Site Review) A majority of the staff have received this training ensuring at
authorized to apply the reasonable and least one staff on site is trained in prudent parent at all times. The remaining staff
prudent parent standard will be trained by the end of the year
2021 Unannounced – All staff were trained in Prudent Parent standard
through the end of 2020. It was identified this training was not properly
entered into the online Relias training system for notification, tracking and
1
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 200115)
completion on an annual basis. All staff are currently within standards and
AKC is working with the IT department to get this training properly entered in
Relias.
Ongoing Training Yes☐ No  (2020 Site Review) Missing documentation
413-215-0556(2)(a) Environmental  (2020 Site Review) Over half of the staff have already received this training for the
emergencies year with plans for the rest to receive the training by the end of the year.
2021 Unannounced – All staff are up to date on this training as of the
unannounced visit. No further action necessary.
Ongoing Training Yes☐ No  (2020 Site Review) Missing documentation
413-215-0556(4) Designated staff authorized  (2020 Site Review) See above prudent parent response
to apply reasonable and prudent parent
standard 2021 Unannounced – All staff were trained in Prudent Parent standard
through the end of 2020. It was identified this training was not properly
entered into the online Relias training system for notification, tracking and
completion on an annual basis. All staff are currently within standards and
AKC is working with the IT department to get this training properly entered in
Relias.
New Findings from Site Visit Comments
413-215-0511 Physical Plant
 All bathrooms with showers had a sloped area near the window with painted plywood. Each of these
Requirements (c) All areas of buildings
areas had the paint peeling with the plywood exposed. This was a known issue that was already
where children in care are present must
being discussed with maintenance and they were working on a solution.
be kept clean and in good repair. Major
appliances and heating, ventilation, - The day following the site visit AKC provided pictures showing each shower area had been
fixed. Their solution was to screw a sheet of plastic to the topside of the plywood,
plumbing, and electrical systems must be
protecting it from water and eliminating the need for paint. No further action necessary.
functional and in good repair.
413-215-0516 Room and Space  Multiple hygiene cabinets were not locked. The tour of the facility occurred just after morning routine
Requirements (1) All parts of the facility and showers. All youth were currently engaged in other activities at the time of the tour and at least
three separate hygiene cabinets were found unsecured. Management planned on re-training and re-
must ensure the safety of the children in
enforcing the need to lock the hygiene cabinets when not in use, starting at that days huddles.
care.
2
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 200115)
Interview Summary
Two clients were interviewed as part of the unannounced visit. The clients stated they felt safe and comfortable at the program. Both felt there
were several staff they could talk to if they had any issues or concerns about anything. Both felt the food was okay, got plenty to eat and had
snacks available to them if they got hungry between meals. Clients stated for school they work on packets provided by Albertina Kerr, but also
weren’t sure how it related to their home school and keeping up with credits. Clients get outside three times a day for a half hour at a time.
With the weather getting nicer they wished they could have more outside time but understood about schedules.
When asked if there were areas the program could improve, one client said nothing to improve on and the other wished for more movement.
They elaborated and said it felt like most of their time was spent at the table in the common area of the pod, whether for eating, groups or
various other activities.
When asked what they thought the program did well, both clients agreed the staff are very good. One stated they do a really good job of
keeping everyone safe and treating everyone well. The other thought the staff was excellent and said it was helpful a lot of staff were near the
same age because it felt like they could relate better. The client also appreciated the balance of time spent with therapists and time on the unit
doing other activities.
Observations
Overall, the program was clean and in good repair with the exception listed above. Albertina Kerr had a solid Covid-19 visitor screening
process in place upon entry to the facility. All the previous deficiencies have been corrected and the fire drills which had been an ongoing
problem have been consistently conducted and documented. This appears to be in large part due to the Psych Tech Supervisors taking
ownership and accountability. The food was also noted as edible and okay, which is a step up from previous reviews where there had been
nothing neutral or positive to be said about the food. AKC stated they continue to work with the vendor to improve the meals and get to the
quality of food they sampled prior to contracting.
There have not been any major changes to the program since the last review and management was very responsive to the few items noted
during this visit.
Corrective Actions and Timeframes:
Please submit the following to verify compliance.
Within 45 days of receipt of this report Albertina Kerr Sub-Acute must submit a letter of verification indicating the agency is in compliance with the
specific rules cited above and describing how compliance will be maintained going forward. Along with the letter of verification, the agency must
submit any and all specific documentation requested in the body of this report. The letter of verification and any additional requested documents can
be emailed directly to Todd Cooley, todd.cooley@dhsoha.state.or.us , or sent by regular mail to the following address:
Department of Human Services
Children’s Care Licensing Program
3
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 200115)
Attn: Todd Cooley
201 High St. SE Suite 500
Salem, OR 97301
6-17-2021
Licensing Coordinator’s Signature: ________________________ Date: ___________________
6-15-2021
Manager Review: ______________________________________ Date: __________________
4
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 200115)

agency_name: Albertina Kerr Centers for Children (AKCC)

program_type: (RC) Residential Care Programs

report_type: Unannounced

view_code: RC

licensee: Albertina Kerr Sub-Acute

executive_director: Jeff Carr

program_director: Chuck Haas

visit_date: June 8th, 2021

licensing_coordinator: Todd Cooley

other_regulatory_agencies: OHA

purpose:
Per OAR 413-215-0101 (1) (b) Children's Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Comments
Findings
Further Action
Needed
Safety 413-215-0541 Yes[ ] No - (2020 Site Review) Documentation of 13 drills over the last 24 months. Only two of
(3)(a) Evacuation drill occurs monthly these were in 2019.
- (2020 Site Review) 3 months were missing since February 2020. AKC is
developing a plan for monthly audits to ensure these are being completed.
2021 Unannounced - Fire drill logs were provided, and they have been
completed consistently since the last unannounced review. No further
action necessary.
Minimum Staffing Requirements 413-215- Yes[ ] No - (2020 Site Review) There are no staff trained in the reasonable and prudent parent
0561 standard.
(5) There is at least one on-site employee - (2020 Site Review) A majority of the staff have received this training ensuring at
authorized to apply the reasonable and least one staff on site is trained in prudent parent at all times. The remaining staff
prudent parent standard will be trained by the end of the year
2021 Unannounced - All staff were trained in Prudent Parent standard
through the end of 2020. It was identified this training was not properly
entered into the online Relias training system for notification, tracking and
1

completion on an annual basis. All staff are currently within standards and
AKC is working with the IT department to get this training properly entered in
Relias.
Ongoing Training Yes[ ] No - (2020 Site Review) Missing documentation
413-215-0556(2)(a) Environmental - (2020 Site Review) Over half of the staff have already received this training for the
emergencies year with plans for the rest to receive the training by the end of the year.
2021 Unannounced - All staff are up to date on this training as of the
unannounced visit. No further action necessary.
Ongoing Training Yes[ ] No - (2020 Site Review) Missing documentation
413-215-0556(4) Designated staff authorized - (2020 Site Review) See above prudent parent response
to apply reasonable and prudent parent
standard 2021 Unannounced - All staff were trained in Prudent Parent standard
through the end of 2020. It was identified this training was not properly
entered into the online Relias training system for notification, tracking and
completion on an annual basis. All staff are currently within standards and
AKC is working with the IT department to get this training properly entered in
Relias.
New Findings from Site Visit Comments
413-215-0511 Physical Plant
- All bathrooms with showers had a sloped area near the window with painted plywood. Each of these
Requirements (c) All areas of buildings
areas had the paint peeling with the plywood exposed. This was a known issue that was already
where children in care are present must
being discussed with maintenance and they were working on a solution.
be kept clean and in good repair. Major
appliances and heating, ventilation, - The day following the site visit AKC provided pictures showing each shower area had been
fixed. Their solution was to screw a sheet of plastic to the topside of the plywood,
plumbing, and electrical systems must be
protecting it from water and eliminating the need for paint. No further action necessary.
functional and in good repair.
413-215-0516 Room and Space - Multiple hygiene cabinets were not locked. The tour of the facility occurred just after morning routine
Requirements (1) All parts of the facility and showers. All youth were currently engaged in other activities at the time of the tour and at least
three separate hygiene cabinets were found unsecured. Management planned on re-training and re-
must ensure the safety of the children in
enforcing the need to lock the hygiene cabinets when not in use, starting at that days huddles.
care.
2

Interview Summary
Two clients were interviewed as part of the unannounced visit. The clients stated they felt safe and comfortable at the program. Both felt there
were several staff they could talk to if they had any issues or concerns about anything. Both felt the food was okay, got plenty to eat and had
snacks available to them if they got hungry between meals. Clients stated for school they work on packets provided by Albertina Kerr, but also
weren't sure how it related to their home school and keeping up with credits. Clients get outside three times a day for a half hour at a time.
With the weather getting nicer they wished they could have more outside time but understood about schedules.
When asked if there were areas the program could improve, one client said nothing to improve on and the other wished for more movement.
They elaborated and said it felt like most of their time was spent at the table in the common area of the pod, whether for eating, groups or
various other activities.
When asked what they thought the program did well, both clients agreed the staff are very good. One stated they do a really good job of
keeping everyone safe and treating everyone well. The other thought the staff was excellent and said it was helpful a lot of staff were near the
same age because it felt like they could relate better. The client also appreciated the balance of time spent with therapists and time on the unit
doing other activities.
Observations
Overall, the program was clean and in good repair with the exception listed above. Albertina Kerr had a solid Covid-19 visitor screening
process in place upon entry to the facility. All the previous deficiencies have been corrected and the fire drills which had been an ongoing
problem have been consistently conducted and documented. This appears to be in large part due to the Psych Tech Supervisors taking
ownership and accountability. The food was also noted as edible and okay, which is a step up from previous reviews where there had been
nothing neutral or positive to be said about the food. AKC stated they continue to work with the vendor to improve the meals and get to the
quality of food they sampled prior to contracting.
There have not been any major changes to the program since the last review and management was very responsive to the few items noted
during this visit.


summary: License Renewals - 3 findings

raw_content:
Licensed Child Caring Agency Site Visit Report
Residential Care
Licensee: Albertina Kerr Date of site visit: February 22, 2022
Executive Director: Miki Herman Licensing Coordinator: Aubrey Kelly
Other Regulatory or Accrediting Agencies: Oregon Health Authority
Program Compliance: The program was found to be compliant or will be compliant with OAR 413-215-0001 to 413-215-0131, Licensing Umbrella
Rules, and OAR 413-215-0501 to 413-215-0586, Licensing Residential Care Agencies Rules. Personnel records were reviewed and compliance
with required background checks was documented for employees in all programs.
Program Description(s): Albertina Kerr Subacute program is a short-term residential program focused on stabilization of symptoms during a
youth’s mental health crisis. In addition to stabilization, treatment includes thorough assessments for on-going mental health needs and detailed
discharge planning.
Capacity and Age Range: 24; 5 through 17.
Funding sources: Greater OR Behavioral Health, Intercommunity Health Medicaid, Care Oregon Medicaid, Options of Southern OR,
Pacific Source Medicaid, Trillium Community Managed Medicaid and Yamhill Community Coordinated Care Organization (CCO).
Contracts and sources for referrals: Legacy Emanuel Children's Hospital, OHSU Dorenbecher Children's Hospital, St. Charles Health
Care System in central Oregon, Asante Health System in Southern Oregon, Providence Health Care System, Unity Center for
Behavioral Health, Kaiser Permanente Health System, Salent Health Hospital, Catholic Community Services, Morrison Child and
Family Services and Lifeworks NW.
Average length of stay: 22.73 days
Average daily population served: 13.51
Number of children served annually: 208
(rev. 03/25/2021)
Use of seclusion or restraint: Yes. Oregon Intervention System (OIS).
Interviews, Observations: Client #1: They have been at the program for 15 days. They were previously at Madrona Recovery. Their therapist at
the program is really good and sees the therapist 2 times a week for individual therapy and 2 times a week for family therapy. The food is not good
but they do get enough to eat. They feel safe and can reach out to staff if they need support. The program has been very helpful. They have phone
calls and virtual visits often. They have not been in a restraint while at the program.
Client #2: They have been at the program for 2 weeks. Everyone is cool here. They feel safe here. They really like their therapist, Jeremy. They
know their treatment goals and are working on them. They can have phone calls frequently. The food is not good, it tastes alright sometimes. They
have not been restrained while at the program. The day prior, they were having a difficult time and staff Brian was able to help him deescalate to the
point staff did not have to restrain him.
Program Strengths: Albertina Kerr subacute is the only Oregon program at this level of care treating children as young as seven. Program staff are
their greatest asset. The program has hired talented and skilled physicians, nurses, child and family therapists, and psychiatric technicians. Kerr
has been a long standing program in Portland serving both children and youth in the Portland area, but also managing multiple group homes for
children, adolescents and adults with Intellectual and Developmental Disabilities (IDD). This culture allows the program to effectively treat children
and youth who display both mental health challenges but also those suffering both IDD and Mental Health challenges.
Program Challenges: Albertina Kerr has undergone a great deal of change in the last year, mostly due to consequences of the COVID Pandemic.
The program has seen a significant reduction in the work-force, mostly impacting the Sub-Acute Unit. They lost psychiatry technicians, registered
nurses and child and family therapists. As a result of work-force shortages, the program’s average daily population has decreased significantly.
Multiple initiatives have been and are currently addressing incentives to attract qualified candidates for all vacant positions. The program has
recently seen an uptick in the numbers of applicants for open positions so the program remains optimistic that things will stabilize soon and they will
be able to serve more youth and families.
Changes that have occurred in the last 2 years: Albertina Kerr has undergone a great deal of change in the last year, mostly due to
consequences of the COVID Pandemic. Miki Herman, who was the previous Board President, has come on as the interim CEO until a more
permanent candidate is found. Chuck Haas, LCSW, LASW, has joined Kerr as Director of Mental Health Programs.
Lawsuits: None
Grievances and complaints filed in the last two years: Yes.
Corrective Actions and Timeframes: Please submit the following to verify compliance.
2
Within 45 days of receipt of this report Albertina Kerr must submit a letter of verification indicating the agency is in compliance with the specific rules
cited above and describing how compliance will be maintained going forward. Along with the letter of verification, the agency must submit any and
all specific documentation requested in the body of this report. The letter of verification and any additional requested documents can be emailed
directly to Aubrey Kelly at Aubrey.J.Kelly@dhsoha.state.or.us or sent by regular mail to the following address:
Department of Human Services, Children’s Care Licensing Program
Attn: Aubrey Kelly
201 High St SE, Suite 500
Salem, OR 97301
Recommendations: None
Exceptions: None
Changes in License: None
Summary of Review
Program and Services Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0011(2) Completed
Program and services are in scope of license X
Governance of the Agency Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0021 Completed
(1)(a) Minimum of 5 board members X
(2)(f) Formally evaluate the exec. Director’s X
performance annually
(2)(g) Approves annual budget X
(2)(h) Obtain and review an annual X
independent financial review or audit of
financial records.
(2)(k) Written quality improvement program X
(2)(l) Meeting minutes X
Executive Director or Program Director Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0021 Completed
(3)(a) knowledge of requirements for X
providing care and treatment appropriate to
programs
(3)(g) Approval from BCU X
Discipline, Behavior Management, and Corrective Action
Yes No N/A Corrective Actions/Comments
Suicide Prevention 413-215-0076 Completed
(3) Agency uses appropriate and positive
X
methods of behavior management and
3
nationally recognized non-violent crisis
intervention
(3)(b)(C) Agency does not use chemical and
mechanical restraint (excluding medically X
necessary devices/prescriptions)
(3)(c) Agency uses appropriate time-out
rooms (adequate space, heat, light and
ventilation and is not capable of locking) and X
documents use in child’s record when
applicable
(3)(e) Agency uses seclusion
X
appropriately/consistent with policy
(4) Agency has adequate plan in place to
X
respond to suicidal behavior/warning signs
Contractors (if applicable) Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0061(6) Completed
(a) Agency ensures the contractor meets the
requirements of this rule and Chapter 413 X
division 215
(b)(B) Contract includes the following:
(i) Services provided
(ii) Contractor fees
(iii) Disclosure of information from contractor
to agency
(iv) Lines of authority X
(v) Adherence to rules, including background
check
(vi) Any liability of the agency for acts of the
contractor, rights of indemnity and limitations
on liability
Supplemental Information Provided by Corrective Action
Yes No N/A Corrective Actions/Comments
CCA Completed
Documents as indicated on the form titled
X
“Renewal Licensing Required Documents”
Documents as indicated on form titled
“Required Financial Documents and X
Information”
All required policies and procedures as
X
identified in the “Umbrella Rules”
All required policies and procedures as
X
identified in “Agency Type Specific Rules”
Physical Plant Corrective Action
Yes No N/A Corrective Actions/Comments
Completed
413-215-0046(3)(a) Foster Rights Posted (if X
children in DHS custody)
4
413-215-0051(1) Sufficient safe space, X
equipment, and office equipment
413-215-0091(12) License is posted in X
common area at each facility
413-215-0001(5)(d), 0516(4(a)(I) & 0521(1) X
Adequate furnishings and personal items
413-215-0511(2)(a) &(c) Buildings are X
smoke free, clean and in good repair
413-215-0511(2)(d) Rooms are free of X
harmful drafts, odors, and excessive noise
413-215-0511(2)(e) Rooms are adequate in X
size and arrangement
413-215-0511(2)(f) System provides a X
continuous supply of hot and cold water to
taps located throughout the facility
413-215-0511(2)(h) Building is well X
ventilated and room temperature is within a
normal comfort range
413-215-0516(1) All parts of the facility X
ensure the safety of children
Room and Space Requirements Corrective Action
Yes No N/A Corrective Actions/Comments
Bedrooms 413-215-0516(3) Completed
(a) Adequate furnishings and personal items X
(b) Separate from rooms used for dining, X
living, laundry, kitchen, and storage
(c) Outside room with window allowing X
egress from building
(d) Ceiling at least 90 inches X
(e) Minimum 60 SF per bed X
(f) No more than 25 if dorm style X
(g) Permanently wired fixtures X
(h) Window covering X
(i) Beds are 3 feet apart and maintained to X
ensure safety
Room and Space Requirements Corrective Action
Yes No N/A Corrective Actions/Comments
Bathrooms 413-215-0516(4) Completed
(a)(A)&(B) 1:8 ratio for toilets and sinks X
(a)(D) Hot and cold running water, soap, and X
approved hand drying options
(a)(E) 1:10 ratio for shower or bathtub X
(a)(E) Individual privacy X
(a)(F) Window covering X
(a)(G) Permanently wired fixtures X
(a)(H) Adequate ventilation X
5
(b)&(c) Wooden racks on floors are X
prohibited and impervious shower mats are
disinfected & dried daily
Room and Space Requirements Corrective Action
Yes No N/A Corrective Actions/Comments
Kitchen 413-215-0516(6) Completed
(a) Used exclusively for storage, food X
preparation, dish washing and activities
related to eating
(b) Walls, floors are easily cleanable X
(c) Equipment and utensils are easily X
cleanable, durable, nontoxic, and kept clean
(e) Equipment is easy to clean beneath, X
between and behind
Room and Space Requirements Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0516 Completed
(2) There is a separate living room or lounge X
area – 15 SF minimum per child
(5) There is a separate dining room with X
capacity for ½ of children in care and 15 SF
per child in care
(7) Laundry is separate from living areas, X
kitchen and dining
(8) Separate storage areas are provided for X
food, kitchen supplies, utensils, clean linens,
soiled linens and clothing, cleaning supplies
and equip, poisons, chemicals, outdoor
recreational and maintenance equipment
(9) Outdoor activity area is protected from X
vehicles and other hazards and of a size and
availability appropriate to the age and needs
of children in care
(11) & 413-215-0076(3)(c)(C)Time out rooms X
have adequate space, heat, light and
ventilation and is not capable of locking
Furnishings and Personal Items Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0521 Completed
(1) There is a bed with frame, clean mattress X
and pillow and personal storage (dresser,
closet)
(2) Linens are in good repair. There is a X
waterproof mattress cover or mattress.
Linens are appropriate and towels and
washcloths are provided
(3) Bedding is changed weekly or when X
soiled
6
(4)&(5) Personal hygiene supplies and X
appropriate clothing are provided
Food Services Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0536(1)&(2) Completed
(1)(a) Meals are arranged daily, consistent X
with normal mealtimes that occur during the
hours of operation
(1)(b) Menus are prepared in advance in X
accordance with USDA guidelines, provide a
variety of foods and are adjusted for
seasonal changes.
(1)(b) Menus are kept for at least 6 months X
(1)(c) Drinking water is freely available X
(2)(a) Food is stored, prepared & served in a X
sanitary manner
(2)(c) & (d) Food products are obtained from X
commercial suppliers (exception of fruits &
vegetables), unpasteurized juice is
prohibited, and only Grade A pasteurized
and fortified milk in appropriate container.
Safety Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0541 Completed
(2)(a) Written emergency plan X
(2)(b) Telephone numbers for local police X
and fire are posted near all telephones
(2)(c) Operative flashlights sufficient in X
number are readily available to staff
(3)(a) Evacuation drill occurs monthly under X
varying conditions, is retained 2 yrs and
contains;
(A) identify of person conducting drill
(B) date & time
(C) notification method
(D) staff participating
(E) # of children & staff evacuated
(F) special conditions simulated
(G) problems encountered
(H) time to complete
Safety – Transportation Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0541 Completed
(5)(b) Vehicle has insurance policy, is smoke X
free, safe operating condition, and has first
aid kit and fire extinguisher 2-A:10-BC
Medication Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0551 Completed
7
(3)&(7)(e) Medications have a prescription X
and are stored in the original container with
prescription label
(4)&(5) Herbal supplements and remedies, X
medical treatments, special diets, physical
therapy, physical aides or limitations have a
written order signed by a physician or
qualified medical professional.
(7)(c) Medications are inaccessible to X
children
(8) Medications are disposed in accordance X
with state and federal law
(9) Written record of the disposal of X
medications is maintained and includes:
(a) description and amount
(b) name
(c) reason
(d) method
(e) staff & witness signature
(10) Written record of the administration of X
medication includes:
(a) name
(b) description
(c) dates and times
(d) missed doses
(e) medication disposed
(f) method of administration
(g) ID of person administering
(h) possible adverse reactions
(i) medication taken outside facility
Extracurricular, Enrichment, Cultural &
Corrective Action
Social Activities Yes No N/A Corrective Actions/Comments
Completed
413-215-0554
(2) Children have ongoing opportunities to X
participate in at least one age-appropriate or
developmentally appropriate activity
Minimum Staffing Requirements Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0561 Completed
(1)&(2) Supervision is adequate for the type X
of program, location, age and type of
children, ability of supervisor to respond,
electronic back-up systems.
Minimum ratios are maintained:
Under 30 months of age: 1:4
8
30 months to ˃ 6 yrs or non-ambulatory: 1:6
Ages 6 and older: 1:7
Overnight (staff awake)
1:10
(4)(a) When one staff on duty, there is X
additional staff immediately available with
max response time of 30 minutes
(5) There is at least one on-site employee X
authorized to apply the reasonable and
prudent parent standard
Separation of Residents Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0566 Completed
(1) Children are in separate bedrooms than X
adults, unless parent and child, or there is
written approval from guardian/parent and
licensing coordinator
(2) There is adequate supervision of children X
if both males and females are served by the
program
Personnel Files Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0061 Completed
Staff Name/Position X
(3)(g) Date of Hire X
(3)(a) record of education, training and
X
previous employment
(1)(b) & (3)(b) reference checks completed
X
and documented
(1)(a) & (3)(c) Background check completed
and documented X Annual performance evaluations have not been completed
on a consistent basis. The program shall ensure staff receive
(3)(d) Annual performance evaluations X
annual performance evaluations and they are documented in
(3)(f) Record of personnel actions X each staff’s personnel file.
(3)(g) Termination date, reason for
X
termination
(3)(h) Current job description (1)(c)
Employee meets minimum qualifications X
stated in current job description
9
New Employee Orientation – Umbrella
Corrective Action
Requirements (30 days) Yes No N/A Corrective Actions/Comments
Completed
413-215-0061(4)
(a) Agency policies and procedures X
(b) Ethical and professional guidelines X
(c) Organizational lines of authority X
(d) Attributes of population served X
(e) & (5)(a) to (c) Mandatory reporting that
includes:
(a) legal definition of child abuse ORS
419B.005, Oregon Laws 2016, chapter 106,
X
section 36
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to
the employee
(f) Privacy laws X
(g) Emergency procedures X
New Employee Orientation – Residential
Corrective Action
(30 days) Yes No N/A Corrective Actions/Comments
Completed
413-215-0556
(1)(a) Discipline and behavior management
including de-escalation, crisis prevention,
Behavior management training has been completed by staff,
positive behavior management, and X however it was not consistently completed within 30 days of
disciplinary techniques that are non-punitive
hire. The program shall ensure staff complete all required
in nature
trainings within 30 days of hire.
(1)(b) Restraint and seclusion (if applicable) X
Ongoing Training Corrective Action
Yes No N/A Corrective Actions/Comments
Completed
413-215-0536(2)(b) Employees who handle X
food served to children have a valid food
handler’s card
413-215-0541(5)(a) Employees transporting
children have: current driver’s license,
insurance, trained in emergency procedures X
and behavior management, and training for
15+ passenger vans if applicable)
413-215-0556(2)(a) Environmental
X
emergencies
413-215-0556(2)(b) Universal Precautions X
413-215-0556(2)(c) Discipline and Behavior
X
Management
10
413-215-0556(3) Staff providing direct care
must maintain current CPR/First Aid X
certification
413-215-0556(4) Designated staff authorized
to apply reasonable and prudent parent
X
standard are trained in application of the
standard
413-215-0061(5) Mandatory reporting
(annually) that includes:
(a) legal definition of child abuse ORS
419B.005, Oregon Laws 2016, chapter 106,
X
section 36
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to
the employee
Children’s Records Corrective Action
Yes No N/A Corrective Actions/Comments
Completed
Health Services
413-215-0546
(2) Medical history obtained within 30 days
(significant findings, current immunizations,
history of surgical procedures-health issues- X
injuries, allergies, dental, vision, hearing,
behavioral health, and physician orders)
(2)(e) Documentation of age appropriate
instruction – pregnancy prevention, nutrition,
prevention of HIV & AIDS, and prevention X
and treatment of sexually transmitted
disease
(4)(a) to (f) Medical exams (3 in first year of
life, 2,4,6,9,14) X
Consents Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0576(1) Completed
(a) Provide routine and emergency medical
X
care
(b) Use the discipline and behavior
X
management system
11
(c) Use restraint or seclusion (if applicable).
Must specify the reasons for the intervention X
and how staff are trained and supervised
(d) Restrict contact with persons outside of
X
the agency
(e) Allow access as defined in 413-215-0091
X
& 0101
(f) Impose a dress code X
(g) Apply the reasonable and prudent parent
X
standard
Disclosures
Corrective Action
413-215-0576(2) Parent/guardian has Yes No N/A Corrective Actions/Comments
Completed
acknowledged in writing:
(a) Information regarding personal or room
searches and protocols for confiscation of X
contraband
(b) Statement of Rights of Children and
X
Parents/Guardians
(c) Any policies and procedures upon
X
request
Authorizations Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0576(3) Completed
(a) Disclose or exchange information with
X
others
(b) Child specific visitors X
(c) Visitation resources are pre-approved X
(d) Activity specific authorizations are pre-
approved to allow children to participate in
potentially hazardous activities, including but X
not limited to using motorized yard
equipment, swimming, and horseback riding.
Information about Children in Care
Corrective Action
413-215-0581(1) Summary sheet contains Yes No N/A Corrective Actions/Comments
Completed
the following:
(a)The name, gender, date of birth, religious
X
preference, and previous address
(b) Name and location of previous and
X
current school
(c) Date of admission X
(d) Legal custody X
12
(e) The name, address, and telephone
number of:
(A) The child in care's parents.
(B) The child in care's legal guardian, if
different than the parents, and a copy of
X
the document that provides for his or her
authority over the child in care.
(C) Other persons significant to child
(D) Other professionals to be involved in
service planning (if applicable)
Service Planning Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0581(2) Completed
(b) Intake document is completed the date
child accepted into care (emergency X
placement 48 hours)
(d) Assessment is completed within 30 days
and contains relevant historical info., current
behavioral observations, identified need for X
services, and how agency will provide
services
(e) (A)&(B) Service plan within 60 days
(parent, guardian and child actively
involved). Describes how child’s issues will X
be addressed, anticipated outcomes and
reviewed by child and guardian/parent.
(e)(C)&(D) Service plan is reviewed quarterly
and revised when information indicates other X
services should be provided
Case Management Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0581(3) Completed
(a) Services are documented, progress
X
toward achieving goals is tracked
(b)-(d) discharge planning and instructions X
(f) Incident Reports X
Financial Records Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0581(4) Completed
Records contain date, amount, source,
X
purpose, signatures
Personal Possessions Records Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0581(5) Completed
13
Individual written inventory of all personal
possessions is maintained and updated as X
needed
Records and Documentation Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0071 Completed
(1) Stored safely X
(2) Permanent, legible, dated, and signed X
(3)&(4) Uniform in organization, readily
identifiable and accessible, current, and
X
complete, containing all required info. No
eraser tape or white out.
(7) Permanent registry for each child
includes:
Name
Gender
X
Birth date
Names, addresses of parents or guardians
Dates of admission
Placement upon discharge
Licensing Coordinator’s Signature: ________________________ Date: _0_3_-2_1_-_2_0_2_2__________
Manager Review: ______________________________________ Date: _ _ 0_3_-_1_1_-_2_0_2_2_ ______
14

facility_type: Residential Care

visit_date: February 22, 2022

licensing_coordinator: Aubrey Kelly

other_regulatory_agencies: Oregon Health Authority

program_description:
Albertina Kerr Subacute program is a short-term residential program focused on stabilization of symptoms during a
youth's mental health crisis. In addition to stabilization, treatment includes thorough assessments for on-going mental health needs and detailed
discharge planning.

capacity_age_range: 24; 5 through 17.

use_of_seclusion_or_restraint: Yes. Oregon Intervention System (OIS).

program_challenges:
Albertina Kerr has undergone a great deal of change in the last year, mostly due to consequences of the COVID Pandemic.
The program has seen a significant reduction in the work-force, mostly impacting the Sub-Acute Unit. They lost psychiatry technicians, registered
nurses and child and family therapists. As a result of work-force shortages, the program's average daily population has decreased significantly.
Multiple initiatives have been and are currently addressing incentives to attract qualified candidates for all vacant positions. The program has
recently seen an uptick in the numbers of applicants for open positions so the program remains optimistic that things will stabilize soon and they will
be able to serve more youth and families.

grievances_and_complaints: Yes.

excerpt: (3)(d) Annual performance evaluations

excerpt:
(1)(a) Discipline and behavior management
including de-escalation, crisis prevention,
positive behavior management, and
disciplinary techniques that are non-punitive
in nature Behavior management training has been completed by staff,
however it was not consistently completed within 30 days of
hire. The program shall ensure staff complete all required
trainings within 30 days of hire.