facility_name: West Linn Clementine

summary: License Renewals - 15 findings

raw_content:
Licensed Child Caring Agency Site Visit Report
Residential Care
Licensee: West Linn Clementine Date of site visit: January 29, 2021
Executive Director: Stephanie Waguespak Licensing Coordinator: Holly Ivey
Other Regulatory or Accrediting Agencies: Joint Commission
Program Compliance: The program is or will be compliant with OAR 413-215-0001 through 0131 Licensing Umbrella Rules and OAR 413-215-
0501 through 413-215-0586 Licensing Residential Care Agency Rules.
Personnel records were reviewed and compliance with required background checks was documented for employees in all programs.
Program Description(s): West Linn Clementine is a residential facility exclusively for adolescent girls seeking treatment for multiple eating
disorders or exercise addiction. They offer medical and psychiatric care integrated with personalized clinical and nutritional care as well as
academic and family support. The program offers 24 hour on-site medical oversight and nursing care, weekly medical monitoring, 24-hour access
to psychiatrists, medication management, family involvement, individual and group counselling sessions and weekly nutrition and cooking groups.
The program serves females, ages 11-17 with a capacity of 12.
Program type and services: Residential Services that specialize in eating disorders treatment.
Capacity and age-range: 12 youth, ages 11-17 years old.
Funding sources: Medicaid, private insurance, Oregon Health Plan and private pay.
Contracts and sources for referrals: Contracts with insurance companies.
Average length of stay: The average length of stay is 2-3 months.
Average daily population served: The program stays at full capacity, 12 youth.
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 170823)
Number of children served annually: Approximately 50 youth served.
Use of seclusion or restraint: N/A
Interviews, Observations: Stephanie Waguespak, Regional Administrator, Melissa Peterson Clinical Director, Erin Holl, Assistant Clinical Director,
Amanda Vonfedlt, Nursing Manager, and a youth was interviewed at the review. Staff and youth were observed at the program at the inspection.
The youth that were at the program that day appeared to be at ease, and comfortable in the environment. The facility was observed to be clean and
in good repair.
The following information was obtained in a private interview with a youth residing in the program:
The youth stated she appreciated the community of staff and her peers at the program. She mentioned that staff were very supportive, and that
everyone got along well. She stated she was getting her needs met with school while residing at the program. She mentioned that visiting hours
with COVID had been challenging. The youth were able to have 10-minute phone calls at night with their approved contacts. The youth could send
and receive mail. She stated staff were very cautious of exercise urges and general safety of the youth. She stated the quality of food was good,
and that she always was provided with enough to eat. If youth were hungry after a meal, they could request seconds or extra snacks. Two snacks
were provided daily to the youth. She stated that she always felt safe while residing at the program. She mentioned the program monitors
roommates and wanted the youth to feel safe with their room share.
Program Strengths: The following strengths were identified by leadership at the review:
 The program has solid staff that are passionate about the work.
 The program has strong individual & family therapy, group support, physical, mental health, and nutritional components.
 The program has a licensed teacher on staff to help the youth find balance with school.
 The youth can engage in yoga as the program has a yoga instructor. The youth have been doing a virtual yoga class during COVID.
 The program is data driven and analysis outcome results.
 The program provides 24-hour nursing.
Program Challenges: The following challenges were identified by leadership:
 The ever-changing aspects of the COVID Pandemic have been challenging. The program did all they could do to keep youth and staff as
safe as possible. Some of the impacts were: restrictions on youths’ in-person visits with family, staff group meetings by zoom.
 Some insurance companies do not allow for sufficient time for treatment stays, which would allow for the youth to have the full benefit of
treatment.
Changes that have occurred in the last 2 years: The following changes were stated by leadership at the time of the review:
 The program has adopted a new Electronic Record System and went live with it in October 2020.
2
 COVID brought a lot of change to some of the operations at the program.
Lawsuits: None identified at the time of the review.
Grievances and complaints filed in the last two years: None of significance acknowledged at the time of the
Corrective Actions and Timeframes: Please submit the following to verify compliance.
Within 45 days of receipt of this report West Linn Clementine, 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 Holly.r.ivey@state.or.us or sent by regular mail to the following address:
Department of Human Services, Children’s Care Licensing Program
Attn: Holly Ivey, DHS Licensing Coordinator
201 High St SE, Suite 500
Salem, OR 97301
Exceptions: N/A
Changes in License: N/A
Summary of Review
Program and Services Corrective Action
Yes No N/A Corrective Actions
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
413-215-0021 Completed
(1)(a) Minimum of 5 board members X
3
(2)(f) Formally evaluate the exec. Director’s X Governance of the Agency 413-215-0021(2)(g) Approves
performance annually annual budget. (REPEAT FINDING 2019)
(2)(g) Approves annual budget X
(2)(h) Obtain and review an annual X
 The agency must submit the above required
independent financial review or audit of
information to the Licensing Coordinator.
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
413-215-0021 Completed
(3)(a) knowledge of requirements for X
providing care and treatment appropriate to
programs
(3)(g) Approval from BCU X
Physical Plant Corrective Action
Yes No N/A Corrective Actions
Completed
413-215-0046(3)(a) Foster Rights Posted (if X
children in DHS custody)
413-215-0051(1) Sufficient safe space, X
equipment, and office equipment
413-215-0091(12) License is posted in X
common area at each facility
413-215-0001(5)(d), 0516(4(a)(I) & 0521(1) X
Adequate furnishings and personal items
413-215-0511(2)(a) &(c) Buildings are X
smoke free, clean and in good repair
413-215-0511(2)(d) Rooms are free of X
harmful drafts, odors, and excessive noise
413-215-0511(2)(e) Rooms are adequate in X
size and arrangement
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
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
4
(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
N/A- The program does not have dorm
style bedroom.
(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
Bathrooms 413-215-0516(4) Completed
(a)(A)&(B) 1:8 ratio for toilets and sinks X
(a)(D) Hot and cold running water, soap, and X
approved hand drying options
(a)(E) 1:10 ratio for shower or bathtub X
(a)(E) Individual privacy X
(a)(F) Window covering X
(a)(G) Permanently wired fixtures X
(a)(H) Adequate ventilation X
(b)&(c) Wooden racks on floors are X
prohibited and impervious shower mats are
disinfected & dried daily
Room and Space Requirements Corrective Action
Yes No N/A Corrective Actions
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
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
5
(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 X
rooms have adequate space, heat, light and
ventilation and is not capable of locking
N/A- The program does not utilize time
out rooms.
Furnishings and Personal Items Corrective Action
Yes No N/A Corrective Actions
413-215-0521 Completed
(1) There is a bed with frame, clean mattress X
and pillow and personal storage (dresser,
closet)
(2) Linens are in good repair. There is a X
waterproof mattress cover or mattress.
Linens are appropriate and towels and
washcloths are provided
(3) Bedding is changed weekly or when X
soiled
(4)&(5) Personal hygiene supplies and X
appropriate clothing are provided
Food Services Corrective Action
Yes No N/A Corrective Actions
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.
6
Safety Corrective Action
Yes No N/A Corrective Actions
413-215-0541 Completed
(2)(a) Written emergency plan X Safety 413-215-0541(3)(a) Evacuation drill….. contains;
(2)(b) Telephone numbers for local police X (C) notification method
and fire are posted near all telephones
(2)(c) Operative flashlights sufficient in X  The above required information was not found on the
number are readily available to staff evacuation drill logs.
(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
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
413-215-0551 Completed
(3)&(7)(e) Medications have a prescription X Medication 413-215-0551(9) Written record of the
and are stored in the original container with disposal of medications is maintained and includes: (c)
prescription label reason (d) method.
(4)&(5) Herbal supplements and remedies, X  The medication disposal log were missing the
medical treatments, special diets, physical above required information.
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
7
(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
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
413-215-0561 Completed
(1)&(2) Supervision is adequate for the type X
of program, location, age and type of
children, ability of supervisor to respond,
electronic back-up systems.
Minimum ratios are maintained:
Under 30 months of age: 1:4
30 months to ˃ 6 yrs or non-ambulatory: 1:6
Ages 6 and older: 1:7
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
N/A- The program always has a minimum
of two staff at all times on site.
(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
413-215-0566 Completed
(1) Children are in separate bedrooms than X
adults, unless parent and child, or there is
8
written approval from guardian/parent and
licensing coordinator
N/A The program serves 17 and younger.
(2) There is adequate supervision of children X
if both males and females are served by the
program
N/A The program only serves female
youth.
Personnel Files Corrective Action
Yes No N/A Corrective Actions
413-215-0061 Completed
Staff Name/Position X
(3)(g) Date of Hire X
(3)(a) record of education, training and X
previous employment
(1)(b) & (3)(b) reference checks completed X
and documented
(1)(a) & (3)(c) Background check completed X
and documented
(3)(d) Annual performance evaluations X
(3)(f) Record of personnel actions
N/A- This was not viewed in the files X
reviewed.
(3)(g) Termination date, reason for
termination
X
N/A- This was not viewed in the files
reviewed.
(3)(h) Current job description (1)(c)
Employee meets minimum qualifications X
stated in current job description
New Employee Orientation – Umbrella
Corrective Action
Requirements (30 days) Yes No N/A Corrective Actions
Completed
413-215-0061(4)
(a) Agency policies and procedures X
(b) Ethical and professional guidelines X New Employee Orientation – Umbrella Requirements (30
(c) Organizational lines of authority X days) 413-215-0061(4) (a) Agency policies and
(d) Attributes of population served X procedures (b) Ethical and professional guidelines
(e) & (5)(a) to (c) Mandatory reporting that X
includes:
9
(a) legal definition of child abuse ORS  The above required orientation was not
419B.005, Oregon Laws 2016, chapter 106, consistently completed within 30 days of hire in
section 36 the files reviewed.
(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
Completed
413-215-0556
(1)(a) Discipline and behavior New Employee Orientation – Residential (30 days)
management including de-escalation, 413-215-0556(1)(a) Discipline and behavior management
crisis prevention, positive behavior X including de-escalation, crisis prevention, positive
management, and disciplinary techniques behavior management, and disciplinary techniques that
that are non-punitive in nature are non-punitive in nature (REPEAT FINDING SINCE
2019)
 The program was providing staff with a discipline
training within 30 days; however, it was not a
(1)(b) Restraint and seclusion (if applicable) X nationally recognized model. The program is
utilizing CPI, which is nationally recognized.
Staff must be oriented to CPI within 30 days of
hire.
Ongoing Training Corrective Action
Yes No N/A Corrective Actions
Completed
413-215-0536(2)(b) Employees who handle X Ongoing Trainings
food served to children have a valid food 413-215-0556(2)(a) Environmental emergencies
handler’s card 413-215-0556(2)(b) Universal Precautions
413-215-0556(2)(c) Discipline and Behavior Management,
413-215-0541(5)(a) Employees transporting
413-215-0556(4) Designated staff authorized to apply
children have: current driver’s license,
reasonable and prudent parent standard are trained in
insurance, trained in emergency procedures
application of the standard
and behavior management, and training for X
413-215-0061(5) Mandatory reporting (annually) that
15+ passenger vans if applicable)
includes:(a) legal definition of child abuse ORS
N/A-The program does not have a 15plus
419B.005, Oregon Laws 2016, chapter 106, section 36
passenger van.
(b) legal responsibility to immediately report
413-215-0556(2)(a) Environmental X (c) legal responsibility to report is personal to the
emergencies employee
413-215-0556(2)(b) Universal Precautions X
 There was no documentation to verify that the
413-215-0556(2)(c) Discipline and X
above required ongoing (annual) trainings
Behavior Management
10
413-215-0556(3) Staff providing direct care occurred in the files reviewed. Ongoing trainings
must maintain current CPR/First Aid X must occur annually and be documented in
certification personnel files.
413-215-0556(4) Designated staff X
authorized to apply reasonable and
prudent parent standard are trained in
application of the standard
413-215-0061(5) Mandatory reporting X
(annually) that includes:
(a) legal definition of child abuse ORS
419B.005, Oregon Laws 2016, chapter
106, section 36
(b) legal responsibility to immediately
report
(c) legal responsibility to report is
personal to the employee
Contractors (if applicable) Corrective Action
Yes No N/A Corrective Actions
413-215-0061(6) Completed
(a) Agency ensures the contractor meets the X
requirements of this rule and Chapter 413
division 215
(b)(B) Contract includes the following: X
(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
Comments:
11
Children’s Records Corrective Action
Yes No N/A Corrective Actions
Completed
Name X
Health Services
413-215-0546
(2) Medical history obtained within 30 days X
(significant findings, current immunizations,
history of surgical procedures-health issues-
injuries, allergies, dental, vision, hearing,
behavioral health, and physician orders)
(2)(e) Documentation of age appropriate X
instruction – pregnancy prevention, nutrition,
prevention of HIV & AIDS, and prevention
and treatment of sexually transmitted
disease
(4)(a) to (f) Medical exams (3 in first year of X
life, 2,4,6,9,14)
Consents Corrective Action
Yes No N/A Corrective Actions
413-215-0576(1) Completed
(a) Provide routine and emergency medical
X
care
(b) Use the discipline and behavior
X
management system
(c) Use restraint or seclusion (if applicable).
Must specify the reasons for the intervention Consents 413-215-0576(1) (b) Use the discipline and
and how staff are trained and supervised X behavior management system (REPEAT FINDING
N/A-The program does not utilize SINCE 2019) (f) Impose a dress code
restraint or seclusion.
(d) Restrict contact with persons outside of  The above required consents, signed by
the agency X guardians, were not found in the youth files
reviewed.
(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
Completed
acknowledged in writing:
12
(a) Information regarding personal or room X
searches and protocols for confiscation of
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
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- X
approved 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
Corrective Action
413-215-0581(1) Summary sheet contains Yes No N/A Corrective Actions
Completed
the following:
(a)The name, gender, date of birth,
X
religious preference, and previous address
(b) Name and location of previous and
X
current school
(c) Date of admission X Information about Children in Care 413-215-0581(1)
(d) Legal custody X Summary sheet contains the following: (a)….religious
(e) The name, address, and telephone X preference…(b) Name and location of previous school
number of:
(A) The child in care's parents.  The summaries reviewed were missing the above
(B) The child in care's legal guardian, if required information.
different than the parents, and a copy of
the document that provides for his or her
authority over the child in care.
(C) Other persons significant to child
(D) Other professionals to be involved in
service planning (if applicable)
Service Planning Corrective Action
Yes No N/A Corrective Actions
413-215-0581(2) Completed
(b) Intake document is completed the date X
child accepted into care (emergency
placement 48 hours)
13
(d) Assessment is completed within 30 days X
and contains relevant historical info., current
behavioral observations, identified need for
services, and how agency will provide
services
(e) (A)&(B) Service plan within 60 days X
(parent, guardian and child actively
involved). Describes how child’s issues will
be addressed, anticipated outcomes and
reviewed by child and guardian/parent.
(e)(C)&(D) Service plan is reviewed quarterly X
and revised when information indicates other
services should be provided
Case Management Corrective Action
Yes No N/A Corrective Actions
413-215-0581(3) Completed
(a) Services are documented, progress X
toward achieving goals is tracked
(b)-(d) discharge planning and instructions X
(f) Incident Reports X
Financial Records Corrective Action
Yes No N/A Corrective Actions
413-215-0581(4) Completed
Records contain date, amount, source,
X
purpose, signatures
Personal Possessions Records Corrective Action
Yes No N/A Corrective Actions
413-215-0581(5) Completed
Individual written inventory of all personal
possessions is maintained and updated as X
needed
Records and Documentation Corrective Action
Yes No N/A Corrective Actions
413-215-0071 Completed
(1) Stored safely X
(2) Permanent, legible, dated, and signed X
(3)&(4) Uniform in organization, readily X
identifiable and accessible, current, and
complete, containing all required info. No
eraser tape or white out.
(7) Permanent registry for each child X
includes:
Name
Gender
Birth date
14
Names, addresses of parents or guardians
Dates of admission
Placement upon discharge
Comments:
CORRECTIVE ACTION-DOCUMENTS MUST BE SUMBITTED TO LICENSING:
 Sanitation Inspection (REPEAT FINDING 2019)
02-19-2021
Licensing Coordinator’s Signature: ________________________ Date: ___________________
Manager Review: ______________________________________ Date: __0__2_-_1_8_-_2_0_2__1_ ____
15

agency_name: West Linn Clementine (WLC)

program_name: West Linn Clementine

report_type: License Renewals

visit_date: January 29, 2021

licensing_coordinator: Holly Ivey

other_regulatory_agencies: Joint Commission

capacity_age_range: 12 youth, ages 11-17 years old.

contracts_and_referrals: Contracts with insurance companies.

number_of_children_served_annually: Approximately 50 youth served.

program_strengths:
The following strengths were identified by leadership at the review:
- The program has solid staff that are passionate about the work.
- The program has strong individual & family therapy, group support, physical, mental health, and nutritional components.
- The program has a licensed teacher on staff to help the youth find balance with school.
- The youth can engage in yoga as the program has a yoga instructor. The youth have been doing a virtual yoga class during COVID.
- The program is data driven and analysis outcome results.
- The program provides 24-hour nursing.

program_challenges:
The following challenges were identified by leadership:
- The ever-changing aspects of the COVID Pandemic have been challenging. The program did all they could do to keep youth and staff as
safe as possible. Some of the impacts were: restrictions on youths' in-person visits with family, staff group meetings by zoom.
- Some insurance companies do not allow for sufficient time for treatment stays, which would allow for the youth to have the full benefit of
treatment.

changes_in_last_two_years:
The following changes were stated by leadership at the time of the review:
- The program has adopted a new Electronic Record System and went live with it in October 2020.
2
- COVID brought a lot of change to some of the operations at the program.

excerpt: (2)(g) Approves annual budget

excerpt:
(3)(a) Evacuation drill occurs monthly under
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

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

excerpt:
(a) Agency policies and procedures New Employee Orientation – Umbrella Requirements (30
days) 413-215-0061(4) (a) Agency policies and
procedures (b) Ethical and professional guidelines

excerpt: (b) Ethical and professional guidelines

excerpt:
(1)(a) Discipline and behavior
management including de-escalation,
crisis prevention, positive behavior
management, and disciplinary techniques
that are non-punitive in nature New Employee Orientation – Residential (30 days)
413-215-0556(1)(a) Discipline and behavior management
including de-escalation, crisis prevention, positive
behavior management, and disciplinary techniques that
are non-punitive in nature (REPEAT FINDING SINCE
2019)
 The program was providing staff with a discipline
training within 30 days; however, it was not a
nationally recognized model. The program is
utilizing CPI, which is nationally recognized.
Staff must be oriented to CPI within 30 days of
hire.

excerpt:
Environmental
emergencies

excerpt: Universal Precautions

excerpt:
Discipline and
Behavior Management

excerpt:
Designated staff
authorized to apply reasonable and
prudent parent standard are trained in
application of the standard

excerpt:
Mandatory reporting
(annually) that includes:
(a) legal definition of child abuse ORS
419B.005, Oregon Laws 2016, chapter
106, section 36
(b) legal responsibility to immediately
report
(c) legal responsibility to report is
personal to the employee Consents 413-215-0576(1) (b) Use the discipline and
behavior management system (REPEAT FINDING
SINCE 2019) (f) Impose a dress code
 The above required consents, signed by
guardians, were not found in the youth files
reviewed.

excerpt: (f) Impose a dress code

excerpt:
(a)The name, gender, date of birth,
religious preference, and previous address Information about Children in Care 413-215-0581(1)
Summary sheet contains the following: (a)….religious
preference…(b) Name and location of previous school
 The summaries reviewed were missing the above
required information.

excerpt:
(b) Name and location of previous and
current school


state: OR

summary: License Renewals - 8 findings

raw_content:
Licensed Child Caring Agency Site Visit Report
Residential Care
Licensee: West Linn Clementine Date of site visit: January 25, 2023
Executive Director: Melissa Peterson Licensing Coordinator: Holly Ivey
Other Regulatory or Accrediting Agencies: Joint Commission, and the Oregon Health Authority
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(s): West Linn Clementine is a residential facility exclusively for adolescent girls seeking treatment for multiple eating
disorders or exercise addiction. They offer medical and psychiatric care integrated with personalized clinical and nutritional care as well as
academic and family support. The program offers 24 hour on-site medical oversight and nursing care, weekly medical monitoring, 24-hour access
to psychiatrists, medication management, family involvement, individual and group counselling sessions and weekly nutrition and cooking groups.
The program serves females, ages 11-17 with a capacity of 12.
Program type and services: Residential Services that specialize in eating disorders treatment.
Capacity and Age Range: 12 youth, ages 11-17 years old.
Funding sources: Medicaid, private insurance, Oregon Health Plan and private pay.
Contracts and sources for referrals: Contracts with insurance companies.
Average length of stay: The average length of stay is 45 days.
Average daily population served: The average daily population is 11 youth.
Number of children served annually: Approximately 79 youth served.
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Use of seclusion or restraint: N/A
Interviews, Observations:
Staff Interviews:
The following staff were informally interviewed by the Licensing Coordinator at the review: Miranda Acharya, Clinical Director, Staci Fajardo,
Program Manager, Kelly Grove, Human Resources.
Youth Interviews:
Two youth were privately interviewed by the Licensing Coordinator at the review. The youth interviews consisted of the following information
obtained:
 Both youth stated things were going well at the program. One youth stated, “Clementine is a great place, I feel like it has helped me
a lot.”
 When the youth were asked what they appreciated most about the program, the following was stated by the youth: “The staff are
really supportive, and so are the clients, it’s just a nice environment.” “The staff and peers, the therapy groups with staff and peers
that we have every day.”
 When the youth were asked what they enjoy doing for fun at the program, the following was stated by the youth: “Watch movies,
listen to music, make bracelets, knitting, art projects, painting.” “There are a lot of books, and puzzles, we do tie die, and we’ve done
a spa day.”
 Both youth confirmed that they have daily contact with their approved contacts outside of the program and that they are private
phone calls.
 Both youth stated that they receive three meals a day and are provided three snacks a day. The youth stated, “There is always
enough food here, it is never a problem. The cooking is great, it makes me happy.” “I can always ask for seconds.”
 Both youth confirmed they receive hygiene products from the program if needed.
 Both youth stated they felt respected by staff at the program. One youth stated the following, “The staff always knows what to do, and
what to say.”
 When the youth were asked what they would change about the program, the following was stated by the youth: “The cost of
attending, some people have to pay before the insurance approves it. I wouldn’t be able to do that.” “It’s a pretty good place, I’d say.”
“Longer time for phone calls, it goes by so fast.”
o The youth reported that they have one ten minute, and one five-minute phone call per day.
o After the youth reviews, the Licensing Coordinator, spoke with Miranda Acharya, Clinical Director, about the youths desire to
have lengthened phone call time. Ms. Acharya stated that youth can ask staff for additional phone calls if they would
like/need it.
 Both youth stated they felt safe at the program.
Observations: A walk through of the site was conducted by the Licensing Coordinator. The youth at the programs were observed to be at
ease and comfortable in the environment. All areas of the program (inside and outside) where youth had access were observed to be well
kept, clean and in good repair. The program had a new dining room table and new furniture in a therapy room. The program has a
commercial cleaning company that cleans the facility three times a week. The cleaning company also washes and changes the youth’s
linens and towels. The agency vehicles that the youth ride in were observed and met all the requirements per Licensing Rules. Food was
observed to be in the refrigerator and in the pantry. The program has a chef who is responsible for the meals, which are prepared fresh
onsite. The program has a dietitian that ensures the residents receive proper nutrition. Medication was observed to be locked up and
inaccessible to the youth.
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Program Strengths: The following strengths were stated by leadership at the review:
“Well educated staff that easily builds strong therapeutic relationships with clients and their
families: reliable staff that is passionate and excited to be at work, which creates a positive
work environment; professional; great communication between staff and clients; united team;
home-like environment; client centered/empowerment at forefront with their treatment.”
Program Challenges: The following challenges were stated by leadership at the review:
“Staff can be overly responsive/reactive to certain incidences/crises that can cause anxiety,
which has required additional training and supervision.”
Changes that have occurred in the last 2 years: The following changes were stated by leadership at the time of the review:
“Staff turnover past two years (direct care staff and therapists); COVID safety precautions;
Increase in acuity of the clients that have admitted.”
Lawsuits: None identified at the time of the review.
Grievances and complaints filed in the last two years: None of significance acknowledged at the time of the review.
Corrective Actions and Timeframes: Please submit the following to verify compliance.
Within 45 days of receipt of this report West Linn Clementine, 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 Holly Ivey at Holly.r.ivey@dhsoha.state.or us
Exceptions: N/A
Changes in License: N/A
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Summary of Review
Program and Services
Yes No N/A Corrective Actions/Comments
419-400-0020 (2)
Program and services are in scope of license X
Governance of the Agency
Yes No N/A Corrective Actions/Comments
419-400-0040
(1)(a) Minimum of 5 board members X
(2)(f) Formally evaluate the exec. Director’s
X
performance annually
(2)(g) Approves annual budget Governance of the Agency419-400-0040(2)(g) Approves annual budget
 The board minutes submitted to Licensing verified the budget was reviewed by
the board. However, there was no documentation verifying the board approved
X the budget. The program must provide the Licensing Coordinator with written
documentation, such as additional board minutes, e-mails or a signed letter,
indicting the board’s approval of the program’s budget.
(2)(h) Obtain and review an annual
independent financial review or audit of X
financial records.
(2)(k) Written quality improvement program X
(2)(l) Meeting minutes X
Executive Director or Program Director
Yes No N/A Corrective Actions/Comments
419-400-0040
(3)(a) knowledge of requirements for
providing care and treatment appropriate to X
programs
(3)(g) Approval from BCU Executive Director or Program Director 419-400-0040(3)(g) Approval from BCU
 A copy of documentation from the ODHS Background Check Unit’s (BCU)
approval of the Executive Director must be submitted to the Licensing
X
Coordinator. At the review the agency was awaiting a fitness determination from
the BCU.
Discipline, Behavior Management, and
Suicide Prevention Yes No N/A Corrective Actions/Comments
419-400-0150
(3) Agency uses appropriate and positive
methods of behavior management and
X
nationally recognized non-violent crisis
intervention
(3)(b)(C) Agency does not use chemical and
mechanical restraint (excluding medically X
necessary devices/prescriptions)
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(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)
Yes No N/A Corrective Actions/Comments
419-400-0120(6)
(a) Agency ensures the contractor meets the X
requirements of this rule and Chapter 413
division 215
(b)(B) Contract includes the following: X
(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
Restraints and Involuntary Seclusion
Yes No N/A Corrective Actions/Comments
419-400-0180
(11)(d) Each child caring agency that
submits a report under this section shall
make its quarterly report available to the
X
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
Yes No N/A Corrective Actions/Comments
CCA
Documents as indicated on the form titled Supplemental Information Provided by CCA Documents as indicated on the form titled
“Renewal Licensing Required Documents” “Renewal Licensing Required Documents”
 The program must provide the Licensing Coordinator with documentation of
X
updated approvals for Miranda Acharya and Staci Fajardo from the ODHS
Background Check Unit (BCU).
Documents as indicated on form titled
“Required Financial Documents and X
Information”
All required policies and procedures as Supplemental Information Provided by CCA
X
identified in the “Umbrella Rules” All required policies and procedures as identified in the “Umbrella Rules”
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 *See page 16 for details of Umbrella Policy Revision requirements.
All required policies and procedures as
X
identified in “Agency Type Specific Rules”
Physical Plant
Yes No N/A Corrective Actions/Comments
419-400-0090(3)(a) Foster Rights Posted (if
X
children in DHS custody)
419-400-0100(1) Sufficient safe space,
X
equipment, and office equipment
419-400-0230(12) License is posted in
X
common area at each facility
419-470-0020(2)(a) &(c) Buildings are
X
smoke free, clean and in good repair
419-470-0020 (2)(d) Rooms are free of X
harmful drafts, odors, and excessive noise
419-470-0020 (2)(e) Rooms are adequate in X
size and arrangement
419-470-0020 (2)(f) System provides a X
continuous supply of hot and cold water to
taps located throughout the facility
419-470-0020 (2)(h) Building is well X
ventilated and room temperature is within a
normal comfort range
419-470-0030 (1) All parts of the facility X
ensure the safety of children
Room and Space Requirements
Yes No N/A Corrective Actions/Comments
419-470-0030
(2) There is a separate living room or lounge X
area – 15 SF minimum per child
(5) There is a separate dining room with X
capacity for ½ of children in care and 15 SF
per child in care
(7) Laundry is separate from living, kitchen, X
and dining areas
(8) Separate storage areas are provided for X
food, kitchen supplies, utensils, clean linens,
soiled linens and clothing, cleaning supplies
and equip, poisons, chemicals, outdoor
recreational and maintenance equipment.
(Hazardous materials are properly labeled, in
original container and locked)
(9) Outdoor activity area is protected from X
vehicles and other hazards and of a size and
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availability appropriate to the age and needs
of children in care
(11) Time-out rooms: Rooms used for time X
out or quiet time must have adequate space,
heat, light and ventilation and must not be
capable of locking.
Room and Space Requirements
Bedrooms Yes No N/A Corrective Actions/Comments
419-470-0030(3)
(a) Adequate furnishings and personal items X
(b) Separate from rooms used for dining, X
living, laundry, kitchen, and storage
(c) 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
Room and Space Requirements
Bathrooms Yes No N/A Corrective Actions/Comments
419-470-0030(4)
(a) (A)& (B) 1:8 ratio for toilets and sinks X
(a)(D) Hot and cold running water, soap, and X
approved hand drying options
(a)(E) 1:10 ratio for shower or bathtub X
(a)(E) Individual privacy X
(a)(F) Window covering X
(a)(G) Permanently wired fixtures X
(a)(H) Adequate ventilation X
(b)&(c) Wooden racks on floors are
prohibited and impervious shower mats are X
disinfected & dried daily
Room and Space Requirements
Kitchen Yes No N/A Corrective Actions/Comments
419-470-0030(6)
(a) Used exclusively for storage, food X
preparation, dishwashing, 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
Furnishings and Personal Items Yes No N/A Corrective Actions/Comments
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419-470-0040
(1) There is a bed with frame, clean mattress X
and pillow and personal storage (dresser,
closet)
(2) Linens are in good repair. There is a X
waterproof mattress cover or mattress.
Linens are appropriate and towels and
washcloths are provided
(3) Bedding is changed weekly or when X
soiled
(4) & (5) Personal hygiene supplies and X
appropriate clothing are provided
Food Services
Yes No N/A Corrective Actions/Comments
419-470-0070
(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.
Residential Care Safety
Yes No N/A Corrective Actions/Comments
419-470-0080
(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
varying conditions, is retained 2 years and
Residential Care Safety 419-470-0080(3)(a) Evacuation drill occurs monthly under
contains:
varying conditions, is retained 2 years and contains: (F) special conditions simulated
(A) identify of person conducting drill
 The documentation of some of the evacuation drills was missing the above
(B) date & time X
required information.
(C) notification method
(D) staff participating
(E) # of children & staff evacuated
(F) special conditions simulated
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(G) problems encountered
(H) time to complete
Umbrella Safety
Yes No N/A Corrective Actions/Comments
419-400-0200
(5)(b) Vehicle has insurance policy, is smoke X
free, safe operating condition, and has first
aid kit and fire extinguisher 2-A:10-BC
(1)(b)(A) Each vehicle used to transport a X
child in care must be: properly registered,
covered by an insurance policy in full force
and effect, maintained in safe operating
condition, and smoke-free.
(3) If a child-caring agency has a swimming X
pool on the premises that is accessible to
children in care or if a child-caring agency
plans to have children in care engage in
swimming, the child-caring agency must
have and adhere to policies and procedures
that address, at a minimum, providing
disclosures and obtaining consents,
assessing swimming ability of children in
care, and ensuring the safety of pool access.
(4)(a) The school protects children from X
potentially harmful items and materials.
(4)(b) Direct supervision of children who do X
not have the ability to adjust and control
water temperature
(4)(c) Light fixtures have protective covers X
unless designed to be used without one
Medication
Yes No N/A Corrective Actions/Comments
419-470-0100
(3) & (7)(e) Medications have a prescription 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
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(b) name
(c) reason
(d) method
(e) staff & witness signature
(10) Written record of the administration of X
medication includes:
(a) name
(b) description
(c) dates and times
(d) missed doses
(e) medication disposed
(f) method of administration
(g) ID of person administering
(h) possible adverse reactions
(i) medication taken outside facility
Extracurricular, Enrichment, Cultural &
Social Activities Yes No N/A Corrective Actions/Comments
419-470-0110
(2) Children have ongoing opportunities to X
participate in at least one age-appropriate or
developmentally appropriate activity
Minimum Staffing Requirements
Yes No N/A Corrective Actions/Comments
419-470-0130
(1) & (2) Supervision is adequate for the type X
of program, location, age and type of
children, ability of supervisor to respond,
electronic back-up systems.
Minimum ratios are maintained:
Under 30 months of age: 1:4
30 months to ˃ 6 years or non-ambulatory:
1:6
Ages 6 and older: 1:7
Overnight (staff awake)
1:10
(4)(a) When one staff on duty, there is X
additional staff immediately available with
max response time of 30 minutes
(5) There is at least one on-site employee X
authorized to apply the reasonable and
prudent parent standard
Separation of Residents
Yes No N/A Corrective Actions/Comments
419-470-0140
(1) Children are in separate bedrooms than X
adults, unless parent and child, or there is
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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
Yes No N/A Corrective Actions/Comments
419-400-0120
Staff Name/Position X
(3)(g) Date of Hire X
(3)(a) record of education, training, and X
previous employment
(1)(b) & (3)(b) reference checks completed X
and documented
(1)(a) & (3)(c) Background check completed X
and documented
(3)(d) Annual performance evaluations X
(3)(f) Record of personnel actions X
(3)(g) Termination date, reason for X
termination
(3)(h) Current job description (1)(c) X
Employee meets minimum qualifications
stated in current job description
New Employee Orientation – Umbrella
Requirements (30 days) Yes No N/A Corrective Actions/Comments
419-400-0120(4)
(a) Agency policies and procedures X
(b) Ethical and professional guidelines X
(c) Suicide prevention and intervention X
(d) Attributes of population served X
(e) & (5)(a) to (c) Mandatory reporting that X
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
(f) Privacy laws X
(g) Emergency procedures X
New Employee Orientation
Residential (30 days) Yes No N/A Corrective Actions/Comments
419-470-0120
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(1)(a) Discipline and behavior management
including de-escalation, crisis prevention,
positive behavior management, and X
disciplinary techniques that are non-punitive
in nature
(1)(b) Restraint and seclusion (if applicable) X
Crisis Intervention Training Standards
and Certification Yes No N/A Corrective Actions/Comments
419-400-0160(4) (as applicable)
(a)Complete a minimum of 12 hours of initial
training in person from a certified instructor,
including but not limited to a minimum of six
hours of training focused on positive
X
behavior support, nonviolent crisis
intervention and other methods of
nonphysical intervention to support children
in care during a crisis
(d) Receive a certificate that states:
(A) The dates during which the certification
is current
(B) The type of restraint which the individual
is certified to perform if applicable
(C) The type of training the individual is
certified to conduct if applicable X
(D) Any special endorsements earned by the
individual
(E) The level of training
(F) The name of the certified instructor who
conducted the training and administered the
assessment of proficiency.
(e) A certification issued:
(A) Must be personal to the individual
certified by the training provider X
(B) May be valid for no more than two years
with recertification
Ongoing Training Yes No N/A Corrective Actions/Comments
419-470-0070(2)(b) Employees who handle X
food served to children have a valid food
handler’s card
419-400-0200 (1) Employees transporting X
children have: current driver’s license,
insurance, trained in emergency procedures
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and behavior management, and training for
15+ passenger vans if applicable)
419-470-0120 (2)(a) Environmental X
emergencies
419-470-0120 (2)(b) Universal Precautions X
419-470-0120 (2)(c) Discipline and Behavior X
Management
419-470-0120 (3) Staff providing direct care X
must maintain current CPR/First Aid
certification
419-470-0120 (4) Designated staff X
authorized to apply reasonable and prudent
parent standard are trained in application of
the standard
419-400-0120(5) Mandatory reporting X
(annually) that 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 X
education (as applicable on crisis
intervention training) from a certified
instructor on an annual basis
Comments:
Children’s Records Yes No N/A Corrective Actions/Comments
Health Services
419-470-0090
(2) Medical history obtained within 30 days X
(significant findings, current immunizations,
history of surgical procedures-health issues-
injuries, allergies, dental, vision, hearing,
behavioral health, and physician orders)
(2)(e) Documentation of age-appropriate X
instruction – pregnancy prevention, nutrition,
prevention of HIV & AIDS, and prevention
and treatment of sexually transmitted disease
(4)(a) to (f) Medical exams (3 in first year of
X
life, 2,4,6,9,14)
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Consents
Yes No N/A Corrective Actions/Comments
419-470-0160(1)
(a) Provide routine and emergency medical X
care
(b) Use the discipline and behavior X
management system
(c) Use restraint or seclusion (if applicable). X
Must specify the reasons for the intervention
and how staff are trained and supervised
(d) Restrict contact with persons outside of X
the agency
(e) Allow access as defined in 419-400-0230 X
& 0240
(f) Impose a dress code X
(g) Apply the reasonable and prudent parent X
standard
Disclosures
419-470-0160(2) Yes No N/A Corrective Actions/Comments
Parent/guardian has acknowledged in writing:
(a) Information regarding personal or room X
searches and protocols for confiscation of
contraband
(b) Statement of Rights of Children and X
Parents/Guardians
Disclosures419-470-0160(2) Parent/guardian has acknowledged in writing: (c) Any
policies and procedures upon request
(c) Any policies and procedures upon request X
 The above required information was missing on the consent document.
Authorizations
Yes No N/A Corrective Actions/Comments
419-470-0160(3)
(a) Disclose or exchange information with X
others
(b) Child specific visitors X
(c) Visitation resources are pre-approved X
(d) Activity specific authorizations are pre- X
approved 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
419-400-0190(1) Yes No N/A Corrective Actions/Comments
Summary sheet contains the following:
(a)The name, gender, date of birth, religious X
preference, and previous address
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(b) Name and location of previous and X
current school
(c) Date of admission X
(d) Legal custody X
(e) The name, address, and telephone X
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
the document that provides for his or her
authority over the child in care.
(C) Other persons significant to child
(D) Other professionals to be involved in
service planning (if applicable)
Service Planning
Yes No N/A Corrective Actions/Comments
419-470-0170(2)
(b) Intake document is completed the date X
child accepted into care (emergency
placement 48 hours)
(d) Assessment is completed within 30 days X
and contains relevant historical info., current
behavioral observations, identified need for
services, and how agency will provide
services
(e) (A)&(B) Service plan within 60 days X
(parent, guardian and child actively involved).
Describes how child’s issues will be
addressed, anticipated outcomes, and
reviewed by child and guardian/parent.
(e)(C) & (D) Service plan is reviewed X
quarterly and revised when information
indicates other services should be provided
Case Management
Yes No N/A Corrective Actions/Comments
419-470-0170(3)
(a) Services are documented, progress X
toward achieving goals is tracked
(b)-(d) discharge planning and instructions X
(f) Incident Reports X
Records Relating to Restraint &
Yes No N/A Corrective Actions/Comments
Involuntary Seclusion
419-400-0180(13)(e) Each child caring Records Relating to Restraint & Involuntary Seclusion 419-400-0180(13)(e) Each
agency shall provide notice regarding how to child caring agency shall provide notice regarding how to access the quarterly reports to
access the quarterly reports to the parents or X the parents or guardians of children in care in the program. The child caring agency shall
guardians of children in care in the program. provide the notice upon the child in care’s admission and at least two times each year
The child caring agency shall provide the thereafter.
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notice upon the child in care’s admission and  Youth files reviewed didn’t contain documentation to verify that the above
at least two times each year thereafter. requirement had been met.
Records Relating to Restraint & Involuntary Seclusion 419-400-0190(1) Information
419-400-0190(1) Information provided to provided to children in care relating to Restraint & Involuntary Seclusion
children in care relating to Restraint & X  Youth files reviewed didn’t contain documentation to verify that the above
Involuntary Seclusion requirement had been met.
Financial Records
Yes No N/A Corrective Actions/Comments
419-470-0170(4)
Records contain date, amount, source,
X
purpose, signatures
Personal Possessions Records
Yes No N/A Corrective Actions/Comments
419-470-0170 (5)
Individual written inventory of all personal
possessions is maintained and updated as X
needed
Records and Documentation
Yes No N/A Corrective Actions/Comments
419-400-0140
(1) Stored safely X
(2) Permanent, legible, dated, and signed X
(3) & (4) Uniform in organization, readily X
identifiable and accessible, current, and
complete, containing all required info. No
eraser tape or white out.
(7) Permanent registry for each child X
includes:
Name
Gender
Birth date
Names, addresses of parents or guardians
Dates of admission
Placement upon discharge
Comments:
*Supplemental information provided by the CCA as stated above (page 5).
All revisions made to policies must be highlighted prior to sending to Licensing. Required Policy Revisions:
419-400-0090 Licensing Umbrella Rules: Children and Families Rights Policy and Grievance Procedures
(2) Grievance Procedures (a) A child-caring agency must enact and adhere to written procedures for the children in care and families the child-caring agency serves
to submit a grievance. For an academic boarding school, this subsection only applies to grievances about health or safety issues. The child-caring agency must
provide the procedures to each child in care and family. The procedures must include all of the following: (C) A procedure to follow, in the event the grievance is
filed against the executive director, that ensures that the executive director does not make the final decision on the grievance (b) Grievances and complaints filed
with the child-caring agency and all information obtained in their resolution must be maintained for a minimum of two years and provided to the Department upon
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Form Rev. 12/14/2022
request(D) The name, address, and phone number of: (i) A Department licensing coordinator; and (ii) Any other governmental entities with oversight
responsibilities(b) Grievances and complaints filed with the child-caring agency and all information obtained in their resolution must be maintained for a minimum of
two years and provided to the Department upon request.
o The agency’s Grievance Policy for Children and Families did not contain some of the required provisions.
 The policy lacked information to state that the executive director will not make the final decision on the grievance if the grievance is about
the executive director.
 The policy must state the Licensing Coordinator’s name, and contact information, as well as Carrie Wouda’s name and contact into at the
Oregon Health Authority.
419-400-0110 Licensing Umbrella Rules: Policies and Procedures (1) Transportation. If a child-caring agency transports children in care in a vehicle, the agency
must have policies and procedures that address all of the following:(a) Driver requirements. (A) Each employee transporting a child in care in a motor vehicle must
have a current driver license on record with the child-caring agency and must comply with applicable traffic laws when transporting children in care. (C) The child-
caring agency must ensure that employees providing transportation are trained in emergency procedures, including behavior management if applicable, while in a
vehicle.
o The above stated language must be added to the agency’s policies.
419-400-0130 Licensing Umbrella Rules: Privacy (4) A person making a report of abuse as required in ORS 418.258 and 419B.010 may include references to
otherwise confidential information for the sole purpose of making the report.
o The above required language must be added to the agency’s Privacy Policy.
419-400-0150 Licensing Umbrella Rules: Discipline, Behavior Management & Training, and Suicide Prevention (Excluding Adoption Agencies (1) A child-caring
agency, except a child-caring agency licensed only to provide adoption services under OAR 419-420-0010 to 419-420-0160, must adopt and adhere to written
policies and procedures on discipline, behavior management, and suicide prevention that meet all of the requirements of this rule. (b) The discipline and behavior
management policies and procedures must prohibit the following: (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.
o The above required prohibition must be added to the agency’s Behavior Management Policy.
 The Behavior Management Policy must be revised to add verbiage, that at no time should a restraint be utilized on youth in the program.
Notwithstanding policy to not use physical restraints, the policy should indicate that if a staff physically intervenes in an extreme circumstance,
all reporting requirements, and timelines in OAR 419-400-0180 (12)(13) will be met. In addition, the policy must state who from the program
will ensure reporting requirements are met and the required debrief meeting occurs in accordance with OAR 419-400-0180 (12)(d).
419-400-0200 Licensing Umbrella Rules: (4) Hazards (a) A child-caring agency must protect children in care it serves from guns, drugs, sharps, paint, hazardous
materials, bio-hazardous materials, and other potentially harmful items. A child-caring agency must have a written policy that addresses potentially harmful
materials that are in areas accessible to the children in care in the program or on the grounds of the program.
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Form Rev. 12/14/2022
o The above stated language must be added to the agency’s policies.
Licensing Coordinator’s Signature: ________________________ Date: _0_2_-1_7_-_2_0_2_3_ _________
Manager Review: ______________________________________ Date: _0_2_-1_7_-_2_0_2_3_ ________
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Form Rev. 12/14/2022

program_type: (RC) Residential Care Programs

view_code: RC

facility_type: Residential Care

visit_date: January 25, 2023

average_length_of_stay: The average length of stay is 45 days.

interviews_observations:
Staff Interviews:
The following staff were informally interviewed by the Licensing Coordinator at the review: Miranda Acharya, Clinical Director, Staci Fajardo,
Program Manager, Kelly Grove, Human Resources.
Youth Interviews:
Two youth were privately interviewed by the Licensing Coordinator at the review. The youth interviews consisted of the following information
obtained:
- Both youth stated things were going well at the program. One youth stated, "Clementine is a great place, I feel like it has helped me
a lot."
- When the youth were asked what they appreciated most about the program, the following was stated by the youth: "The staff are
really supportive, and so are the clients, it's just a nice environment." "The staff and peers, the therapy groups with staff and peers
that we have every day."
- When the youth were asked what they enjoy doing for fun at the program, the following was stated by the youth: "Watch movies,
listen to music, make bracelets, knitting, art projects, painting." "There are a lot of books, and puzzles, we do tie die, and we've done
a spa day."
- Both youth confirmed that they have daily contact with their approved contacts outside of the program and that they are private
phone calls.
- Both youth stated that they receive three meals a day and are provided three snacks a day. The youth stated, "There is always
enough food here, it is never a problem. The cooking is great, it makes me happy." "I can always ask for seconds."
- Both youth confirmed they receive hygiene products from the program if needed.
- Both youth stated they felt respected by staff at the program. One youth stated the following, "The staff always knows what to do, and
what to say."
- When the youth were asked what they would change about the program, the following was stated by the youth: "The cost of
attending, some people have to pay before the insurance approves it. I wouldn't be able to do that." "It's a pretty good place, I'd say."
"Longer time for phone calls, it goes by so fast."
o The youth reported that they have one ten minute, and one five-minute phone call per day.
o After the youth reviews, the Licensing Coordinator, spoke with Miranda Acharya, Clinical Director, about the youths desire to
have lengthened phone call time. Ms. Acharya stated that youth can ask staff for additional phone calls if they would
like/need it.
- Both youth stated they felt safe at the program.
Observations: A walk through of the site was conducted by the Licensing Coordinator. The youth at the programs were observed to be at
ease and comfortable in the environment. All areas of the program (inside and outside) where youth had access were observed to be well
kept, clean and in good repair. The program had a new dining room table and new furniture in a therapy room. The program has a
commercial cleaning company that cleans the facility three times a week. The cleaning company also washes and changes the youth's
linens and towels. The agency vehicles that the youth ride in were observed and met all the requirements per Licensing Rules. Food was
observed to be in the refrigerator and in the pantry. The program has a chef who is responsible for the meals, which are prepared fresh
onsite. The program has a dietitian that ensures the residents receive proper nutrition. Medication was observed to be locked up and
inaccessible to the youth.
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program_strengths:
The following strengths were stated by leadership at the review:
"Well educated staff that easily builds strong therapeutic relationships with clients and their
families: reliable staff that is passionate and excited to be at work, which creates a positive
work environment; professional; great communication between staff and clients; united team;
home-like environment; client centered/empowerment at forefront with their treatment."

program_challenges:
The following challenges were stated by leadership at the review:
"Staff can be overly responsive/reactive to certain incidences/crises that can cause anxiety,
which has required additional training and supervision."

changes_in_last_two_years:
The following changes were stated by leadership at the time of the review:
"Staff turnover past two years (direct care staff and therapists); COVID safety precautions;
Increase in acuity of the clients that have admitted."

changes_in_license:
N/A
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excerpt:
(2)(g) Approves annual budget Governance of the Agency419-400-0040(2)(g) Approves annual budget
 The board minutes submitted to Licensing verified the budget was reviewed by
the board. However, there was no documentation verifying the board approved
the budget. The program must provide the Licensing Coordinator with written
documentation, such as additional board minutes, e-mails or a signed letter,
indicting the board’s approval of the program’s budget.

excerpt:
(3)(g) Approval from BCU Executive Director or Program Director 419-400-0040(3)(g) Approval from BCU
 A copy of documentation from the ODHS Background Check Unit’s (BCU)
approval of the Executive Director must be submitted to the Licensing
Coordinator. At the review the agency was awaiting a fitness determination from
the BCU.

excerpt:
Documents as indicated on the form titled
“Renewal Licensing Required Documents” Supplemental Information Provided by CCA Documents as indicated on the form titled
“Renewal Licensing Required Documents”
 The program must provide the Licensing Coordinator with documentation of
updated approvals for Miranda Acharya and Staci Fajardo from the ODHS
Background Check Unit (BCU).

excerpt:
All required policies and procedures as
identified in the “Umbrella Rules” Supplemental Information Provided by CCA
All required policies and procedures as identified in the “Umbrella Rules”  *See page 16 for details of Umbrella Policy Revision requirements.

excerpt:
(3)(a) Evacuation drill occurs monthly under
varying conditions, is retained 2 years and
contains:
(A) identify of person conducting drill
(B) date & time
(C) notification method
(D) staff participating
(E) # of children & staff evacuated
(F) special conditions simulated Residential Care Safety 419-470-0080(3)(a) Evacuation drill occurs monthly under
varying conditions, is retained 2 years and contains: (F) special conditions simulated
 The documentation of some of the evacuation drills was missing the above
required information.

excerpt:
(c) Any policies and procedures upon request Disclosures419-470-0160(2) Parent/guardian has acknowledged in writing: (c) Any
policies and procedures upon request
 The above required information was missing on the consent document.

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

excerpt:
Information provided to
children in care relating to Restraint &
Involuntary Seclusion Records Relating to Restraint & Involuntary Seclusion 419-400-0190(1) Information
provided to children in care relating to Restraint & Involuntary Seclusion
 Youth files reviewed didn’t contain documentation to verify that the above
requirement had been met.