facility_name: Klamath Basin Behavioral Health (KBBH)

summary: Unannounced - 4 findings

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Licensee: Klamath Child and Family Treatment Center (KBBH)
Executive Director: Stanley Gilbert
Program Director(s): Nicole Rodgers
Date of Unannounced: June 23rd, 2021
Licensing Coordinator: Ed Wyller
Other Regulatory or Accrediting Agencies: Department of Human Services – Treatment Services
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
Unannounced Site Visit 03/03/2020 Findings
Further Action
Needed
413-215-0511(2)(c) Physical plant Yes No☐  Throughout KBBH Pineview interior walls need repainting. Patched holes
requirements. All areas of buildings where in walls are throughout the facility that have not been re-painted. (3/3/20)
children in care are present must be kept  Attic entrance on ceiling in stairwell going from kitchen to downstairs trim is
clean and in good repair. Major coming apart and needs to be attached to ceiling. Could be pulled off by
appliances and heating, ventilation, an upset youth. (3/3/20)
plumbing, and electrical systems must be
functional and in good repair. Note Holes in boy’s bedroom walls and a damaged door frame have been
identified by KBBH and are in the process of being fixed. (3/3/20)
On 6/23/21 Ed Wyller observed patched holes from property damage throughout
Pineview. Licensor noted more significant damage then previous site visit in
March 3, 2020. Note attic entrance has been fixed. Pineview reports that the
walls have been repainted in past and this is new property damage and property
damage by the youth is ongoing.
New Findings from Site Visit Comments
1
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 200115)
413-215-0511(2)(c) Physical plant  Numerous broken doors throughout facility including staff offices.
requirements. All areas of buildings
where children in care are present must
be kept clean and in good repair. Major
appliances and heating, ventilation,
plumbing, and electrical systems must
be functional and in good repair.
413-215-0511(2)(c) Physical plant  Bedrooms were dirty / disorganized and need of a deep clean.
requirements. All areas of buildings
where children in care are present must
be kept clean and in good repair. Major
appliances and heating, ventilation,
plumbing, and electrical systems must
be functional and in good repair.
413-215-0091 (11) (b) Within one  On 6/21/21 a youth had conducted major property damage by kicking in locked staff offices.
business day if a critical event occurs. Youth had broken into locked control area staff office and broke into medication cabinet.
As used in this section, "critical event" Staff were present. Licensing did not receive notification of this event within the required 24
means a significant event occurring in hours notification process. Licensing did receive a question on 6/22/21 regarding rules
the operation of a child-caring agency around metal framed doors and hinges. During debrief DHS CCLP Licensor Ed Wyller
that is considered likely to cause reported that critical events need to notify licensor within 24 hours. This was discovered
complaints, generate concerns, or come during unannounced site visit on 6/23/21.
to the attention of the media, law
enforcement agencies, first responders,
Child Protective Services, or other
regulatory agencies. Compliance with
this notification requirement does not
satisfy mandatory child abuse reporting
requirements under ORS 419B.005 to
419B.045.
Interview Summary
KBBH currently has two youth at their Pineview residential center. I interviewed both youths separately and in a private area that they felt
comfortable. On a scale from 0-10 (0=worst program and 10=best program) youth indicated the following ratings on that scale for Pineview: 7.5
and 9. Youth stated Pineview to be a “really good program a really good place”, and “best program I have been in.” Both youths reported they
feel safe at Pineview. I asked since there was a recent critical event two days prior if they felt safe at that time. Both youths reported they felt
safe and reported that the other youth would not hurt them. Food was described as “pretty good” and “good”. One youth reported food changes
quite a bit and the variety includes both Mexican and Chinese foods. Staff are described as “really care and genuinely give a shit”. “You can
tell they care as they get hit and keep caring and doing their jobs”. One youth reported not the cleanest place as youth will wipe boogers on the
2
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 200115)
wall. Both youths reported going on outings to river and lake to swim. Youth also report going recently to Walmart for an outing. Youth report
being supervised by staff.
Observations
Upon arrival I observed that the yard has been mowed and kept up. A pride flag was flying on front yard flagpole. Youth and staff were
engaged in cleaning windows. They were not aware of my visit as this was unannounced. I noted two staff and two youth with proper
supervision. During my visit watched positive interactions with youth staff and youth and social service staff. After my youth interviews the two
youth went to play basketball on the basketball court.
Pineview is starting to repair the recently damaged doors and door frames that were kicked in earlier this week. They have switched to metal
doors and metal door frames.
Corrective Actions and Timeframes:
Please submit the following to verify compliance.
Within 45 days of receipt of this report Klamath Child and Family Treatment Center 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 Ed Wyller, Edward.Wyller@dhsoha.state.or.us or sent by regular mail to the following address:
Due to Covid-19 pandemic and working remotely the preferred method is to send directly to Ed Wyller at his email address.
Department of Human Services
Children’s Care Licensing Program
Attn: Ed Wyller
201 High St. SE Suite 500
Salem, OR 97301
6/30/2021
Licensing Coordinator’s Signature: ________________________ Date: ___________________
6-30-2021
Manager Review: ______________________________________ Date: __________________
3
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agency_name: Klamath Basin Behavioral Health (KBBH)

executive_director: Stanley Gilbert

program_director: Nicole Rodgers

other_regulatory_agencies: Department of Human Services - Treatment Services

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
Unannounced Site Visit 03/03/2020 Findings
Further Action
Needed
413-215-0511(2)(c) Physical plant Yes No[ ] - Throughout KBBH Pineview interior walls need repainting. Patched holes
requirements. All areas of buildings where in walls are throughout the facility that have not been re-painted. (3/3/20)
children in care are present must be kept - Attic entrance on ceiling in stairwell going from kitchen to downstairs trim is
clean and in good repair. Major coming apart and needs to be attached to ceiling. Could be pulled off by
appliances and heating, ventilation, an upset youth. (3/3/20)
plumbing, and electrical systems must be
functional and in good repair. Note Holes in boy's bedroom walls and a damaged door frame have been
identified by KBBH and are in the process of being fixed. (3/3/20)
On 6/23/21 Ed Wyller observed patched holes from property damage throughout
Pineview. Licensor noted more significant damage then previous site visit in
March 3, 2020. Note attic entrance has been fixed. Pineview reports that the
walls have been repainted in past and this is new property damage and property
damage by the youth is ongoing.
New Findings from Site Visit Comments
1

413-215-0511(2)(c) Physical plant - Numerous broken doors throughout facility including staff offices.
requirements. All areas of buildings
where children in care are present must
be kept clean and in good repair. Major
appliances and heating, ventilation,
plumbing, and electrical systems must
be functional and in good repair.
413-215-0511(2)(c) Physical plant - Bedrooms were dirty / disorganized and need of a deep clean.
requirements. All areas of buildings
where children in care are present must
be kept clean and in good repair. Major
appliances and heating, ventilation,
plumbing, and electrical systems must
be functional and in good repair.
413-215-0091 (11) (b) Within one - On 6/21/21 a youth had conducted major property damage by kicking in locked staff offices.
business day if a critical event occurs. Youth had broken into locked control area staff office and broke into medication cabinet.
As used in this section, "critical event" Staff were present. Licensing did not receive notification of this event within the required 24
means a significant event occurring in hours notification process. Licensing did receive a question on 6/22/21 regarding rules
the operation of a child-caring agency around metal framed doors and hinges. During debrief DHS CCLP Licensor Ed Wyller
that is considered likely to cause reported that critical events need to notify licensor within 24 hours. This was discovered
complaints, generate concerns, or come during unannounced site visit on 6/23/21.
to the attention of the media, law
enforcement agencies, first responders,
Child Protective Services, or other
regulatory agencies. Compliance with
this notification requirement does not
satisfy mandatory child abuse reporting
requirements under ORS 419B.005 to
419B.045.
Interview Summary
KBBH currently has two youth at their Pineview residential center. I interviewed both youths separately and in a private area that they felt
comfortable. On a scale from 0-10 (0=worst program and 10=best program) youth indicated the following ratings on that scale for Pineview: 7.5
and 9. Youth stated Pineview to be a "really good program a really good place", and "best program I have been in." Both youths reported they
feel safe at Pineview. I asked since there was a recent critical event two days prior if they felt safe at that time. Both youths reported they felt
safe and reported that the other youth would not hurt them. Food was described as "pretty good" and "good". One youth reported food changes
quite a bit and the variety includes both Mexican and Chinese foods. Staff are described as "really care and genuinely give a shit". "You can
tell they care as they get hit and keep caring and doing their jobs". One youth reported not the cleanest place as youth will wipe boogers on the
2

wall. Both youths reported going on outings to river and lake to swim. Youth also report going recently to Walmart for an outing. Youth report
being supervised by staff.
Observations
Upon arrival I observed that the yard has been mowed and kept up. A pride flag was flying on front yard flagpole. Youth and staff were
engaged in cleaning windows. They were not aware of my visit as this was unannounced. I noted two staff and two youth with proper
supervision. During my visit watched positive interactions with youth staff and youth and social service staff. After my youth interviews the two
youth went to play basketball on the basketball court.
Pineview is starting to repair the recently damaged doors and door frames that were kicked in earlier this week. They have switched to metal
doors and metal door frames.

excerpt:
413-215-0091 (11) (b) Within one - On 6/21/21 a youth had conducted major property damage by kicking in locked staff offices.
business day if a critical event occurs. Youth had broken into locked control area staff office and broke into medication cabinet.
As used in this section, "critical event" Staff were present. Licensing did not receive notification of this event within the required 24
means a significant event occurring in hours notification process. Licensing did receive a question on 6/22/21 regarding rules
the operation of a child-caring agency around metal framed doors and hinges. During debrief DHS CCLP Licensor Ed Wyller
that is considered likely to cause reported that critical events need to notify licensor within 24 hours. This was discovered
complaints, generate concerns, or come during unannounced site visit on 6/23/21.
to the attention of the media, law
enforcement agencies, first responders,
Child Protective Services, or other
regulatory agencies. Compliance with
this notification requirement does not
satisfy mandatory child abuse reporting
requirements under ORS 419B.005 to
419B.045.
1


state: OR

summary: License Renewals - 6 findings

raw_content:
Licensed Child Caring Agency Site Visit Report
Residential Care
Licensee: Klamath Basin Behavioral Health - Pineview Date of site visit: August 9th/10th, 2021
Executive Director: Stanley Gilbert (CEO) Licensing Coordinator: Ed Wyller
Board Chairperson: Mel Ferguson
Other Regulatory or Accrediting Agencies: DHS – Treatment Services
Program Compliance: The program was found to be compliant or will be compliant with OAR 413-215-0001 to 413-215-0131, Licensing Umbrella
Rules, and OAR 413-215-0501 to 413-215-0586, Licensing Residential Care Agencies Rules. Personnel records were reviewed and compliance
with required background checks was documented for employees in all programs.
Program Description(s): KBBH reports “Pineview is a youth residential facility providing behavioral rehabilitation services to youth in DHS
custody who are experiencing a sever behavioral health episode. Services are provided to male and female adolescents age 10-14 and include
24/7 supervision, intensive weekly skills building, medication management, and care coordination. Temporary crises respite services are available
for non-qualifying youth who need mental health supervision while waiting for less restrictive services”.
Program type and services: Residential – Behavioral Rehabilitation Services
Capacity and Age Range: 12 youth ages 10-17 years old
Funding sources: Department of Human Services
Contracts and sources for referrals: Department of Human Services
Average length of stay: 5 months
Average daily population served: 5.5 youth
Number of children served annually: 28 youth
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Use of seclusion or restraint: Pineview does not utilize restraint or seclusion
Interviews, Observations: During my tour of Pineview facility I noted the following new items and improvements: new living room couches, new
living room tv, new hallway lights, new fire extinguisher cases, new computers, new medicine cabinet, new blinds, new kitchen refrigerator, new dish
sanitizer, new oven, newly replaced steel doors, doorknobs and locks throughout facility, new rugs in youth bedrooms and newly painted outside
metal handrail. The interior walls have been repainted with trauma informed colors.
I interviewed four of the five current youth at Pineview during my facility site inspection. I met with youth outside to ensure privacy during the
interview. Three of the youth reported feeling safe at Pineview. One youth report they have never felt safe in their life and that they do not like
Pineview and is the process of going to another program soon. All youth indicated that they have plenty of food and that the food is good. All youth
indicated going on outings. These outings include the following: parks, movies, stores, and going to the library. Youth reported at the facility
listening to music, playing basketball, watching tv, Legos, and color/drawing. Youth reported yesterday they went to the library and the last movie
they went to see was “Jungle Cruise”. On a scale from 0-10 (0=worst program, 10=best program) youth reported Pineview to be a: 0, 7, 7, and a
10.
Program Strengths: KBBH reports the following: “KBBH: Leadership, facilities, collaboration with community agencies, leader in the community,
Community Mental Health Program. Certified Community Behavioral Health Center, certification renewal track record, consistent financial audits,
commitment to staff training, monthly cultural awareness trainings. 24/7 crisis team, great psychiatric team made up of PMHNP’s. Pineview: Staff,
commitment to kids, collaboration, and working relationship with Department of Human Services.”
Program Challenges: KBBH reports the following: “KBBH: change at CEO position coming soon, legislative changes, Covid and the ongoing
changes/mandates, workforce shortages, no psychiatrist on staff. Pineview: Covid, facility needs constant work dure to destruction by youth, and
has some improvements inside, need to have activities outside for youth.”
Changes that have occurred in the last 2 years: Covid -19 constantly changing mandates/rules, new insurance company staring in July 2021.
Lawsuits: No lawsuits for Day Treatment. A former employee in another KBBH program sued for improper termination and insurance company
chose to settle
Grievances and complaints filed in the last two years: Pineview reports one grievance was filled and was resolved.
Corrective Actions and Timeframes: Please submit the following to verify compliance.
Within 45 days of receipt of this report Klamath Basin Behavioral Health - Pineview 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,
2
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 Edward.Wyller@dhsoha.state.or.us or sent by regular mail to the following address:
Due to Covid-19 pandemic and working remotely the preferred method is to send directly to Ed Wyller at his email address.
Department of Human Services
Children’s Care Licensing Program
Attn: Ed Wyller
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/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
performance annually x
(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
3
Executive Director or Program Director Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0021 Completed
(3)(a) knowledge of requirements for x
providing care and treatment appropriate to
programs
(3)(g) Approval from BCU x
Discipline, Behavior Management, and Corrective Action
Yes No N/A Corrective Actions/Comments
Suicide Prevention 413-215-0076 Completed
(3) Agency uses appropriate and positive
methods of behavior management and
x
nationally recognized non-violent crisis
intervention
(3)(b)(C) Agency does not use chemical and
mechanical restraint (excluding medically x
necessary devices/prescriptions)
(3)(c) Agency uses appropriate time-out
rooms (adequate space, heat, light and
ventilation and is not capable of locking) and x
documents use in child’s record when
applicable
(3)(e) Agency uses seclusion
x
appropriately/consistent with policy
(4) Agency has adequate plan in place to
x
respond to suicidal behavior/warning signs
Contractors (if applicable) Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0061(6) Completed
(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  Missing certificate of occupancy
“Renewal Licensing Required Documents”
4
Documents as indicated on form titled
“Required Financial Documents and x
Information”
All required policies and procedures as  Mandatory abuse reporting policy is missing current
identified in the “Umbrella Rules” x definitions of abuse for CCA’s and the need to
immediately report abuse. (OAR 413-215-0046)
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  Pineview did not have foster rights posted.
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  Pineview roof and gutters had debris collected,
smoke free, clean and in good repair creating both a drainage and fire hazard (needles
413-215-0511(2)(d) Rooms are free of x and branches).
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
5
(i) Beds are 3 feet apart and maintained to x
ensure safety
Room and Space Requirements Corrective Action
Yes No N/A Corrective Actions/Comments
Bathrooms 413-215-0516(4) Completed
(a)(A)&(B) 1:8 ratio for toilets and sinks x
(a)(D) Hot and cold running water, soap, and x
approved hand drying options
(a)(E) 1:10 ratio for shower or bathtub x
(a)(E) Individual privacy x
(a)(F) Window covering x
(a)(G) Permanently wired fixtures x
(a)(H) Adequate ventilation x
(b)&(c) Wooden racks on floors are x
prohibited and impervious shower mats are
disinfected & dried daily
Room and Space Requirements Corrective Action
Yes No N/A Corrective Actions/Comments
Kitchen 413-215-0516(6) Completed
(a) Used exclusively for storage, food x
preparation, dish washing and activities
related to eating
(b) Walls, floors are easily cleanable x
(c) Equipment and utensils are easily x
cleanable, durable, nontoxic, and kept clean
(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
6
(11) & 413-215-0076(3)(c)(C)Time out rooms x
have adequate space, heat, light and
ventilation and is not capable of locking
Furnishings and Personal Items Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0521 Completed
(1) There is a bed with frame, clean mattress x
and pillow and personal storage (dresser,
closet)
(2) Linens are in good repair. There is a x
waterproof mattress cover or mattress.
Linens are appropriate and towels and
washcloths are provided
(3) Bedding is changed weekly or when x
soiled
(4)&(5) Personal hygiene supplies and x
appropriate clothing are provided
Food Services Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0536(1)&(2) Completed
(1)(a) Meals are arranged daily, consistent x
with normal mealtimes that occur during the
hours of operation
(1)(b) Menus are prepared in advance in x
accordance with USDA guidelines, provide a
variety of foods and are adjusted for
seasonal changes.
(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;
7
(A) identify of person conducting drill
(B) date & time
(C) notification method
(D) staff participating
(E) # of children & staff evacuated
(F) special conditions simulated
(G) problems encountered
(H) time to complete
Safety – Transportation Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0541 Completed
(5)(b) Vehicle has insurance policy, is smoke x
free, safe operating condition, and has first
aid kit and fire extinguisher 2-A:10-BC
Medication Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0551 Completed
(3)&(7)(e) Medications have a prescription x
and are stored in the original container with
prescription label
(4)&(5) Herbal supplements and remedies, x
medical treatments, special diets, physical
therapy, physical aides or limitations have a
written order signed by a physician or
qualified medical professional.
(7)(c) Medications are inaccessible to x
children
(8) 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
8
Extracurricular, Enrichment, Cultural &
Corrective Action
Social Activities Yes No N/A Corrective Actions/Comments
Completed
413-215-0554
(2) Children have ongoing opportunities to x
participate in at least one age-appropriate or
developmentally appropriate activity
Minimum Staffing Requirements Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0561 Completed
(1)&(2) Supervision is adequate for the type x
of program, location, age and type of
children, ability of supervisor to respond,
electronic back-up systems.
Minimum ratios are maintained:
Under 30 months of age: 1:4
30 months to ˃ 6 yrs or non-ambulatory: 1:6
Ages 6 and older: 1:7
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
9
(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)
Employee meets minimum qualifications x
stated in current job description
New Employee Orientation – Umbrella
Corrective Action
Requirements (30 days) Yes No N/A Corrective Actions/Comments
Completed
413-215-0061(4)
(a) Agency policies and procedures x
(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:  KBBH Pineview report that they train on
(a) legal definition of child abuse ORS organizational lines of authority. Reviewer was
419B.005, Oregon Laws 2016, chapter 106, unable to see record or any indication of this training
x
section 36 in personnel files.
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to
the employee
(f) Privacy laws x
(g) Emergency procedures x
New Employee Orientation – Residential
Corrective Action
(30 days) Yes No N/A Corrective Actions/Comments
Completed
413-215-0556
(1)(a) Discipline and behavior management
including de-escalation, crisis prevention,
positive behavior management, and x
disciplinary techniques that are non-punitive
in nature
(1)(b) Restraint and seclusion (if applicable) x
Ongoing Training Corrective Action
Yes No N/A Corrective Actions/Comments
Completed
10
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
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
Comments:
11
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
(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  Repeated Finding: Pineview had consent allowing
(e) Allow access as defined in 413-215-0091 DHS caseworker visitation but does not cover the
& 0101 x entire scope of allowed access as defined in 413-
215-0091 and 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
12
(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
(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 x
behavioral observations, identified need for
13
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
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
14
Placement upon discharge
Comments:
KBBH – Pineview utilizes Credible electronic database for youth records and documentation.
9-13-2021
Licensing Coordinator’s Signature: ________________________ Date: ___________________
9-7-2021
Manager Review: ______________________________________ Date: __________________
15

program_type: (RC) Residential Care Programs

report_type: License Renewals

view_code: RC

facility_type: Residential Care

executive_director: Stanley Gilbert (CEO)

board_chairperson: Mel Ferguson

visit_date: August 9th/10th, 2021

licensing_coordinator: Ed Wyller

other_regulatory_agencies: DHS - Treatment Services

program_description:
KBBH reports "Pineview is a youth residential facility providing behavioral rehabilitation services to youth in DHS
custody who are experiencing a sever behavioral health episode. Services are provided to male and female adolescents age 10-14 and include
24/7 supervision, intensive weekly skills building, medication management, and care coordination. Temporary crises respite services are available
for non-qualifying youth who need mental health supervision while waiting for less restrictive services".

program_services: Residential - Behavioral Rehabilitation Services

capacity_age_range: 12 youth ages 10-17 years old

funding_sources: Department of Human Services

contracts_and_referrals: Department of Human Services

average_length_of_stay: 5 months

average_daily_population_served: 5.5 youth

number_of_children_served_annually: 28 youth

interviews_observations:
During my tour of Pineview facility I noted the following new items and improvements: new living room couches, new
living room tv, new hallway lights, new fire extinguisher cases, new computers, new medicine cabinet, new blinds, new kitchen refrigerator, new dish
sanitizer, new oven, newly replaced steel doors, doorknobs and locks throughout facility, new rugs in youth bedrooms and newly painted outside
metal handrail. The interior walls have been repainted with trauma informed colors.
I interviewed four of the five current youth at Pineview during my facility site inspection. I met with youth outside to ensure privacy during the
interview. Three of the youth reported feeling safe at Pineview. One youth report they have never felt safe in their life and that they do not like
Pineview and is the process of going to another program soon. All youth indicated that they have plenty of food and that the food is good. All youth
indicated going on outings. These outings include the following: parks, movies, stores, and going to the library. Youth reported at the facility
listening to music, playing basketball, watching tv, Legos, and color/drawing. Youth reported yesterday they went to the library and the last movie
they went to see was "Jungle Cruise". On a scale from 0-10 (0=worst program, 10=best program) youth reported Pineview to be a: 0, 7, 7, and a
10.

program_strengths:
KBBH reports the following: "KBBH: Leadership, facilities, collaboration with community agencies, leader in the community,
Community Mental Health Program. Certified Community Behavioral Health Center, certification renewal track record, consistent financial audits,
commitment to staff training, monthly cultural awareness trainings. 24/7 crisis team, great psychiatric team made up of PMHNP's. Pineview: Staff,
commitment to kids, collaboration, and working relationship with Department of Human Services."

program_challenges:
KBBH reports the following: "KBBH: change at CEO position coming soon, legislative changes, Covid and the ongoing
changes/mandates, workforce shortages, no psychiatrist on staff. Pineview: Covid, facility needs constant work dure to destruction by youth, and
has some improvements inside, need to have activities outside for youth."

lawsuits: No

excerpt:
Documents as indicated on the form titled
“Renewal Licensing Required Documents”  Missing certificate of occupancy

excerpt:
All required policies and procedures as
identified in the “Umbrella Rules”  Mandatory abuse reporting policy is missing current
definitions of abuse for CCA’s and the need to
immediately report abuse. (OAR 413-215-0046)

excerpt:
Foster Rights Posted (if
children in DHS custody)  Pineview did not have foster rights posted.
 Pineview roof and gutters had debris collected,
creating both a drainage and fire hazard (needles
and branches).

excerpt:
&(c) Buildings are
smoke free, clean and in good repair

excerpt:
(c) Organizational lines of authority  Repeated Finding: Pineview had consent allowing
DHS caseworker visitation but does not cover the
entire scope of allowed access as defined in 413-
215-0091 and 0101.

excerpt:
(e) Allow access as defined in 413-215-0091
& 0101


summary: Unannounced - 6 findings

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Residential Care
Licensee: Klamath Basin Behavioral Health - Pineview
Executive Director: Kendall Alexander (CEO)
Board Chairperson: Mel Ferguson
Date of Unannounced: March 7th, 2022
Licensing Coordinator: Ed Wyller
Other Regulatory or Accrediting Agencies: DHS – Treatment Services
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
License Renewal 08/09/2021 & 08/10/2021 Findings
Further Action
Needed
413-215-0046(3)(a) Foster Rights Posted (if Yes☐ No
children in DHS custody):
“Pineview did not have foster rights posted.”
413-215-0511(2)(a) &(c) Buildings are Yes No☐  Pineview continues to have debris collected on roof and gutters creating both a
smoke free, clean and in good repair: drainage and fire hazard. Program must provide photographic documentation
“Pineview roof and gutters had debris collected, indicating the situation has been corrected.
creating both a drainage and fire hazard (needles
and branches).”
413-215-0061(4) (c) Organizational lines of Yes☐ No
authority:
“KBBH Pineview report that they train on
organizational lines of authority. Reviewer was
unable to see record or any indication of this
training in personnel files.”
1
(rev. 200115)
413-215-0576(1) (e) Allow access as defined in Yes☐ No
413-215-0091& 0101:
“Repeated Finding: Pineview had consent
allowing
DHS caseworker visitation but does not cover the
entire scope of allowed access as defined in 413-
215-0091 and 0101.”
New Findings from Site Visit Comments
413-215-0511(2)(a) &(c) Buildings are  Mold was found in girls’ bathroom above door by ceiling.
smoke free, clean and in good repair:  Mold was found in boys’ bathroom ceiling adjacent to the exhaust/ventilation system.
 Quiet Room had a pulled ceiling panel that will need to be replaced.
 Carpet throughout building was soiled and dirty.
 Love seat in living room by front windows should be removed, soiled and broken
 Trash was littered around the front yard and in backyard bags are piled. It what was reported to be
leaves in the bags.
 Living room holes in walls and previously patched ones in need of painting.
Interview Summary
I interviewed two of the current five youth. Youth had good things to report on their experiences of Pineview. On a scale from 0-10 (0=worst program in the
State, 10=best program in the State) youth reported Pineview to be a 9.5, and 10 on that scale. Youth reported they feel safe, respected by staff, feel like they
have freedom to step outside, and enjoy activities. Youth reported they like going to public school. Youth reported the following outings since being in
program: bowling, movies, library, parks, walks, and visiting local stores and downtown district. Youth reported food to be “pretty good” and “Amazing-really
good”. One youth reported that on special occasions program will purchase buffalo wings. One youth is a long-term resident and they reported that they
attend groups and individual counseling. This youth understood their treatment goals and discharge plan at this time. The other resident is a respite youth,
and they reported that one on one time with staff, “helps me out a lot!”. This youth understands their discharge plan to go to another treatment program and
they report they wish they could stay at KBBH-Pineview.
2
(rev. 200115)
Observations
Youth and staff interactions observed were positive and supportive. Staff had good rapport with the youth and amongst other staff during my visit. Program
has added new curtains and new kitchen equipment. Program’s tv was broken and program is utilizing a projector and the youth have been enjoying this
while waiting for a new TV.
Corrective Actions and Timeframes:
Please submit the following to verify compliance.
Within 45 days of receipt of this report Klamath Basin Behavioral Health 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 Ed Wyller, Edward.Wyller@dhsoha.state.or.us or sent by regular mail to the following address:
Due to Covid-19 pandemic and working remotely the preferred method is to send directly to Ed Wyller at his email address.
Department of Human Services
Children’s Care Licensing Program
Attn: Ed Wyller
201 High St. SE Suite 500
Salem, OR 97301
Licensing Coordinator’s Signature: ________________________ Date: __3_/_2_4_/_2_2___________
Manager Review: ______________________________________ Date: _ _3_-2_2_-_2_0_2_2_ ________
3
(rev. 200115)

report_type: Unannounced

executive_director: Kendall Alexander (CEO)

visit_date: March 7th, 2022

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
License Renewal 08/09/2021 & 08/10/2021 Findings
Further Action
Needed
413-215-0046(3)(a) Foster Rights Posted (if Yes[ ] No
children in DHS custody):
"Pineview did not have foster rights posted."
413-215-0511(2)(a) &(c) Buildings are Yes No[ ] - Pineview continues to have debris collected on roof and gutters creating both a
smoke free, clean and in good repair: drainage and fire hazard. Program must provide photographic documentation
"Pineview roof and gutters had debris collected, indicating the situation has been corrected.
creating both a drainage and fire hazard (needles
and branches)."
413-215-0061(4) (c) Organizational lines of Yes[ ] No
authority:
"KBBH Pineview report that they train on
organizational lines of authority. Reviewer was
unable to see record or any indication of this
training in personnel files."
1

413-215-0576(1) (e) Allow access as defined in Yes[ ] No
413-215-0091& 0101:
"Repeated Finding: Pineview had consent
allowing
DHS caseworker visitation but does not cover the
entire scope of allowed access as defined in 413-
215-0091 and 0101."
New Findings from Site Visit Comments
413-215-0511(2)(a) &(c) Buildings are - Mold was found in girls' bathroom above door by ceiling.
smoke free, clean and in good repair: - Mold was found in boys' bathroom ceiling adjacent to the exhaust/ventilation system.
- Quiet Room had a pulled ceiling panel that will need to be replaced.
- Carpet throughout building was soiled and dirty.
- Love seat in living room by front windows should be removed, soiled and broken
- Trash was littered around the front yard and in backyard bags are piled. It what was reported to be
leaves in the bags.
- Living room holes in walls and previously patched ones in need of painting.
Interview Summary
I interviewed two of the current five youth. Youth had good things to report on their experiences of Pineview. On a scale from 0-10 (0=worst program in the
State, 10=best program in the State) youth reported Pineview to be a 9.5, and 10 on that scale. Youth reported they feel safe, respected by staff, feel like they
have freedom to step outside, and enjoy activities. Youth reported they like going to public school. Youth reported the following outings since being in
program: bowling, movies, library, parks, walks, and visiting local stores and downtown district. Youth reported food to be "pretty good" and "Amazing-really
good". One youth reported that on special occasions program will purchase buffalo wings. One youth is a long-term resident and they reported that they
attend groups and individual counseling. This youth understood their treatment goals and discharge plan at this time. The other resident is a respite youth,
and they reported that one on one time with staff, "helps me out a lot!". This youth understands their discharge plan to go to another treatment program and
they report they wish they could stay at KBBH-Pineview.
2

Observations
Youth and staff interactions observed were positive and supportive. Staff had good rapport with the youth and amongst other staff during my visit. Program
has added new curtains and new kitchen equipment. Program's tv was broken and program is utilizing a projector and the youth have been enjoying this
while waiting for a new TV.