summary: License Renewals - 66 findings

raw_content:
Licensed Child Caring Agency Site Visit Report
Residential Care - License Renewal
Licensee: Madrona Recovery Date of site visit: 04/28/2025
Executive Director: Paul Bryant Licensing Coordinator: Jeff Minden, Aubrey Kelly, Irvin Minten
Board Chairperson: Michael Knapp
Other Regulatory or Accrediting Agencies: Oregon Health Committee, The Joint Commission
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): From the Program: Madrona Recovery is a leading recovery organization committed to compassionately
serving youth struggling with mental health and substance use. With a focus on healing relationships, comprehensive care, and support
for caregivers, Madrona Recovery empowers individuals and their families to navigate the path from crisis to opportunity
Program type and services: Psychiatric Residential Treatment Facility
Capacity and age range: 22, All Genders, Ages 13-17
Funding sources: Oregon Health Plan and Private
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Contracts and sources for referrals: Contracts: Kaiser, Blue Cross Blue Shield , PBH, Yamhill, Moda, Pacific Source Health, Pacific
Source Community Partners, United Health. Sources for Referrals: OHSU, Providence, Randalls, Unity and outpatient provider
Average length of stay: 29 Days
Average daily population served: 9
Number of children served annually: 145
Use of seclusion or restraint: Restraint Only, staff are trained in Crisis Prevention Institute (CPI).
Interviews/observations: A tour of the program was conducted as a part of the review process. The program appeared clean and well
maintained. Although there was some minor graffiti, the program appeared to be on top of it. Bedrooms were spacious and well
furnished, and common areas were well maintained. There was art throughout the program, including in common areas, hallways and
the dining room.
Irvin Minten randomly selected and individually interviewed 4 youth currently enrolled in the program. Two of the youth reported they
had been enrolled in the program for about 4 days, and 2 of the youth reported they had been enrolled in the program for more than 25
days.
During interview with each of the youth, all reported they felt safe in the program, both during the day and at night, while in their
individual bedrooms. Each of the youth also stated that staff were helpful and nice to them. Two of the youth stated the staff were also
welcoming to all the youth. Each of the youth also reported they believed staff were sufficiently trained to assist them with their needs
and treatment goals, and all the youth denied they had ever been, or that they had observed another youth in the program, being
placed into a physical hold or prevented from leaving a room and placed in seclusion by staff. Each of the youth were also able to
identify things they were learning in the program. One of the youths stated staff go “above and beyond” in talking with him, listening to
him, and that staff are teaching him new things, such as learning about triggers, learning coping skills, journaling about his thoughts and
feelings, and teaching him how to meditate, as prior to entering the program he stated he “didn’t know how to cope with issues other
than using drugs and alcohol.” This youth also stated that he was “learning a great deal about himself", that he felt “more stable than
Form revised 3/12/2025 Page 2 of 27
he ever has,” and that staff were good at de-escalating other youth when their emotions and behavior became escalated, and at talking
with the youth and “figuring out what the problem was.” This youth also stated that even new staff who began working at the program
about a week ago, and who shadowed more seasoned staff during their first week of employment, were “already amazing.” This youth
also stated that he was set to be graduating from the program soon but hoped to get an extension for an additional 15 day stay in the
program. Each of the youth also stated the food in the program was good, with one of the youths stating the food was “amazing,” that
they could get seconds if they wanted, and that if they were ever hungry, they could ask for and receive a snack. Two of the youth also
stated that if they needed an “energy break” because they felt overwhelmed in group or just needed some time to themselves, they
could go to their room and lay down or go outside and play for 15 minutes. Each of the youth also stated they could call people they
care about and individuals on their contact list each day and that their conversations were private. One youth stated he could make 2
calls a day and could talk on the phone for about 30 minutes each day. Each of the youth also reported they were involved in the
development of their treatment plan and each of the youth was able to identify their discharge plan. Two of the youth also stated they
could earn “Madrona Bucks” for being helpful to staff, being a “good kid” or “doing nice things, and they could spend this money to buy
cool things at the program store such as fake tattoos and snacks. Finally, when asked if they would improve or change anything about
the program, one of the youth could not think of anything they would change One stated they wished they could have their phone for at
least a short time each day, one wished they didn’t have so many groups each day, as “socializing’ for them was hard and they needed
more “down time,” and one wished they had about 30-60 minutes of “free time” throughout the day to just talk with other youth or staff,
take a longer shower, or journal.
Aubrey Kelly conducted 4 staff interviews:
Staff 1 – She’s been working at Madrona for 2 months. This is the first residential program she’s worked at. She likes working at the
program. She completed many orientation trainings within the first week of work. She’s never had to place a client in a restraint. The
program runs a ratio of 1:3 during her day shift. They try to not count group counselors toward meeting ratio requirements. The program
meets ratio, but it’s difficult when one client needs an energy break. She feels supported by management. She doesn’t see them very
often but they are available. She has a good relationship with other staff. If she could change anything about the program, she would
give the clients more options, as they tend to get bored.
Staff 2 – She’s been working at Madrona for 7 months. She’s a wellness counselor. On Saturdays she also does an art class for the
clients. She loves working here. She feels supported by management. The program runs a 1:3 ratio, but they don’t always meet ratio
Form revised 3/12/2025 Page 3 of 27
because of so many call outs. When she first started at the program, not meeting ratio was very frequent. The ability to meet ratio
recently has been much better. There has been a lot of new staff starting over the last few months. She keeps up with trainings, and
she’s had CPI renewal trainings, CPR, Dialectical Behavioral Therapy (DBT), and there are a lot of opportunities for training. She has
never participated in a restraint; however, she has removed furniture and other clients from the room when other staff are performing a
restraint. She has good relationship with the other staff. Some staff don’t understand they are in charge, and they are not friends with
the clients. Management will show up and step up when there are staff call outs.
Staff 3 – He’s been working at Madrona for 3 years, and he’s currently a Program Manager. He previously worked at the program;
however, he left to attend nursing school, and the culture at the program was too toxic. In January 2024, he came back to the program,
and there had been a huge culture shift. The change from going to serving Behavioral Rehabilitation Services (BRS) kids to then
becoming a Psychiatric Residential Treatment Facility (PRTF) was a huge shift, and staff struggled. The biggest struggle was going
from a ratio of 1:6 to 1:3. They don’t always have enough staff cover breaks. The program has enough staff to meet the 1:3 ratio, but
the staff are just not always managed appropriately to meet the ratio. In January and February of 2025, there were over 100 call outs.
There have not been as many call outs recently. He’s a CPI trainer. The prior CPI trainer did not define holds currently. CPS and DBT
are new trainings. Staff are staying longer and are feeling more supported. 99% of staff feel supported by management. When he
needs help, he gets it. He has asked for more feedback. He gets along with the other staff. Since February 2025, he’s conducted 10
CPI trainings for staff. His supervisor is Angie, and he feels supported by her. He would like floor staff to feel like they can communicate
with management above him. He described the managers as very professional. They need to be more personable.
Staff 4 – She’s been working at the program for 8 months. She’s a Lead Wellness worker. She’s more attached to the clinical side, and
she’s a liaison between clinical staff and floor staff and the clients. She’s been a lead worker since the end of March. She loves her new
role, as she is more active in relationships with the clients. She feels very supported working here, and she feels very taken care of.
She gets along with the other staff. When she started, staffing was very low. In the last 3-4 months, staffing has gotten much better.
There are less call outs. She believes call outs are a reflection of milieu at times.
Program strengths: From the Program: Madrona Recovery now has a robust internship program that helps to drive innovation and
develop the workforce. We are integrating a theory of change logic model to establish program improvement planning approaches that
uplift client and staff voices. Leadership has a vision for program growth and are committed to maintaining a focus on improvements so
Form revised 3/12/2025 Page 4 of 27
that future community impacts align with our mission and values. We are developing the leadership capacity of middle managers in
preparation for growth and from a commitment to the professional development of our staff.
Program challenges: From the program: It continues to be a challenge to attract and retain direct care staff. We are working toward
the development of a long term retention strategy. Intermittent FMLA as contributed to challenges in predictability causing additional
challenges in hiring and staffing. Staffing for multiple buildings particularly during the night is a challenge. Increasing stresses youth and
families face is contributing to increase in stress and strain on our staff as they strive to support many and varied complex needs in the
community.
Changes that have occurred in the last two years: Change in licensing, new Medical Director, Dr. Han Liang, and Executive
Director, Paul Bryant.
Lawsuits: None
Grievances and complaints filed in the last two years: 1 grievance filed by a staff member that was followed up on by human
resources. 4 client grievances that were addressed appropriately by management.
Corrective actions and timeframes: Please submit the following to verify compliance.
Within 45 days of receipt of this report Madrona Recovery 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 Jeff Minden, Jeffrey.E.Minden@odhsoha.oregon.gov
Recommendations: It is recommended that Madrona Recovery create a form to better track individual employee's training at hire and
the annual ongoing trainings. One form that includes all the required trainings and their required due dates would assist with tracking
and compliance.
Exceptions: None
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Changes in license: None
Summary of review
Program and services Yes/No Corrective actions/comments
419-400-0020 (2) or N/A
Program and services are in scope of license Yes
Governance of the agency Yes/No Corrective actions/comments
419-400-0040 or N/A
(1)(a) Minimum of 5 board members Yes
(2)(f) Formally evaluate the Executive Director’s
Yes
performance annually
(2)(g) Approves annual budget Yes
(2)(h) Obtain and review an annual independent Madrona Recovery's Audit is in progress and was not
No
financial review or audit of financial records. complete prior to the review completion.
(2)(k) Written quality improvement program Yes
(2)(l) Meeting minutes Yes
Executive Director or Program Director Yes/No Corrective actions/comments
419-400-0040 or N/A
(3)(a) knowledge of requirements for providing care
Yes
and treatment appropriate to programs
(3)(g) Approval from BCU Yes
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Installation and use of video equipment used to Yes/No Corrective actions/comments
monitor or record children in care or N/A
419-400-0145
(1) If a child-caring agency installs video equipment
to monitor or record a child in care, all employees,
volunteers, parents or guardians and children in Yes
care must be informed about the intended use and
locations of the equipment.
Discipline, behavior management and suicide Yes/No Corrective actions/comments
prevention or N/A
419-400-0150
(3) Agency uses appropriate and positive methods
of behavior management and nationally recognized Yes
non-violent crisis intervention
(3)(b)(C) Agency does not use chemical and
mechanical restraint (excluding medically necessary Yes
devices/prescriptions)
(3)(c) Agency uses appropriate time-out rooms
(adequate space, heat, light and ventilation and is
Yes
not capable of locking) and documents use in
child’s record when applicable
(3)(e) Agency uses seclusion
N/A Agency does not use Seclusion
appropriately/consistent with policy
(4) Agency has adequate plan in place to respond
Yes
to suicidal behavior/warning signs
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Contractors (if applicable) Yes/No Corrective actions/comments
419-400-0120(6) or N/A
(a) Agency ensures the contractor meets the
requirements of this rule and Chapter 413 division N/A Agency does not utilize contractors
215
(b)(B) Contract includes the following:
(i) Services provided
(ii) Contractor fees
(iii) Disclosure of information from contractor to
agency
N/A Agency does not utilize contractors
(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 Corrective actions/comments
419-400-0180 or N/A
(13)(d) Each child caring agency that submits a
report under this section shall make its quarterly
report available to the public upon request at the Yes
child caring agency’s main office and on the child
caring agency’s website if applicable.
Supplemental information provided by CCA Yes/No Corrective actions/comments
or N/A
Documents as indicated on the form titled “Renewal
Yes
Licensing Required Documents”
Documents as indicated on form titled “Required Madrona Recovery is still in the process of completing the
No
Financial Documents and Information” annual audit. They have also requested the tax compliance
Form revised 3/12/2025 Page 8 of 27
Supplemental information provided by CCA Yes/No Corrective actions/comments
or N/A
certificate, but it was not received prior to the completion of
the review.
All required policies and procedures as identified in
Yes
the “Umbrella Rules”
All required policies and procedures as identified in
Yes
“Agency Type Specific Rules”
Physical plant Yes/No Corrective actions/comments
or N/A
419-400-0090(3)(a) Foster Rights Posted (if
Yes
children in ODHS custody)
419-400-0100(1) Sufficient safe space, equipment
Yes
and office equipment
419-400-0230(12) License is posted in common
Yes
area at each facility
419-470-0020(2)(a) and (c) Buildings are smoke
Yes
free, clean and in good repair
419-470-0020 (2)(d) Rooms are free of harmful
Yes
drafts, odors and excessive noise
419-470-0020 (2)(e) Rooms are adequate in size
Yes
and arrangement
419-470-0020 (2)(f) System provides a continuous
supply of hot and cold water to taps located Yes
throughout the facility
419-470-0020 (2)(h) Building is well ventilated and
Yes
room temperature is within a normal comfort range
419-470-0030 (1) All parts of the facility ensure the
Yes
safety of children
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Room and space requirements Yes/No Corrective actions/comments
419-470-0030 or N/A
(2) There is a separate living room or lounge area –
Yes
15 SF minimum per child
(5) There is a separate dining room with capacity for
Yes
½ of children in care and 15 SF per child in care
(7) Laundry is separate from living, kitchen and
Yes
dining areas
(8) Separate storage areas are provided for food,
kitchen supplies, utensils, clean linens, soiled linens
and clothing, cleaning supplies and equipment,
Yes
poisons, chemicals, outdoor recreational and
maintenance equipment. (Hazardous materials are
properly labeled, in original container and locked)
(9) Outdoor activity area is protected from vehicles
and other hazards and of a size and availability Yes
appropriate to the age and needs of children in care
(11) Time-out rooms: Rooms used for time out or
quiet time must have adequate space, heat, light Yes
and ventilation and must not be capable of locking.
Room and space requirements -bedrooms Yes/No Corrective actions/comments
419-470-0030(3) or N/A
(a) Adequate furnishings and personal items Yes
(b) Separate from rooms used for dining, living,
Yes
laundry, kitchen and storage
(c) Meet Oregon Fire Code Requirements Yes
(d) Be an outside room, with a window that operates
as designed. If the window is modified from its
original design, the fire marshal must approve the Yes
modification and indicate this room still meets
applicable Oregon Fire Code.
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Room and space requirements -bedrooms Yes/No Corrective actions/comments
419-470-0030(3) or N/A
(d) Ceiling at least 90 inches Yes
(e) Minimum 60 SF per occupant Yes
(f) No more than 25 if dorm style Yes
(g) Permanently wired fixtures Yes
(h) Window covering Yes
Room and space requirements - bathrooms Yes/No Corrective actions/comments
419-470-0030(4) or N/A
(a)(A) and (B) 1:8 ratio for toilets and sinks Yes
(a)(D) Hot and cold running water, soap and
Yes
approved hand drying options
(a)(E) 1:10 ratio for shower or bathtub Yes
(a)(E) Individual privacy Yes
(a)(F) Window covering Yes
(a)(G) Permanently wired fixtures Yes
(a)(H) Adequate ventilation Yes
(b) and (c) Wooden racks on floors are prohibited
and impervious shower mats are disinfected and Yes
dried daily be in good condition and free of mold
Room and space requirements - Yes/No Corrective actions/comments
kitchen or N/A
419-470-0030(6)
(a) Used exclusively for storage, food preparation,
dishwashing and activities related to eating and Yes
food preparation activities
(b) Walls, floors are easily cleanable Yes
(c) Equipment and utensils are easily cleanable,
Yes
durable, nontoxic and kept clean
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Room and space requirements - Yes/No Corrective actions/comments
kitchen or N/A
419-470-0030(6)
(e) Equipment is easy to clean beneath, between
Yes
and behind
Furnishings and personal items Yes/No Corrective actions/comments
419-470-0040 or N/A
(1) There is a bed with frame Yes
(1)(b) clean mattress in good condition, with a
Yes
minimum thickness of five inches
(1)(c) a pillow in good condition Yes
(1)(d) a private dresser, closet, or similar storage
area for personal belongings that is readily Yes
accessible
(2) Linens are in good repair. There is a waterproof
mattress cover or mattress. Linens are appropriate Yes
and towels and washcloths are provided
(3) Bedding is changed weekly or when soiled Yes
(4) and (5) Personal hygiene supplies and
Yes
appropriate clothing are provided
Food services Yes/No Corrective actions/comments
419-470-0070 or N/A
(1)(a) Meals are arranged daily, consistent with
normal mealtimes that occur during the hours of Yes
operation and provide snacks between mealtimes
(1)(b) Menus are prepared in advance in
accordance with USDA guidelines, provide a variety
Yes
of foods and are adjusted for seasonal changes
including snacks
Form revised 3/12/2025 Page 12 of 27
Food services Yes/No Corrective actions/comments
419-470-0070 or N/A
(1)(b) Menus are kept for at least 6 months Yes
(1)(c) Drinking water is freely available Yes
(2)(a) Food is stored, prepared and served in a
Yes
sanitary manner
(2)(c) and (d) Food products are obtained from
commercial suppliers (exception of fruits and
vegetables), unpasteurized juice is prohibited, and Yes
only Grade A pasteurized and fortified milk in
appropriate container.
Residential care safety Yes/No Corrective actions/comments
419-470-0080 or N/A
(2) Written emergency plan that includes Yes
(a) Identifying the types of emergencies most likely
to happen where the residential care agency is Yes
located
(b) Identifying a place to meet for each type of
Yes
emergency identified
(c) Identifying an alternate shelter if necessary Yes
(d) Ensuring access to necessary medications or
Yes
medical equipment
(e) How to help each child in care recover after a
Yes
disaster
(3) Telephone numbers for local police, fire
department, poison control, after hours medical
Yes
advice and other appropriate emergency numbers
must be posted near all telephones.
(4) Operative flashlights sufficient in number are
Yes
readily available to staff
Form revised 3/12/2025 Page 13 of 27
Residential care safety Yes/No Corrective actions/comments
419-470-0080 or N/A
(5)(a) Evacuation drill occurs monthly under varying
conditions, is retained 2 years and contains:
(A) identify of person conducting drill
(B) date and time
(C) notification method
Yes
(D) staff participating
(E) number of children and staff evacuated
(F) special conditions simulated
(G) problems encountered
(H) time to complete
Umbrella safety Yes/No Corrective actions/comments
419-400-0200 or N/A
(5)(b) Vehicle has insurance policy, is smoke free,
safe operating condition, and has first aid kit and N/A Agency does not have vehicles for transporting children
fire extinguisher 2-A:10-BC
(1)(b)(A) Each vehicle used to transport a child in
care must be: properly registered,
covered by an insurance policy in full force and N/A Agency does not have vehicles for transporting children
effect, maintained in safe operating condition and
smoke-free.
(3) If a child-caring agency has a swimming 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 N/A Agency does not have a swimming pool
that address, at a minimum, providing disclosures
and obtaining consents, assessing swimming ability
of children in care and ensuring the safety of pool
access.
Form revised 3/12/2025 Page 14 of 27
Umbrella safety Yes/No Corrective actions/comments
419-400-0200 or N/A
(4)(a) The program protects children from
Yes
potentially harmful items and materials.
(4)(b) Direct supervision of children who do not
have the ability to adjust and control water Yes
temperature
(4)(c) Light fixtures have protective covers unless
Yes
designed to be used without one
Medication Yes/No Corrective actions/comments
419-470-0100 or N/A
(3) and (7)(e) Medications have a prescription and
are stored in the original container with prescription Yes
label
(4) and (5) Herbal supplements and remedies,
medical treatments, special diets, physical therapy,
physical aides or limitations have a written order
signed by a physician or qualified medical
Yes
professional. A written order, signed by a physician
or qualified medical professional, is also required
before a restriction on diet or physical activity is
imposed.
(7)(c) Medications are inaccessible to children and
stored behind at least two locking mechanisms. Yes
This does not apply to Naloxone.
(8) Medications are disposed in accordance with
Yes
state and federal law
(9) Written record of the disposal of medications is
maintained and includes:
Yes
(a) description and amount
(b) name
Form revised 3/12/2025 Page 15 of 27
Medication Yes/No Corrective actions/comments
419-470-0100 or N/A
(c) reason
(d) method
(e) staff and witness signature
(10) Written record of the administration of
medication includes:
(a) name
(b) description
(c) dates and times
(d) missed doses Yes
(e) medication disposed
(f) method of administration
(g) ID of person administering
(h) possible adverse reactions
(i) medication taken outside facility
Extracurricular, enrichment, cultural and social Yes/No Corrective actions/comments
activities or N/A
419-470-0110
(2) Children have ongoing opportunities to
participate in at least one age-appropriate or Yes
developmentally appropriate activity
Minimum staffing requirements Yes/No Corrective actions/comments
419-470-0130 or N/A
(1) and (2) Supervision is adequate for the type of
program, location, age and type of children, ability
of supervisor to respond, electronic back-up
Yes
systems.
Minimum ratios are maintained:
Form revised 3/12/2025 Page 16 of 27
Minimum staffing requirements Yes/No Corrective actions/comments
419-470-0130 or N/A
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 additional
staff immediately available with max response time N/A At no time is there only 1 staff on duty at the program
of 30 minutes
(5) There is at least one on-site employee
authorized to apply the reasonable and prudent Yes
parent standard
Sleeping arrangements Yes/No Corrective actions/comments
419-470-0140 or N/A
(1) Children are in separate bedrooms than adults,
unless parent and child, or there is written approval Yes
from guardian/parent and licensing coordinator
(2) There is adequate supervision of children when
Yes
sleeping
(3) When assigning bedrooms a residential care
agency must consider all of the following:
(a) Chronological age
(b) Developmental age
Yes
(c) Gender identity
(d) Personal history, including medical, mental
health, behavioral health and past adverse
experiences including any physical or sexual abuse
Form revised 3/12/2025 Page 17 of 27
Personnel files Yes/No Corrective actions/comments
419-400-0120 or N/A
Staff name/position Yes
(3)(g) Date of hire Yes
(3)(a) record of education, training and previous
Yes
employment
(1)(b) and (3)(b) reference checks completed and
Yes
documented
(1)(a) and (3)(c) Background check completed and
Yes
documented
(3)(d) Annual performance evaluations Yes
(3)(f) Record of personnel actions Yes
(3)(g) Termination date, reason for termination Yes
(3)(h) Current job description (1)(c) Employee
meets minimum qualifications stated in current job Yes
description
New employee orientation – Umbrella Yes/No Corrective actions/comments
Requirements (30 days) or N/A
419-400-0120(4)
(a) Agency policies and procedures Yes
(b) Ethical and professional guidelines Yes
(c) Suicide prevention and intervention 2 files were missing required training on suicide prevention.
On further discussion it was learned that the program has a
No
significant number of employees that have not completed the
required training on suicide prevention
(d) Attributes of population served No 1 reviewed file did not have the required training
(e) and (5)(a) to (c) Mandatory reporting that
Although all reviewed files included Mandatory Reporter
includes:
No training, 1 of the files showed that the training was not
(a) legal definition of child abuse in ORS 418.257
completed until well beyond the 30 day requirement.
and 419B.005
Form revised 3/12/2025 Page 18 of 27
New employee orientation – Umbrella Yes/No Corrective actions/comments
Requirements (30 days) or N/A
419-400-0120(4)
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to the
employee
(f) Privacy laws Yes
(g) Emergency procedures Yes
New employee orientation Yes/No Corrective actions/comments
residential (prior to working alone and within 30 or N/A
days)
419-470-0120(1)
(a) Discipline and behavior management including
de-escalation, crisis prevention, positive behavior
Yes
management and disciplinary techniques that are
non-punitive in nature
(b) CPR and First Aid sufficient to retain a current Although all 3 files did indicate that CPR training had been
certification No completed, the timeline for one of the files was outside of the
30 days requirement.
(c) Universal precautions and hygiene Yes
(d) Application of the reasonable and prudent
Yes
parent standard
(e) Training on the agency’s policy on suicide 2 files were missing required training on suicide prevention.
prevention and suicide risk assessment tool On further discussion it was learned that the program has a
No
significant number of employees that have not completed the
required training on suicide prevention
Form revised 3/12/2025 Page 19 of 27
Crisis intervention training standards and Yes/No Corrective actions/comments
certification or N/A
419-400-0160(4) (as applicable)
(a)Complete a minimum of 12 hours of initial
training in person from a certified instructor,
including but not limited to a minimum of six hours
of training focused on positive behavior support, Yes
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
Madrona Recovery is using a form for CPI certification that is
conduct if applicable Yes
clear, detailed and easy to review
(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 Yes
(B) May be valid for no more than two years with
recertification
Form revised 3/12/2025 Page 20 of 27
Ongoing training Yes/No Corrective actions/comments
or N/A
419-470-0070(2)(b) Employees who handle food Only kitchen staff have food handler cards, as they are the
served to children have a valid food handler’s card N/A only ones who prepare food, and none of their files were
reviewed.
419-400-0200 (1) Employees transporting children
have: current driver’s license, insurance, trained in
N/A The program does not transport children in care
emergency procedures and behavior management
and training for 15+ passenger vans if applicable)
419-470-0120 (2)(a) Environmental emergencies Yes
419-470-0120 (2)(b) Universal precautions Yes
419-470-0120 (2)(c) Discipline and behavior
Yes
management
419-470-0120 (2)(d) Agency’s policy on suicide
Yes
prevention and risk assessment tool
419-470-0120 (3) Staff providing direct care must
Yes
maintain current CPR/First Aid certification
419-470-0120 (4) Designated staff authorized to
apply reasonable and prudent parent standard are Yes
trained in application of the standard
419-400-0120(5) Mandatory reporting (annually)
that includes:
(a) legal definition of child abuse in ORS 418.257
One reviewed file did not have the required annual mandatory
and 419B.005 No
reporter training.
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to the
employee
419-400-0160(4)(b) Receive continuing education
(as applicable on crisis intervention training) from a Yes
certified instructor on an annual basis
Form revised 3/12/2025 Page 21 of 27
Children’s records Yes/No Corrective actions/comments
health services or N/A
419-470-0090
(2) Medical history obtained within 30 days
(significant findings, current immunizations, history
of surgical procedures-health issues-injuries, Yes
allergies, dental, vision, hearing, behavioral health
and physician orders)
(4)(a) to (f) Medical exams (3 in first year of life,
All reviewed client files were older than the ages required for
2,4,6,9,14) N/A
exams
(g) Have a physical examination within the first 60
days after admission of a child in care.
Documentation of a physical examination having Yes
occurred within the calendar year will meet this
requirement.
Consents Yes/No Corrective actions/comments
419-470-0160(1) or N/A
(a) Provide routine and emergency medical care Yes
(b) Use the discipline and behavior management
Yes
system
(c) Use restraint or seclusion (if applicable). Must
specify the reasons for the intervention and how Yes
staff are trained and supervised
(d) Restrict contact with persons outside of the
Yes
agency
(e) Allow access as defined in 419-400-0230 and The form did not refer to the correct OAR and needs to be
No
0240 updated to meet the 419 OAR requirements
(f) Impose a dress code Yes
Form revised 3/12/2025 Page 22 of 27
Consents Yes/No Corrective actions/comments
419-470-0160(1) or N/A
(g) Apply the reasonable and prudent parent
Yes
standard
Disclosures Yes/No Corrective actions/comments
419-470-0160(2) or N/A
Parent/guardian has acknowledged in writing:
(a) Information regarding personal or room
searches and protocols for confiscation of Yes
contraband
(b) Statement of Rights of Children and
Yes
Parents/Guardians
(c) Any policies and procedures upon request Yes
Authorizations Yes/No Corrective actions/comments
419-470-0160(3) or N/A
(a) Disclose or exchange information with others Yes
(b) Child specific visitors Yes
(c) Visitation resources are pre-approved Yes
(d) Activity specific authorizations are pre-approved
to allow children to participate in potentially
The program does not have the option for any potentially
hazardous activities, including but not limited to N/A
hazardous activites.
using motorized yard equipment, swimming and
horseback riding.
Form revised 3/12/2025 Page 23 of 27
Information about children in care Yes/No Corrective actions/comments
419-400-0190(1) or N/A
Summary sheet contains the following:
(a)The name, gender, date of birth, religious
Yes
preference and previous address
(b) Name and location of previous and current
Yes
school
(c) Date of admission Yes
(d) Legal custody Yes
(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 the document
that provides for his or her authority over the Yes
child in care.
(C) Other persons significant to child
(D) Other professionals to be involved in service
planning (if applicable)
Service planning Yes/No Corrective actions/comments
419-470-0170(2) or N/A
(b) Intake document is completed the date child
accepted into care (emergency placement 48 Yes
hours)
(d) Assessment is completed within 30 days and
contains relevant historical information, current
Yes
behavioral observations, identified need for
services and how agency will provide services
(e) (A) and (B) Service plan within 60 days (parent, Service plans were completed on time, however 2 of the
guardian and child actively involved). Describes No reviewed files did not include client or parent/guardian
how child’s issues will be addressed, anticipated signatures.
Form revised 3/12/2025 Page 24 of 27
Service planning Yes/No Corrective actions/comments
419-470-0170(2) or N/A
outcomes and reviewed by child and
guardian/parent.
(e)(C) and (D) Service plan is reviewed quarterly
Clients are not in the program long enough to require
and revised when information indicates other N/A
quarterly updates.
services should be provided
Case management Yes/No Corrective actions/comments
419-470-0170(3) or N/A
(a) Services are documented, progress toward
Yes
achieving goals is tracked
(c) Discharge summary must include:
(A)Current medications
(B)Name of the physician or qualified medical
professional who prescribed each medication
(C)Any outstanding medical or other appointments
Yes
(D)Summary of the child’s participation in the
program and progress achieved
(E)Results of evaluations
(F)Recommendations regarding services
(G)Discharge destination
(e) Follow up services Yes
(f) Incident reports Yes
Records relating to Restraint and Involuntary Yes/No Corrective actions/comments
Seclusion or N/A
419-400-0180 (12) Records Program did not have documentation to comply with: 419-
No 400-0180(10)(e) The child-caring agency must have a policy
that prohibits the application of a nonviolent restraint to a child
Form revised 3/12/2025 Page 25 of 27
Records relating to Restraint and Involuntary Yes/No Corrective actions/comments
Seclusion or N/A
in care who has a documented physical condition that would
contraindicate the use of that restraint unless a qualified
medical professional has previously and specifically
authorized its use in writing for the child in care.
Documentation of the authorization must be maintained in the
child of care’s record.
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 Yes
agency shall provide the notice upon the child in
care’s admission and at least two times each year
thereafter.
419-400-0190(1) Information provided to children in Although the program does consents for restraints, the
care relating to Restraint and Involuntary Seclusion documentation around reporting wrongful restraint, how to do
it and a notice that there is will not be retaliation is incomplete.
No
After the review and prior to the completion of this report the
program updated their Client and Family handbook to meet
this requirement.
Financial records Yes/No Corrective actions/comments
419-470-0170(4) or N/A
Records contain date, amount, source, purpose, Program does not accept or maintain individual finances for
N/A
signatures youth.
Personal possessions records Yes/No Corrective actions/comments
419-470-0170 (5) or N/A
Individual written inventory of all personal
Yes
possessions is maintained and updated as needed
Form revised 3/12/2025 Page 26 of 27
Records and documentation Yes/No Corrective actions/comments
419-400-0140 or N/A
(1) Stored safely Yes
(2) Permanent, legible, dated and signed Yes
(3) and (4) Uniform in organization, readily
identifiable and accessible, current and complete,
Yes
containing all required info. No eraser tape or white
out.
(7) Permanent registry for each child includes:
Name
Gender
Birth date Yes
Names, addresses of parents or guardians
Dates of admission
Placement upon discharge
5-7-2025 5-7-2025
Jeff Minden Harry Gilmore
Licensing Coordinator's Signature Manager Review
Form revised 3/12/2025 Page 27 of 27

report_type: License Renewals

report_title: Licensed Child Caring Agency Site Visit Report

facility_type: Residential Care - License Renewal

executive_director: Paul Bryant

licensing_coordinator: Jeff Minden, Aubrey Kelly, Irvin Minten

other_regulatory_agencies: Oregon Health Committee, The Joint Commission

program_services: Psychiatric Residential Treatment Facility

capacity_age_range: 22, All Genders, Ages 13-17

funding_sources: Oregon Health Plan and Private Form revised 3/12/2025 Page 1 of 27

average_length_of_stay: 29 Days

use_of_seclusion_or_restraint: Restraint Only, staff are trained in Crisis Prevention Institute (CPI). Interviews/observations: A tour of the program was conducted as a part of the review process. The program appeared clean and well maintained. Although there was some minor graffiti, the program appeared to be on top of it. Bedrooms were spacious and well furnished, and common areas were well maintained. There was art throughout the program, including in common areas, hallways and the dining room. Irvin Minten randomly selected and individually interviewed 4 youth currently enrolled in the program. Two of the youth reported they had been enrolled in the program for about 4 days, and 2 of the youth reported they had been enrolled in the program for more than 25 days. During interview with each of the youth, all reported they felt safe in the program, both during the day and at night, while in their individual bedrooms. Each of the youth also stated that staff were helpful and nice to them. Two of the youth stated the staff were also welcoming to all the youth. Each of the youth also reported they believed staff were sufficiently trained to assist them with their needs and treatment goals, and all the youth denied they had ever been, or that they had observed another youth in the program, being placed into a physical hold or prevented from leaving a room and placed in seclusion by staff. Each of the youth were also able to identify things they were learning in the program. One of the youths stated staff go "above and beyond" in talking with him, listening to him, and that staff are teaching him new things, such as learning about triggers, learning coping skills, journaling about his thoughts and feelings, and teaching him how to meditate, as prior to entering the program he stated he "didn't know how to cope with issues other than using drugs and alcohol." This youth also stated that he was "learning a great deal about himself", that he felt "more stable than Form revised 3/12/2025 Page 2 of 27 he ever has," and that staff were good at de-escalating other youth when their emotions and behavior became escalated, and at talking with the youth and "figuring out what the problem was." This youth also stated that even new staff who began working at the program about a week ago, and who shadowed more seasoned staff during their first week of employment, were "already amazing." This youth also stated that he was set to be graduating from the program soon but hoped to get an extension for an additional 15 day stay in the program. Each of the youth also stated the food in the program was good, with one of the youths stating the food was "amazing," that they could get seconds if they wanted, and that if they were ever hungry, they could ask for and receive a snack. Two of the youth also stated that if they needed an "energy break" because they felt overwhelmed in group or just needed some time to themselves, they could go to their room and lay down or go outside and play for 15 minutes. Each of the youth also stated they could call people they care about and individuals on their contact list each day and that their conversations were private. One youth stated he could make 2 calls a day and could talk on the phone for about 30 minutes each day. Each of the youth also reported they were involved in the development of their treatment plan and each of the youth was able to identify their discharge plan. Two of the youth also stated they could earn "Madrona Bucks" for being helpful to staff, being a "good kid" or "doing nice things, and they could spend this money to buy cool things at the program store such as fake tattoos and snacks. Finally, when asked if they would improve or change anything about the program, one of the youth could not think of anything they would change One stated they wished they could have their phone for at least a short time each day, one wished they didn't have so many groups each day, as "socializing' for them was hard and they needed more "down time," and one wished they had about 30-60 minutes of "free time" throughout the day to just talk with other youth or staff, take a longer shower, or journal. Aubrey Kelly conducted 4 staff interviews: Staff 1 - She's been working at Madrona for 2 months. This is the first residential program she's worked at. She likes working at the program. She completed many orientation trainings within the first week of work. She's never had to place a client in a restraint. The program runs a ratio of 1:3 during her day shift. They try to not count group counselors toward meeting ratio requirements. The program meets ratio, but it's difficult when one client needs an energy break. She feels supported by management. She doesn't see them very often but they are available. She has a good relationship with other staff. If she could change anything about the program, she would give the clients more options, as they tend to get bored. Staff 2 - She's been working at Madrona for 7 months. She's a wellness counselor. On Saturdays she also does an art class for the clients. She loves working here. She feels supported by management. The program runs a 1:3 ratio, but they don't always meet ratio Form revised 3/12/2025 Page 3 of 27 because of so many call outs. When she first started at the program, not meeting ratio was very frequent. The ability to meet ratio recently has been much better. There has been a lot of new staff starting over the last few months. She keeps up with trainings, and she's had CPI renewal trainings, CPR, Dialectical Behavioral Therapy (DBT), and there are a lot of opportunities for training. She has never participated in a restraint; however, she has removed furniture and other clients from the room when other staff are performing a restraint. She has good relationship with the other staff. Some staff don't understand they are in charge, and they are not friends with the clients. Management will show up and step up when there are staff call outs. Staff 3 - He's been working at Madrona for 3 years, and he's currently a Program Manager. He previously worked at the program; however, he left to attend nursing school, and the culture at the program was too toxic. In January 2024, he came back to the program, and there had been a huge culture shift. The change from going to serving Behavioral Rehabilitation Services (BRS) kids to then becoming a Psychiatric Residential Treatment Facility (PRTF) was a huge shift, and staff struggled. The biggest struggle was going from a ratio of 1:6 to 1:3. They don't always have enough staff cover breaks. The program has enough staff to meet the 1:3 ratio, but the staff are just not always managed appropriately to meet the ratio. In January and February of 2025, there were over 100 call outs. There have not been as many call outs recently. He's a CPI trainer. The prior CPI trainer did not define holds currently. CPS and DBT are new trainings. Staff are staying longer and are feeling more supported. 99% of staff feel supported by management. When he needs help, he gets it. He has asked for more feedback. He gets along with the other staff. Since February 2025, he's conducted 10 CPI trainings for staff. His supervisor is Angie, and he feels supported by her. He would like floor staff to feel like they can communicate with management above him. He described the managers as very professional. They need to be more personable. Staff 4 - She's been working at the program for 8 months. She's a Lead Wellness worker. She's more attached to the clinical side, and she's a liaison between clinical staff and floor staff and the clients. She's been a lead worker since the end of March. She loves her new role, as she is more active in relationships with the clients. She feels very supported working here, and she feels very taken care of. She gets along with the other staff. When she started, staffing was very low. In the last 3-4 months, staffing has gotten much better. There are less call outs. She believes call outs are a reflection of milieu at times.

changes_in_last_two_years:
Change in licensing, new Medical Director, Dr. Han Liang, and Executive
Director, Paul Bryant.

exceptions:
None
Form revised 3/12/2025 Page 5 of 27

excerpt:
419-400-0040 or N/A
(1)(a) Minimum of 5 board members Yes
(2)(f) Formally evaluate the Executive Director's
Yes
performance annually
(2)(g) Approves annual budget Yes
(2)(h) Obtain and review an annual independent Madrona Recovery's Audit is in progress and was not
No
financial review or audit of financial records. complete prior to the review completion.
(2)(k) Written quality improvement program Yes
(2)(l) Meeting minutes Yes
Executive Director or Program Director Yes/No Corrective actions/comments

excerpt:
419-400-0150
(3) Agency uses appropriate and positive methods
of behavior management and nationally recognized Yes
non-violent crisis intervention
(3)(b)(C) Agency does not use chemical and
mechanical restraint (excluding medically necessary Yes
devices/prescriptions)
(3)(c) Agency uses appropriate time-out rooms
(adequate space, heat, light and ventilation and is
Yes
not capable of locking) and documents use in
child's record when applicable
(3)(e) Agency uses seclusion
N/A Agency does not use Seclusion
appropriately/consistent with policy
(4) Agency has adequate plan in place to respond
Yes
to suicidal behavior/warning signs
Form revised 3/12/2025 Page 7 of 27
Contractors (if applicable) Yes/No Corrective actions/comments

excerpt:
419-400-0180 or N/A
(13)(d) Each child caring agency that submits a
report under this section shall make its quarterly
report available to the public upon request at the Yes
child caring agency's main office and on the child
caring agency's website if applicable.
Supplemental information provided by CCA Yes/No Corrective actions/comments
or N/A
Documents as indicated on the form titled "Renewal
Yes
Licensing Required Documents"
Documents as indicated on form titled "Required Madrona Recovery is still in the process of completing the
No
Financial Documents and Information" annual audit. They have also requested the tax compliance
Form revised 3/12/2025 Page 8 of 27
Supplemental information provided by CCA Yes/No Corrective actions/comments
or N/A
certificate, but it was not received prior to the completion of
the review.
All required policies and procedures as identified in
Yes
the "Umbrella Rules"
All required policies and procedures as identified in
Yes
"Agency Type Specific Rules"
Physical plant Yes/No Corrective actions/comments
or N/A

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

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

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

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

excerpt:
419-470-0020 (2)(d) Rooms are free of harmful
Yes
drafts, odors and excessive noise

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

excerpt:
419-470-0030 or N/A
(2) There is a separate living room or lounge area -
Yes
15 SF minimum per child
(5) There is a separate dining room with capacity for
Yes
½ of children in care and 15 SF per child in care
(7) Laundry is separate from living, kitchen and
Yes
dining areas
(8) Separate storage areas are provided for food,
kitchen supplies, utensils, clean linens, soiled linens
and clothing, cleaning supplies and equipment,
Yes
poisons, chemicals, outdoor recreational and
maintenance equipment. (Hazardous materials are
properly labeled, in original container and locked)
(9) Outdoor activity area is protected from vehicles
and other hazards and of a size and availability Yes
appropriate to the age and needs of children in care
(11) Time-out rooms: Rooms used for time out or
quiet time must have adequate space, heat, light Yes
and ventilation and must not be capable of locking.
Room and space requirements -bedrooms Yes/No Corrective actions/comments

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

excerpt:
419-400-0120(4)
(a) Agency policies and procedures Yes
(b) Ethical and professional guidelines Yes
(c) Suicide prevention and intervention 2 files were missing required training on suicide prevention.
On further discussion it was learned that the program has a
No
significant number of employees that have not completed the
required training on suicide prevention
(d) Attributes of population served No 1 reviewed file did not have the required training
(e) and (5)(a) to (c) Mandatory reporting that
Although all reviewed files included Mandatory Reporter
includes:
No training, 1 of the files showed that the training was not
(a) legal definition of child abuse in ORS 418.257
completed until well beyond the 30 day requirement.
and 419B.005
Form revised 3/12/2025 Page 18 of 27
New employee orientation - Umbrella Yes/No Corrective actions/comments
Requirements (30 days) or N/A

excerpt:
419-470-0120(1)
(a) Discipline and behavior management including
de-escalation, crisis prevention, positive behavior
Yes
management and disciplinary techniques that are
non-punitive in nature
(b) CPR and First Aid sufficient to retain a current Although all 3 files did indicate that CPR training had been
certification No completed, the timeline for one of the files was outside of the
30 days requirement.
(c) Universal precautions and hygiene Yes
(d) Application of the reasonable and prudent
Yes
parent standard
(e) Training on the agency's policy on suicide 2 files were missing required training on suicide prevention.
prevention and suicide risk assessment tool On further discussion it was learned that the program has a
No
significant number of employees that have not completed the
required training on suicide prevention
Form revised 3/12/2025 Page 19 of 27
Crisis intervention training standards and Yes/No Corrective actions/comments
certification or N/A

excerpt:
419-470-0070(2)(b) Employees who handle food Only kitchen staff have food handler cards, as they are the
served to children have a valid food handler's card N/A only ones who prepare food, and none of their files were
reviewed.

excerpt:
419-400-0200 (1) Employees transporting children
have: current driver's license, insurance, trained in
N/A The program does not transport children in care
emergency procedures and behavior management
and training for 15+ passenger vans if applicable)

excerpt: 419-470-0120 (2)(a) Environmental emergencies Yes

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

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

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

excerpt:
419-470-0120 (3) Staff providing direct care must
Yes
maintain current CPR/First Aid certification

excerpt:
419-400-0160(4)(b) Receive continuing education
(as applicable on crisis intervention training) from a Yes
certified instructor on an annual basis
Form revised 3/12/2025 Page 21 of 27
Children's records Yes/No Corrective actions/comments
health services or N/A

excerpt:
419-470-0170(2) or N/A
(b) Intake document is completed the date child
accepted into care (emergency placement 48 Yes
hours)
(d) Assessment is completed within 30 days and
contains relevant historical information, current
Yes
behavioral observations, identified need for
services and how agency will provide services
(e) (A) and (B) Service plan within 60 days (parent, Service plans were completed on time, however 2 of the
guardian and child actively involved). Describes No reviewed files did not include client or parent/guardian
how child's issues will be addressed, anticipated signatures.
Form revised 3/12/2025 Page 24 of 27
Service planning Yes/No Corrective actions/comments

excerpt:
419-470-0170(3) or N/A
(a) Services are documented, progress toward
Yes
achieving goals is tracked
(c) Discharge summary must include:
(A)Current medications
(B)Name of the physician or qualified medical
professional who prescribed each medication
(C)Any outstanding medical or other appointments
Yes
(D)Summary of the child's participation in the
program and progress achieved
(E)Results of evaluations
(F)Recommendations regarding services
(G)Discharge destination
(e) Follow up services Yes
(f) Incident reports Yes
Records relating to Restraint and Involuntary Yes/No Corrective actions/comments
Seclusion or N/A

excerpt:
419-400-0180 (12) Records Program did not have documentation to comply with: 419-
No 400-0180(10)(e) The child-caring agency must have a policy
that prohibits the application of a nonviolent restraint to a child
Form revised 3/12/2025 Page 25 of 27
Records relating to Restraint and Involuntary Yes/No Corrective actions/comments
Seclusion or N/A
in care who has a documented physical condition that would
contraindicate the use of that restraint unless a qualified
medical professional has previously and specifically
authorized its use in writing for the child in care.
Documentation of the authorization must be maintained in the
child of care's record.

excerpt:
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 Yes
agency shall provide the notice upon the child in
care's admission and at least two times each year
thereafter.


state: OR

facility_name: Marion County GAP Program

summary: Unannounced - 8 findings

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Licensee: Marion County Juvenile Department (GAP)
Executive Director: Troy Gregg
Program Director: Jose Miranda
Date of Unannounced: June 2, 2021
Licensing Coordinator: Holly Ivey
Other Regulatory or Accrediting Agencies: The Oregon Youth Authority
Purpose: Per OAR 413-215-0101 (1) (b) Children’s Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Comments
Findings
Further Action
Needed
Medication 413-215-0551(9) Written record Yes☐ No June 2, 2021
of the disposal of medications is At the unannounced inspection the Licensing Coordinator observed the medication
maintained and includes: (d) method. disposal log being utilized. “method of disposal” was found on the form.
(Sited in the July 2020 Unannounced
Inspection) REPEAT FINDING-The method of
disposal was not found on the medication
disposal logs observed. After the inspection,
the Program Manager sent the Licensing
Coordinator an updated disposal log that met
all the required elements per Licensing Rules.
It was reported by the Program Manager the
form began being utilized on 8/12/20.
Medication 413-215-0551(9) (10) Written Yes No☐ June 2, 2021
record of the administration of medication The Licensing Coordinator observed the medication administration record being utilized.
includes: (e) medication dropped or “Medication dropped or disposed” was not found to be in the list of codes for the
disposed of medication record.
1
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 200115)
(Sited in the July 2020 Unannounced
Inspection) REPEAT FINDING-The
medication administrative record was missing
a field for “medication disposed of or
dropped”. This needs to be added to the
MAR.
Personnel Files 413-215-0061(1)(a) & (3)(c) Yes☐ No June 2, 2021
Background check completed and Observed to be in compliance; the Licensing Coordinator reviewed two staff who were
documented: recently promoted, the agency had re-run the background checks with the change in
positions.
(Sited in the July 2020 Unannounced
Inspection) “Background checks were not
found in personnel files when promotions
occurred which is required by BCU Rules.”
Consents 413-215-0576(1)(e) Allow access Yes☐ No June 2, 2021
as defined in 413-215-0091 & 0101: Observed to be in compliance; the Licensing Coordinator reviewed some youth files and
observed allowing access was on the consent form and was being signed by guardians at
(Sited in the July 2020 Unannounced intake.
Inspection) “The above required consent was
not found in the youth files reviewed.”
Information about Children in Care Yes No☐ June 2, 2021
413-215-0581(1) Summary sheet contains Observed to be in compliance; the Licensing Coordinator reviewed the Summary Sheets,
the following;(a)… gender, date of birth and they were observed to be in compliance with the following: gender, date of birth,
and previous address(b)location of location of previous and current school.
previous and current school:
The following was found to be out of compliance on the Summary Sheets:
(Sited in the July 2020 Unannounced In the youth summaries reviewed by the Licensing Coordinator, the field for
Inspection) “The above information was “previous address” was blank.
missing on the Summary Sheet.”
New Findings from Site Visit Comments
413-215-0046 Licensing Umbrella
Rules: Children and Families Rights (1)
June 3, 2021 (Youth phone interviews)
(a) Except as provided in paragraph (B)
While conducting interviews, the DHS Licensing Coordinator received information from the youth
of this subsection, the child in care's
regarding phone contact with approved contacts. The following was stated:
right to uncensored communication with
2
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 200115)
legal guardians, caseworkers, legal  Youth had opportunities to call approved contacts for 5 minutes two times a week on the
representatives, and other persons lowest level of the program, and for 10 minutes two times a week on higher levels.
 Youth received daily points for appropriate behavior, 5 points could be used to make10 minute
approved for communication by the legal
phone calls with approved contacts.
guardian or as provided in a court order.
(A) This right cannot be waived,
The program must allow daily phone calls with approved contacts. The duration of the phone calls
including voluntarily. Restriction on must increase from 5 minutes, to allow for meaningful communication in compliance with DHS
communication between a child in care Licensing Rules.
and his or her legal guardian may not be
a condition of participation in the
program. (B) A child-caring agency may
place reasonable limits on
communication, but only as provided in
the child-caring agency's policy.
Reasonable limits include, but are not
limited to, having set time periods during
the day for visitation and phone calls and
imposing moderate limits on the duration
of calls or visits. However, a limitation is
not considered reasonable if it prevents
the ability to meaningfully communicate,
such as not allowing contact with a child
in care's attorney during regular
business hours.
413-215-0079 Licensing Umbrella
Rules: Safety (Adopted 1/1/19) (b) June 2, 2021
The following was found to be out of compliance, the DHS Licensing Coordinator did not see the
Vehicle requirements. (A) Each vehicle
following in the vehicles used to drive youth:
used to transport a child in care must be:
 Registrations
(i) Properly registered; (ii) Covered by an
 Insurance
insurance policy in full force and effect;
Interview Summary
The program supervisor spoke to the Licensing Coordinator while conducting a walkthrough of the facility. Two youth were
interviewed over the phone on May 3, 2021, as youth were not present at the unannounced site inspection. Both of the youth stated
they appreciated the staff. The youth stated they had enough food to eat, and that they received snacks daily. One youth stated
that if he could change anything it would be the detention food. (The food is cooked and brought down to the program from Marion
County Detention in hot boxes for the youth). Both youth stated they felt safe in the program. The only concerns identified in the
youth interviews are described above regarding phone contact, and this is sited as Licensing Rule violation.
3
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 200115)
Observations
The facility was clean and in good repair, no concerns were observed.
Corrective Actions and Timeframes:
Please submit the following to verify compliance.
Within 45 days of receipt of this report Marion County GAP Program 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@dhsoha.state.or.us or sent by regular mail to the following address:
Department of Human Services
Children’s Care Licensing Program
Attn: Holly Ivey, Licensing Coordinator
201 High St. SE Suite 500
Salem, OR 97301
6-23-2021
Licensing Coordinator’s Signature: ________________________ Date: ___________________
6-11-2021
Manager Review: ______________________________________ Date: __________________
4
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 200115)

agency_name: Marion County Juvenile Department (MARIONCJD)

program_name: GAP

program_type: (RC) Residential Care Programs

report_type: Unannounced

view_code: RC

licensee: Marion County Juvenile Department (GAP)

executive_director: Troy Gregg

program_director: Jose Miranda

licensing_coordinator: Holly Ivey

other_regulatory_agencies: The Oregon Youth Authority

purpose:
Per OAR 413-215-0101 (1) (b) Children's Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Comments
Findings
Further Action
Needed
Medication 413-215-0551(9) Written record Yes[ ] No June 2, 2021
of the disposal of medications is At the unannounced inspection the Licensing Coordinator observed the medication
maintained and includes: (d) method. disposal log being utilized. "method of disposal" was found on the form.
(Sited in the July 2020 Unannounced
Inspection) REPEAT FINDING-The method of
disposal was not found on the medication
disposal logs observed. After the inspection,
the Program Manager sent the Licensing
Coordinator an updated disposal log that met
all the required elements per Licensing Rules.
It was reported by the Program Manager the
form began being utilized on 8/12/20.
Medication 413-215-0551(9) (10) Written Yes No[ ] June 2, 2021
record of the administration of medication The Licensing Coordinator observed the medication administration record being utilized.
includes: (e) medication dropped or "Medication dropped or disposed" was not found to be in the list of codes for the
disposed of medication record.
1

(Sited in the July 2020 Unannounced
Inspection) REPEAT FINDING-The
medication administrative record was missing
a field for "medication disposed of or
dropped". This needs to be added to the
MAR.
Personnel Files 413-215-0061(1)(a) & (3)(c) Yes[ ] No June 2, 2021
Background check completed and Observed to be in compliance; the Licensing Coordinator reviewed two staff who were
documented: recently promoted, the agency had re-run the background checks with the change in
positions.
(Sited in the July 2020 Unannounced
Inspection) "Background checks were not
found in personnel files when promotions
occurred which is required by BCU Rules."
Consents 413-215-0576(1)(e) Allow access Yes[ ] No June 2, 2021
as defined in 413-215-0091 & 0101: Observed to be in compliance; the Licensing Coordinator reviewed some youth files and
observed allowing access was on the consent form and was being signed by guardians at
(Sited in the July 2020 Unannounced intake.
Inspection) "The above required consent was
not found in the youth files reviewed."
Information about Children in Care Yes No[ ] June 2, 2021
413-215-0581(1) Summary sheet contains Observed to be in compliance; the Licensing Coordinator reviewed the Summary Sheets,
the following;(a)… gender, date of birth and they were observed to be in compliance with the following: gender, date of birth,
and previous address(b)location of location of previous and current school.
previous and current school:
The following was found to be out of compliance on the Summary Sheets:
(Sited in the July 2020 Unannounced In the youth summaries reviewed by the Licensing Coordinator, the field for
Inspection) "The above information was "previous address" was blank.
missing on the Summary Sheet."
New Findings from Site Visit Comments
413-215-0046 Licensing Umbrella
Rules: Children and Families Rights (1)
June 3, 2021 (Youth phone interviews)
(a) Except as provided in paragraph (B)
While conducting interviews, the DHS Licensing Coordinator received information from the youth
of this subsection, the child in care's
regarding phone contact with approved contacts. The following was stated:
right to uncensored communication with
2

legal guardians, caseworkers, legal - Youth had opportunities to call approved contacts for 5 minutes two times a week on the
representatives, and other persons lowest level of the program, and for 10 minutes two times a week on higher levels.
- Youth received daily points for appropriate behavior, 5 points could be used to make10 minute
approved for communication by the legal
phone calls with approved contacts.
guardian or as provided in a court order.
(A) This right cannot be waived,
The program must allow daily phone calls with approved contacts. The duration of the phone calls
including voluntarily. Restriction on must increase from 5 minutes, to allow for meaningful communication in compliance with DHS
communication between a child in care Licensing Rules.
and his or her legal guardian may not be
a condition of participation in the
program. (B) A child-caring agency may
place reasonable limits on
communication, but only as provided in
the child-caring agency's policy.
Reasonable limits include, but are not
limited to, having set time periods during
the day for visitation and phone calls and
imposing moderate limits on the duration
of calls or visits. However, a limitation is
not considered reasonable if it prevents
the ability to meaningfully communicate,
such as not allowing contact with a child
in care's attorney during regular
business hours.
413-215-0079 Licensing Umbrella
Rules: Safety (Adopted 1/1/19) (b) June 2, 2021
The following was found to be out of compliance, the DHS Licensing Coordinator did not see the
Vehicle requirements. (A) Each vehicle
following in the vehicles used to drive youth:
used to transport a child in care must be:
- Registrations
(i) Properly registered; (ii) Covered by an
- Insurance
insurance policy in full force and effect;
Interview Summary
The program supervisor spoke to the Licensing Coordinator while conducting a walkthrough of the facility. Two youth were
interviewed over the phone on May 3, 2021, as youth were not present at the unannounced site inspection. Both of the youth stated
they appreciated the staff. The youth stated they had enough food to eat, and that they received snacks daily. One youth stated
that if he could change anything it would be the detention food. (The food is cooked and brought down to the program from Marion
County Detention in hot boxes for the youth). Both youth stated they felt safe in the program. The only concerns identified in the
youth interviews are described above regarding phone contact, and this is sited as Licensing Rule violation.
3

Observations
The facility was clean and in good repair, no concerns were observed.