summary: Unannounced - 17 findings

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Licensee: A Village for One
Executive Director: Cassie Trahan
Board President & Treasurer: Robert Edwards
Date of Unannounced: 10.12.2023
Licensing Coordinator: Jorge Pelinski & Aubrey Kelly
Other Regulatory or Accrediting Agencies:
Purpose: Per OAR 419-400-0240 (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 Site Visit 02/02/2023 Findings
Further Action
Needed
Physical Plant Yes☐ No✓ • The agency made needed repairs.
419-470-0020(2)(a) &(c) Buildings are smoke
free, clean and in good repair. Agency is in compliance.
• Environmental Health Inspection
completed on 1.03.2023. Per Building
inspector, “Kitchen floor peeling up.”
Corrective Action: Agency will ensure that
floors in kitchen are repaired. Executive
Director stated that Agency has scheduled a
date with a company to come out and fix
flooring in the kitchen.
Room and Space Requirements Yes☐ No✓ • Agency has completed tree trimming in the identified areas.
419-470-0030
(9) Outdoor activity area is protected from Agency is in compliance
vehicles and other hazards and of a size and
1| P age
Form Rev. 01/23/2023
availability appropriate to the age and needs
of children in care
• Environmental Health Inspection
completed on 1.03.2023. Per Building
inspector, areas used for recreation,
“Tree care/trimming needed for
safety.” Agency has contacted
arborist for an evaluation and the
evaluation has been completed.
Corrective Actions: Agency will ensure tree
care/trimming is completed for safety
Medication Yes✓No☐ • On October 12, 2023, the licensing coordinator reviewed the agencies MAR. The
419-470-0100 program will add a space on the MAR to document when medication is taken
(10) Written record of the administration of outside the facility.
medication includes:
(a) name Repeat Finding from previous review in February 2023
(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
• In review of the MARS, there is not a
notation for when medication is taken
outside the facility.
Corrective Action: The program will add a
space on the MAR to document when
medication is taken outside the facility.
New Employee Orientation – Umbrella Yes☐ No✓ • Licensing coordinator reviewed employee files and training for attributes of
Requirements (30 days) population served was consistently found.
419-400-0120(4)
(d) Attributes of population served Agency is in compliance
• In staff files reviewed, training in
attributes of population served was
not consistently found.
2| P age
Form Rev. 01/23/2023
Corrective Action: Agency will ensure that all
required training is completed and
documented in all personnel files.
Crisis Intervention Training Standards and Yes☐ No✓ • The agency’s employees receive 12 hours of training that is required for Crisis
Certification Intervention Training Standards and Certification.
419-400-0160(4) (as applicable)
(a)Complete a minimum of 12 hours of initial Agency is in compliance.
training in person from a certified instructor,
including but not limited to a minimum of six
hours of training focused on positive behavior
support, nonviolent crisis intervention and
other methods of nonphysical intervention to
support children in care during a crisis.
• All files reviewed for Crisis
Intervention had 10 hours of training,
as opposed to the 12 hours of training
needed.
Corrective Action: Agency will ensure that all
staff receive 12 hours of Crisis Intervention
Training during their orientation period.
Consents Yes☐ No✓ • Agency has created a consent form to allow access as defined.
419-470-0160(1)
(e) Allow access as defined in 419-400-0230 Agency is in compliance.
& 0240
• Files reviewed did not have the
consent to allow access.
Corrective Action: Agency will create a
consent form to allow access as defined in
419-400-0239 & 0240.
Consents Yes☐ No✓ • Youth files reviewed have the required consent.
419-470-0160(1)
(g) Apply the reasonable and prudent parent Agency is in compliance.
standard
• Files reviewed, did not have the
consent to apply the reasonable and
prudent parent standard.
Corrective Action: Agency will ensure that all
youth files will have the required consent.
3| P age
Form Rev. 01/23/2023
Service Planning Yes☐ No✓ • All client files reviewed have a completed intake document.
419-470-0170(2)
(b) Intake document is completed the date Agency is in compliance
child accepted into care (emergency
placement 48 hours)
• Client files did not consistently have
an intake document.
Corrective Action: Agency will ensure that all
client files have a completed intake document.
Restraints and Involuntary Seclusion Yes☐ No✓ • Agency has created a document for youth and families regarding how youth and
419-400-0180(13)(e) families can access the Quarterly Reports which explains that the information is
Each child caring agency shall provide notice provided upon admission and at least two times each year thereafter.
regarding how to access the quarterly reports
to the parents or guardians of children in care Agency is in compliance
in the program. The child caring agency shall
provide the notice upon the child in care’s
admission and at least two times each year
thereafter.
• All files reviewed did not have the
above required information related to
Quarterly Reports.
Corrective Action: Agency will ensure a
process where youth and families have
access to the Quarterly Reports and that this
information is provided upon admission and at
least two times each year thereafter.
Restraints and Involuntary Seclusion Yes☐ No✓ • Agency has not had a child in care in a restraint or involuntary seclusion since the
419-400-0180 last review which was in February 2023.
If a program places a child in care in a
restraint or involuntary seclusion, the program N/A – Licensing Coordinator will follow up by reviewing files at next site visit.
shall provide the child in care’s case manager,
attorney, court appointed special advocate
and parents or guardians with the following:
• Attorney
• Court Appointed Special Advocate
All files reviewed did not provide the attorney
or the Court Appointed Special Advocate a
copy of their youth restraint report.
4| P age
Form Rev. 01/23/2023
Corrective Action: Agency will ensure that
the attorney and the Court Appointed Special
Advocate will receive a copy of the restraint
report.
Restraints and Involuntary Seclusion Yes☐ No✓ • Agency has not had a child in care in a restraint or involuntary seclusion since the
419-400-0180 last review which was in February 2023.
For each individual identified in this
subparagraph (D)(i), the following items were
identified: N/A – Licensing Coordinator will follow up by reviewing files at next site visit.
Written notes of the debriefing meeting were
recorded.
• All files reviewed did not reflect
written notes on the debriefing
meeting.
Corrective Action: Agency will ensure that all
files will have written notes on the debriefing
meeting.
Restraints and Involuntary Seclusion Yes☐ No✓
419-400-0180 • Agency has not had a child in care in a restraint or involuntary seclusion since the
Copies of the written notes from debriefing last review which was in February 2023.
meeting were provided to the child in care’s
case manager attorney, court appointed
special advocate and parents or guardians. N/A – Licensing Coordinator will follow up by reviewing files at next site visit.
Case Manager
Attorney
Court Appointed Special Advocate
Parents or Legal Guardian
• All files reviewed did not indicate that
written notes from debriefing meeting
were provided to all required parties
listed above.
Correction Action: Agency will ensure that
the Case Manager, Attorney, Court Appointed
Special Advocate, and Parents of or Legal
Guardian will receive written notes from the
debriefing meeting.
5| P age
Form Rev. 01/23/2023
Residential Care Agencies: Safety Yes☐ No✓ • Fire Marshal Inspection was completed on March 8, 2023.
419-470-0080
A residential care agency must meet all of the Agency is in compliance.
following requirements related to safety:
(1) Fire safety. Prior to licensure and every
two years upon license renewal, the program
must be assessed and approved by the State
Fire Marshall or designee for the following fire
safety areas:
• The program has made several
attempts to schedule their Fire
Marshal Inspection. However, the
inspection has not been completed at
the time of the review.
Corrective Action: The agency will ensure
that the Fire Marshal Inspection is completed
and, in the meantime, will provide copies of
correspondence with Fire Inspection
authorities
New Findings from Site Visit Comments
Physical Plant During site visit, Foster Rights were not posted. During site visit the agency posted the Foster Rights. The
419-470-0090(3)(a) Foster Rights Posted (if finding is now resolved. No follow up needed.
children in DHS custody)
Physical Plant The following youth rooms were identified as needing cleaning.
419-470-0020(2)(a) &(c) Buildings are
smoke free, clean and in good repair. • Yellow Room was cluttered and messy and must be cleaned.
• Green Room was cluttered and messy and must be cleaned.
Agency sent pictures of the Yellow Room and Green Room after it was cleaned.
6| P age
Form Rev. 01/23/2023
Interview Summary
Licensing Coordinators spoke with Executive Director, Cassie Trahan. Cassie shared that the agency currently has five youth residing in the program. Cassie
also shared that more insulation was installed in the house and new flooring. New dishwasher and washer/dryer are commercial grade. Cassie stated that she
hopes for the construction of a new residential home adjacent to the existing facility will be completed soon, and she is hoping for a June 2024 opening.
Youth interviews x2:
• When asked what they appreciated most about living in the programs, one youth stated: “New experiences”, therapy is helping one youth grow as a
person. The second youth stated that it helped her with her trauma. One youth talked about the different groups she attends such as nutrition group,
and creativity group, which is her favorite since she loves to paint.
• Fun activities and recreation reported by the youth: Water slides, hikes swimming, “fun places”, pumpkin patches, going to the park, spending time at
the gym, riding horses, and being outdoors in general.
• All youth mentioned that they receive three meals a day, with multiple snacks. The youth reported fresh fruit are always available. One youth reported
that they wished they could have bigger portions of food. This youth did say that plenty of snacks in between meals are offered.
• Both youths reported the program provides hygiene products, which includes, soap, shampoo, feminine products, and toothpaste.
• Both youths reported that they could talk to staff if they had a concern or need.
• Both youths stated there are privacy restrictions in contacting their approved contacts. They stated they could have daily phone calls and staff are
present in the room during phone calls. One youth described this as a safety and security thing. She said the reason the program does this is so youth
are not calling people that are not on their approved contact list. CCLP is working with the program to ensure youth are able to have private calls with
approved individuals using a communication device that prevents the user from dialing other numbers and potentially communicating with unapproved
persons.
When asked if the youth feel safe in the program, one youth stated she felt safe because she believes staff know what they are doing, and they keep the youth
safe. The other youth interviewed felt safe most of the time, except for when her peers are in crisis. This youth shared that they had told a staff member that
she didn’t feel safe during a crisis involving another youth. This youth explained that when they told a staff member that they did not feel safe, the staff
member told her to quiet down. When this writer clarified with youth regarding the staff telling them to quiet down, the youth shared that it is difficult for staff to
calm her down in the moment when staff are managing crisis with another youth. This writer validated youth’s concerns. This youth also shared that staff can
help her feel safe by giving her the attention she needs when the staff member is not attending to a youth in crisis at that moment.
This writer followed up with Executive Director, Cassie Trahan, regarding privacy restrictions for phone calls and the concern one of the youths brought up
about feeling unsafe. The Executive Director shared that the staff always follow up with the youth and they also address any safety concerns in daily groups
as well. The youth have access to outside crisis support 24 hours a day and a mental health support person on site. Regarding phone calls, The Executive
Director shared that the two-youth interviewed have parent monitored phone calls advised by their DHS Caseworkers for safety concerns. Staff are in the
general area when you make phone calls, so the youth aren’t calling people not on their approved call list for safety concerns. The Youth can have privacy
Zoom calls with legal guardians, legal representatives, and CASA Workers.
7| P age
Form Rev. 01/23/2023
Observations
At the Unannounced Inspection, Program Staff assisted with the walk-through of the programs with Jorge Pelinski and Aubrey Kelly, ODHS Licensing
Coordinators. Staff were observed at the program during the inspection walk-through. The youth that were at the program were in their rooms. The rest of the
youth went out on an outing with staff. The staff were observed to be at ease and comfortable in the environment. All areas of the program (inside and
outside) where youth had access were observed. The program, in general, appeared to be clean and in good repair. Two youth rooms were observed to be
cluttered and messy. The Executive Director talked to one of youth while licensing coordinators were on site about the need to clean up their room. Medication
was observed to be kept in locked cabinets inaccessible to youth.
Corrective Actions and Timeframes:
Please submit the following to verify compliance.
Within 45 days of receipt of this report A Village for One 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 Licensing Coordinator at jorge.l.pelinski@odhsoha.oregon.gov
Licensing Coordinator’s Signature: ________________________ Date: _1_0_.1_9_._2_0_2_3_ _________
Manager Review: ______________________________________ Date: _1_0_-_1_9_-_2_0_2_3_ _______
8| P age
Form Rev. 01/23/2023

other_regulatory_agencies: Purpose: Per OAR 419-400-0240 (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 Site Visit 02/02/2023 Findings Further Action Needed Physical Plant Yes[ ] No✓ - The agency made needed repairs. 419-470-0020(2)(a) &(c) Buildings are smoke free, clean and in good repair. Agency is in compliance. - Environmental Health Inspection completed on 1.03.2023. Per Building inspector, "Kitchen floor peeling up." Corrective Action: Agency will ensure that floors in kitchen are repaired. Executive Director stated that Agency has scheduled a date with a company to come out and fix flooring in the kitchen. Room and Space Requirements Yes[ ] No✓ - Agency has completed tree trimming in the identified areas. 419-470-0030 (9) Outdoor activity area is protected from Agency is in compliance vehicles and other hazards and of a size and availability appropriate to the age and needs of children in care - Environmental Health Inspection completed on 1.03.2023. Per Building inspector, areas used for recreation, "Tree care/trimming needed for safety." Agency has contacted arborist for an evaluation and the evaluation has been completed. Corrective Actions: Agency will ensure tree care/trimming is completed for safety Medication Yes✓No[ ] - On October 12, 2023, the licensing coordinator reviewed the agencies MAR. The 419-470-0100 program will add a space on the MAR to document when medication is taken (10) Written record of the administration of outside the facility. medication includes: (a) name Repeat Finding from previous review in February 2023 (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 - In review of the MARS, there is not a notation for when medication is taken outside the facility. Corrective Action: The program will add a space on the MAR to document when medication is taken outside the facility. New Employee Orientation - Umbrella Yes[ ] No✓ - Licensing coordinator reviewed employee files and training for attributes of Requirements (30 days) population served was consistently found. 419-400-0120(4) (d) Attributes of population served Agency is in compliance - In staff files reviewed, training in attributes of population served was not consistently found. Corrective Action: Agency will ensure that all required training is completed and documented in all personnel files. Crisis Intervention Training Standards and Yes[ ] No✓ - The agency's employees receive 12 hours of training that is required for Crisis Certification Intervention Training Standards and Certification. 419-400-0160(4) (as applicable) (a)Complete a minimum of 12 hours of initial Agency is in compliance. training in person from a certified instructor, including but not limited to a minimum of six hours of training focused on positive behavior support, nonviolent crisis intervention and other methods of nonphysical intervention to support children in care during a crisis. - All files reviewed for Crisis Intervention had 10 hours of training, as opposed to the 12 hours of training needed. Corrective Action: Agency will ensure that all staff receive 12 hours of Crisis Intervention Training during their orientation period. Consents Yes[ ] No✓ - Agency has created a consent form to allow access as defined. 419-470-0160(1) (e) Allow access as defined in 419-400-0230 Agency is in compliance. & 0240 - Files reviewed did not have the consent to allow access. Corrective Action: Agency will create a consent form to allow access as defined in 419-400-0239 & 0240. Consents Yes[ ] No✓ - Youth files reviewed have the required consent. 419-470-0160(1) (g) Apply the reasonable and prudent parent Agency is in compliance. standard - Files reviewed, did not have the consent to apply the reasonable and prudent parent standard. Corrective Action: Agency will ensure that all youth files will have the required consent. Service Planning Yes[ ] No✓ - All client files reviewed have a completed intake document. 419-470-0170(2) (b) Intake document is completed the date Agency is in compliance child accepted into care (emergency placement 48 hours) - Client files did not consistently have an intake document. Corrective Action: Agency will ensure that all client files have a completed intake document. Restraints and Involuntary Seclusion Yes[ ] No✓ - Agency has created a document for youth and families regarding how youth and 419-400-0180(13)(e) families can access the Quarterly Reports which explains that the information is Each child caring agency shall provide notice provided upon admission and at least two times each year thereafter. regarding how to access the quarterly reports to the parents or guardians of children in care Agency is in compliance in the program. The child caring agency shall provide the notice upon the child in care's admission and at least two times each year thereafter. - All files reviewed did not have the above required information related to Quarterly Reports. Corrective Action: Agency will ensure a process where youth and families have access to the Quarterly Reports and that this information is provided upon admission and at least two times each year thereafter. Restraints and Involuntary Seclusion Yes[ ] No✓ - Agency has not had a child in care in a restraint or involuntary seclusion since the 419-400-0180 last review which was in February 2023. If a program places a child in care in a restraint or involuntary seclusion, the program N/A - Licensing Coordinator will follow up by reviewing files at next site visit. shall provide the child in care's case manager, attorney, court appointed special advocate and parents or guardians with the following: - Attorney - Court Appointed Special Advocate All files reviewed did not provide the attorney or the Court Appointed Special Advocate a copy of their youth restraint report. Corrective Action: Agency will ensure that the attorney and the Court Appointed Special Advocate will receive a copy of the restraint report. Restraints and Involuntary Seclusion Yes[ ] No✓ - Agency has not had a child in care in a restraint or involuntary seclusion since the 419-400-0180 last review which was in February 2023. For each individual identified in this subparagraph (D)(i), the following items were identified: N/A - Licensing Coordinator will follow up by reviewing files at next site visit. Written notes of the debriefing meeting were recorded. - All files reviewed did not reflect written notes on the debriefing meeting. Corrective Action: Agency will ensure that all files will have written notes on the debriefing meeting. Restraints and Involuntary Seclusion Yes[ ] No✓ 419-400-0180 - Agency has not had a child in care in a restraint or involuntary seclusion since the Copies of the written notes from debriefing last review which was in February 2023. meeting were provided to the child in care's case manager attorney, court appointed special advocate and parents or guardians. N/A - Licensing Coordinator will follow up by reviewing files at next site visit. Case Manager Attorney Court Appointed Special Advocate Parents or Legal Guardian - All files reviewed did not indicate that written notes from debriefing meeting were provided to all required parties listed above. Correction Action: Agency will ensure that the Case Manager, Attorney, Court Appointed Special Advocate, and Parents of or Legal Guardian will receive written notes from the debriefing meeting. Residential Care Agencies: Safety Yes[ ] No✓ - Fire Marshal Inspection was completed on March 8, 2023. 419-470-0080 A residential care agency must meet all of the Agency is in compliance. following requirements related to safety: (1) Fire safety. Prior to licensure and every two years upon license renewal, the program must be assessed and approved by the State Fire Marshall or designee for the following fire safety areas: - The program has made several attempts to schedule their Fire Marshal Inspection. However, the inspection has not been completed at the time of the review. Corrective Action: The agency will ensure that the Fire Marshal Inspection is completed and, in the meantime, will provide copies of correspondence with Fire Inspection authorities New Findings from Site Visit Comments Physical Plant During site visit, Foster Rights were not posted. During site visit the agency posted the Foster Rights. The 419-470-0090(3)(a) Foster Rights Posted (if finding is now resolved. No follow up needed. children in DHS custody) Physical Plant The following youth rooms were identified as needing cleaning. 419-470-0020(2)(a) &(c) Buildings are smoke free, clean and in good repair. - Yellow Room was cluttered and messy and must be cleaned. - Green Room was cluttered and messy and must be cleaned. Agency sent pictures of the Yellow Room and Green Room after it was cleaned. Interview Summary

interview_summary:
Licensing Coordinators spoke with Executive Director, Cassie Trahan. Cassie shared that the agency currently has five youth residing in the program. Cassie
also shared that more insulation was installed in the house and new flooring. New dishwasher and washer/dryer are commercial grade. Cassie stated that she
hopes for the construction of a new residential home adjacent to the existing facility will be completed soon, and she is hoping for a June 2024 opening.
Youth interviews x2:
- When asked what they appreciated most about living in the programs, one youth stated: "New experiences", therapy is helping one youth grow as a
person. The second youth stated that it helped her with her trauma. One youth talked about the different groups she attends such as nutrition group,
and creativity group, which is her favorite since she loves to paint.
- Fun activities and recreation reported by the youth: Water slides, hikes swimming, "fun places", pumpkin patches, going to the park, spending time at
the gym, riding horses, and being outdoors in general.
- All youth mentioned that they receive three meals a day, with multiple snacks. The youth reported fresh fruit are always available. One youth reported
that they wished they could have bigger portions of food. This youth did say that plenty of snacks in between meals are offered.
- Both youths reported the program provides hygiene products, which includes, soap, shampoo, feminine products, and toothpaste.
- Both youths reported that they could talk to staff if they had a concern or need.
- Both youths stated there are privacy restrictions in contacting their approved contacts. They stated they could have daily phone calls and staff are
present in the room during phone calls. One youth described this as a safety and security thing. She said the reason the program does this is so youth
are not calling people that are not on their approved contact list. CCLP is working with the program to ensure youth are able to have private calls with
approved individuals using a communication device that prevents the user from dialing other numbers and potentially communicating with unapproved
persons.
When asked if the youth feel safe in the program, one youth stated she felt safe because she believes staff know what they are doing, and they keep the youth
safe. The other youth interviewed felt safe most of the time, except for when her peers are in crisis. This youth shared that they had told a staff member that
she didn't feel safe during a crisis involving another youth. This youth explained that when they told a staff member that they did not feel safe, the staff
member told her to quiet down. When this writer clarified with youth regarding the staff telling them to quiet down, the youth shared that it is difficult for staff to
calm her down in the moment when staff are managing crisis with another youth. This writer validated youth's concerns. This youth also shared that staff can
help her feel safe by giving her the attention she needs when the staff member is not attending to a youth in crisis at that moment.
This writer followed up with Executive Director, Cassie Trahan, regarding privacy restrictions for phone calls and the concern one of the youths brought up
about feeling unsafe. The Executive Director shared that the staff always follow up with the youth and they also address any safety concerns in daily groups
as well. The youth have access to outside crisis support 24 hours a day and a mental health support person on site. Regarding phone calls, The Executive
Director shared that the two-youth interviewed have parent monitored phone calls advised by their DHS Caseworkers for safety concerns. Staff are in the
general area when you make phone calls, so the youth aren't calling people not on their approved call list for safety concerns. The Youth can have privacy
Zoom calls with legal guardians, legal representatives, and CASA Workers.

excerpt:
419-470-0020(2)(a) &(c) Buildings are
smoke free, clean and in good repair. - Yellow Room was cluttered and messy and must be cleaned.
- Green Room was cluttered and messy and must be cleaned.
Agency sent pictures of the Yellow Room and Green Room after it was cleaned.
Physical Plant During site visit, Foster Rights were not posted. During site visit the agency posted the Foster Rights. The


state: OR

facility_name: Anisa's Place

summary: Unannounced - 2 findings

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Residential Care
Licensee: A Village for One
Executive Director: Cassie Trahan
Date of Unannounced: 4.4.2024
Licensing Coordinator: Jorge Pelinski
Other Regulatory or Accrediting Agencies: Oregon Department of Human Services, Child Welfare, Oregon Health Authority, and Oregon Youth
Authority
Purpose: Per OAR 419-400-0240 (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 10/12/2023 Findings
Further Action
Needed
Medication Yes☐ No✓ Agency is in compliance with rule.
419-470-0100
(10) Written record of the administration of
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
• On October 12, 2023, the licensing
coordinator reviewed the agencies
MAR. The program will add a space
Form Rev. 11/14/2023 P age 1 | 4
on the MAR to document when
medication is taken outside the
facility.
Repeat Finding from previous review in
February 2023
Physical Plant Yes☐ No✓ Agency is in compliance with rule.
419-470-0020(2)(a) &(c) Buildings are smoke
free, clean and in good repair.
• The following youth rooms were
identified as needing cleaning.
• Yellow Room was cluttered and messy and
must be cleaned.
• Green Room was cluttered and messy and
must be cleaned.
Agency sent pictures of the Yellow Room and
Green Room after it was cleaned.
New Findings from Site Visit Comments
N/A No new findings were found during site visit.
Form Rev. 11/14/2023 P age 2 | 4
Interview Summary
This writer interviewed one youth at the program during the unannounced site review. The youth interviewed is 14 years old and has
been in the program for 16 days. Youth reported that she gets along well with staff. She feels safe in the program and can
communicate her concerns and needs as necessary. Youth talks with her family on the phone. Youth enjoys skating and relaxing.
Youth does not like the food very much that the program provides. However, the youth does enjoy eating macaroni & cheese, Top
Ramen, and drinking smoothies. Youth shared that she gets plenty of snacks.
This writer interviewed the Executive Director, Clinical Director, and Program Director while at the program. The Executive Director
is working almost full time and is available four days a week. June 15th is the Executive Director’s last day. The agency is
interviewing and scheduling more interviews for the Executive Director Position.
It was reported that the program is providing more structure and consistency when working with the youth. Staff are feeling
confident with working with the youth. Administration is modeling for staff on how to be more consistent when working with the
youth. Recently, administration fired two staff. The agency has scheduled a lot of interviews for open positions before and since the
two staff were recently let go. The Program Director stated his goal is to have some new trainings for staff. Currently, the agency
has two youth in the program and one in the hospital. The program is hoping to have two new youth move into the program soon.
Observations
At the Unannounced Inspection, Program Staff assisted with the walk-through of the program with Jorge Pelinski, ODHS Licensing
Coordinator. Staff were observed at the program during the inspection walk-through. The youth that were at the program appeared
to be at ease and comfortable in the environment. All areas of the program (inside and outside) where youth had access were
observed. The program, in general, appeared to be clean and in good repair. Medication was observed to be kept in locked
cabinets inaccessible to youth.
Form Rev. 11/14/2023 P age 3 | 4
Corrective Actions and Timeframes:
Please submit the following to verify compliance.
Within 45 days of receipt of this report A Village for One 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 Jorge Pelinski Jorge.L.Pelinski@odhsoha.oregon.gov.
Licensing Coordinator’s Signature: ________________________ Date: ___4_/_0_8_/2_0_2__4________
Manager Review: ______________________________________ Date: _4_/8_/_2_0_2_4___________
Form Rev. 11/14/2023 P age 4 | 4

agency_name: A Village for One (AVFO)

program_name: Anisa's Place

program_type: (RC) Residential Care Programs

report_type: Unannounced

view_code: RC

facility_type: Residential Care

licensee: A Village for One

executive_director: Cassie Trahan

licensing_coordinator: Jorge Pelinski

purpose:
Per OAR 419-400-0240 (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 10/12/2023 Findings
Further Action
Needed
Medication Yes[ ] No✓ Agency is in compliance with rule.
419-470-0100
(10) Written record of the administration of
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
- On October 12, 2023, the licensing
coordinator reviewed the agencies
MAR. The program will add a space

on the MAR to document when
medication is taken outside the
facility.
Repeat Finding from previous review in
February 2023
Physical Plant Yes[ ] No✓ Agency is in compliance with rule.
419-470-0020(2)(a) &(c) Buildings are smoke
free, clean and in good repair.
- The following youth rooms were
identified as needing cleaning.
- Yellow Room was cluttered and messy and
must be cleaned.
- Green Room was cluttered and messy and
must be cleaned.
Agency sent pictures of the Yellow Room and
Green Room after it was cleaned.
New Findings from Site Visit Comments
N/A No new findings were found during site visit.

Interview Summary
This writer interviewed one youth at the program during the unannounced site review. The youth interviewed is 14 years old and has
been in the program for 16 days. Youth reported that she gets along well with staff. She feels safe in the program and can
communicate her concerns and needs as necessary. Youth talks with her family on the phone. Youth enjoys skating and relaxing.
Youth does not like the food very much that the program provides. However, the youth does enjoy eating macaroni & cheese, Top
Ramen, and drinking smoothies. Youth shared that she gets plenty of snacks.
This writer interviewed the Executive Director, Clinical Director, and Program Director while at the program. The Executive Director
is working almost full time and is available four days a week. June 15th is the Executive Director's last day. The agency is
interviewing and scheduling more interviews for the Executive Director Position.
It was reported that the program is providing more structure and consistency when working with the youth. Staff are feeling
confident with working with the youth. Administration is modeling for staff on how to be more consistent when working with the
youth. Recently, administration fired two staff. The agency has scheduled a lot of interviews for open positions before and since the
two staff were recently let go. The Program Director stated his goal is to have some new trainings for staff. Currently, the agency
has two youth in the program and one in the hospital. The program is hoping to have two new youth move into the program soon.
Observations
At the Unannounced Inspection, Program Staff assisted with the walk-through of the program with Jorge Pelinski, ODHS Licensing
Coordinator. Staff were observed at the program during the inspection walk-through. The youth that were at the program appeared
to be at ease and comfortable in the environment. All areas of the program (inside and outside) where youth had access were
observed. The program, in general, appeared to be clean and in good repair. Medication was observed to be kept in locked
cabinets inaccessible to youth.

excerpt:
419-470-0020(2)(a) &(c) Buildings are smoke
free, clean and in good repair.
- The following youth rooms were
identified as needing cleaning.
- Yellow Room was cluttered and messy and
must be cleaned.
- Green Room was cluttered and messy and
must be cleaned.
Agency sent pictures of the Yellow Room and
Green Room after it was cleaned.
New Findings from Site Visit Comments
N/A No new findings were found during site visit.
N/A No new findings were found during site visit.


summary: License Renewals - 4 findings

raw_content:
Licensed Child Caring Agency Site Visit Report
Residential Care
Licensee: A Village for One Date of site visit: 2.4.2025
Executive Director: Lynn Renken Licensing Coordinator: Jorge Pelinski & Aubrey Kelly
Board Chairperson: Robert Edwards
Other Regulatory or Accrediting Agencies:
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): A Village for One – Anisa’s Place is a residential program serving clients who are identified as Commercially Sexually
Exploited Children (CSEC). The program places a great emphasis on providing a nurturing, safe and trauma-informed milieu that allows for healing
and growth.
Program type and services: A Village for One (Anisa’s Place) provides Behavior Rehabilitation Services (BRS) residential care, Individual mental
health counseling, drug and alcohol counseling, group mental health counseling, family counseling, education services, social and community
activities, access to medical, dental, and vision care, skills training, and job search/career development.
Capacity: 6
Age Range: 12-18
Funding sources: ODHS, Corporate and Foundation Grants, Fee-for-Service (Medicaid Billing), General Donation.
Contracts and sources for referrals: ODHS, Juvenile Justice System
Average length of stay: 4-5 months
Average daily population served: 4
P a g e 1 | 18
Form Rev. 1/2/2024
Number of children served annually: 12
Use of seclusion or restraint: Restraint – Mandt. System, Program does not utilize Seclusion.
Interviews:
At the Licensing Review, 1 youth was interviewed.
The following information was gained during the interview with the youth:
The youth interviewed is 14 years old and has been at the program for one year. This youth appreciates the staff and feels like the staff support is
the best thing about the program. This youth enjoys all the outings and especially anything related to roller-skating. Youth reports making phone
calls to people on contact list. Youth reported getting three meals a day and plenty of snacks. Youth reports that the program provides soap,
shampoo, toothpaste and other essentials as needed. Youth reported feeling comfortable with staff as well as feeling respected. Youth reported
feeling safe at the program.
The following information was gained during the interview with the staff:
Staff reported that the program would benefit from the Program Manager spending more time supporting the staff at the program. This staff also
reported more communication in general would benefit the team of staff.
Licensing coordinator followed up with management regarding feedback from youth and feedback from staff interviewed.
Observations: The youth were observed to be relaxed and comfortable in the milieu. The house in general was clean, organized and well
maintained. One of the youth bedrooms was observed to be cluttered and messy. The program staff have been working with the youth on cleaning
their room regularly.
Program Strengths: Per Program: We have strong community partnerships that allow our youth to have high level of access to diversity
experience, both in the house and in the community. The dedication of our core administrative and clinical staff allows us to overcome
various hurdles and challenges. Our ability to individualize our services to meet the needs of our youth. Ability to safety plan with our
youth and their teams to make a safe environment for them (e.g., have a discharge plan from day 1). Lastly, our goats!
Program Challenges: Per Program: Recruitment of direct care staff. On-call burden for the clinical staff. Provide continuous training and
mentoring to new and existing staff to handle crisis situations and behavioral challenges of residents. Keeping up with inflation as it
related to programmatic cost (e.g., grocery, gas) and personnel cost (e.g., salary).
P a g e 2 | 18
Form Rev. 1/2/2024
Changes that have occurred in the last 2 years: Per Program: We switched to 4 X 10s for Day and Swing shifts, providing greater
overlap between shifts We added a 6-hour 3rd -on shift to provide additional one-on-one supervision of residents We changed the THP
Clinician position to Residential Case Manager to provide increased day-to-day supervision and support to youth and staff, while
utilizing mental health services from our outpatient therapists and other external therapists.
Lawsuits: No lawsuits in the last two years per program.
Grievances and complaints filed in the last two years: No grievances and complaints in the last two years per program.
Corrective Actions and Timeframes: Please submit the following to verify compliance.
Within 45 days of receipt of this report (insert name of agency) 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 (Licensing Coordinator and email address).
Recommendations: Licensing does not have any recommendations regarding this review.
Exceptions: The program does not have any Exceptions currently.
Changes in License: No changes in the License.
Summary of Review
Program and Services
Yes No N/A Corrective Actions/Comments
419-400-0020 (2)
Program and services are in scope of license x
Governance of the Agency
Yes No N/A Corrective Actions/Comments
419-400-0040
(1)(a) Minimum of 5 board members x
(2)(f) Formally evaluate the exec. Director’s
x
performance annually
(2)(g) Approves annual budget x
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Form Rev. 1/2/2024
(2)(h) Obtain and review an annual
independent financial review or audit of x
financial records.
(2)(k) Written quality improvement program x
(2)(l) Meeting minutes x
Executive Director or Program Director
Yes No N/A Corrective Actions/Comments
419-400-0040
(3)(a) knowledge of requirements for
providing care and treatment appropriate to x
programs
(3)(g) Approval from BCU x
Installation and Use of Video Equipment
Used to Monitor or Record Children in
Yes No N/A Corrective Actions/Comments
Care
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
x
guardians, and children in care must be
informed about the intended use and
locations of the equipment.
Discipline, Behavior Management, and
Suicide Prevention Yes No N/A Corrective Actions/Comments
419-400-0150
(3) Agency uses appropriate and positive
methods of behavior management and
x
nationally recognized non-violent crisis
intervention
(3)(b)(C) Agency does not use chemical and
mechanical restraint (excluding medically x
necessary devices/prescriptions)
(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 The program does not use seclusion.
appropriately/consistent with policy
(4) Agency has adequate plan in place to
x
respond to suicidal behavior/warning signs
Contractors (if applicable)
Yes No N/A Corrective Actions/Comments
419-400-0120(6)
(a) Agency ensures the contractor meets the
requirements of this rule and Chapter 413 x
division 215
(b)(B) Contract includes the following: x
P a g e 4 | 18
Form Rev. 1/2/2024
(i) Services provided
(ii) Contractor fees
(iii) Disclosure of information from contractor
to agency
(iv) Lines of authority
(v) Adherence to rules, including background
check
(vi) Any liability of the agency for acts of the
contractor, rights of indemnity and limitations
on liability
Restraints and Involuntary Seclusion
Yes No N/A Corrective Actions/Comments
419-400-0180
(13)(d) Each child caring agency that
submits a report under this section shall
make its quarterly report available to the
x
public upon request at the Child Caring
Agency’s main office and on the child caring
agency’s website if applicable.
Supplemental Information Provided by
Yes No N/A Corrective Actions/Comments
CCA
Documents as indicated on the form titled Program did not submit their Tax Compliance Certificate.
“Renewal Licensing Required Documents”
Corrective Action
x
• Agency will submit Tax Compliance Certificate once received as part of their
Corrective Action Plan..
Documents as indicated on form titled Program did not submit their Tax Compliance Certificate.
“Required Financial Documents and
Information” x Corrective Action:
• Please see above regarding corrective action.
All required policies and procedures as
x
identified in the “Umbrella Rules”
All required policies and procedures as
x
identified in “Agency Type Specific Rules”
Physical Plant
Yes No N/A Corrective Actions/Comments
419-400-0090(3)(a) Foster Rights Posted (if
x
children in DHS custody)
419-400-0100(1) Sufficient safe space,
x
equipment, and office equipment
419-400-0230(12) License is posted in
x
common area at each facility
419-470-0020(2)(a) &(c) Buildings are
x
smoke free, clean and in good repair
P a g e 5 | 18
Form Rev. 1/2/2024
419-470-0020 (2)(d) Rooms are free of
x
harmful drafts, odors, and excessive noise
419-470-0020 (2)(e) Rooms are adequate in
x
size and arrangement
419-470-0020 (2)(f) System provides a
continuous supply of hot and cold water to x
taps located throughout the facility
419-470-0020 (2)(h) Building is well
ventilated and room temperature is within a x
normal comfort range
419-470-0030 (1) All parts of the facility
x
ensure the safety of children
Room and Space Requirements
Yes No N/A Corrective Actions/Comments
419-470-0030
(2) There is a separate living room or lounge x
area – 15 SF minimum per child
(5) There is a separate dining room with x
capacity for ½ of children in care and 15 SF
per child in care
(7) Laundry is separate from living, kitchen, x
and dining areas
(8) Separate storage areas are provided for x
food, kitchen supplies, utensils, clean linens,
soiled linens and clothing, cleaning supplies
and equip, poisons, chemicals, outdoor
recreational and maintenance equipment.
(Hazardous materials are properly labeled, in
original container and locked)
(9) Outdoor activity area is protected from x
vehicles and other hazards and of a size and
availability appropriate to the age and needs
of children in care
(11) Time-out rooms: Rooms used for time x The program does not utilize time-outs.
out or quiet time must have adequate space,
heat, light and ventilation and must not be
capable of locking.
Room and Space Requirements
Bedrooms Yes No N/A Corrective Actions/Comments
419-470-0030(3)
(a) Adequate furnishings and personal items x
(b) Separate from rooms used for dining,
x
living, laundry, kitchen, and storage
(c) Meet Oregon Fire Code Requirements x
(d) Be an outside room, with a window that
operates as designed. If the window is x
modified from its original design, the fire
P a g e 6 | 18
Form Rev. 1/2/2024
marshal must approve the modification and
indicate this room still meets applicable
Oregon Fire Code.
(d) Ceiling at least 90 inches x
(e) Minimum 60 SF per occupant x
(f) No more than 25 if dorm style x
(g) Permanently wired fixtures x
(h) Window covering x
Room and Space Requirements
Bathrooms Yes No N/A Corrective Actions/Comments
419-470-0030(4)
(a)(A)&(B) 1:8 ratio for toilets and sinks x
(a)(D) Hot and cold running water, soap, and
x
approved hand drying options
(a)(E) 1:10 ratio for shower or bathtub x
(a)(E) Individual privacy x
(a)(F) Window covering x
(a)(G) Permanently wired fixtures x
(a)(H) Adequate ventilation x
(b)&(c) Wooden racks on floors are
prohibited and impervious shower mats are
x Program does not use wooden racks.
disinfected & dried daily be in good condition
and free of mold
Room and Space Requirements
Kitchen Yes No N/A Corrective Actions/Comments
419-470-0030(6)
(a) Used exclusively for storage, food
preparation, dishwashing, and activities
x
related to eating and food preparation
activities
(b) Walls, floors are easily cleanable x
(c) Equipment and utensils are easily
x
cleanable, durable, nontoxic, and kept clean
(e) Equipment is easy to clean beneath,
x
between and behind
Furnishings and Personal Items
Yes No N/A Corrective Actions/Comments
419-470-0040
(1) There is a bed with frame, x
(1)(b) clean mattress in good condition,
x
with a minimum thickness of five inches
(1)(c) a pillow in good condition x
(1)(d) a private dresser, closet, or similar
storage area for personal belongings that x
is readily accessible
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Form Rev. 1/2/2024
(2) Linens are in good repair. There is a
waterproof mattress cover or mattress.
x
Linens are appropriate and towels and
washcloths are provided
(3) Bedding is changed weekly or when
x
soiled
(4)&(5) Personal hygiene supplies and
x
appropriate clothing are provided
Food Services
Yes No N/A Corrective Actions/Comments
419-470-0070
(1)(a) Meals are arranged daily, consistent
with normal mealtimes that occur during the
x
hours of operation and provide snacks
between mealtimes
(1)(b) Menus are prepared in advance in
accordance with USDA guidelines, provide a
x
variety of foods and are adjusted for
seasonal changes including snacks
(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
commercial suppliers (exception of fruits &
vegetables), unpasteurized juice is x
prohibited, and only Grade A pasteurized
and fortified milk in appropriate container.
Residential Care Safety
Yes No N/A Corrective Actions/Comments
419-470-0080
(2) Written emergency plan that includes x
(a) Identifying the types of emergencies most
likely to happen where the residential care x
agency is located
(b) Identifying a place to meet for each type
x
of emergency identified
(c) Identifying an alternate shelter if
x
necessary
(d) Ensuring access to necessary
x
medications or medical equipment
(e) How to help each child in care recover
x
after a disaster
(3) Telephone numbers for local police, fire
department, poison control, after hours x
medical advice and other appropriate
P a g e 8 | 18
Form Rev. 1/2/2024
emergency numbers must be posted near all
telephones.
(4) Operative flashlights sufficient in number
x
are readily available to staff
(5)(a) Evacuation drill occurs monthly under
varying conditions, is retained 2 years and
contains:
(A) identify of person conducting drill
(B) date & time
(C) notification method x
(D) staff participating
(E) # of children & staff evacuated
(F) special conditions simulated
(G) problems encountered
(H) time to complete
Umbrella Safety
Yes No N/A Corrective Actions/Comments
419-400-0200
(5)(b) Vehicle has insurance policy, is smoke x
free, safe operating condition, and has first
aid kit and fire extinguisher 2-A:10-BC
(1)(b)(A) Each vehicle used to transport a x 1 out of 3 vehicles inspected by licensing did not have a fire extinguisher and a safety kit.
child in care must be: properly registered,
covered by an insurance policy in full force Corrective Action:
and effect, maintained in safe operating
condition, and smoke-free. Program will ensure the vehicle has a fire extinguisher and safety kit and submit this as
part of their Corrective Action Plan.
(3) If a child-caring agency has a swimming x Program does not have access to a swimming pool on the premises.
pool on the premises that is accessible to
children in care or if a child-caring agency
plans to have children in care engage in
swimming, the child-caring agency must
have and adhere to policies and procedures
that address, at a minimum, providing
disclosures and obtaining consents,
assessing swimming ability of children in
care, and ensuring the safety of pool access.
(4)(a) The program protects children from x
potentially harmful items and materials.
(4)(b) Direct supervision of children who do x Program does not have youth in the program that are not physically able to adjust and
not have the ability to adjust and control control water temperature.
water temperature
(4)(c) Light fixtures have protective covers x
unless designed to be used without one
Medication
Yes No N/A Corrective Actions/Comments
419-470-0100
P a g e 9 | 18
Form Rev. 1/2/2024
(3)&(7)(e) Medications have a prescription
and are stored in the original container with x
prescription label
(4)&(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 professional. A written x
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
x
locking mechanisms. This does not apply to
Naloxone.
(8) Medications are disposed in accordance
x
with state and federal law
(9) Written record of the disposal of
medications is maintained and includes:
(a) description and amount
(b) name x
(c) reason
(d) method
(e) staff & witness signature
(10) Written record of the administration of
medication includes:
(a) name
(b) description
(c) dates and times
(d) missed doses x
(e) medication disposed
(f) method of administration
(g) ID of person administering
(h) possible adverse reactions
(i) medication taken outside facility
Extracurricular, Enrichment, Cultural &
Social Activities Yes No N/A Corrective Actions/Comments
419-470-0110
(2) Children have ongoing opportunities to x
participate in at least one age-appropriate or
developmentally appropriate activity
Minimum Staffing Requirements
Yes No N/A Corrective Actions/Comments
419-470-0130
(1)&(2) Supervision is adequate for the type x
of program, location, age and type of
P a g e 10 | 18
Form Rev. 1/2/2024
children, ability of supervisor to respond,
electronic back-up systems.
Minimum ratios are maintained:
Under 30 months of age: 1:4
30 months to ˃ 6 years or non-ambulatory:
1:6
Ages 6 and older: 1:7
Overnight (staff awake)
1:10
(4)(a) When one staff on duty, there is x
additional staff immediately available with
max response time of 30 minutes
(5) There is at least one on-site employee x
authorized to apply the reasonable and
prudent parent standard
Sleeping Arrangements
Yes No N/A Corrective Actions/Comments
419-470-0140
(1) Children are in separate bedrooms than x
adults, unless parent and child, or there is
written approval from guardian/parent and
licensing coordinator
(2) There is adequate supervision of children x
when sleeping
(3) When assigning bedrooms a residential x
care agency must consider all of the
following:
(a) Chronological age
(b) Developmental age
(c) Gender identity
(d) Personal history, including medical,
mental health, behavioral health, and past
adverse experiences including any physical
or sexual abuse
Personnel Files
Yes No N/A Corrective Actions/Comments
419-400-0120
Staff Name/Position x
(3)(g) Date of Hire x
(3)(a) record of education, training, and
x
previous employment
(1)(b) & (3)(b) reference checks completed
x
and documented
P a g e 11 | 18
Form Rev. 1/2/2024
(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
Requirements (30 days) Yes No N/A Corrective Actions/Comments
419-400-0120(4)
(a) Agency policies and procedures x
(b) Ethical and professional guidelines
(c) Suicide prevention and intervention x
(d) Attributes of population served x
(e) & (5)(a) to (c) Mandatory reporting that
includes:
(a) legal definition of child abuse in ORS
418.257 and 419B.005 x
(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 (Prior to working alone and
Yes No N/A Corrective Actions/Comments
within 30 days)
419-470-0120(1)
(a) Discipline and behavior management
including de-escalation, crisis prevention,
positive behavior management, and x
disciplinary techniques that are non-punitive
in nature
(b) CPR and First Aid sufficient to retain a
x
current certification
(c) Universal precautions and hygiene x
(d) Application of the reasonable and
x
prudent parent standard
(e) Training on the agency’s policy on
suicide prevention and suicide risk x
assessment tool
Crisis Intervention Training Standards
Yes No N/A Corrective Actions/Comments
and Certification
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Form Rev. 1/2/2024
419-400-0160(4) (as applicable)
(a)Complete a minimum of 12 hours of initial
training in person from a certified instructor,
including but not limited to a minimum of six
hours of training focused on positive
x
behavior support, nonviolent crisis
intervention and other methods of
nonphysical intervention to support children
in care during a crisis
(d) Receive a certificate that states:
(A) The dates during which the certification
is current
(B) The type of restraint which the individual
is certified to perform if applicable
(C) The type of training the individual is
certified to conduct if applicable x
(D) Any special endorsements earned by the
individual
(E) The level of training
(F) The name of the certified instructor who
conducted the training and administered the
assessment of proficiency.
(e) A certification issued:
(A) Must be personal to the individual
certified by the training provider x
(B) May be valid for no more than two years
with recertification
Ongoing Training Yes No N/A Corrective Actions/Comments
419-470-0070(2)(b) Employees who handle
food served to children have a valid food x
handler’s card
419-400-0200 (1) 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)
419-470-0120 (2)(a) Environmental
x
emergencies
419-470-0120 (2)(b) Universal Precautions x
419-470-0120 (2)(c) Discipline and Behavior
x
Management
P a g e 13 | 18
Form Rev. 1/2/2024
419-470-0120 (2)(d) Agency’s policy on
x
suicide prevention and risk assessment tool
419-470-0120 (3) Staff providing direct care
must maintain current CPR/First Aid x
certification
419-470-0120 (4) Designated staff
authorized to apply reasonable and prudent
x
parent standard are 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 and 419B.005 x
(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
x
intervention training) from a certified
instructor on an annual basis
Comments:
Children’s Records Yes No N/A Corrective Actions/Comments
Health Services
419-470-0090
(2) Medical history obtained within 30 days
(significant findings, current immunizations,
history of surgical procedures-health issues- x
injuries, allergies, dental, vision, hearing,
behavioral health, and physician orders)
(4)(a) to (f) Medical exams (3 in first year of
life, 2,4,6,9,14) x
(g) Have a physical examination within the
first 60 days after admission of a child in x
care. Documentation of a physical
P a g e 14 | 18
Form Rev. 1/2/2024
examination having occurred within the
calendar year will meet this requirement.
Consents
Yes No N/A Corrective Actions/Comments
419-470-0160(1)
(a) Provide routine and emergency medical
x
care
(b) Use the discipline and behavior
x
management system
(c) Use restraint or seclusion (if applicable).
Must specify the reasons for the intervention x Program utilizes Mandt Training.
and how staff are trained and supervised
(d) Restrict contact with persons outside of
x
the agency
(e) Allow access as defined in 419-400-0230
x
& 0240
(f) Impose a dress code x
(g) Apply the reasonable and prudent parent
x
standard
Disclosures
419-470-0160(2) Yes No N/A Corrective Actions/Comments
Parent/guardian has acknowledged in writing:
(a) Information regarding personal or room
searches and protocols for confiscation of x
contraband
(b) Statement of Rights of Children and
x
Parents/Guardians
(c) Any policies and procedures upon request x
Authorizations
Yes No N/A Corrective Actions/Comments
419-470-0160(3)
(a) Disclose or exchange information with
x
others
(b) Child specific visitors x
(c) Visitation resources are pre-approved x
(d) Activity specific authorizations are pre-
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
419-400-0190(1) Yes No N/A Corrective Actions/Comments
Summary sheet contains the following:
(a)The name, gender, date of birth, religious
x
preference, and previous address
(b) Name and location of previous and
x
current school
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Form Rev. 1/2/2024
(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
Yes No N/A Corrective Actions/Comments
419-470-0170(2)
(b) Intake document is completed the date
child accepted into care (emergency x
placement 48 hours)
(d) Assessment is completed within 30 days
and contains relevant historical info., current
behavioral observations, identified need for x
services, and how agency will provide
services
(e) (A)&(B) Service plan within 60 days
(parent, guardian and child actively involved).
Describes how child’s issues will be x
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
Yes No N/A Corrective Actions/Comments
419-470-0170(3)
(a) Services are documented, progress
x
toward 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 x
(D)Summary of the child’s participation in the
program and progress achieved
(E)Results of evaluations
(F)Recommendations regarding services
(G)Discharge destination
P a g e 16 | 18
Form Rev. 1/2/2024
(e) Follow up services x
(f) Incident Reports x
Records Relating to Restraint &
Yes No N/A Corrective Actions/Comments
Involuntary Seclusion
419-400-0180 (12) Records x
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. x
The child caring agency shall provide the
notice upon the child in care’s admission and
at least two times each year thereafter.
The agency is proving information to children in care relating to Restraint & Involuntary
Seclusion. Some required details were missing from the information provided to children
419-400-0190(1) Information provided to in care. This has been corrected.
children in care relating to Restraint & x
Involuntary Seclusion Corrective Action:
• Agency will submit this as part of their Corrective Action Plan.
Financial Records
Yes No N/A Corrective Actions/Comments
419-470-0170(4)
Records contain date, amount, source,
x
purpose, signatures
Personal Possessions Records
Yes No N/A Corrective Actions/Comments
419-470-0170 (5)
Individual written inventory of all personal
possessions is maintained and updated as x
needed
Records and Documentation
Yes No N/A Corrective Actions/Comments
419-400-0140
(1) Stored safely x
(2) Permanent, legible, dated, and signed x
(3)&(4) Uniform in organization, readily
identifiable and accessible, current, and
x
complete, containing all required info. No
eraser tape or white out.
(7) Permanent registry for each child
includes:
Name
Gender
x
Birth date
Names, addresses of parents or guardians
Dates of admission
Placement upon discharge
P a g e 17 | 18
Form Rev. 1/2/2024
Comments:
Licensing Coordinator’s Signature: ________________________ Date: ___2_-_1_3_-2_0_2_5_________
Manager Review: ______________________________________ Date: __2_-1__3_-2_0_2__5_ _______
P a g e 18 | 18
Form Rev. 1/2/2024

report_type: License Renewals

board_chairperson: Robert Edwards

licensing_coordinator: Jorge Pelinski & Aubrey Kelly

program_description:
A Village for One - Anisa's Place is a residential program serving clients who are identified as Commercially Sexually
Exploited Children (CSEC). The program places a great emphasis on providing a nurturing, safe and trauma-informed milieu that allows for healing
and growth.

program_services:
A Village for One (Anisa's Place) provides Behavior Rehabilitation Services (BRS) residential care, Individual mental
health counseling, drug and alcohol counseling, group mental health counseling, family counseling, education services, social and community
activities, access to medical, dental, and vision care, skills training, and job search/career development.
Capacity: 6
Age Range: 12-18

contracts_and_referrals: ODHS, Juvenile Justice System

average_length_of_stay: 4-5 months

use_of_seclusion_or_restraint: Restraint - Mandt. System, Program does not utilize Seclusion. Interviews: At the Licensing Review, 1 youth was interviewed. The following information was gained during the interview with the youth: The youth interviewed is 14 years old and has been at the program for one year. This youth appreciates the staff and feels like the staff support is the best thing about the program. This youth enjoys all the outings and especially anything related to roller-skating. Youth reports making phone calls to people on contact list. Youth reported getting three meals a day and plenty of snacks. Youth reports that the program provides soap, shampoo, toothpaste and other essentials as needed. Youth reported feeling comfortable with staff as well as feeling respected. Youth reported feeling safe at the program. The following information was gained during the interview with the staff: Staff reported that the program would benefit from the Program Manager spending more time supporting the staff at the program. This staff also reported more communication in general would benefit the team of staff.

changes_in_license: No changes in the License.

excerpt:
Documents as indicated on the form titled
“Renewal Licensing Required Documents” Program did not submit their Tax Compliance Certificate.
Corrective Action
• Agency will submit Tax Compliance Certificate once received as part of their
Corrective Action Plan..

excerpt:
Documents as indicated on form titled
“Required Financial Documents and
Information” Program did not submit their Tax Compliance Certificate.
Corrective Action:
• Please see above regarding corrective action.

excerpt:
(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 effect, maintained in safe operating
condition, and smoke-free. 1 out of 3 vehicles inspected by licensing did not have a fire extinguisher and a safety kit.
Corrective Action:
Program will ensure the vehicle has a fire extinguisher and safety kit and submit this as
part of their Corrective Action Plan.

excerpt:
Information provided to
children in care relating to Restraint &
Involuntary Seclusion The agency is proving information to children in care relating to Restraint & Involuntary
Seclusion. Some required details were missing from the information provided to children
in care. This has been corrected.
Corrective Action:
• Agency will submit this as part of their Corrective Action Plan.


facility_name: ADAPT - Deer Creek

summary: Unannounced - 05/19/2022

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Licensee: Adapt – Deer Creek
Executive Director: Dr. Gregory Brigham
Program Director(s): Ronald Farley
Date of Unannounced: 5/19/2022
Licensing Coordinator: Mary Torres
Other Regulatory or Accrediting Agencies: Oregon Health Authority (OHA)
Purpose: Per OAR 413-215-0101 (1) (b) Children’s Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Comments
Findings
Further Action
Needed
Program had no previous findings from the Yes☐ No☐
last Licensing site visit
Yes☐ No☐
Yes☐ No☐
1
(rev. 200115)
New Findings from Site Visit Comments
Program had no findings from this Licensing
site visit.
Interview Summary
Individual conversations were held with Deer Creek’s Program’s Director, Lead Counselor, Intake Coordinator and current residents.
The program’s current census includes three, male residents. The second floor of the program where female residents are housed has been unoccupied for
the past 5 months as the program does not have enough staff to supervised both floors. During COVID, the average population was 6 youth. Current referrals
are reflecting high acuity and the program is unable to serve the majority of the youth being referred. Primary referral sources continue to be from Adapt
outpatient services, Linn and Curry Counties and parents. Despite low census, there are no external pressures to increase population from the larger parent
company.
School continues to take place on campus. The program’s school contract is scheduled to be renegotiated soon. The program will be asking for cameras to be
installed on the back side of the school. This would allow the monitoring of the gazebo and garden area.
Family visits are still occurring on site. Families are able to visit their child for an hour at a time.
The Adapt parent program is still working towards the development of a “recovery campus”. This 40 acre campus will provide detox services to adults and
youth. Two to four beds will be earmarked for adolescents.
In speaking to the residents, all youth report only positive things about the program. All youth express liking their current placement and find staff to be helpful
and supportive. Strengths for the program include helping youth become clean and sober, that staff are willing to help youth when struggling, the program
helps youth establish and use good coping skills and staff seeing potential in all youth. No areas of weakness for the program were identified.
2
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 200115)
Observations
COVID precautions are still in place with staff masking.
The facility characteristically was found clean and well maintained.
Youth were in school during the tour of the facility and then were observed working in the program’s garden under the supervision of staff. Youth were
positively engaged with each other and the counselor working alongside them.
Corrective Actions and Timeframes:
Please submit the following to verify compliance.
Within 45 days of receipt of this report Adapt Deer Creek 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 Licensing Coordinator email address or sent by regular mail to the following address:
Department of Human Services
Children’s Care Licensing Program
Attn: Mary Torres
201 High St. SE Suite 500
Salem, OR 97301
Licensing Coordinator’s Signature: ________________________ Date: _ _ _ _6_/1_0_/_2_0_2_2_ _______
Manager Review: ______________________________________ Date: _ _6_-_8_-2__0_2_2_________
3
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 200115)

agency_name: ADAPT

licensee: Adapt - Deer Creek

executive_director: Dr. Gregory Brigham

program_director: Ronald Farley

licensing_coordinator: Mary Torres

other_regulatory_agencies: Oregon Health Authority (OHA)

purpose:
Per OAR 413-215-0101 (1) (b) Children's Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Comments
Findings
Further Action
Needed
Program had no previous findings from the Yes[ ] No[ ]
last Licensing site visit
Yes[ ] No[ ]
Yes[ ] No[ ]
1

New Findings from Site Visit Comments
Program had no findings from this Licensing
site visit.
Interview Summary
Individual conversations were held with Deer Creek's Program's Director, Lead Counselor, Intake Coordinator and current residents.
The program's current census includes three, male residents. The second floor of the program where female residents are housed has been unoccupied for
the past 5 months as the program does not have enough staff to supervised both floors. During COVID, the average population was 6 youth. Current referrals
are reflecting high acuity and the program is unable to serve the majority of the youth being referred. Primary referral sources continue to be from Adapt
outpatient services, Linn and Curry Counties and parents. Despite low census, there are no external pressures to increase population from the larger parent
company.
School continues to take place on campus. The program's school contract is scheduled to be renegotiated soon. The program will be asking for cameras to be
installed on the back side of the school. This would allow the monitoring of the gazebo and garden area.
Family visits are still occurring on site. Families are able to visit their child for an hour at a time.
The Adapt parent program is still working towards the development of a "recovery campus". This 40 acre campus will provide detox services to adults and
youth. Two to four beds will be earmarked for adolescents.
In speaking to the residents, all youth report only positive things about the program. All youth express liking their current placement and find staff to be helpful
and supportive. Strengths for the program include helping youth become clean and sober, that staff are willing to help youth when struggling, the program
helps youth establish and use good coping skills and staff seeing potential in all youth. No areas of weakness for the program were identified.
2

Observations
COVID precautions are still in place with staff masking.
The facility characteristically was found clean and well maintained.
Youth were in school during the tour of the facility and then were observed working in the program's garden under the supervision of staff. Youth were
positively engaged with each other and the counselor working alongside them.