state: OR

facility_name: Rising Light

summary: Unannounced - 18 findings

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Licensee: Douglas County Juvenile Department
Executive Director: Aric Fromdahl
Assistant Director: Rob Salerno
Date of Unannounced: 5/22/23
Licensing Coordinator: Mary Torres
Other Regulatory or Accrediting Agencies: Oregon Department of Human Services (ODHS) Child Welfare – Treatment Services, Oregon Health
Authority (OHA), Joint Commission
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 from 2022 Review Repeat Comments
Findings
Further Action
Needed
All required policies and procedures as Yes☐ No A revised policy meeting Licensing Rule was submitted to Licensing on 7/26/22.
identified in the “Umbrella Rules”
The policy submitted to cover Conflict of
Interest, Policy # A-10, does not meet
Licensing Rule.
CORRECTIVE ACTION: Create a Conflict-of-
Interest policy that meets Licensing Rule.
All required policies and procedures as Yes☐ No A revised policy meeting Licensing Rule was submitted to Licensing on 7/26/22.
identified in the “Umbrella Rules”
The submitted Youth and Parent/Guardian
Rights (Policy #CTS-8) is missing required
items.
1 |P ag e
Form Rev. 01/23/2023
CORRECTIVE ACTION: Revise Policy #CTS-
8 that is reflective of the related Licensing
Rule.
All required policies and procedures as Yes☐ No A revised policy meeting Licensing Rule was submitted to Licensing on 7/26/22.
identified in the “Umbrella Rules”
The existing Grievance Procedure (Policy #
CTS-9) requires revision to meet compliance.
CORRECTIVE ACTION: Revise Policy #
CTS-9 that is reflective of the related
Licensing Rule.
All required policies and procedures as Yes☐ No A revised policy meeting Licensing Rule was submitted to Licensing on 9/6/22.
identified in the “Umbrella Rules”
The existing policy related to mandatory child
abuse reporting (Policy# A-17) requires
revision to meet compliance.
CORRECTIVE ACTION: Revise the existing
policy that is reflective of the related Licensing
Rule.
All required policies and procedures as Yes☐ No A revised policy meeting Licensing Rule was submitted to Licensing on 7/26/22.
identified in the “Umbrella Rules”
A policy regarding documenting and reporting
critical events was not submitted for review.
CORRECTIVE ACTION: Submit a copy of
this policy. If one does not exist, generate this
policy as outlined by the related Licensing
Rule.
All required policies and procedures as Yes☐ No A revised policy meeting Licensing Rule was submitted to Licensing on 11/15/22.
identified in the “Umbrella Rules”
Submitted policy regarding personnel (Policy#
A-12) requires revision to meet compliance.
CORRECTIVE ACTION: Revise Policy# A-12
that is reflective of the related Licensing Rule.
All required policies and procedures as Yes☐ No A revised policy meeting Licensing Rule was submitted to Licensing on 7/26/22.
identified in the “Umbrella Rules”
2 |P ag e
Form Rev. 01/23/2023
The policy submitted regarding privacy
(Policy# A-11) is related to employees and not
youth and their families.
CORRECTIVE ACTION: Submit privacy
policy for youth and their families for review. If
a policy does not exist, create one reflective of
the related Licensing Rule.
All required policies and procedures as Yes☐ No A revised policy meeting Licensing Rule was submitted to Licensing on 9/1/22.
identified in the “Umbrella Rules”
The existing Behavior Management Policy
(Policy # CTS-1) requires revision to meet
compliance.
CORRECTIVE ACTION: Revise Policy # CTS
-1 that is reflective of the related Licensing
Rule.
All required policies and procedures as Yes☐ No A revised policy meeting Licensing Rule was submitted to Licensing on 8/23/22.
identified in the “Umbrella Rules”
Youth Searches policy (Policy# YC-1)
requires revision to meet compliance.
CORRECTIVE ACTION: Revise Policy# YC-1
that is reflective of the related Licensing Rule.
All required policies and procedures as Yes☐ No A revised policy meeting Licensing Rule was submitted to Licensing on 9/1/22.
identified in the “Umbrella Rules”
Use of Restraint and Seclusion policy (Policy#
CTS-22) requires revision to meet
compliance.
CORRECTIVE ACTION: Revise Policy# CTS-
22 that is reflective of the related Licensing
Rule.
413-215-0511(2)(a) &(c) Buildings are Yes☐ No Repairs and a plan regarding the towels were made as per the program’s Corrective Action
smoke free, clean and in good repair Plan (CAP) submitted in writing on 7/26/22 to Licensing. Repairs and plan related to the
towels were verified during this 2023 Unannounced site visit.
Room #3 at Rising Light has profanity written
on walls.
Room #4 at River Rock has multiple holes in
the wall.
Room #2 at River Rock door and door frame
damaged
3 |P ag e
Form Rev. 01/23/2023
River Rock has soaked towels outside shower
stall as makeshift bathmat
Bathroom at River Rock has a hole in the wall
CORRECTIVE ACTION:
Wipe clean or paint over profanity.
Repair holes in the walls.
Replace or repair door and door frame
Develop a plan where towels are picked up
from the floor to avoid saturated towels from
being left on floors for extended
periods of time.
Repair hole in wall in bathroom
413-215-0511(2)(h) Building is well Yes☐ No The program verified in their written Corrective Action Plan submitted to Licensing on
ventilated and room temperature is within a 7/26/22, that all room temperatures are functioning normally. Any reported or known
normal comfort range variances in temperature are reported to Building and Facilities for repair. During the
program’s 2023 Unannounced site visit, tour of the building and this specific room did not
Room #10 at River Rock noticeably cool result in any temperature concerns.
during the facility’s tour.
CORRECTIVE ACTION: Assess youth’s
comfort level with the room’s temperature and
evaluate what maybe causing the noticeable
difference in room temperature to ensure a
normal comfort range.
Room and Space Requirements Yes☐ No A window exception was submitted to Licensing on 7/26/22 and granted by Licensing for
Bedrooms 413-215-0516(3) (c) Outside room the next Licensing period (2022-2024).
with window allowing
egress from building
Bedrooms at River Rock and Rising Light
have either no or fixed windows that require
an exception from Licensing.
CORRECTIVE ACTION: Submit new window
exception for this next licensing period (2022-
2024).
Room and Space Requirements Yes☐ No The program’s Corrective Action Plan submitted on 7/26/22 documents that a work order to
Bathrooms 413-215-0516(4) install ventilation was submitted to Building and Facilities. It was determined that the
(a)(H) Adequate ventilation bathroom already had a supply and return air system. This system was verified during this
2023 Unannounced visit.
REPEAT FINDING from 2021 Unannounced
Visit - Bathroom at River Rock continues not
to have a source of ventilation.
4 |P ag e
Form Rev. 01/23/2023
CORRECTIVE ACTION: Address lack of
ventilation during the facility’s current
remodel.
Safety – Transportation 413-215-0541 Yes☐ No The program’s Corrective Action Plan submitted to Licensing on 7/26/22 documented
(5)(b) Vehicle has insurance policy, is smoke requested repairs and missing items were obtained. During this 2023 Unannounced visit,
free, safe operating condition, and has first aid the repairs to the black Impala was verified. One of the vans is no longer used to transport
kit and fire extinguisher 2-A:10-BC youth and the other van was off site at the time of the visit.
Black Impala (without cage) – driver’s seat
has no back cover
15 passenger van has no 1st aid kit and
padlock key to emergency box is missing
14 passenger van 2021 has expired
registration
CORRECTIVE ACTION: Make necessary
repairs to the driver’s seat in the black Impala.
Ensure that the 15-passenger van has a 1st
aid kit and that a lock to the padlock is placed
on the van’s key chain. Renew the registration
for the 2021 14 passenger van. Place
insurance and accident packet in each
vehicle.
Medication 413-215-0551(10) Written record Yes☐ No As per the submitted Corrective Action plan on 7/26/22, all staff were reminded/coached on
of the administration of medication includes: the importance of accurate medication documentation.
(d) missed doses
Medication Administration Records (MARs)
reviewed at Rising Light, and River Rock
reflected several times where missed
medication was not appropriately
documented.
CORRECTIVE ACTION: Determine if the
missed documentation is related to a specific
staff member and follow up with additional
training. Remind all staff the
importance of medication documentation.
Personnel Files 413-215-0061 (3)(f) Record of Yes☐ No☐ The program’s Corrective Action Plan submitted on 7/26/22 documents Administrative
personnel actions Managers being reminded to file all completed performance evaluations in their respective
employee files. Compliance in this area will be verified in a subsequent site visit.
Four out of the five personnel files reviewed
did not document the completion of annual
evaluations.
5 |P ag e
Form Rev. 01/23/2023
CORRECTIVE ACTION: Ensure that annual
performance evaluations are completed and
maintained in their respective
personnel files from this point forward.
New Employee Orientation – Umbrella Yes☐ No☐ The program acknowledges that not meeting compliance in this area is a result of a
Requirements (30 days) deficiency in the documentation and storage of training records. New employee training is
413-215-0061(4) done individually without the consistency of single trainers due to previous COVID
(a) Agency policies and procedures restrictions that has directly affected appropriate training documentation. The program is
(b) Ethical and professional guidelines exploring a change in the existing training database to reduce multiple persons accessing
(c) Organizational lines of authority and storing information. New hire training checklists have been created to ensure that each
(d) Attributes of population served employee is receiving required training. Compliance in this area will be verified in a
(e) & (5)(a) to (c) Mandatory reporting subsequent site visit.
(f) Privacy laws
(g) Emergency procedures
New Employee Orientation for three staff
members could not be verified during the
audit of personnel files.
CORRECTIVE ACTION: Submit a plan as to
how new employee training will be provided
and appropriately documented from this point
forward.
Ongoing Training Yes☐ No☐ The program acknowledges that not meeting compliance in this area is a result of a
413-215-0541(5)(a) Employees transporting deficiency in the documentation and storage of training records. The program is exploring a
children have: current driver’s license, change in the existing training database to reduce multiple persons accessing and storing
insurance, trained in emergency procedures information. The program also plans to send annual training reminders. Compliance in this
and behavior management, and training for area will be verified in a subsequent site visit.
15+ passenger vans if applicable)
413-215-0556(2)(a) Environmental
Emergencies
413-215-0556(2)(b) Universal Precautions
413-215-0556(2)(c) Discipline and Behavior
Management
413-215-0061(5) Mandatory reporting
(annually)
Four out of five personnel files did not reflect
the completion of required ongoing training in
these areas.
CORRECTIVE ACTION: Submit a plan as to
how this training will be provided and
appropriately documented from
6 |P ag e
Form Rev. 01/23/2023
this point forward.
Children’s Records Health Services Yes☐ No☐ As per the program’s Corrective Action Plan dated 7/26/22, the documentation of age-
413-215-0546 (2)(e) Documentation of age- appropriate instruction is now included in the program’s Assessment and Evaluation
appropriate instruction – pregnancy document. Compliance in this area will be verified in a subsequent site visit.
prevention, nutrition, prevention of HIV &
AIDS, and prevention and treatment of
sexually transmitted disease
Youth files reviewed do not reflect the
documentation of age-appropriate instruction.
CORRECTIVE ACTION: Develop a
procedure where age appropriate
instruction is documented in the youths’ files
from this point forward.
Consents 413-215-0576(1) Yes☐ No☐ As per the program’s Corrective Action Plan submitted on 7/26/22, these required consents
(e) Allow access as defined in 413- have been added to their intake paperwork. Compliance in this area will be verified in a
215-0091 & 0101 subsequent site visit.
(f) Impose a dress code
(g) Apply the reasonable and prudent
parent standard
Consent allowing access could not be located
in the youth files.
Consent imposing a dress code could not be
located in the youth files.
Consent applying reasonable and prudent
parent standard could not be located in the
youth files.
CORRECTIVE ACTION: Add required
consents to intake packet.
Disclosures 413-215-0576(2) Parent/guardian Yes☐ No☐ As per the program’s Corrective Action Plan submitted on 7/26/22, these required
has acknowledged in writing: disclosures have been added to their Program and Youth Handbook. Compliance in this
area will be verified in a subsequent site visit.
(a) Information regarding personal or room
searches and protocols for confiscation of
contraband
(c) Any policies and procedures upon
request
7 |P ag e
Form Rev. 01/23/2023
Disclosure regarding personal and room
searches and protocols for confiscation of
contraband could not be located in the youth
files.
Disclosure stating that policies and
procedures will be provided upon request
could not be located in the youth files.
CORRECTIVE ACTION: Add required
disclosures to intake packet.
Authorizations 413-215-0576(3) (d) Activity Yes☐ No☐ As per the program’s Corrective Action Plan submitted on 7/26/22, this required
specific authorizations are preapproved authorization will be obtained and kept in the respective youth files moving forward.
to allow children to participate in Compliance in this area will be verified in a subsequent site visit.
potentially hazardous activities, including but
not limited to using motorized yard
equipment, swimming, and horseback riding.
Two out the five youth files reviewed did not
have activity specific authorizations.
CORRECTIVE ACTION: Ensure that this
authorization is obtained and kept in the
respective youth file from this point
forward.
413-215-0526 New Facility or Remodel Yes☐ No The program submitted requested floor plan via email on 12/22/22.
(Technical Amended 01/13/20)
(1) Building plans.
(a) A residential care agency must submit to
the Department for approval a set of plans
and specifications for each building used for
children in care operated by the residential
care agency
River Rock was recently renovated.
CORRECTIVE ACTION: Submit a copy of
River Rock’s renovated floor plan
8 |P ag e
Form Rev. 01/23/2023
New Findings from Site Visit Comments
No new findings identified
Interview Summary
During this unannounced site visit conversations were held with the program’s Residential Referral and Admissions Coordinator, River Rock’s Program
Manager and the program’s Assistant Director.
The program continues to receive a steady flow of referrals with an increase of voluntary placement requests. Staffing continues to ebb and flow. Despite a
differential pay increase, swing shift remains a difficult shift to keep fully staffed. Census remains moderately low with 8 youth at River Rock and 6 youth in
Rising Light. The program recently completed their accreditation review by The Joint Commission and did well. This year’s evaluator understood the
program’s service scope and was focused on the treatment and behavioral piece of the daily work. River Rock had recent maintenance on the building’s
sump pump. A malfunction in this equipment left the laundry room and one of the facility’s bathrooms temporarily out of service. Laundry was taken to two
nearby buildings to be washed, Detention and Rising Light.
An available youth from River Rock was interviewed. All youth from Rising Light were off campus, attending school. The youth interviewed shared two
scenarios that left them feeling unsafe during their stay at both Rising Light and River Rock involving staff members. These concerns were reported to the
Child Abuse Hotline and closed at screening. Given the youth’s disclosure of feeling unsafe in combination with the youth’s reservation in speaking freely, this
youth interview was brief. The youth was able to highlight no push button showers as a program positive. Changes that the youth would suggest included
making River Rock feel more like a home by adding warm lighting and rugs. It was also suggested that there be more fresh produce and variety in the meals
being offered. The youth is looking forward to more promised summer activies that staff have mentioned as the school year draws to a close.
Observations
Tours of both buildings did not produce any physical findings. The remodel at River Rock is in the final stages. The facility’s capacity increased from 10
bedrooms to 14 individual bedrooms.
9 |P ag e
Form Rev. 01/23/2023
Corrective Actions and Timeframes:
Please submit the following to verify compliance.
Within 45 days of receipt of this report Douglas County Juvenile Department 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 Mary Torres at mary.torres@odhsoha.oregon.gov.
Licensing Coordinator’s Signature: ________________________ Date: _7_/5_/_2_3_ _____________
Manager Review: ______________________________________ Date: _7_-3_-_2_0_2_3_ __________
10 | P a g e
Form Rev. 01/23/2023

agency_name: Douglas County Juvenile Dept (DCJD)

program_name: Rising Light

program_type: (RC) Residential Care Programs

report_type: Unannounced

view_code: RC

licensee: Douglas County Juvenile Department

executive_director: Aric Fromdahl

other_regulatory_agencies: Oregon Department of Human Services (ODHS) Child Welfare - Treatment Services, Oregon Health Authority (OHA), Joint Commission

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 from 2022 Review Repeat Comments
Findings
Further Action
Needed
All required policies and procedures as Yes[ ] No A revised policy meeting Licensing Rule was submitted to Licensing on 7/26/22.
identified in the "Umbrella Rules"
The policy submitted to cover Conflict of
Interest, Policy # A-10, does not meet
Licensing Rule.
CORRECTIVE ACTION: Create a Conflict-of-
Interest policy that meets Licensing Rule.
All required policies and procedures as Yes[ ] No A revised policy meeting Licensing Rule was submitted to Licensing on 7/26/22.
identified in the "Umbrella Rules"
The submitted Youth and Parent/Guardian
Rights (Policy #CTS-8) is missing required
items.

CORRECTIVE ACTION: Revise Policy #CTS-
8 that is reflective of the related Licensing
Rule.
All required policies and procedures as Yes[ ] No A revised policy meeting Licensing Rule was submitted to Licensing on 7/26/22.
identified in the "Umbrella Rules"
The existing Grievance Procedure (Policy #
CTS-9) requires revision to meet compliance.
CORRECTIVE ACTION: Revise Policy #
CTS-9 that is reflective of the related
Licensing Rule.
All required policies and procedures as Yes[ ] No A revised policy meeting Licensing Rule was submitted to Licensing on 9/6/22.
identified in the "Umbrella Rules"
The existing policy related to mandatory child
abuse reporting (Policy# A-17) requires
revision to meet compliance.
CORRECTIVE ACTION: Revise the existing
policy that is reflective of the related Licensing
Rule.
All required policies and procedures as Yes[ ] No A revised policy meeting Licensing Rule was submitted to Licensing on 7/26/22.
identified in the "Umbrella Rules"
A policy regarding documenting and reporting
critical events was not submitted for review.
CORRECTIVE ACTION: Submit a copy of
this policy. If one does not exist, generate this
policy as outlined by the related Licensing
Rule.
All required policies and procedures as Yes[ ] No A revised policy meeting Licensing Rule was submitted to Licensing on 11/15/22.
identified in the "Umbrella Rules"
Submitted policy regarding personnel (Policy#
A-12) requires revision to meet compliance.
CORRECTIVE ACTION: Revise Policy# A-12
that is reflective of the related Licensing Rule.
All required policies and procedures as Yes[ ] No A revised policy meeting Licensing Rule was submitted to Licensing on 7/26/22.
identified in the "Umbrella Rules"

The policy submitted regarding privacy
(Policy# A-11) is related to employees and not
youth and their families.
CORRECTIVE ACTION: Submit privacy
policy for youth and their families for review. If
a policy does not exist, create one reflective of
the related Licensing Rule.
All required policies and procedures as Yes[ ] No A revised policy meeting Licensing Rule was submitted to Licensing on 9/1/22.
identified in the "Umbrella Rules"
The existing Behavior Management Policy
(Policy # CTS-1) requires revision to meet
compliance.
CORRECTIVE ACTION: Revise Policy # CTS
-1 that is reflective of the related Licensing
Rule.
All required policies and procedures as Yes[ ] No A revised policy meeting Licensing Rule was submitted to Licensing on 8/23/22.
identified in the "Umbrella Rules"
Youth Searches policy (Policy# YC-1)
requires revision to meet compliance.
CORRECTIVE ACTION: Revise Policy# YC-1
that is reflective of the related Licensing Rule.
All required policies and procedures as Yes[ ] No A revised policy meeting Licensing Rule was submitted to Licensing on 9/1/22.
identified in the "Umbrella Rules"
Use of Restraint and Seclusion policy (Policy#
CTS-22) requires revision to meet
compliance.
CORRECTIVE ACTION: Revise Policy# CTS-
22 that is reflective of the related Licensing
Rule.
413-215-0511(2)(a) &(c) Buildings are Yes[ ] No Repairs and a plan regarding the towels were made as per the program's Corrective Action
smoke free, clean and in good repair Plan (CAP) submitted in writing on 7/26/22 to Licensing. Repairs and plan related to the
towels were verified during this 2023 Unannounced site visit.
Room #3 at Rising Light has profanity written
on walls.
Room #4 at River Rock has multiple holes in
the wall.
Room #2 at River Rock door and door frame
damaged

River Rock has soaked towels outside shower
stall as makeshift bathmat
Bathroom at River Rock has a hole in the wall
CORRECTIVE ACTION:
Wipe clean or paint over profanity.
Repair holes in the walls.
Replace or repair door and door frame
Develop a plan where towels are picked up
from the floor to avoid saturated towels from
being left on floors for extended
periods of time.
Repair hole in wall in bathroom
413-215-0511(2)(h) Building is well Yes[ ] No The program verified in their written Corrective Action Plan submitted to Licensing on
ventilated and room temperature is within a 7/26/22, that all room temperatures are functioning normally. Any reported or known
normal comfort range variances in temperature are reported to Building and Facilities for repair. During the
program's 2023 Unannounced site visit, tour of the building and this specific room did not
Room #10 at River Rock noticeably cool result in any temperature concerns.
during the facility's tour.
CORRECTIVE ACTION: Assess youth's
comfort level with the room's temperature and
evaluate what maybe causing the noticeable
difference in room temperature to ensure a
normal comfort range.
Room and Space Requirements Yes[ ] No A window exception was submitted to Licensing on 7/26/22 and granted by Licensing for
Bedrooms 413-215-0516(3) (c) Outside room the next Licensing period (2022-2024).
with window allowing
egress from building
Bedrooms at River Rock and Rising Light
have either no or fixed windows that require
an exception from Licensing.
CORRECTIVE ACTION: Submit new window
exception for this next licensing period (2022-
2024).
Room and Space Requirements Yes[ ] No The program's Corrective Action Plan submitted on 7/26/22 documents that a work order to
Bathrooms 413-215-0516(4) install ventilation was submitted to Building and Facilities. It was determined that the
(a)(H) Adequate ventilation bathroom already had a supply and return air system. This system was verified during this
2023 Unannounced visit.
REPEAT FINDING from 2021 Unannounced
Visit - Bathroom at River Rock continues not
to have a source of ventilation.

CORRECTIVE ACTION: Address lack of
ventilation during the facility's current
remodel.
Safety - Transportation 413-215-0541 Yes[ ] No The program's Corrective Action Plan submitted to Licensing on 7/26/22 documented
(5)(b) Vehicle has insurance policy, is smoke requested repairs and missing items were obtained. During this 2023 Unannounced visit,
free, safe operating condition, and has first aid the repairs to the black Impala was verified. One of the vans is no longer used to transport
kit and fire extinguisher 2-A:10-BC youth and the other van was off site at the time of the visit.
Black Impala (without cage) - driver's seat
has no back cover
15 passenger van has no 1st aid kit and
padlock key to emergency box is missing
14 passenger van 2021 has expired
registration
CORRECTIVE ACTION: Make necessary
repairs to the driver's seat in the black Impala.
Ensure that the 15-passenger van has a 1st
aid kit and that a lock to the padlock is placed
on the van's key chain. Renew the registration
for the 2021 14 passenger van. Place
insurance and accident packet in each
vehicle.
Medication 413-215-0551(10) Written record Yes[ ] No As per the submitted Corrective Action plan on 7/26/22, all staff were reminded/coached on
of the administration of medication includes: the importance of accurate medication documentation.
(d) missed doses
Medication Administration Records (MARs)
reviewed at Rising Light, and River Rock
reflected several times where missed
medication was not appropriately
documented.
CORRECTIVE ACTION: Determine if the
missed documentation is related to a specific
staff member and follow up with additional
training. Remind all staff the
importance of medication documentation.
Personnel Files 413-215-0061 (3)(f) Record of Yes[ ] No[ ] The program's Corrective Action Plan submitted on 7/26/22 documents Administrative
personnel actions Managers being reminded to file all completed performance evaluations in their respective
employee files. Compliance in this area will be verified in a subsequent site visit.
Four out of the five personnel files reviewed
did not document the completion of annual
evaluations.

CORRECTIVE ACTION: Ensure that annual
performance evaluations are completed and
maintained in their respective
personnel files from this point forward.
New Employee Orientation - Umbrella Yes[ ] No[ ] The program acknowledges that not meeting compliance in this area is a result of a
Requirements (30 days) deficiency in the documentation and storage of training records. New employee training is
413-215-0061(4) done individually without the consistency of single trainers due to previous COVID
(a) Agency policies and procedures restrictions that has directly affected appropriate training documentation. The program is
(b) Ethical and professional guidelines exploring a change in the existing training database to reduce multiple persons accessing
(c) Organizational lines of authority and storing information. New hire training checklists have been created to ensure that each
(d) Attributes of population served employee is receiving required training. Compliance in this area will be verified in a
(e) & (5)(a) to (c) Mandatory reporting subsequent site visit.
(f) Privacy laws
(g) Emergency procedures
New Employee Orientation for three staff
members could not be verified during the
audit of personnel files.
CORRECTIVE ACTION: Submit a plan as to
how new employee training will be provided
and appropriately documented from this point
forward.
Ongoing Training Yes[ ] No[ ] The program acknowledges that not meeting compliance in this area is a result of a
413-215-0541(5)(a) Employees transporting deficiency in the documentation and storage of training records. The program is exploring a
children have: current driver's license, change in the existing training database to reduce multiple persons accessing and storing
insurance, trained in emergency procedures information. The program also plans to send annual training reminders. Compliance in this
and behavior management, and training for area will be verified in a subsequent site visit.
15+ passenger vans if applicable)
413-215-0556(2)(a) Environmental
Emergencies
413-215-0556(2)(b) Universal Precautions
413-215-0556(2)(c) Discipline and Behavior
Management
413-215-0061(5) Mandatory reporting
(annually)
Four out of five personnel files did not reflect
the completion of required ongoing training in
these areas.
CORRECTIVE ACTION: Submit a plan as to
how this training will be provided and
appropriately documented from

this point forward.
Children's Records Health Services Yes[ ] No[ ] As per the program's Corrective Action Plan dated 7/26/22, the documentation of age-
413-215-0546 (2)(e) Documentation of age- appropriate instruction is now included in the program's Assessment and Evaluation
appropriate instruction - pregnancy document. Compliance in this area will be verified in a subsequent site visit.
prevention, nutrition, prevention of HIV &
AIDS, and prevention and treatment of
sexually transmitted disease
Youth files reviewed do not reflect the
documentation of age-appropriate instruction.
CORRECTIVE ACTION: Develop a
procedure where age appropriate
instruction is documented in the youths' files
from this point forward.
Consents 413-215-0576(1) Yes[ ] No[ ] As per the program's Corrective Action Plan submitted on 7/26/22, these required consents
(e) Allow access as defined in 413- have been added to their intake paperwork. Compliance in this area will be verified in a
215-0091 & 0101 subsequent site visit.
(f) Impose a dress code
(g) Apply the reasonable and prudent
parent standard
Consent allowing access could not be located
in the youth files.
Consent imposing a dress code could not be
located in the youth files.
Consent applying reasonable and prudent
parent standard could not be located in the
youth files.
CORRECTIVE ACTION: Add required
consents to intake packet.
Disclosures 413-215-0576(2) Parent/guardian Yes[ ] No[ ] As per the program's Corrective Action Plan submitted on 7/26/22, these required
has acknowledged in writing: disclosures have been added to their Program and Youth Handbook. Compliance in this
area will be verified in a subsequent site visit.
(a) Information regarding personal or room
searches and protocols for confiscation of
contraband
(c) Any policies and procedures upon
request

Disclosure regarding personal and room
searches and protocols for confiscation of
contraband could not be located in the youth
files.
Disclosure stating that policies and
procedures will be provided upon request
could not be located in the youth files.
CORRECTIVE ACTION: Add required
disclosures to intake packet.
Authorizations 413-215-0576(3) (d) Activity Yes[ ] No[ ] As per the program's Corrective Action Plan submitted on 7/26/22, this required
specific authorizations are preapproved authorization will be obtained and kept in the respective youth files moving forward.
to allow children to participate in Compliance in this area will be verified in a subsequent site visit.
potentially hazardous activities, including but
not limited to using motorized yard
equipment, swimming, and horseback riding.
Two out the five youth files reviewed did not
have activity specific authorizations.
CORRECTIVE ACTION: Ensure that this
authorization is obtained and kept in the
respective youth file from this point
forward.
413-215-0526 New Facility or Remodel Yes[ ] No The program submitted requested floor plan via email on 12/22/22.
(Technical Amended 01/13/20)
(1) Building plans.
(a) A residential care agency must submit to
the Department for approval a set of plans
and specifications for each building used for
children in care operated by the residential
care agency
River Rock was recently renovated.
CORRECTIVE ACTION: Submit a copy of
River Rock's renovated floor plan

New Findings from Site Visit Comments
No new findings identified
Interview Summary
During this unannounced site visit conversations were held with the program's Residential Referral and Admissions Coordinator, River Rock's Program
Manager and the program's Assistant Director.
The program continues to receive a steady flow of referrals with an increase of voluntary placement requests. Staffing continues to ebb and flow. Despite a
differential pay increase, swing shift remains a difficult shift to keep fully staffed. Census remains moderately low with 8 youth at River Rock and 6 youth in
Rising Light. The program recently completed their accreditation review by The Joint Commission and did well. This year's evaluator understood the
program's service scope and was focused on the treatment and behavioral piece of the daily work. River Rock had recent maintenance on the building's
sump pump. A malfunction in this equipment left the laundry room and one of the facility's bathrooms temporarily out of service. Laundry was taken to two
nearby buildings to be washed, Detention and Rising Light.
An available youth from River Rock was interviewed. All youth from Rising Light were off campus, attending school. The youth interviewed shared two
scenarios that left them feeling unsafe during their stay at both Rising Light and River Rock involving staff members. These concerns were reported to the
Child Abuse Hotline and closed at screening. Given the youth's disclosure of feeling unsafe in combination with the youth's reservation in speaking freely, this
youth interview was brief. The youth was able to highlight no push button showers as a program positive. Changes that the youth would suggest included
making River Rock feel more like a home by adding warm lighting and rugs. It was also suggested that there be more fresh produce and variety in the meals
being offered. The youth is looking forward to more promised summer activies that staff have mentioned as the school year draws to a close.
Observations
Tours of both buildings did not produce any physical findings. The remodel at River Rock is in the final stages. The facility's capacity increased from 10
bedrooms to 14 individual bedrooms.

new_findings: No new findings identified

excerpt:
413-215-0526 New Facility or Remodel Yes[ ] No The program submitted requested floor plan via email on 12/22/22.
(Technical Amended 01/13/20)
(1) Building plans.
(a) A residential care agency must submit to
the Department for approval a set of plans
and specifications for each building used for
children in care operated by the residential
care agency
River Rock was recently renovated.
CORRECTIVE ACTION: Submit a copy of
River Rock's renovated floor plan
New Findings from Site Visit Comments
No new findings identified
No new findings identified


facility_name: Family Solutions - Cascade House

summary: Unannounced - 7 findings

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Licensee: Family Solutions – Cascade House and Willow House
Executive Director: Tom Johnson
Program Director(s): Dorothy Provencio
Date of Unannounced: May 13, 2021
Licensing Coordinator: Robin DuVal
Other Regulatory or Accrediting Agencies: Oregon Department of Human Services (ODHS) Child Welfare Treatment Services
Program Compliance: OAR 413-215-0001 to 413-215-0136 Licensing Umbrella Rules, and OAR 413-215-0501 to 413-215-0586, Licensing
Residential Care Agencies Rules.
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 Findings Comments
-Willow House 6-Mth Review 01/20/2021 Further Action
Needed
-Cascade House Unannounced Site Visit 11/3/2020 (no Findings)
413-215-0511(2)(a) &(c) Buildings are smoke free, clean and in good Yes☐ No
repair:
 The left front window nearest the front door has tape over the
cracked glass and furniture inside blocks access to the window.
The agency is aware and working on repair, including possible
other solutions for that window space.”
413-215-0551(10) Written record of the administration of medication Yes☐ No Willow House - Note: The Adverse Reaction binder shall be
includes: (h) possible adverse reactions: easily accessible to staff.
 The requirement is unmet for (10)(h) Adverse Reactions. The
agency shall ensure possible adverse reactions are listed for all
medications.”
1
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 200115)
413-215-0546(2)(e) Documentation of age appropriate instruction – Yes No☐ Willow House: Documentation of age appropriate
pregnancy prevention, nutrition, prevention of HIV & AIDS, and instruction is unmet. The agency shall implement a
prevention and treatment of sexually transmitted disease: systematic procedure to ensure this requirement is met.
 Documentation of age appropriate instruction is unmet. The This is a REPEAT FINDING.
agency shall ensure age appropriate instruction occurs and is
appropriately documented.
413-215-0581(1) Summary sheet contains the following: (a)The name, Yes No☐ Willow House: The summary sheet is missing religious
gender, date of birth, religious preference, and previous address(b) preference and name and location of previous and/or
Name and location of previous and current school: current school. The agency shall ensure the updated form
 The summary sheets are missing religious preference; and name capturing all requirements is implemented going forward.
and location of previous and/or current school. The agency shall This is a REPEAT FINDING.
ensure this information is captured and appropriately documented.
413-215-0581(4) Records contain date, amount, source, purpose, Yes☐ No
signatures:
 The agency shall update the form to include source and purpose
of deposits to and withdrawals from youths’ personal funds and
ensure signatures are obtained instead of initials.
413-215-0071(3)&(4) Uniform in organization, readily identifiable and Yes No☐ Willow House: Records are incomplete missing information
accessible, current, and complete, containing all required info. No as noted above.
eraser tape or white out:
 Youth records are incomplete missing information as noted above.
New Findings from Site Visit Comments
413-215-0511(2)(a) &(c) Buildings are At Willow House, several bedrooms were observed with large amounts of clothing, possessions, etc. strewn
smoke free, clean and in good repair: about the floors with minimal sight of the bare floor. The agency shall ensure cleanliness and safety from
potential hazards.
2
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 200115)
Interview Summary
Youth M. is 14 years old and has been at Willow House for approximately 6 months and reports the program is helping with anger issues, staff
are trusting, feels safe here, has contact with family and time isn’t limited, food is good and plentiful. Gives input into treatment plan and feels
listened to. No problems getting medications as ordered. Regular activities and outings were described. Doesn’t really like school in general and
they need additional explanation to help understand. Feels that staff really don’t understand their background and what led up to them being in
this program. Doesn’t like the peers here and that the program only serves one gender population.
Youth T. #1 is 14 years old and has been at Cascade House for approximately 4 months. It’s their first time being in a program and is still adjusting.
The program is kind of helping but described some peer and environment stressors. There’s a couple staff who are trusting and there when they
need it. Feels safe in the house but doesn’t like the neighborhood. Has contact with family and time isn’t limited. Hasn’t really thought about giving
input into their treatment plan. Dislikes the food but is a picky eater, and reports big meals are made for leftovers. Favorite thing about the program
is the friends that have been made. Least favorite is “everything”. Has school on-site but would rather be in-person at a school building. Regular
activities and outings were described.
Youth T. #2 is 13 years old and has been at Cascade House for approximately 3 weeks and reports the program is helping with coping techniques,
cussing, and to think before speaking. Staff are trusting, especially the therapist. It’s ok here, still adjusting and feels safe. Activities and outings
were described. Has regular phone contact with family and time isn’t limited. Food is good, gets enough and reports big meals are made for
leftovers. No problems getting medications as ordered. Frustrated that caseworker never answers or returns calls but is looking forward to their
upcoming team meeting. School is good and gets help. Feels there’s some unfair privileges, especially with the youth that have runaway and
returned, and peer boundaries and rules are unfair among peers. The program does well at teaching right and wrong.
Both youth at Cascade House shared some statements made by staff that they felt aren’t appropriate for the youth being served in the program.
This coordinator discussed the concerns with the House Manager, and the program is taking it seriously and is taking actions to correct.
Current census: 5 at Willow House and 6 at Cascade House.
Observations
Willow House: The program had good COVID-19 protocols and all staff wore face masks, as mandated statewide due to the COVID-19 pandemic.
Adequate food supply was evident by dry and canned goods on shelves and in multiple refrigerators and freezers. Several bedrooms were
observed with large amounts of clothing, possessions, etc. strewn about the floors with minimal sight of the bare floor, and a recommendation
was provided to utilize Collaborative Problem Solving techniques to encourage the youth to maintain a level of cleanliness and reduce risk of
safety hazards.
Cascade House: The program had good COVID-19 protocols and all staff wore face masks, as mandated statewide due to the COVID-19
pandemic. Adequate food supply was evident by dry and canned goods on shelves and in multiple refrigerators and freezers. The fire extinguisher
3
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 200115)
upstairs on A. side was missing from the mount, which was installed the following day. There are two egresses to the medication/staff office and
one door had the glass replaced with wood. The facility is an aging building and the program makes efforts to maintain good repair.
Corrective Actions and Timeframes:
Please submit the following to verify compliance.
Within 45 days of receipt of this report Family Solutions 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 are to be emailed
directly to Robin DuVal, ROBIN.M.DuVal@dhsoha.state.or.us
6/1/2021
Licensing Coordinator’s Signature: ________________________ Date: ___________________
5-31-2021
Manager Review: ______________________________________ Date: __________________
4
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 200115)

agency_name: Family Solutions (FS)

licensee: Family Solutions - Cascade House and Willow House

executive_director: Tom Johnson

program_director: Dorothy Provencio

licensing_coordinator: Robin DuVal

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 Findings Comments
-Willow House 6-Mth Review 01/20/2021 Further Action
Needed
-Cascade House Unannounced Site Visit 11/3/2020 (no Findings)
413-215-0511(2)(a) &(c) Buildings are smoke free, clean and in good Yes[ ] No
repair:
- The left front window nearest the front door has tape over the
cracked glass and furniture inside blocks access to the window.
The agency is aware and working on repair, including possible
other solutions for that window space."
413-215-0551(10) Written record of the administration of medication Yes[ ] No Willow House - Note: The Adverse Reaction binder shall be
includes: (h) possible adverse reactions: easily accessible to staff.
- The requirement is unmet for (10)(h) Adverse Reactions. The
agency shall ensure possible adverse reactions are listed for all
medications."
1

413-215-0546(2)(e) Documentation of age appropriate instruction - Yes No[ ] Willow House: Documentation of age appropriate
pregnancy prevention, nutrition, prevention of HIV & AIDS, and instruction is unmet. The agency shall implement a
prevention and treatment of sexually transmitted disease: systematic procedure to ensure this requirement is met.
- Documentation of age appropriate instruction is unmet. The This is a REPEAT FINDING.
agency shall ensure age appropriate instruction occurs and is
appropriately documented.
413-215-0581(1) Summary sheet contains the following: (a)The name, Yes No[ ] Willow House: The summary sheet is missing religious
gender, date of birth, religious preference, and previous address(b) preference and name and location of previous and/or
Name and location of previous and current school: current school. The agency shall ensure the updated form
- The summary sheets are missing religious preference; and name capturing all requirements is implemented going forward.
and location of previous and/or current school. The agency shall This is a REPEAT FINDING.
ensure this information is captured and appropriately documented.
413-215-0581(4) Records contain date, amount, source,

interview_summary:
Youth M. is 14 years old and has been at Willow House for approximately 6 months and reports the program is helping with anger issues, staff
are trusting, feels safe here, has contact with family and time isn't limited, food is good and plentiful. Gives input into treatment plan and feels
listened to. No problems getting medications as ordered. Regular activities and outings were described. Doesn't really like school in general and
they need additional explanation to help understand. Feels that staff really don't understand their background and what led up to them being in
this program. Doesn't like the peers here and that the program only serves one gender population.
Youth T. #1 is 14 years old and has been at Cascade House for approximately 4 months. It's their first time being in a program and is still adjusting.
The program is kind of helping but described some peer and environment stressors. There's a couple staff who are trusting and there when they
need it. Feels safe in the house but doesn't like the neighborhood. Has contact with family and time isn't limited. Hasn't really thought about giving
input into their treatment plan. Dislikes the food but is a picky eater, and reports big meals are made for leftovers. Favorite thing about the program
is the friends that have been made. Least favorite is "everything". Has school on-site but would rather be in-person at a school building. Regular
activities and outings were described.
Youth T. #2 is 13 years old and has been at Cascade House for approximately 3 weeks and reports the program is helping with coping techniques,
cussing, and to think before speaking. Staff are trusting, especially the therapist. It's ok here, still adjusting and feels safe. Activities and outings
were described. Has regular phone contact with family and time isn't limited. Food is good, gets enough and reports big meals are made for
leftovers. No problems getting medications as ordered. Frustrated that caseworker never answers or returns calls but is looking forward to their
upcoming team meeting. School is good and gets help. Feels there's some unfair privileges, especially with the youth that have runaway and
returned, and peer boundaries and rules are unfair among peers. The program does well at teaching right and wrong.
Both youth at Cascade House shared some statements made by staff that they felt aren't appropriate for the youth being served in the program.
This coordinator discussed the concerns with the House Manager, and the program is taking it seriously and is taking actions to correct.
Current census: 5 at Willow House and 6 at Cascade House.

observations:
Willow House: The program had good COVID-19 protocols and all staff wore face masks, as mandated statewide due to the COVID-19 pandemic.
Adequate food supply was evident by dry and canned goods on shelves and in multiple refrigerators and freezers. Several bedrooms were
observed with large amounts of clothing, possessions, etc. strewn about the floors with minimal sight of the bare floor, and a recommendation
was provided to utilize Collaborative Problem Solving techniques to encourage the youth to maintain a level of cleanliness and reduce risk of
safety hazards.
Cascade House: The program had good COVID-19 protocols and all staff wore face masks, as mandated statewide due to the COVID-19
pandemic. Adequate food supply was evident by dry and canned goods on shelves and in multiple refrigerators and freezers. The fire extinguisher
3

upstairs on A. side was missing from the mount, which was installed the following day. There are two egresses to the medication/staff office and
one door had the glass replaced with wood. The facility is an aging building and the program makes efforts to maintain good repair.

previous_findings:
Repeat Findings Comments
-Willow House 6-Mth Review 01/20/2021 Further Action
Needed
-Cascade House Unannounced Site Visit 11/3/2020 (no Findings)
413-215-0511(2)(a) &(c) Buildings are smoke free, clean and in good Yes[ ] No
repair:
- The left front window nearest the front door has tape over the
cracked glass and furniture inside blocks access to the window.
The agency is aware and working on repair, including possible
other solutions for that window space."
413-215-0551(10) Written record of the administration of medication Yes[ ] No Willow House - Note: The Adverse Reaction binder shall be
includes: (h) possible adverse reactions: easily accessible to staff.
- The requirement is unmet for (10)(h) Adverse Reactions. The
agency shall ensure possible adverse reactions are listed for all
medications."
1

413-215-0546(2)(e) Documentation of age appropriate instruction - Yes No[ ] Willow House: Documentation of age appropriate
pregnancy prevention, nutrition, prevention of HIV & AIDS, and instruction is unmet. The agency shall implement a
prevention and treatment of sexually transmitted disease: systematic procedure to ensure this requirement is met.
- Documentation of age appropriate instruction is unmet. The This is a REPEAT FINDING.
agency shall ensure age appropriate instruction occurs and is
appropriately documented.
413-215-0581(1) Summary sheet contains the following: (a)The name, Yes No[ ] Willow House: The summary sheet is missing religious
gender, date of birth, religious preference, and previous address(b) preference and name and location of previous and/or
Name and location of previous and current school: current school. The agency shall ensure the updated form
- The summary sheets are missing religious preference; and name capturing all requirements is implemented going forward.
and location of previous and/or current school. The agency shall This is a REPEAT FINDING.
ensure this information is captured and appropriately documented.
413-215-0581(4) Records contain date, amount, source, purpose, Yes[ ] No
signatures:
- The agency shall update the form to include source and purpose
of deposits to and withdrawals from youths' personal funds and
ensure signatures are obtained instead of initials.
413-215-0071(3)&(4) Uniform in organization, readily identifiable and Yes No[ ] Willow House: Records are incomplete missing information
accessible, current, and complete, containing all required info. No as noted above.
eraser tape or white out:
- Youth records are incomplete missing information as noted above.
New Findings from Site Visit Comments
413-215-0511(2)(a) &(c) Buildings are At Willow House, several bedrooms were observed with large amounts of clothing, possessions, etc. strewn
smoke free, clean and in good repair: about the floors with minimal sight of the bare floor. The agency shall ensure cleanliness and safety from
potential hazards.
2


summary: Unannounced - 08/13/2021

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: 8/13/2021
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
The program had no previous findings Yes☐ No☐
to review from the last Licensing on-
site inspection completed in
December of 2020.
New Findings from Site Visit Comments
There were no new findings from this
site visit
1
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 200115)
Interview Summary
Program Director, Ron Farley, was interviewed and facilitated a tour of the campus.
Information gathered during site visit:
- The program currently has 6 youth, 3 males/3 females. A 7th resident is pending intake.
- The majority of referrals coming in to Adapt are not a good match for the program as the youths’ needs are much higher than
the program can accommodate. The program is receiving 3 - 4 referrals a week. With the new COVID surge, referral
numbers have decreased.
- A new electronic filing system was adopted, making intakes difficult to enter, but staff are doing their best to maneuver
through this computer system.
- Staff are grieving the unexpected death of a long-time employee. This employee had been with Adapt for 32 years.
- Youth are attending school Monday through Friday. An instructor from the local school district is on campus Tuesday,
Wednesday and Thursday. On Monday and Friday, Adapt staff assist residents with their school work. Youth are currently
wearing masks while in school as required by the Department of Education.
- There are three open staff positions. Two resident assistants (RA) and a counselor. One open position is a result of an out
of state move while two are a result of covering additional shifts related to under staffing. The program raised their entry level
rate to $15.15/hr., but employment interest remains low.
- Family on-site visits were suspended again due to COVID. Youth continue to have daily phone contact with their family and
participate in zoom visits on the weekends. Prior to the new COVID surge, the program had hosted four months of family
visits and had recently began allowing siblings, ages 12 years and older, to visit. When on-site visits were occurring,
everyone wore masks and no food was allowed.
- Some youth in program are vaccinated.
- Licensing recapped mandatory reporting, stressing the importance of reporting any suspected child abuse to the Child Abuse
Hotline rather than conducting an internal investigation.
Two youth were interviewed. Both report feeling safe in the program. One youth shared a recent incident where a power struggle
took place between staff and youth. This was described as an isolated incident and an uncommon occurrence for the staff involved.
This information was given to the Program Director at the time of the site visit. The Program Director was already aware of the
situation and has plans to look into the matter further. Neither youth enjoy the program’s meals that are prepared off site in an
industrial kitchen. One resident stated that the food was generally “not good” while the other said the food had “no flavor.” Youth
report getting enough to eat, however, as the facility has two kitchens available where residents can prepare quick meals and have
snacks throughout the day. Youth confirm daily phone calls and zoom calls on the weekends with family. Both youth shared that it
would be nice if daily call times could be increased to 15 minutes. Right now, residents are allowed only 10-minute phone calls.
Youth understand that when the program is full, that 10 minute calls allow everyone an opportunity to use the phone, but when
2
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 200115)
resident numbers are low, youth would like to see their phone times increased. Youth report possessing a good understanding of
their treatment goals while in program and have a sense of what their after care plan may look like. A program strength was
identified as staff’s consistency with enforcing rules. A program weakness was stated as staff “not listening” to youth. Youth
explained that staff will stop a youth from sharing during a conversation, encouraging them, instead, to talk to their counselor. Youth
acknowledge that at times speaking to a counselor is more appropriate, but youth may want to talk to staff knowing that their
counselor is immediately unavailable to them. Both youth identified the same staff member who does not exhibit the same level of
engagement as the rest of the staff. This staff member is said to be on their phone the majority of their shift time and does the “bare
minimum.” This information was also provided to the Program Director who is actively coaching this staff member.
Observations
Despite the uncommonly high temperatures, the facility was well air conditioned and comfortable.
The youths’ rooms have a supply of masks for youth to use as needed.
There were no new findings regarding the program’s physical campus.
Corrective Actions and Timeframes:
Please submit the following to verify compliance.
Within 45 days of receipt of this report Agency Name 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: Licensing Coordinator
201 High St. SE Suite 500
Salem, OR 97301
Licensing Coordinator’s Signature: ________________________ Date: _ _ _ _8_/2_5_/_2_0_2_1_ _______
Manager Review: ______________________________________ Date: __8_-_2_3__-2__0_2_1_______
3
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 200115)

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
The program had no previous findings Yes[ ] No[ ]
to review from the last Licensing on-
site inspection completed in
December of 2020.
New Findings from Site Visit Comments
There were no new findings from this
site visit
1

Interview Summary

interview_summary:
Program Director, Ron Farley, was interviewed and facilitated a tour of the campus.
Information gathered during site visit:
- The program currently has 6 youth, 3 males/3 females. A 7th resident is pending intake.
- The majority of referrals coming in to Adapt are not a good match for the program as the youths' needs are much higher than
the program can accommodate. The program is receiving 3 - 4 referrals a week. With the new COVID surge, referral
numbers have decreased.
- A new electronic filing system was adopted, making intakes difficult to enter, but staff are doing their best to maneuver
through this computer system.
- Staff are grieving the unexpected death of a long-time employee. This employee had been with Adapt for 32 years.
- Youth are attending school Monday through Friday. An instructor from the local school district is on campus Tuesday,
Wednesday and Thursday. On Monday and Friday, Adapt staff assist residents with their school work. Youth are currently
wearing masks while in school as required by the Department of Education.
- There are three open staff positions. Two resident assistants (RA) and a counselor. One open position is a result of an out
of state move while two are a result of covering additional shifts related to under staffing. The program raised their entry level
rate to $15.15/hr., but employment interest remains low.
- Family on-site visits were suspended again due to COVID. Youth continue to have daily phone contact with their family and
participate in zoom visits on the weekends. Prior to the new COVID surge, the program had hosted four months of family
visits and had recently began allowing siblings, ages 12 years and older, to visit. When on-site visits were occurring,
everyone wore masks and no food was allowed.
- Some youth in program are vaccinated.
- Licensing recapped mandatory reporting, stressing the importance of reporting any suspected child abuse to the Child Abuse
Hotline rather than conducting an internal investigation.
Two youth were interviewed. Both report feeling safe in the program. One youth shared a recent incident where a power struggle
took place between staff and youth. This was described as an isolated incident and an uncommon occurrence for the staff involved.
This information was given to the Program Director at the time of the site visit. The Program Director was already aware of the
situation and has plans to look into the matter further. Neither youth enjoy the program's meals that are prepared off site in an
industrial kitchen. One resident stated that the food was generally "not good" while the other said the food had "no flavor." Youth
report getting enough to eat, however, as the facility has two kitchens available where residents can prepare quick meals and have
snacks throughout the day. Youth confirm daily phone calls and zoom calls on the weekends with family. Both youth shared that it
would be nice if daily call times could be increased to 15 minutes. Right now, residents are allowed only 10-minute phone calls.
Youth understand that when the program is full, that 10 minute calls allow everyone an opportunity to use the phone, but when
2

resident numbers are low, youth would like to see their phone times increased. Youth report possessing a good understanding of
their treatment goals while in program and have a sense of what their after care plan may look like. A program strength was
identified as staff's consistency with enforcing rules. A program weakness was stated as staff "not listening" to youth. Youth
explained that staff will stop a youth from sharing during a conversation, encouraging them, instead, to talk to their counselor. Youth
acknowledge that at times speaking to a counselor is more appropriate, but youth may want to talk to staff knowing that their
counselor is immediately unavailable to them. Both youth identified the same staff member who does not exhibit the same level of
engagement as the rest of the staff. This staff member is said to be on their phone the majority of their shift time and does the "bare
minimum." This information was also provided to the Program Director who is actively coaching this staff member.

observations:
Despite the uncommonly high temperatures, the facility was well air conditioned and comfortable.
The youths' rooms have a supply of masks for youth to use as needed.
There were no new findings regarding the program's physical campus.


summary: Unannounced - 7 findings

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Residential Care
Licensee: Family Solutions – Cascade House Date of Unannounced: August 23, 2023
Executive Director: Dorothy Provencio Licensing Coordinator: Robin DuVal, accompanied by Katie Wyland with
Program Manager: Susan Shorey Child Welfare Treatment Services.
Program Director(s): Roy Lindsay
Other Regulatory or Accrediting Agencies: Oregon Health Authority (OHA) and Oregon Department of Human Services Child Welfare Treatment
Services (ODHS).
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.
Repeat
Previous Findings: Findings
Comments or Corrective Actions
License Renewal Site Visit 08/31/2022 Further Action
Needed
SB710 Requirements: Policy and Procedures; notifications to Yes☐ No This notification is provided to guardians and children in care
guardian and children in care. OAR 419-400-0180(8)(e), and documented as being provided.
(11)(e) and OAR 419-400-0190(1).
 No further corrective action is needed at this time.
 This licensor provided edits and recommendations to
the notification document for guardians and children in Note: The form had an outdated email extension for the
care. The agency shall ensure the notification is licensing contact. The agency staff person will update and
updated and implemented going forward. ensure the new form is utilized going forward.
Medication 419-470-0100(9) Written record of the disposal of Yes No☐ Requirement (9)(e) remains unmet: initials instead of
medications is maintained and includes: signatures; and several instances with only one staff person
(a) description and amount without a witness.
(b) name
(c) reason Some disposed medications are disposed on-site utilizing the
(d) method Rx Destroyer product, however other disposed medications
(e) staff & witness signature were in a bin labeled “disposal” with no tracking document
within said bin, creating a risk of mismanagement or theft.
1 of 6 | P a g e
Form Rev. 01/23/2023
 (9)(e) The agency shall ensure staff and witness
provide a signature, not initials. When speaking to several staff and the program manager,
there was a lack of clarity on the process of medication
Note: This licensor and staff discussed ways to update administration documentation and medication disposal and
documentation and processes. The agency is working on disposal documentation. There have been recent staff
updating policies and procedures to be clearer and reduce changes, and new hires that may not have received required
potential errors. training.
Corrective Action. The Agency shall:
1) Ensure staff and a witness provide a signature, not
initials.
2) Ensure two staff (one staff and one staff witness) are
disposing medications and signing the disposal
record.
3) Review medication policies and procedures to ensure
it meets requirements in related OARs and the
practices set forth by Family Solutions.
4) Ensure all staff who handle medications are provided
medication policies and procedures, are trained, and
demonstrate competency before administering and
disposing medications as well as proper
documentation.
5) Ensure management oversight for quality check and
assurances and any follow-up training needed.
**This is a repeat finding.**
2 of 6 | P a g e
Form Rev. 01/23/2023
Medication 419-470-0100(10) Written record of the Yes No☐ Requirements (10)(d) and (e) are unmet. There were several
administration of medication includes: blank areas on the medication administration record with no
(a) name corresponding notes to document the circumstances where
(b) description space is provided for such notes on the back of the sheet.
(c) dates and times
(d) missed doses When speaking to several staff and the program manager,
(e) medication disposed there was a lack of clarity on the process of medication
(f) method of administration administration documentation and medication disposal and
(g) ID of person administering disposal documentation. There have been recent staff
(h) possible adverse reactions changes, and new hires that may not have received required
(i) medication taken outside facility training.
 Requirements (10)(e) and (i) are unmet. The agency Corrective Action – The Agency shall:
shall ensure all requirements are included on the
medication administration record. 1) The agency shall ensure the written record of the
medication administration are filled out accurately with
Note: This licensor and staff discussed ways to update no blanks, indicating missed doses or medication
documentation and processes. The agency is working on disposed.
updating policies and procedures to be clearer and reduce  Medication errors, or anomalies in documentation or
potential errors. administration, can be documented by adding a
notation to the medication administration record.
2) Review medication policies and procedures to ensure
it meets requirements in related OARs and the
practices set forth by Family Solutions.
3) Ensure all staff who handle medications are provided
medication policies and procedures, are trained, and
demonstrate competency before administering and
disposing medications as well as proper
documentation.
4) Ensure management oversight for quality check and
assurances and any follow-up training needed.
**This is a repeat finding.**
3 of 6 | P a g e
Form Rev. 01/23/2023
Children’s Records Health Services 419-470-0090 Yes No 
(2)(e) Documentation of age-appropriate instruction – This rule changed effective 4/18/2023 and is now required
pregnancy prevention, nutrition, prevention of HIV & AIDS, and under 419-470-0090(3)(a) Health Services Medical exams.
prevention and treatment of sexually transmitted disease
 No further corrective action is needed at this time
 (2)(e) is unmet. The agency shall ensure age-
appropriate instruction is provided and appropriately
documented in each youth file. Repeat finding.
Financial Records 419-470-0170 (4) Records contain date, Yes☐ No Financial records are being signed by both staff and the child
amount, source, purpose, signatures. in care.
 Signatures were inconsistent. The agency shall ensure  No further corrective action is needed at this time.
signatures are regularly obtained.
Note: the administrative staff person recently implemented a
weekly quality check to verify accurate documentation and
initials when complete. This licensor recommended revising
the log form to include a column for this review and signature.
New Findings from Site Visit Corrective Actions
Physical Plant Requirements 419-470- All upstairs toilets had various levels of rings in the toilet indicating a deep cleaning and regular upkeep
0020(2)(c) All areas of buildings where was lacking. It’s recommended that the agency utilize Collaborative Problem Solving techniques to
children in care are present must be kept encourage the youth to meet cleaning expectations.
clean and in good repair. Major
appliances and heating, ventilation,  Corrective Action: The agency is ultimately responsible and must ensure agency staff are
plumbing, and electrical systems must be completing necessary cleaning.
functional and in good repair.
There is dark discolored flooring around one of the upstairs toilets indicating a potential water leak,
mold, rotting floor, or other unknown reason. Mold is a health hazard, and a rotting floor structure is
a safety concern.
 Corrective Action: The agency shall seek out a professional assessment and remedy the
problem.
4 of 6 | P a g e
Form Rev. 01/23/2023
Interview Summary
The program manager began a site tour with this licensor before attending the scheduled all-staff training. The current census is 6 with one
potential new intake soon. Katie Wyland interviewed two youth and three staff. This licensor interviewed one youth and the in-house schoolteacher
and met three newer staff and briefly talked with two longer term staff.
Youth Interviews: Youth reported wanting to do more activities and get out of the program more. They’ve spent most of the summer break sitting
around watching TV and playing video games in the downstairs main living room. They’re not allowed to use the upstairs recreation room until
after 3pm. Outings have included swimming, the park, or drives. They reported only two outings in the last two weeks. There’s no structured daily
physical activity time. Staff aren’t following the outing or activity schedule that’s posted. Groups haven’t been happening. School starts next week,
so they’re hoping for more daily structure. There are staff that are trusting. With the recent staffing changes, it feels disorganized. Food is described
as good, but there’s a lot of frozen meals and approximately two cooked meals per week. Phone calls with approved contact persons occur at the
end of each day for 15 minutes per youth, but it’s a tight schedule to start/stop for the next youth to make a call. Phone calls occur at the kitchen
table which provides semi-privacy as youth and staff might be walking thru or doing chores. One of the therapists recently left the agency, and
the youth are seeing the other one, but it’s reported their approach is more of a hands-off, listening type rather than helping them process through
feelings or providing tools to work through feelings.
Staff Interviews: Staff report that the youth need more routine and structure, and that there’s been too much sitting watching TV and playing
video games during the day. This is due to not having enough staff, especially due to the recently implemented staffing ratio for outings where if
two youth go on an outing there must be two staff to accompany them, which means all youth go on the outing or there is no outing. Some youth
lose outing privileges, due to safety concerns, which contributes to the staffing/outing dilemma. It was reported the funds for outings are not always
sufficient, and there doesn’t seem to be oversight of those funds or sufficient funds for the types of outings that may cost more. One staff reports
that youth are going on outings 4-5 times a week, just not on day shift, and outings include YMCA for swimming (M, W & F), drives, bowling and,
if funds allow, to the movies or coffee shop.
There’s been recent staff changes and the atmosphere among coworkers feels stressed. Schedules are all over the place. Hands-on training for
new staff isn’t happening as thoroughly i.e., showing a new staff person how to do a proper room check requires two staff to leave the floor, which
is nearly impossible to accommodate; staff either don’t know the house rules or they’re not consistent with the house rules; and only receiving a
5-minute training on BRS service documentation.
Staff report various levels of feeling comfortable going to management with concerns as well as mixed feedback about issues getting resolved or
not. Staff expressed a desire to have the program manager be more involved on the floor on a regular basis, especially during times of staff
changes, training, new client intakes and during times when client behaviors are challenging to manage.
5 of 6 | P a g e
Form Rev. 01/23/2023
Observations
The facility is an aging building, was originally built as a house, has original or aging bathrooms and some areas appear more worn down. The
agency works at keeping it maintained and clean. A couple maintenance issues are noted above in “New Findings”. Youth bedrooms were
observed and were relatively clean and tidy. Food was observed in the cupboards and in refrigerators and freezers. The walk-through consisted
of the classroom, and all rooms, bathrooms, and common areas on the first and second floor of the residential side of the building. It was smokey
outside due to wildfires, so the youth were inside finishing up breakfast and then in the living room either watching tv or playing video games.
Staff had a scheduled training (in-person and virtual) soon after this licensor arrived, and accommodations were made to continue the
unannounced visit.
Corrective Actions and Timeframes: Please submit the following to verify compliance.
Within 45 days of receipt of this report Family Solutions must submit a letter of verification indicating the agency is in compliance with the specific
rules cited above and describing how compliance will be maintained going forward. Along with the letter of verification, the agency must submit any
and all specific documentation requested in the body of this report. The letter of verification and any additional requested documents can be emailed
directly to robin.m.duval@dhsoha.state.or.us.
Licensing Coordinator’s Signature: ________________________ Date: _9_/1_2_/_2_0_2_3_ __________
Manager Review: ______________________________________ Date: _9_-_1_2_-2__0_2_3_ ________
6 of 6 | P a g e
Form Rev. 01/23/2023

facility_type: Residential Care

licensee: Family Solutions - Cascade House

executive_director: Dorothy Provencio

program_director: Roy Lindsay

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.
Repeat
Previous Findings: Findings
Comments or Corrective Actions
License Renewal Site Visit 08/31/2022 Further Action
Needed
SB710 Requirements: Policy and Procedures; notifications to Yes[ ] No This notification is provided to guardians and children in care
guardian and children in care. OAR 419-400-0180(8)(e), and documented as being provided.
(11)(e) and OAR 419-400-0190(1).
- No further corrective action is needed at this time.
- This licensor provided edits and

interview_summary:
The program manager began a site tour with this licensor before attending the scheduled all-staff training. The current census is 6 with one
potential new intake soon. Katie Wyland interviewed two youth and three staff. This licensor interviewed one youth and the in-house schoolteacher
and met three newer staff and briefly talked with two longer term staff.
Youth Interviews: Youth reported wanting to do more activities and get out of the program more. They've spent most of the summer break sitting
around watching TV and playing video games in the downstairs main living room. They're not allowed to use the upstairs recreation room until
after 3pm. Outings have included swimming, the park, or drives. They reported only two outings in the last two weeks. There's no structured daily
physical activity time. Staff aren't following the outing or activity schedule that's posted. Groups haven't been happening. School starts next week,
so they're hoping for more daily structure. There are staff that are trusting. With the recent staffing changes, it feels disorganized. Food is described
as good, but there's a lot of frozen meals and approximately two cooked meals per week. Phone calls with approved contact persons occur at the
end of each day for 15 minutes per youth, but it's a tight schedule to start/stop for the next youth to make a call. Phone calls occur at the kitchen
table which provides semi-privacy as youth and staff might be walking thru or doing chores. One of the therapists recently left the agency, and
the youth are seeing the other one, but it's reported their approach is more of a hands-off, listening type rather than helping them process through
feelings or providing tools to work through feelings.
Staff Interviews: Staff report that the youth need more routine and structure, and that there's been too much sitting watching TV and playing
video games during the day. This is due to not having enough staff, especially due to the recently implemented staffing ratio for outings where if
two youth go on an outing there must be two staff to accompany them, which means all youth go on the outing or there is no outing. Some youth
lose outing privileges, due to safety concerns, which contributes to the staffing/outing dilemma. It was reported the funds for outings are not always
sufficient, and there doesn't seem to be oversight of those funds or sufficient funds for the types of outings that may cost more. One staff reports
that youth are going on outings 4-5 times a week, just not on day shift, and outings include YMCA for swimming (M, W & F), drives, bowling and,
if funds allow, to the movies or coffee shop.
There's been recent staff changes and the atmosphere among coworkers feels stressed. Schedules are all over the place. Hands-on training for
new staff isn't happening as thoroughly i.e., showing a new staff person how to do a proper room check requires two staff to leave the floor, which
is nearly impossible to accommodate; staff either don't know the house rules or they're not consistent with the house rules; and only receiving a
5-minute training on BRS service documentation.
Staff report various levels of feeling comfortable going to management with concerns as well as mixed feedback about issues getting resolved or
not. Staff expressed a desire to have the program manager be more involved on the floor on a regular basis, especially during times of staff
changes, training, new client intakes and during times when client behaviors are challenging to manage.
5 of 6 | P a g e

observations:
The facility is an aging building, was originally built as a house, has original or aging bathrooms and some areas appear more worn down. The
agency works at keeping it maintained and clean. A couple maintenance issues are noted above in "New Findings". Youth bedrooms were
observed and were relatively clean and tidy. Food was observed in the cupboards and in refrigerators and freezers. The walk-through consisted
of the classroom, and all rooms, bathrooms, and common areas on the first and second floor of the residential side of the building. It was smokey
outside due to wildfires, so the youth were inside finishing up breakfast and then in the living room either watching tv or playing video games.
Staff had a scheduled training (in-person and virtual) soon after this licensor arrived, and accommodations were made to continue the
unannounced visit.

previous_findings:
Findings
Comments or Corrective Actions
License Renewal Site Visit 08/31/2022 Further Action
Needed
SB710 Requirements: Policy and Procedures; notifications to Yes[ ] No This notification is provided to guardians and children in care
guardian and children in care. OAR 419-400-0180(8)(e), and documented as being provided.
(11)(e) and OAR 419-400-0190(1).
- No further corrective action is needed at this time.
- This licensor provided edits and recommendations to
the notification document for guardians and children in Note: The form had an outdated email extension for the
care. The agency shall ensure the notification is licensing contact. The agency staff person will update and
updated and implemented going forward. ensure the new form is utilized going forward.
Medication 419-470-0100(9) Written record of the disposal of Yes No[ ] Requirement (9)(e) remains unmet: initials instead of
medications is maintained and includes: signatures; and several instances with only one staff person
(a) description and amount without a witness.
(b) name
(c) reason Some disposed medications are disposed on-site utilizing the
(d) method Rx Destroyer product, however other disposed medications
(e) staff & witness signature were in a bin labeled "disposal" with no tracking document
within said bin, creating a risk of mismanagement or theft.
1 of 6 | P a g e

- (9)(e) The agency shall ensure staff and witness
provide a signature, not initials. When speaking to several staff and the program manager,
there was a lack of clarity on the process of medication
Note: This licensor and staff discussed ways to update administration documentation and medication disposal and
documentation and processes. The agency is working on disposal documentation. There have been recent staff
updating policies and procedures to be clearer and reduce changes, and new hires that may not have received required
potential errors. training.
Corrective Action. The Agency shall:
1) Ensure staff and a witness provide a signature, not
initials.
2) Ensure two staff (one staff and one staff witness) are
disposing medications and signing the disposal
record.
3) Review medication policies and procedures to ensure
it meets requirements in related OARs and the
practices set forth by Family Solutions.
4) Ensure all staff who handle medications are provided
medication policies and procedures, are trained, and
demonstrate competency before administering and
disposing medications as well as proper
documentation.
5) Ensure management oversight for quality check and
assurances and any follow-up training needed.
**This is a repeat finding.**
2 of 6 | P a g e

Medication 419-470-0100(10) Written record of the Yes No[ ] Requirements (10)(d) and (e) are unmet. There were several
administration of medication includes: blank areas on the medication administration record with no
(a) name corresponding notes to document the circumstances where
(b) description space is provided for such notes on the back of the sheet.
(c) dates and times
(d) missed doses When speaking to several staff and the program manager,
(e) medication disposed there was a lack of clarity on the process of medication
(f) method of administration administration documentation and medication disposal and
(g) ID of person administering disposal documentation. There have been recent staff
(h) possible adverse reactions changes, and new hires that may not have received required
(i) medication taken outside facility training.
- Requirements (10)(e) and (i) are unmet. The agency Corrective Action - The Agency shall:
shall ensure all requirements are included on the
medication administration record. 1) The agency shall ensure the written record of the
medication administration are filled out accurately with
Note: This licensor and staff discussed ways to update no blanks, indicating missed doses or medication
documentation and processes. The agency is working on disposed.
updating policies and procedures to be clearer and reduce - Medication errors, or anomalies in documentation or
potential errors. administration, can be documented by adding a
notation to the medication administration record.
2) Review medication policies and procedures to ensure
it meets requirements in related OARs and the
practices set forth by Family Solutions.
3) Ensure all staff who handle medications are provided
medication policies and procedures, are trained, and
demonstrate competency before administering and
disposing medications as well as proper
documentation.
4) Ensure management oversight for quality check and
assurances and any follow-up training needed.
**This is a repeat finding.**
3 of 6 | P a g e

Children's Records Health Services 419-470-0090 Yes No
(2)(e) Documentation of age-appropriate instruction - This rule changed effective 4/18/2023 and is now required
pregnancy prevention, nutrition, prevention of HIV & AIDS, and under 419-470-0090(3)(a) Health Services Medical exams.
prevention and treatment of sexually transmitted disease
- No further corrective action is needed at this time
- (2)(e) is unmet. The agency shall ensure age-
appropriate instruction is provided and appropriately
documented in each youth file. Repeat finding.
Financial Records 419-470-0170 (4) Records contain date, Yes[ ] No Financial records are being signed by both staff and the child
amount, source, purpose, signatures. in care.
- Signatures were inconsistent. The agency shall ensure - No further corrective action is needed at this time.
signatures are regularly obtained.
Note: the administrative staff person recently implemented a
weekly quality check to verify accurate documentation and
initials when complete. This licensor recommended revising
the log form to include a column for this review and signature.
New Findings from Site Visit Corrective Actions
Physical Plant Requirements 419-470- All upstairs toilets had various levels of rings in the toilet indicating a deep cleaning and regular upkeep
0020(2)(c) All areas of buildings where was lacking. It's recommended that the agency utilize Collaborative Problem Solving techniques to
children in care are present must be kept encourage the youth to meet cleaning expectations.
clean and in good repair. Major
appliances and heating, ventilation, - Corrective Action: The agency is ultimately responsible and must ensure agency staff are
plumbing, and electrical systems must be completing necessary cleaning.
functional and in good repair.
There is dark discolored flooring around one of the upstairs toilets indicating a potential water leak,
mold, rotting floor, or other unknown reason. Mold is a health hazard, and a rotting floor structure is
a safety concern.
- Corrective Action: The agency shall seek out a professional assessment and remedy the
problem.
4 of 6 | P a g e