raw_content:
John Peloquin, CEO							3/3/2023
Discovery Practice Management
4281 Katella Avenue, Suite #111
Los Alamitos, CA  90720

Re: Licensing Inspection for Stamford GH
Regulatory Consultants: Tom Cuchara, Keith Bryan & Pat Hughes

Dear Mr. Peloquin,

On 1/24/23 and 1/25/23 a biennial re-licensing inspection was conducted at 929 Newfield Avenue, Stamford, CT.  This inspection was conducted to determine the compliance of this facility with the Regulations for Operation of Child-Caring Agencies and Facilities 17a-145-48 through 17a-145-98, as well as the DCF Guidelines for the Administration of Medication by Certified Staff and the DCF Nursing Standards.  Below are listed the areas of regulatory non-compliance which were identified during the re-licensing inspection. Please review the areas identified and submit a Service Development Plan to address each area.  The plan must be submitted within 30 days of receipt of this letter and should identify: 1. the steps to be taken to correct the non-compliance; and 2. the date the correction(s) will be completed.  The areas of non-compliance are listed on the attached DCF Licensing Report form. Please use this form to submit the Service Development Plan as well.  Also included in the report are recommendations.  Recommendations are meant to highlight areas that are not currently areas of non-compliance, but may become non-compliant if actions are not taken.  Recommendations do not require the submission of a plan of a Service Development Plan.

Section 17a-145-64. Personnel policies and procedures.
Evidence:  Twelve files reviewed.
CPR: Three files did not have evidence of CPR training. S.H., M.R., C.B.
Restraint: Four files did not have evidence of restraint training.  S.H., M.R., C.B., G.P.

Medication Administration:
DCF Reg: 17a145-75 (d) and 17a -6(g) - 16 (c)
Evidence:
1.	Based on the review of the training records the facility failed to provide quarterly training from 2021 and 2022.  No documentation that the med certified staff attended to training for two years.

2.	Submit a DCF-2272 Monthly Medication Administration Program Supervision and Review to DCF Risk Management.

3.	Based on the review of the DCF Data entry system the facility failed to submit the monthly summaries from 07/2021 to January 2023.
•	Annual Observation of Medication Administration Skills Once a year the facility nurse must observe medication certified staff performing the DCF medication administration procedure. This must be documented using the DCF-2275 DCF Medication Administration Program Procedure Checklist and placed in the employee's file.

4.	Based on the review of the records the facility failed to do Medication Administration Skills Once a year.
•	Evidence: The following medication administration certified staff members' annual skills verification not done. M.C., L., R., M.V., N.R., A.F.

5.	Quarterly Review of Policies and Procedures Quarterly, the supervising registered nurse or licensed medical person will document a review of the facility’s medication policies and a review of the continuing education offered related to medication administration.

6.	Based on the review of the records the facility failed to review the quarterly policy.
•	Missing-January 2022
•	10/01/22 No MD signature/nurse
•	01/26/21-no MD signature

7.	Mandatory Annual Epi-pen & Inhaler & Training for all staff
•	This training must be provided at least annually and whenever necessary to maintain a safe environment for children.
•	Documentation shall be maintained listing staff who have been successfully trained and deemed competent to administer Epi-pens and emergency inhalers.

8.	Based on the review of the training records the facility failed to provide annual epi-pen-asthma training.
       Evidence:  Annual epi-pen & asthma training missing in 2021 & 2022.

Once licensing has reviewed and accepted the Service Development Plan and has determined that your agency is in compliance with the regulations a decision on the issuance of a regular twenty-four month license for the program will be made.  Until DCF makes this decision the current license will remain in effect.

Should you have any questions or comments regarding the contents of this report please do not hesitate to call me at (203) 675-6975.

Sincerely,

__Thomas S. Cuchara_______________________________
Thomas S. Cuchara
Regulatory Consultant

Copy: file|


state: CT

summary: Visit conducted on 12/22/2022. Visit covered 6 main areas/topics. Found 1 compliance issues. Implemented 4 corrective actions.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

  NAME OF FACILITY / PROGRAM: Discovery Practice Management / Discovery Mood and Anxiety Program/ Stamford

 TIME OF VISIT (FROM - TO):       11:45am                       			 DATE: 12/22/2022

 AGENCY PERSONNEL WHO PARTICIPATED:

Name	Job Title
KA	Facility Manager

List of Areas / Topics covered during visit:
•	Census is 10 LBC 12. 7 females and 3 males.
•	Physical plant inspection of the Group Home.  No concerns.
•	Discussed the programing and resident's treatment and compliance.
•	No staff vacancies. KA reported the Agency hired a nursing supervisor, 10/22, to cover Stamford and Fairfield.
•	Medication Administration review of control medication found documentation correct.
•	Residents observed attending group with staff. No concerns.

Corrective Actions implemented as a result of previous visit:
Section 17a-145-76. Kitchens, equipment, food-handling.  Completed.
•	The dishwasher was removed due repair needed.  The handy man will assess repair needs.  Licensing will follow up on next visit.
•	Several kitchen floor tiles were found to be broken and present as a tripping hazard.

Areas of regulatory non-compliance identified during this visit:

No SDP required.

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Thomas S. Cuchara            __2/3/2023______________
Regulatory Consultant                                   Date

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

type: general

description: No SDP required.


summary: Visit conducted on 9/22/2022. Visit covered 4 main areas/topics. Found 4 compliance issues. Implemented 1 corrective actions.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

  NAME OF FACILITY / PROGRAM: Discovery Practice Management / Discovery Mood and Anxiety Program/ Stamford

 TIME OF VISIT (FROM - TO):       9:30am                       			 DATE: 9/22/2022

 AGENCY PERSONNEL WHO PARTICIPATED:

Name	Job Title
M	Program Director
KA	Facility Manager

List of Areas / Topics covered during visit:
•	Census is 12 LBC 12. 4 males and 8 females.
•	Physical plant inspection of the Group Home.  No concerns.
•	Discussed the programing and resident's treatment and compliance.
•	Residents observed attending group with staff. No concerns.

Corrective Actions implemented as a result of previous visit:
No SDP last quarter

Areas of regulatory non-compliance identified during this visit:
Section 17a-145-76. Kitchens, equipment, food-handling.
•	The dishwasher was removed due repair needed.  The handy man will assess repair needs.  Licensing will follow up on next visit.
•	Several kitchen floor tiles were found to be broken and present as a tripping hazard.

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Thomas S. Cuchara            __11/10/2022______________
Regulatory Consultant                                   Date

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

description: 76. Kitchens, equipment, food

description: handling.

personnel:
M	Program Director
KA	Facility Manager


areas_topics_covered: Census is 12 LBC 12. 4 males and 8 females.

areas_topics_covered: Physical plant inspection of the Group Home. No concerns.

areas_topics_covered: Discussed the programing and resident's treatment and compliance.

areas_topics_covered: Residents observed attending group with staff. No concerns.

description: 76. Kitchens, equipment, food

description: handling.

description: The dishwasher was removed due repair needed. The handy man will assess repair needs. Licensing will follow up on next visit.

description: Several kitchen floor tiles were found to be broken and present as a tripping hazard.

facility_name: Discovery Practice Management / Discovery Mood and Anxiety Program/ Stamford


facility_name: Family & Children's Aid, Inc./Girls, 10 Harmony

summary: Visit conducted on 6/10/25. Visit covered 6 main areas/topics. Found 1 compliance issues.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

  NAME OF FACILITY / PROGRAM: FCA / 10 Harmony GH

 TIME OF VISIT (FROM - TO):       __10am to 10:30am                                          DATE: 6/10/25

 AGENCY PERSONNEL WHO PARTICIPATED:

	Job Title
	Program Director
	Program Manager
	APRN

List of Areas / Topics covered during visit:
•	LBC 5. Census 5.
•	No vacant positions.
•	The physical plant is in good condition.  No concern.
•	Two youth are out of school but out of building with staff.  Three youth are in school.
•	Discussed youth's extreme and challenging behaviors with staff.
•	Program APRN sees youth daily for mental health checks, clinical, etc.  Discussed programs challenges when youth cannot be admitted to the hospital due to unsafe behaviors in the Group Home and community and how they have begun working with Danbury Hospital to explore a more human way to meet the youth's needs.

Corrective Actions implemented as a result of previous visit:
N/A

Areas of regulatory non-compliance identified during this visit:
No Regulatory Compliance Plan required

Thomas S. Cuchara                           		Date 6/10/25
Regulatory Consultant

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

facility_name: FCA / 10 Harmony GH

personnel:
Program Director
Program Manager
APRN


summary: Visit conducted on 3/31/25 & 4/1/25. Visit covered 6 main areas/topics. Found 1 compliance issues.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

  NAME OF FACILITY / PROGRAM: FCA / 10 Harmony GH

 TIME OF VISIT (FROM - TO):       __10am to 10:30am                                          DATE: 3/31/25 & 4/1/25

 AGENCY PERSONNEL WHO PARTICIPATED:

	Job Title
	Program Director
	Shift Coordinator

List of Areas / Topics covered during visit:
•	Quarterly visit completed in person, 3/31/25 and follow up phone call to Program Director, 4/1/25.
•	The Census is 4 with LBC of 5.
•	The physical plant is in good condition.  No concern.
•	One youth was in the house meeting with the clinician during the visit.  Youth did not have school, today.
•	Only one vacant position noted on 2nd shift.  Program currently using per diem staff to provide coverage.
•	One youth continually exhibit extreme challenging behaviors that as resulted in two summons to juvenile court.  Youth has assaulted staff, emergency personnel and tried to take a gun away from a police officer.  Youth is not invested in program and does not meet the clinical requirement to be maintained in the program.  Program is working with the Region and Central Office finding a more appropriate placement.

Corrective Actions implemented as a result of previous visit:
N/A

Areas of regulatory non-compliance identified during this visit:
No Regulatory Compliance Plan required

Thomas S. Cuchara                           		Date 4/3/25
Regulatory Consultant

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

personnel:
Program Director
Shift Coordinator


summary: Visit conducted on 12/4/24. Visit covered 5 main areas/topics. Found 1 compliance issues.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

  NAME OF FACILITY / PROGRAM: FCA / 10 Harmony GH

 TIME OF VISIT (FROM - TO):       __9:45am to 12pm_______                           DATE: 12/4/24

 AGENCY PERSONNEL WHO PARTICIPATED:

	Job Title
	Program Director
	RN
	Residential Manager
	Program Coordinator

List of Areas / Topics covered during visit:
Census is 4 with LBC of 5.
•	The physical plant is in good condition.  No concern.
•	QRTP review completed.
•	Most recent admission was 12/3/24.
•	Three youth were at school at the time of the visit. One youth is in the psychiatric hospital since 10/14/24.
•	Program expects she will be returning.

Corrective Actions implemented as a result of previous visit:
N/A

Areas of regulatory non-compliance identified during this visit:
No Regulatory Compliance Plan required.

Thomas S. Cuchara                           		Date 12/20/24
Regulatory Consultant

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|


summary: Visit conducted on 8/27/24. Visit covered 7 main areas/topics. Found 1 compliance issues.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

  NAME OF FACILITY / PROGRAM: FCA / 10 Harmony GH

 TIME OF VISIT (FROM - TO):       __10am to 1pm_______                   DATE: 8/27/24

 AGENCY PERSONNEL WHO PARTICIPATED:

	Job Title
	Program Director
	RN
	Residential Manager
	Program Coordinator

List of Areas / Topics covered during visit:
Census is 3 with LBC of 5.
•	The physical plant is in good condition.  No concern.
•	Staffing;: one FTE 2nd shift open and 1 part-time Sat & Sun open.  Shifts are covered by staff or per diem.
•	All staff are PMT trained.
•	One resident continues to present challenges clinically and her behaviors manifest via fainting, awol, self-harm, etc. , resulting in numerous trips to the ER. Her clinical picture is complicated, but the program continues to work closely with the DCF Area Office.
•	Two youth were in the program at the time of the visit.  Staff took them for a quick outing and returned to eat lunch.  Youth and staff interacted in a positive manner.  The third youth was at school.

Corrective Actions implemented as a result of previous visit:
N/A

Areas of regulatory non-compliance identified during this visit:
No Regulatory Compliance Plan required.

Thomas S. Cuchara                           		Date 8/28/24
Regulatory Consultant

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|


summary: Visit conducted on 6/18/24. Visit covered 7 main areas/topics. Found 1 compliance issues.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

  NAME OF FACILITY / PROGRAM: FCA / 10 Harmony GH

 TIME OF VISIT (FROM - TO):       __9:30am to 12pm_______                   DATE: 6/18/24

 AGENCY PERSONNEL WHO PARTICIPATED:

	Job Title
	Program Director

List of Areas / Topics covered during visit:
Census is 5 with LBC of 5.
•	The physical plant is in good condition.
•	Staffing;: one FTE 2nd shift open and 1 part-time Sat & Sun open.  Shifts are covered by staff or per diem.
•	All staff are PMT trained.
•	Two back to back incidents occurred when youth were on an outing with staff and other residents. Licensing followed up and determined the program responded appropriately and immediately addressed clinical and behavioral needs of residents.
•	One resident is struggling with their behavior dues to medication changes.  She is being closely monitored by staff, nursing and medical director.
•	Physical plant in good condition.

Corrective Actions implemented as a result of previous visit:
N/A

Areas of regulatory non-compliance identified during this visit:
No SDP required

Thomas S. Cuchara                           		Date 6/28/24
Regulatory Consultant

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|


summary: Visit conducted on 2/28/224 & 3/26/24. Found 1 compliance issues.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

  NAME OF FACILITY / PROGRAM: FCA / 10 Harmony GH

 TIME OF VISIT (FROM - TO):       __9:30am to 12pm_______                   DATE: 2/28/224 & 3/26/24

 AGENCY PERSONNEL WHO PARTICIPATED:

	Job Title
	Program Director
	Program Coordinator
	Program Coordinator / Clinician

List of Areas / Topics covered during visit:
Quarterly visits completed on two occasions following 6 month personnel file reviews, 2/28/24 & 3/26/24.
The Census is 3 with LBC of 5.
The physical plant is in good condition.
One youth (the same) was in the house during both quarterly visits.  She was quiet and interacted positively with staff.  The program works closely with the agency's psychiatrist, DCF SW, youth's Nexus to make necessary clinical and educational plans as needed.  Staff report the youth's struggles with school is complex and not completely understood at this time.  It is not entirely clear as to why this is a problem.  A PPT scheduled today which she will attend.

Corrective Actions implemented as a result of previous visit:
N/A

Areas of regulatory non-compliance identified during this visit:
No SDP required

Thomas S. Cuchara                           		Date 3/26/24
Regulatory Consultant

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|


summary: Visit conducted on 12/19/23. Visit covered 7 main areas/topics. Found 1 compliance issues. Implemented 3 corrective actions.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

  NAME OF FACILITY / PROGRAM: FCA / 10 Harmony GH

 TIME OF VISIT (FROM - TO):       __9:30am to 12pm_______                   DATE: 12/19/23

 AGENCY PERSONNEL WHO PARTICIPATED:

	Job Title
	Program Director
	Program Coordinator (x2)
	RN

List of Areas / Topics covered during visit:

•	Census is 1. LBC 5.
•	At the time of the visit youth is in school.
•	Physical plant inspection was conducted.  No concerns.
•	Discussed the programing, resident safety.
•	Discussed staffing of shifts.
o	Two 1st shift weekend part-time positions open. One 2nd shift weekend part-time position open.
•	The clinical coordinator has given notice to leave the program and will remain until 1/4/24.  Program Director and one of the licensed Program Coordinator's will share clinical responsibilities.
•	QRTP review was completed.

Corrective Actions implemented as a result of previous visit:
 Deficiency for regulation -17a-145-93 &  17a-6(g)-16(b)(2)    COMPLETED.
Based on a review of clinical record, facility's documentation, facility's policy and interviews for one youth reviewed for medication omission (class B). The facility failed to provide appropriate medical intervention when youth left facility via absence without official leave (AWOL). Youth was admitted to facility 05/09/2023 with diagnosis that included disruptive mood dysregulation and alcohol use disorder. Last psych evaluation completed 08/2023. A review of a complaint submitted from youth; adverse event report identified youth did not receive medication as a result of AWOL.
A review of youth's medication administration record (MAR) identified a physician's order dated 09/2023 that directed youth to have Lamictal 100 MG po every morning, Cymbalta 60 MG po every evening, Latuda 20 MG po every evening and melatonin 5 MG po every evening. Further review of MAR identified that there were three missed medications Latuda 20 MG, Cymbalta 60 MG, and Melatonin 5 MG that were not administered on the following dates -09/23, 09/24, 09/26 and 09/27/2023. A review of clinical record failed to identify a nursing or medical assessment that was performed during or after each AWOL event. A review of physician's orders failed to identify directive to withhold medication for days noted. Interview with APRN and MD on 09/28/2023 identified that staff provided update to nurse that youth had AWOL, nurse/staff provided update to MD and only an oral directive was given to withhold medication each time youth AWOL. (Per regulation telephone orders can legally be accepted only by a pharmacist or a nurse. Facility's policy must identify the timeframe during which licensed practitioners must cosign any telephone order and must not exceed 30 days the facility failed to meet this requirement). The nurse at facility failed to transcribe order for staff to follow and failed to perform an assessment after youth AWOL.

A review of facility's AWOL policy directed in part that if a resident is observed to be under the influence of drugs and/or alcohol, the resident must be medically cleared by the town's hospital or nearby hospital. The facility will recommend to hospital that a physical exam, drug test, gynecological exam (if applicable), mental status exam and possible medication evaluation and administration occur (facility staff called EMS and police, Youth was not taken to hospital based on Police/ EMS decision).

Areas of regulatory non-compliance identified during this visit:
No SDP.

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Thomas S. Cuchara                           ___12/26/23
Regulatory Consultant                                   Date

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

description: No SDP.


summary: Visit conducted on 9/28/23. Visit covered 7 main areas/topics. Found 2 compliance issues.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

  NAME OF FACILITY / PROGRAM: FCA / 10 Harmony GH

 TIME OF VISIT (FROM - TO):       __9:45am to 2:30pm_______    DATE: 9/28/23

 AGENCY PERSONNEL WHO PARTICIPATED:

	Job Title
	Program Director
	Program Coordinator (x2)
	FCA APRN
	Medical Director
	Nurse Consultant DCF

List of Areas / Topics covered during visit:

•	Census is 4. LBC 5.
•	At the time of the visit all youth were in school.
•	Physical plant inspection was conducted.  No concerns.
•	Discussed the programing, resident safety.
•	Followed up on significant event reports.
•	Discussed staffing of shifts.
•	Program hired two Program Coordinators.

Corrective Actions implemented as a result of previous visit:
•	N/A

Areas of regulatory non-compliance identified during this visit:

Deficiency for regulation -17a-145-93 &  17a-6(g)-16(b)(2)
Based on a review of clinical record, facility's documentation, facility's policy and interviews for one youth reviewed for medication omission (class B). The facility failed to provide appropriate medical intervention when youth left facility via absence without official leave (AWOL). Youth was admitted to facility 05/09/2023 with diagnosis that included disruptive mood dysregulation and alcohol use disorder. Last psych evaluation completed 08/2023. A review of a complaint submitted from youth; adverse event report identified youth did not receive medication as a result of AWOL.
A review of youth's medication administration record (MAR) identified a physician's order dated 09/2023 that directed youth to have Lamictal 100 MG po every morning, Cymbalta 60 MG po every evening, Latuda 20 MG po every evening and melatonin 5 MG po every evening. Further review of MAR identified that there were three missed medications Latuda 20 MG, Cymbalta 60 MG, and Melatonin 5 MG that were not administered on the following dates -09/23, 09/24, 09/26 and 09/27/2023. A review of clinical record failed to identify a nursing or medical assessment that was performed during or after each AWOL event. A review of physician's orders failed to identify directive to withhold medication for days noted. Interview with APRN and MD on 09/28/2023 identified that staff provided update to nurse that youth had AWOL, nurse/staff provided update to MD and only an oral directive was given to withhold medication each time youth AWOL. (Per regulation telephone orders can legally be accepted only by a pharmacist or a nurse. Facility's policy must identify the timeframe during which licensed practitioners must cosign any telephone order and must not exceed 30 days the facility failed to meet this requirement). The nurse at facility failed to transcribe order for staff to follow and failed to perform an assessment after youth AWOL.

A review of facility's AWOL policy directed in part that if a resident is observed to be under the influence of drugs and/or alcohol, the resident must be medically cleared by the town's hospital or nearby hospital. The facility will recommend to hospital that a physical exam, drug test, gynecological exam (if applicable), mental status exam and possible medication evaluation and administration occur (facility staff called EMS and police, Youth was not taken to hospital based on Police/ EMS decision).

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Thomas S. Cuchara                           ___10/6/23_______
Regulatory Consultant                                   Date

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

description: 93 & 17a


summary: Visit conducted on 3/23/23. No compliance issues identified.

raw_content:
DCF-3034
1/2013 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

  NAME OF FACILITY / PROGRAM: FCA / 10 Harmony

 TIME OF VISIT (FROM - TO):     10:45am-1:15pm               DATE: 3/23/23

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Title
Program Director
Program Coordinator

Areas / Topics covered during visit:
Current Census= 3, LBC 5. One youth is inpatient.
Staffing:  No vacancies.
Physical Plant Inspection: No concerns
Client Files: Reviewed 2 client files. Found no concerns

Corrections implemented as a result of previous visit:
 N/A

Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning)
N/A

Areas of regulatory non-compliance identified during this visit:
N/A

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Thomas S. Cuchara				3/28/23
______________________________            _________________
Regulatory Consultant                                   Date

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

facility_name: FCA / 10 Harmony

personnel:
Program Director
Program Coordinator


summary: Visit conducted on ___12/28/2022____. Visit covered 4 main areas/topics. No compliance issues identified.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

  NAME OF FACILITY / PROGRAM: Family & Children's Aid / 10 Harmony GH

 TIME OF VISIT (FROM - TO):       __12:30pm _____________________               DATE: ___12/28/2022____

 AGENCY PERSONNEL WHO PARTICIPATED:

Name	Job Title
CH	Program Director
SC	Program Coordinator

List of Areas / Topics covered during visit:
•	Census is 3, but one youth is in the hospital and scheduled to discharged to a hire level of care.
•	At the time of the visit there was no youth in the program. They are at school.
•	An evening visit to see the physical plant was completed.
•	Discussed the programing and working effective client in a group home.

Corrective Actions implemented as a result of previous visit:

Areas of regulatory non-compliance identified during this visit: NONE.

No SDP.

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Thomas S. Cuchara                           2/3/2023_______
Regulatory Consultant                                   Date

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

facility_name: Family & Children's Aid / 10 Harmony GH


summary: Visit conducted on 4-20-22. No compliance issues identified.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

  NAME OF FACILITY / PROGRAM: Family & Children's Aid/10 Harmony Girls' Group Home

 TIME OF VISIT (FROM - TO):  11:15 am -- 12:15 pm                     DATE: 4-20-22

 AGENCY PERSONNEL WHO PARTICIPATED:

	Job Title
CH	Program Director
EK	Program Coordinator

List of Areas / Topics covered during visit:
Verified census and LBC.
	Reviewed the resident's circumstances and response to the program so far.
           Inspected all common areas, the bedrooms, and med room, staff office, and clinician's office.
           Verified med keys were being carried appropriately by a med cert staff.

Corrective Actions implemented as a result of previous visit:
	Not applicable.

Areas of regulatory non-compliance identified during this visit:
	None.

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above. A plan of correction does not have to be filed.

James Richard Moore, LMSW			April 21, 2022
Regulatory Consultant                                    Date

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|


facility_name: Focus Center for Autism  / Shannon / GH #103

summary: Visit conducted on 7/22/25. Visit covered 6 main areas/topics. No compliance issues identified.

raw_content:
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form
This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM:   Shannon House
TIME OF VISIT (FROM - TO):       1:55pm-330pm              			   DATE: 7/22/25
AGENCY PERSONNEL WHO PARTICIPATED: Program Director, Program Clinician Supervisor
List of Areas / Topics covered during visit:
•	Current Census=3, LBC=4
•	Staffing:  Full time clinician hired as of 7/21/25.  All shifts are currently filled.
•	Discharge Planning
•	Significant events: 0
•	Staff/client interactions: One (1) youth was home due to having a dental procedure and was in the dining room having a snack.
•	Corrective Actions implemented as a result of previous visit: Not applicable

Physical Plant: Staff facilitated a tour of the interior/exterior of the physical plant.  All areas appear clean but there was a discussion about having youth organize their belongings and place in their closet as all three (3) bedrooms appeared cluttered.
Corrective Actions implemented as a result of previous visit: None
Areas of regulatory non-compliance identified during this visit:  None
Please submit a regulation compliance plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.  -

Amita Patel
Regulatory Consultant                                   Date  8/5/25

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM

Program Director
File|

facility_name: Shannon House


raw_content:
July 11, 2025

Donna Swanson, Executive Director
18 Shannon Drive
Barkhamsted, CT 06063
RE: CCF # 103

Dear Ms. Swanson
On 6/10/25, a relicensing inspection was conducted at your facility.  This inspection was conducted to determine the compliance of this program with the Regulations for the Licensure of a Child Caring Facility, Sections 17a-145-59 through 17a-145-98.  Listed below are the areas of regulatory non-compliance which were identified during the relicensing inspection.  Please review the areas identified and submit the enclosed service development plan to address each area. The plan must be submitted within 30 days of receipt of this letter and should identify: 1. the steps to be taken to correct the non-compliance and the date correction(s) will be completed. The areas of non-compliance are as follows:

17a-145 Chief Administrative Officer:
•	One (1) file reviewed contained CT state police and DCF background checks that were received after the employee's date of hire. (RF)
•	One (1) file reviewed did not have evidence the employee had been trained in CPS (AG)

Section 17a-145-64:  Personnel policies and procedures:
•	One (1) file reviewed contained a physical and TB test with results that were received after the employee's date of hire. (RF)
•	One (1) file reviewed was missing a physical and TB test with results.  (AG)
Section 17a-145-71. Living Room, lounge:
•	Small hole in the wall at the bottom of the stairs (near front door entry)
•	Small hole in the wall

Section 17a-145-77. Dining areas and supervision:
•	The walls and ceilings have several scuff marks.
Section 17a-145-73-Sleeping Accommodations:
•	Left Bedroom on 2nd floor has a cracked door
•	Right bedroom on the 2nd floor has loose bedroom doorknob and small hole in the wall

Section 17a-145-86	Instructions in Safety Procedures. Supervision.
•	Fire drill evacuation documentation for the licensed period indicates numerous missing reports:
?	2023:   4th quarter-1st shift missing
?	2024:   3rd quarter-2nd shift missing
     4th quarter 1st and 2nd shift missing

Section 17a-145-98. Case records. Reports.
•	Evidence that individual and group therapy (clinical & life skills) sessions were consistently delivered or received with the frequency listed on treatments plans was not found in case records.

Section 17a-151aa- Child placed in residential facility. Written agreement re care and treatment.
•	DCF 469 placement agreement signed nine (9) months after youth's admission date (AW).

Amita Patel
AMITA PATEL, LMSW
REGULATORY CONSULTANT

505 Hudson Street Hartford, CT 06106
Cell Phone: 860-924-8822 | ?Office Phone: 860-550-6373|

report_type: unstructured


summary: Visit conducted on February 20,2025. Visit covered 5 main areas/topics. No compliance issues identified.

raw_content:
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form
This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM: Shannon House

 TIME OF VISIT (FROM - TO):       1:00 pm                  DATE:    February 20,2025
AGENCY PERSONNEL WHO PARTICIPATED:

Job Title
Shannon House Direct Care Workers (2)
Shannon House Program Director

List of Areas / Topics covered during visit:

•	The current census is 3, and the LBC for Shannon House is 4.

•	Discussion of Shannon House's current staffing levels, vacant positions, and hiring activities.

•	Discussion with Shannon House staff regarding the status of the Shannon House milieu, the clinical programming, and the schedule of recreational activities offered to the residents.

•	Inspection of the Shannon House physical plant to assess the cleanliness of the home, as well as to ensure there are no health or safety concerns.

•	Observations of the interactions between the Shannon House residents and the Shannon House staff. Brief discussions with the Shannon House residents about their experiences at Shannon House.

Corrective Actions implemented as a result of previous visit:
Not Applicable.

Areas of regulatory non-compliance identified during this visit:
None at the time of this quarterly visit.

Patrick Hughes                                                                   3/17/25
Regulatory Consultant                                                         Date|

visit_date: February 20,2025


summary: Visit conducted on December 9, 2024. Visit covered 5 main areas/topics. No compliance issues identified.

raw_content:
6/2021 (Revised)

Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form
This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM: Shannon House

 TIME OF VISIT (FROM - TO):       1:30 pm                  DATE:    December 9, 2024
AGENCY PERSONNEL WHO PARTICIPATED:

Job Title
Shannon House Direct Care Workers (2)

List of Areas / Topics covered during visit:

•	The current census is 4, and the LBC for Shannon House is 4.

•	Discussion of Shannon House's current staffing levels, vacant positions, and hiring activities.

•	Discussion with Shannon House staff regarding the status of the Shannon House milieu, the clinical programming, and the schedule of recreational activities offered to the residents.

•	Inspection of the Shannon House physical plant to assess the cleanliness of the home, as well as to ensure there are no health or safety concerns.

•	Observations of the interactions between the Shannon House residents and the Shannon House staff.

Corrective Actions implemented as a result of previous visit:
Not Applicable.

Areas of regulatory non-compliance identified during this visit:
None at the time of this quarterly visit.

Patrick Hughes                                                                   12/9/24
Regulatory Consultant                                                          Date|

visit_date: December 9, 2024


summary: Visit conducted on July 16, 2024. Visit covered 5 main areas/topics. Found 1 compliance issues.

raw_content:
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form
This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM: Shannon House

 TIME OF VISIT (FROM - TO):       1:00 pm                  DATE:    July 16, 2024
AGENCY PERSONNEL WHO PARTICIPATED:

Job Title
Shannon House Program Director
Focus Center for Autism Executive Director
Shannon House Clinician

List of Areas / Topics covered during visit:

•	The current census is 4, and the LBC for Shannon House is 4, one resident is currently hospitalized.

•	Discussion of Shannon House's current staffing levels, vacant positions, and hiring activities.

•	Discussion with Shannon House staff regarding the status the Shannon House milieu, the clinical programming, the summer schedule, and the schedule of recreational activities offered the residents.

•	Inspection of the Shannon House physical plant to assess the cleanliness of the home, as well as to ensure there are no health or safety concerns.

•	Brief discussions with two (3) Shannon House residents about their feelings about living at Shannon House.

Corrective Actions implemented as a result of previous visit:
Not Applicable.

Areas of regulatory non-compliance identified during this visit:
Not at the time of this quarterly visit.

Patrick Hughes                                                                    7/17/24
Regulatory Consultant                                                       Date|


summary: Visit conducted on June 29, 2024. Visit covered 5 main areas/topics. Found 1 compliance issues.

raw_content:
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form
This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM: Shannon House

 TIME OF VISIT (FROM - TO):       2:00 pm                  DATE:    June 29, 2024

AGENCY PERSONNEL WHO PARTICIPATED:

Job Title
Shannon House Program Director
Focus Center for Autism Executive Director
Shannon House Clinician

List of Areas / Topics covered during visit:

•	The current census is 4, and the LBC for Shannon House is 4.

•	Discussion of Shannon House's current staffing levels, vacant positions, and hiring activities.

•	Discussion with Shannon House staff regarding the status the Shannon House milieu, the clinical programming, and the schedule of recreational activities offered the residents.

•	Inspection of the Shannon House physical plant to assess the cleanliness of the home, as well as to ensure there are no health or safety concerns.

•	Brief discussions with three (3) Shannon House residents about their time at Shannon House.

Corrective Actions implemented as a result of previous visit:
Not Applicable.

Areas of regulatory non-compliance identified during this visit:
Not at the time of this quarterly visit.

Patrick Hughes                                                                    7/1/24
Regulatory Consultant                                                      Date|


summary: Visit conducted on March 5, 2024. Visit covered 5 main areas/topics. Found 1 compliance issues.

raw_content:
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form
This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM: Shannon House

 TIME OF VISIT (FROM - TO):       2:00 pm                  DATE:    March 5, 2024

AGENCY PERSONNEL WHO PARTICIPATED:

Job Title

Shannon House Program Director
Focus Center for Autism Executive Director
Shannon House Clinician

List of Areas / Topics covered during visit:

•	The current census is 4, and the LBC for Shannon House is 4.

•	Discussion of Shannon House's current staffing levels, vacant positions, and hiring activities.

•	Discussion with Shannon House staff regarding the status the Shannon House milieu, the clinical programming, and the schedule of recreational activities offered the residents.

•	Inspection of the Shannon House physical plant to assess the cleanliness of the home, as well as to ensure there are no health or safety concerns.

•	Brief discussions with two (2) Shannon House residents about their time at Shannon House.

Corrective Actions implemented as a result of previous visit:
Not Applicable.

Areas of regulatory non-compliance identified during this visit:
Not at the time of this quarterly visit.

Patrick Hughes                                                                    3/6/24
Regulatory Consultant                                                        Date|


summary: Visit conducted on November 29, 2023. Visit covered 5 main areas/topics. Found 1 compliance issues.

raw_content:
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form
This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM: Shannon House

 TIME OF VISIT (FROM - TO):       2:00 pm                  DATE:    November 29, 2023

AGENCY PERSONNEL WHO PARTICIPATED:
Job Title
Shannon House Program Director

List of Areas / Topics covered during visit:

•	The current census, which is 3, and the LBC for Shannon House is 4.

•	Discussion of Shannon House's current staffing levels, vacant positions, and hiring activities.

•	Discussion with Shannon House staff regarding the status the Shannon House milieu, the clinical programming, and the schedule of recreational activities offered the residents.

•	Inspection of the Shannon House physical plant to assess the cleanliness of the home, as well as to ensure there are no health or safety concerns.

•	Discussions with the Shannon House residents about their progress at Shannon House.

Corrective Actions implemented as a result of previous visit:
Not Applicable.

Areas of regulatory non-compliance identified during this visit:
Not at the time of this quarterly visit.

Patrick Hughes                                                                    12/22/23
Regulatory Consultant                                                         Date|

visit_date: November 29, 2023


summary: Visit conducted on September 21, 2023. Visit covered 5 main areas/topics. Found 1 compliance issues.

raw_content:
Field Visit Reporting Form
This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM: Shannon House

 TIME OF VISIT (FROM - TO):       1:30 pm                  DATE:    September 21, 2023

AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles
Shannon House Program Director
Shannon House Supervisor

List of Areas / Topics covered during visit:

•	The current census, which is 1, and the LBC for Shannon House is 4.

•	Discussion of Shannon House's current staffing levels, vacant positions, and hiring activities.

•	Discussion with Shannon House staff regarding the status the Shannon House milieu, the clinical programming, recreational activities and the beginning of the new school year for the residents.

•	Inspection of the Shannon House physical plant to assess the cleanliness of the home, as well as to ensure there are no health or safety concerns.

•	Discussions with the Shannon House residents about their experiences at Shannon House.

Corrective Actions implemented as a result of previous visit:
Not Applicable.

Areas of regulatory non-compliance identified during this visit:
Not at the time of this quarterly visit.

Patrick Hughes                                                                    9/21/23
Regulatory Consultant                                                       Date|

visit_date: September 21, 2023


raw_content:
7/11/2023

Donna Swanson, Executive Director
Focus Center for Autism
326 Albany Turnpike, PO Box 452
Canton, CT 06019

Re: CCF/ GH # 103

Dear Ms. Swanson,

On June 21, 2023, a biennial licensing inspection was conducted at your facility. This inspection was conducted to determine the compliance of this facility with the Regulations for Operation of Child-Caring Agencies and Facilities 17a-145-48 through 17a-145-98, as well as the DCF Guidelines for the Administration of Medication by Certified Staff. Below are the areas of regulatory non-compliance which were identified during the re-licensing inspection.  Please review the areas of non-compliance identified on the enclosed Service Development Plan and submit your responses on the enclosed Service Development Plan to address each area.  The plan must be submitted within 30 days of receipt of this letter and should identify:  1. the steps to be taken to correct the non-compliance; and 2. the date the correction(s) will be completed.  The areas of non-compliance are listed on the attached DCF Licensing Service Development Plan.

Once the licensing unit has reviewed and accepted your plan of correction and has determined that your agency is in compliance with the regulations a decision will be made regarding the issuance of a regular 24-month license.  Please be advised that failure to submit an accepted plan of correction within the timeframe specified may lead to a licensing action, up to and including revocation. Until the Department renders a decision your current license will remain in effect.

Sincerely,

Patrick Hughes
DCF Regulatory Consultant
Licensing Unit

DCF LICENSING UNIT
INSPECTION REPORT

Date of Licensing Visit:

June 21, 2023	Date Licensing Report Received by Facility:
July 12, 2023	License Type:

CCF 	License No. #:

# 103	Date Service Development Plan Submitted to Licensing Unit:

Corporate Name:
Focus Center for Autism	Corporate Address:
326 Albany Turnpike, PO Box 452, Canton, CT 06019

Program Name:
Shannon House	Program Address:
18 Shannon Drive, Barkhamsted, CT 06063

Person Submitting Plan (Name and Title):
	Person Approving Plan (Name and Title):
	Date:

  Statute/
Licensing
Regulation #	Non-Compliance Citation	Plan of Correction/Service Development Plan	A System to Prevent
Re-Occurrence	Completion Date	Title Responsible to Monitor Plan

17a-145-98
Case records. Reports. Confidentiality

The clinical notes have not been entered into the case records in a timely manner.

At the time of the relicensing inspection, several months of clinical notes had not been entered into the case records.

August 29, 2023

Donna Swanson, Executive Director
Focus Center for Autism
326 Albany Turnpike
PO Box 452
Canton, CT 06019

Re: Shannon House CCF # 103

Dear Ms. Swanson,

We visited your agency program on June 21st and June 22nd, 2023, for a biennial licensing inspection. This inspection was conducted to determine the compliance of this program with the Regulations for the Operation of Child Caring Agencies and Facilities; Sections 17a-145-48 through 17a-145-98, as well as DCF Guidelines for the Administration of Medication by Certified Staff. We received your agency's service development plan. The plan submitted by you addresses the areas of non-compliance identified in the inspection report. The Department accepts the service development plan and has determined that your agency has met the requirements for a regular license.

This license is effective as of August 21, 2023 and is valid for twenty-four months. We thank you and your staff for your cooperative participation in the review process.

Sincerely,

Patrick Hughes

Patrick Hughes
Regulatory Consultant
Department of Children and Families
505 Hudson Street
Hartford, CT  06106
(p) 860-550-6552
(f) 860-550-6665
patrick.hughes@ct.gov|


summary: Visit conducted on March 8, 2023. Visit covered 1 main areas/topics. Found 1 compliance issues.

raw_content:
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form
This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM: Shannon House

 TIME OF VISIT (FROM - TO):       3:00 pm                  DATE:    March 8, 2023

 AGENCY PERSONNEL WHO PARTICIPATED:
Job Title
Shannon House Supervisor
Shannon House Direct Care Staff

List of Areas / Topics covered during visit:
Census
The Shannon House census is 3 and the licensed bed capacity (LBC) is 4.
There are no current referrals for the vacant bed at Shannon House.
Staffing
There have been several new staff hired this quarter at Shannon House.
Shannon House continues to hire for their vacant positions.
Shannon House is currently able to fill all shifts at Shannon House.
Program / Milieu
The Shannon House residents are doing well this quarter with very few incidents.
The residents are friendly with each other and are out in the community often.
At the time of this quarterly visit all 3 residents were home and at the kitchen table having a snack. All 3 residents were in good spirits and were talkative with this regulatory consultant. All reported to be doing well and did not have any concerns for their safety or well-being. All interactions observed between Shannon House staff and the residents were friendly and professional.
Physical Plant
During this quarterly visit a physical plant inspection was conducted.
Shannon House was clean, orderly, and nicely decorated with no health or safety concerns observed.

Corrective Actions implemented as a result of previous visit:
Not Applicable.

Areas of regulatory non-compliance identified during this visit:
Not at the time of this quarterly visit.

Patrick Hughes                                             3/16/23
Regulatory Consultant                                   Date|


summary: Visit conducted on December 20, 2022. Visit covered 7 main areas/topics. Found 1 compliance issues.

raw_content:
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form
This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.          NAME OF FACILITY / PROGRAM: Shannon House

 TIME OF VISIT (FROM - TO):       1:30 pm                  DATE:    December 20, 2022

 AGENCY PERSONNEL WHO PARTICIPATED:
Name	Job Title
LE  	Shannon House Program Director
RA  	Shannon House Clinician
List of Areas / Topics covered during visit:
•	Current census is 3 and the licensed bed capacity is 4. Currently one resident is hospitalized. Shannon House has a few referrals from Solnit North's PRTF, and Children's Center of Hamden's PRTF.
•	Discussion of the residents' progress in the program and the program's milieu. The two long term residents continue to do well.  The third and most recently admitted resident is currently hospitalized. Shannon House staff have been keeping in weekly contact with the hospitalized resident. The Shannon House clinician has continued to hold weekly counseling sessions with the resident. The resident is expected to return to Shannon House next week.
•	Discussion of Shannon House's staffing and hiring.  Shannon House is currently able to fill all shifts at Shannon House. Shannon House recently hired a new 2nd shift staff and a new 1st shift staff.
•	Physical plant inspection of the Group Home; Shannon House was clean, orderly and nicely decorated with no health or safety concerns observed.
•	Observation of the residents; at the time of this visit the residents were returning from their school programs. The residents were having free time and checking in with their staff.  Both residents appeared comfortable with staff and the interactions observed were friendly and professional.
•	During the visit this regulatory consultant had brief conversations with both residents. Both residents appeared to be in good spirits and were friendly and comfortable talking to this writer. Both residents reported to be doing well at Shannon House and did not report any concerns for their safety or well-being.

Corrective Actions implemented as a result of previous visit:
•	Not Applicable.

Areas of regulatory non-compliance identified during this visit:
•	Not at the time of this quarterly visit.

Patrick Hughes                                             2/9/23
Regulatory Consultant                                   Date|

visit_date: December 20, 2022


summary: Visit conducted on September 29, 2022. Visit covered 9 main areas/topics. Found 1 compliance issues.

raw_content:
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form
This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM: Shannon House

 TIME OF VISIT (FROM - TO):       1:00 pm                  DATE:    September 29, 2022

 AGENCY PERSONNEL WHO PARTICIPATED:
Name	Job Title
LE	Shannon House Program Director
RA	Shannon House Clinician
List of Areas / Topics covered during visit:

•	Current census is 3 and the licensed bed capacity is 4. There was one admission a month ago to Shannon House. This admission is a Voluntary Services admission with no DCF involvement.
•	Discussion of the residents' progress in the program and the program's milieu. The new resident has had some difficulties adjusting but has been improving. The two long term residents continue to do well.  The addition of the third resident has been helpful to the milieu.
•	Discussion of Shannon House's staffing and hiring.  The 1st and 3rd shifts are fully staffed, however currently there are vacancies for second shift and the weekend shifts. Shannon House continues to interview applicants however only a small percentage of the applicants follow through with their interviews.   The vacant shifts are being covered by the full-time supervisors, the Shannon House per-diem staff and the Shannon house management and clinical teams.
•	Physical plant inspection of the Group Home; Shannon House was clean, orderly and nicely decorated with no health or safety concerns observed.
•	Observation of the residents; at the time of this visit the residents were returning from their school programs. The residents were having free time and checking in with their staff.  All the residents appeared comfortable with staff and the interactions observed were friendly and professional.
•	During the visit this regulatory consultant had brief conversations with all 3 residents. All appeared to be in good spirits and were friendly and comfortable talking to this writer. All 3 residents reported to be doing well at Shannon House and did not report any concerns for their safety or well-being.

Corrective Actions implemented as a result of previous visit:
•	Not Applicable.

Areas of regulatory non-compliance identified during this visit:
•	Not at the time of this quarterly visit.

Patrick Hughes                                           9/29/22
Regulatory Consultant                                   Date|

visit_date: September 29, 2022


summary: Visit conducted on 6/9/2022. Visit covered 9 main areas/topics. Found 1 compliance issues.

raw_content:
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

  NAME OF FACILITY / PROGRAM: Shannon House

 TIME OF VISIT (FROM - TO):       2:45pm                  DATE:    6/9/2022

 AGENCY PERSONNEL WHO PARTICIPATED:

Name	Job Title
LE 	Shannon House Program Director
RA 	Shannon House Clinician

 List of Areas / Topics covered during visit:

•	Current census is 2 and the licensed bed capacity is 4. There is one current voluntary placement referral for Shannon House.
•	Discussion of the residents' progress in the program and the program's milieu. Both boys are doing well at Shannon House with only a few minor issues now and then.
•	Discussion of Shannon House's staffing and hiring. 1st and 3rd shifts are fully staffed, however currently there are no full time second shift direct care staff. The shifts are being covered by the full-time supervisors, the Shannon House per-diem staff and the clinical team.
•	Physical plant inspection of the Home; no health or safety concerns observed.
•	Observation of the residents; at the time of this visit both had returned from their school programs. One resident was watching Anime while the other residents was talking with the staff. Both appeared comfortable with staff and in the group home.
•	Interview with both residents; both residents reported to be doing well at Shannon House and did not report any concerns for their safety or well-being.

Corrective Actions implemented as a result of previous visit:
•	Not Applicable.

Areas of regulatory non-compliance identified during this visit:
•	Not at the time of this quarterly visit.

Patrick Hughes                                           7/6/22
Regulatory Consultant                                   Date|


facility_name: Gilead Community Services Inc., / Anchorage / GH

summary: Visit conducted on 3/23/26. No compliance issues identified. Implemented 1 corrective actions.

raw_content:
99DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM:           Anchorage House TGH

TIME OF VISIT (FROM - TO):12:00pm-1:00pm   	                DATE: 3/23/26

AGENCY PERSONNEL WHO PARTICIPATED:
Job Titles:
Residential Program Director, Program manager

A meeting was held with the Residential Program Director. Topics discussed included:

•	LBC is 4.  Current census is 4. (One resident hospitalized)
•	Discussed Exceptional Circumstance from this quarter.
•	Discussed vacant positions.  Three case managers, two residential support workers, one recovery assistant (part time) and a nurse.  All shifts being covered by Gilead staff.
•	Discussed peer relations, current milieu and discharge plans.
•	Discussed clinical support.
•	Physical plant inspected.  Patched walls will be painted after being repaired and a few basement ceiling tiles will be replaced.

Milieu Observation:
•	The residents were at school.

Physical Plant:
•	The house and grounds were inspected with the Residential Program Manager. No safety concerns observed.

Corrective Actions implemented as a result of previous visit: NA

Areas of regulatory non-compliance identified during this visit: NA

Please submit a regulation compliance plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The regulation compliance plan must be submitted to the attention of the undersigned at the address listed above. No regulation compliance plan is required for this Licensing visit.

James Funaro  				Date:    3-25-26
Regulatory Consultant

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM
Cc: File, Residential Program Director|

facility_name: Anchorage House TGH


raw_content:
12-4-25

Mr. Daniel Osborne
Chief Executive Officer
Gilead Community Services Inc.
222 Main Street Ext PO Box 1000
Middletown, CT  06457

Re: License # CCH/GH - 150

Dear Mr. Osborne,
On 11-12 & 11-13-25, a relicensing inspection was conducted at your facility.  This inspection was conducted to determine the compliance of this program with the Regulations for the Licensure of a Child Caring Facility, Sections 17a-145-59 through 17a-145-98.  Listed below are the areas of regulatory non-compliance which were identified during the relicensing inspection.  Please review the areas identified and submit the enclosed regulation compliance plan to address each area. The plan must be submitted within 30 days of receipt of this letter and should identify: 1. the steps to be taken to correct the non-compliance and 2. the date correction(s) will be completed. The areas of non-compliance are as follows:

Connecticut Public Act 21-172, effective October 1, 2021, requires comprehensive background checks for all prospective and current childcare staff in the state, including state and national criminal history checks and a check of the child abuse registry.
•	One personnel file reviewed did not have evidence that the check was completed prior to the hire date.

Once licensing has reviewed and accepted your regulation compliance plan and has determined that your agency is in compliance with the regulations, a decision on the issuance of a regular twenty-four-month license for your Child Caring Facility will be made. Until the Department makes this decision the current license will remain in effect. Failure to submit a plan within the required time frame may result in a licensing action up to and including refusal to renew a license.
Should you have any questions or comments regarding the content of this report please do not hesitate to call me at (860) 209-3136.

Sincerely,
James Funaro
REGULATORY CONSULTANT
505 Hudson Street Hartford, CT 06106
Cell Phone: 860-209-3136 |  Office Phone: 860-550-6500
505 Hudson Street Hartford, CT 06106|


summary: Visit conducted on 9/9/25. No compliance issues identified. Implemented 1 corrective actions.

raw_content:
99DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM:           Anchorage House TGH

TIME OF VISIT (FROM - TO):  3:00pm-3:45pm   	                DATE: 9/9/25

AGENCY PERSONNEL WHO PARTICIPATED:
Job Titles:
Residential Program Director

A meeting was held with the Residential Program Director. Topics discussed included:

•	LBC is 4.  Current census is 4.
•	Discussed Exceptional Circumstance from August.
•	Discussed vacant positions.  One part time recovery assistant and one full time recovery assistant. Vacant             nursing position has been offered to a candidate.  The program manager position will be vacant on 9/30. There are two case manager positions also vacant.
•	Discussed peer relations and current milieu.
•	Discussed clinical support.

Milieu Observation:
•	Met with resident EN in the dining room.

Physical Plant:
•	The house and grounds were inspected with the Residential Program Manager. No safety concerns observed.

Corrective Actions implemented as a result of previous visit: NA

Areas of regulatory non-compliance identified during this visit: NA

Please submit a regulation compliance plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The regulation compliance plan must be submitted to the attention of the undersigned at the address listed above. No regulation compliance plan is required for this Licensing visit.

James Funaro  				Date:    9-10-25
Regulatory Consultant

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM
Cc: File, Residential Progra|


summary: Visit conducted on 5/22/25. No compliance issues identified. Implemented 1 corrective actions.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM:           Anchorage House TGH

TIME OF VISIT (FROM - TO):  1:00pm-1:30pm   	                DATE: 5/22/25

AGENCY PERSONNEL WHO PARTICIPATED:
Job Titles:
Residential Program Director

A meeting was held with the Program Director. Topics discussed included:

•	LBC is 4.  Current census is 3. One pending placement.
•	Discussed recently discharged youth and current discharge planning.
•	Discussed current plan for staffing coverage.
•	Discussed peer relations and current milieu.
•	Discussed clinical support.
•	No new Exceptional Circumstances or 911 calls since the last quarterly visit.

Milieu Observation:
•	Residents at school.

Physical Plant:
•	The house and grounds were inspected with the Residential Program Manager. No safety concerns observed.  New living room furniture in place and kitchen lighting repairs all completed.

Corrective Actions implemented as a result of previous visit: NA

Areas of regulatory non-compliance identified during this visit: NA

Please submit a regulation compliance plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The regulation compliance plan must be submitted to the attention of the undersigned at the address listed above. No regulation compliance plan is required for this Licensing visit.

James Funaro  				Date:    5-23-25
Regulatory Consultant

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM
Cc: File, Residential Program Director|


summary: Visit conducted on 2/13/25. No compliance issues identified. Implemented 1 corrective actions.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM:           Anchorage House TGH

TIME OF VISIT (FROM - TO):  11:00am-12:30pm   	                DATE: 2/13/25

AGENCY PERSONNEL WHO PARTICIPATED:
Job Titles:
Residential Program Director

A meeting was held with the Program Manager. Topics discussed included:

•	LBC is 4.  Current census is 2. Recent referral and pending intake discussed.
•	Discussed recent discharged youth.
•	Staffing vacancies discussed
•	Discussed recent 823 reports and calls to 911.
•	Discussed peer relations and current milieu.
•	Discussed current discharge planning for both residents.
•	Discussed clinical support.
•	During this quarter licensing completed one incident response note.  The incident occurred on 1-17-25 and
           involved concerns with staff supervision of residents on third shift.

Milieu Observation:
•	Residents at school.

Physical Plant:
•	The house and grounds were inspected with the Residential Program Manager. New dining room furniture obtained.  New TV stand and living room furniture ordered.  Kitchen light being repaired during the visit as a result of recent property destruction by a resident.  No safety concerns observed.

Corrective Actions implemented as a result of previous visit: NA

Areas of regulatory non-compliance identified during this visit: NA

Please submit a regulation compliance plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The regulation compliance plan must be submitted to the attention of the undersigned at the address listed above. No regulation compliance plan is required for this Licensing visit.

James Funaro  				Date:    2-13-25
Regulatory Consultant

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM
Cc: File, Residential Program Director|


summary: Visit conducted on 12/4/24. No compliance issues identified. Implemented 1 corrective actions.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM:           Anchorage House TGH

TIME OF VISIT (FROM - TO):  12:00pm-1:30pm   	                DATE: 12/4/24

AGENCY PERSONNEL WHO PARTICIPATED:
Job Titles:
Residential Program Director

A meeting was held with the Program Manager. Topics discussed included:

•	LBC is 4.  Current census is 3. Discussed recent pending intake.
•	Staffing vacancies (2 full time openings-interviewing this week)
•	No calls for emergency services or 823 reports this quarter.
•	Discussed peer relations and activities in the community (YMCA, laser tag-rec-center).
•	Discussed current discharge planning for all three residents.
•	Discussed clinical support.
•	QRTP review tool completed.

Milieu Observation:
•	Residents at school.

Physical Plant:
•	The house and grounds were inspected with the Residential Program Manager. The resident's rooms were very neat and orderly. No safety concerns observed.

Corrective Actions implemented as a result of previous visit: NA

Areas of regulatory non-compliance identified during this visit: NA

Please submit a regulation compliance plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The regulation compliance plan must be submitted to the attention of the undersigned at the address listed above. No regulation compliance plan is required for this Licensing visit.

James Funaro  				Date:    12-6-24
Regulatory Consultant

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM
Cc: File, Residential Program Director|


summary: Visit conducted on 9/20/24. No compliance issues identified. Implemented 1 corrective actions.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM:           Anchorage House TGH

TIME OF VISIT (FROM - TO):  10:00am-11:00am   	                DATE: 9/20/24

AGENCY PERSONNEL WHO PARTICIPATED:
Job Titles:
Program Manager

A meeting was held with the Program Manager. Topics discussed included:

•	LBC is 4.  Current census is 3. One referral pending. Discussed recent discharge.
•	Staffing vacancies (1 full time case manager, one part time recovery assistant).
•	Discussed calls for emergency services this quarter and 823 reports.
•	Discussed nursing and recent med errors.
•	Discussed peer relations and activities in the community.
•	Discussed current resident's education, family involvement and discharge plans.
•	Kitchen renovation completed.
•	Discussed clinical support.

Milieu Observation:
•	Residents at school.

Physical Plant:
•	The house and grounds were inspected with the Program Manager. No safety concerns observed.

Corrective Actions implemented as a result of previous visit: NA

Areas of regulatory non-compliance identified during this visit: NA

Please submit a service development plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The service development plan must be submitted to the attention of the undersigned at the address listed above. No regulation compliance plan is required for this Licensing visit.

James Funaro  				Date:    9-20-24
Regulatory Consultant

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM
Cc: File, Program Director,|


summary: Visit conducted on 5/30/24. No compliance issues identified. Implemented 1 corrective actions.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM:           Anchorage House TGH

TIME OF VISIT (FROM - TO):  11:00am-11:45am   	                DATE: 5/30/24

AGENCY PERSONNEL WHO PARTICIPATED:
Job Titles:
Program Manager

A meeting was held with the Program Manager. Topics discussed included:

•	LBC is 4.  Current census is 2. Two pending placements.
•	Staffing vacancies (2 third shift RA positions).
•	Discussed calls for emergency services this quarter and 823 reports.
•	Discussed peer relations and activities (movies, beach pass obtained, YMCA).
•	Discussed youth services and familial support and engagement.
•	Recent projects (kitchen counters to be replaced)
•	Discussed clinical support.

Milieu Observation:
•	Both residents at school.

Physical Plant:
•	The house and grounds were inspected with the Program Manager. No safety concerns observed.

Corrective Actions implemented as a result of previous visit: NA

Areas of regulatory non-compliance identified during this visit: NA

Please submit a service development plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The service development plan must be submitted to the attention of the undersigned at the address listed above. No service development plan is required for this Licensing visit.

James Funaro  				Date:    5-30-24
Regulatory Consultant

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM
Cc: File, Program Director,|


raw_content:
January 19, 2024

Mr. Daniel Osborne
Chief Executive Officer
Gilead Community Services Inc.
222 Main Street Ext PO Box 1000
Middletown, CT  06457

Re: License # CCH/GH - 150

Dear Mr. Osborne,

On January 4th and 5th, 2024, a biennial re-licensing inspection was conducted at the Anchorage Home, located at 7 Anchorage Lane, Old Saybrook, CT. This inspection was conducted to determine the compliance of this program with the DCF Regulations for Operation of Child-Caring Agencies and Facilities 17a-145-48 through 17a-145-124.

During the inspection no areas of regulatory non-compliance were identified. Enclosed you will find a renewal license for the residential program.  I thank you and your staff for the cooperation extended to me during the relicensing process.

If you have any questions, please do not hesitate to contact me at (860) 209-3136.

Sincerely,

James Funaro
_____________________________
James Funaro
DCF Regulatory Consultant|


summary: Visit conducted on 12/19/23. No compliance issues identified. Implemented 1 corrective actions.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM:           Anchorage House TGH

TIME OF VISIT (FROM - TO):  11:30am-12:15pm   	                DATE: 12/19/23

AGENCY PERSONNEL WHO PARTICIPATED:
Job Titles:
Program Manager
2 Case Managers

List of Areas / Topics covered during visit: This was a scheduled quarterly Licensing visit to obtain a program update and tour the physical plant.

A meeting was held with the Program Manager. Topics discussed included:
•	LBC is 4.  Current census is 2. One resident currently hospitalized. One resident discharged this quarter.
•	Staffing vacancies (1 second shift, 2 third shift).
•	Discussed calls for emergency services this quarter.
•	Discussed peer relations and activities (movies, bowling, YMCA).
•	Recent projects (new kitchen appliances, cabinet replacement soon)
•	Discussed clinical and nursing support.
•	Upcoming relicensing visit.

Milieu Observation:
•	The resident was at school.

Physical Plant:
•	The house and grounds were inspected with the Program Manager. No safety concerns observed, and the home was very clean and maintained well.

Corrective Actions implemented as a result of previous visit: NA

Areas of regulatory non-compliance identified during this visit: NA

Please submit a service development plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The service development plan must be submitted to the attention of the undersigned at the address listed above. No service development plan is required for this Licensing visit.

James Funaro  				Date:    12-19-23
Regulatory Consultant

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM
Cc: File, Program Director|

personnel:
Program Manager
2 Case Managers


summary: Visit conducted on _09/14/23_. No compliance issues identified.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

  NAME OF FACILITY / PROGRAM: Gilead / Anchorage Home

 TIME OF VISIT (FROM - TO):       First shift_                                                   DATE: _09/14/23_

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:
Program Director

List of Areas / Topics covered during visit:
Status of the home and the physical plant. Two youth were residing in the home and they both were at home. The home had 1 recent discharge and has had 2 recent referrals.

The program director, the clinician and 3 direct care staff were on duty.

Corrective Actions implemented as a result of previous visit:
None

Areas of regulatory non-compliance identified during this visit:
None

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

_Keith Bryan____________                  ____9/14/23__
Regulatory Consultant                                   Date

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

facility_name: Gilead / Anchorage Home

visit_time: First


facility_name: Justice Resource Institute / Chesterfield /GH #127

summary: Visit conducted on October 28, 2025. Visit covered 10 main areas/topics. Found 1 compliance issues.

raw_content:
DCF-3034
1/2013 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

 NAME OF FACILITY / PROGRAM: JRI/ Chesterfield Group Home Program

 TIME OF VISIT (FROM - TO): 11:30 am to 12:30 pm                     DATE: October 28, 2025

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Title
                                                                    Program Director
Division Director

Areas / Topics covered during visit:

•	Census: The group home had four residents at the facility at the time of the quarterly inspection.
•	Admissions: The program reported that there was one new admission in the last quarter.
•	Discharges: It was reported that there was one unplanned discharge in the last quarter.
•	Staff vacancies: The group home had one full-time vacancy and 2 per-diem staff vacancies.
•	Staff hires: It was reported that there was one new employee hired in the last quarter.
•	Medication: The program currently has seven medication certified employees at the facility.
•	Physical plant: A walkthrough of the facility was conducted with the program director and division director to confirm regulatory compliance.

•	SIU Report: There were no reports in the last quarter.

Corrections implemented as a result of previous visit:
N/A

Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning)
N/A

Areas of regulatory non-compliance identified during this visit:
17a-145-75: Health and Medical Treatment. On 11/3/25, the program failed to administer medication to residents at the facility. Medication staff were not scheduled for the third shift, and there were no workers available to administer medication during that time.

Please submit a plan of correction to address the above referenced areas of non-compliance within 7 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Penny Woodward, LCSW                                  November 17, 2025
Regulatory Consultant                                                    Date

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

facility_name: JRI/ Chesterfield Group Home Program

visit_date: October 28, 2025

personnel:
Program Director
Division Director


summary: Visit conducted on June 12, 2025. Visit covered 7 main areas/topics. No compliance issues identified.

raw_content:
DCF-3034
1/2013 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

 NAME OF FACILITY / PROGRAM: JRI/ Chesterfield Group Home Program

 TIME OF VISIT (FROM - TO): 10:55 am to 12:00 pm                     DATE: June 12, 2025

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Title
Program Director

Areas / Topics covered during visit:

•	Census: The group home currently has four youths at the facility and the bed capacity continues to be four.
•	Admissions: The program reported that there was one new admission in the last quarter.
•	Discharges: It was reported that there was one planned discharge in the last quarter.
•	Staff vacancies: The group home had no employee vacancies, and it is operating at full capacity.
•	Staff hires: It was reported that there were no new hires in the last quarter.
•	Medication: The program currently has thirteen medication certified employees at the facility.
•	Physical plant: A walkthrough of the facility was conducted with the program director and no deficiencies were identified.

Corrections implemented as a result of previous visit:
N/A

Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning)
N/A

Areas of regulatory non-compliance identified during this visit:
N/A

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Penny Woodward, LCSW                               June 26, 2025
Regulatory Consultant                                              Date

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|


summary: Visit covered 9 main areas/topics. No compliance issues identified.

raw_content:
DCF-3034
1/2013 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

 NAME OF FACILITY / PROGRAM: JRI/ Chesterfield Group Home Program

 TIME OF VISIT (FROM - TO): 11:40 am to 12:30 pm                     DATE January 30, 2025
 AGENCY PERSONNEL WHO PARTICIPATED:

Job Title
                                                                    Program Director
                                                                   Clinical Case Manager
House Manager

Areas / Topics covered during visit:

•	Census: The group home currently has four residents at the facility and the bed capacity remains at four.
•	Admissions: There was one new admission in the month of November.
•	Discharges: The group home reported that there were no discharges in the last quarter.
•	Staff vacancies: The program has no staff vacancies and is operating at full capacity.
•	Staff hires: The group home hired a new nurse in the last quarter.
•	Medication: The program currently has nine medication certified employees at the facility.
•	Physical plant: A walkthrough of the group home facility was conducted with the program director and the building was being maintained according to regulatory standards
•	Personnel: Employee records and files were not reviewed.
•	SIU Reports: There were no reports in this quarter.

Corrections implemented as a result of previous visit:
N/A

Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning)
N/A

Areas of regulatory non-compliance identified during this visit:
N/A

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Penny Woodward, LCSW                                February 18, 2025
Regulatory Consultant                                              Date

A COPY OF THIS SUMMARY SHOULD BE SET TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|