summary: License Renewals - 3 findings

raw_content:
Licensed Child Caring Agency Site Visit Report
Therapeutic Boarding Schools
Licensee: JBARJ Youth Programs – The Academy at Sisters Date of site visit: 7/5/2022 – 7/7/2022
Executive Director: Stephanie Alvstad Licensing Coordinator: Ed Wyller, assisted by Irvin Minten, and
Program Director: Melinda Hare Jorge Pelinski
Board Chairperson: Jeannette McKenzie
Other Regulatory or Accrediting Agencies: National Association of Therapeutic Schools Programs, Inc (NATSAP), Council on
Accreditation, Cognia, and Sevis approved
Program Compliance: The program was found to be compliant or will be compliant with OAR 413-215-0001 to 413-215-0131, Licensing Umbrella
Rules, and OAR 413-215-0601 to 413-215-0681, Licensing Therapeutic Boarding Schools Rules. Personnel records were reviewed and compliance
with required background checks was documented for employees in all programs.
Program Description(s): JBARJ’s website reports the following “J BAR J Youth Services promotes innovative options for at-risk youth and families
toward self-sufficiency and personal responsibilities. J BAR J Youth services is a 501c non-profit corporation founded in 1968 and is currently the
largest provider of services to youth and families in Central Oregon.
The Academy at Sister’s empowering at-risk girls to lead healthy lives: A therapeutic boarding school using an approach blending both traditional
and experiential therapies, such as: Accountability-Based Cognitive Awareness helps address patterns which influence thoughts, emotions
(feelings), choices, behaviors, and decision making. Dialectical Behavioral Therapy offers additional tools and coping strategies to help manage the
behaviors and issues that are creating stress and discord. Equine Assisted Psychotherapy affords a way to engage youth who are resistant to
traditional to talk therapy through the use of horses as a medium and metaphor to treatment.”
Program type and services: The Academy is a Therapeutic Boarding School
Interventions:
 Individual Therapy
 Group Therapy
 Mindful Self Compassion
(rev. 03/25/2021)
 Dialectical Behavioral Therapy (DBT)
 Skill Building Groups / Organic Gardening
 Community Service Projects and Volunteering
 Experiential Activities
 Family Therapy, Workshops, & Coaching
Academics:
 Accredited Academics
 Proficiency-Based Model with Semester-end Portfolio Presentations
 Experiential Learning
 College preparatory focus
 SAT/ACT Prep
 Opportunity to Transition into local high school when appropriate
Capacity and Age Range: Capacity 28, ages 13-18
Funding sources: Tuition based, private pay, Oregon Department Education (ODE), United States of Department of Agriculture (USDA)
Contracts and sources for referrals: Independent Educational Consultants, Therapists, Wilderness and other therapeutic programs and internet.
Average length of stay: 12-18 months
Average daily population served: 16
Number of children served annually: JBARJ reports as an agency serving 156 youth annually.
Interviews, Observations: Program has installed new flooring throughout the building. New tile in the bathrooms and new carpet as well. The
newly installed carpet in hallway easily tracks dirt and program is considering tiling as well.
I met with two Academy students. Both students reported that they feel safe and on a scale from 0-10 (0=worst program and 10=best program)
both indicated The Academy to be an 8. One student reported the family therapy to be very helpful. This student reported while being at The
Academy learning about themselves, learning goals and values, and how to communicate with their family. The other student reported attending
therapy and family therapy and working on their victim thinking and assertive communication.
Regarding food one student reported the food to be “good” and the other student reported “food has improved”. Both reported that they have
enough food to eat and have options and snacks. Both students reported going on outings into the community such as shopping, farmers markets,
bowling, escape rooms, hikes, ice skating, and movies. On site recreation reported to include: crafts, cards, tv, and yoga. When asked if the
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students could think of how to improve the program one student reported having more input in rule book by students. The other student would like
more consistency amongst the staff.
Program Strengths: JBARJ reports, “Accredited with the Council on Accreditation, as well as Cognia Accreditation for our Education systems
(schools). Leadership and Board have 10 plus years longevity. Use Evidenced Based Cognitive Behavioral treatment. Over thirty years of service
to the community, program started in 1968, the administration and treatment philosophy has been in place since 1989. Involvement in the
community and respond to community needs to continue to develop programs. Parent agency has oversight of smaller programs, thus making
insurance, fiscal oversight, marketing, human relations, and development attainable for small programs. Annual fund raiser brings financial support
in the from the region. Staff encouraged to join boards, and network with local, state, and federal agencies to continue bringing in best practices
and staying on top of new treatments, rules, and regulations.”
Program Challenges: JBARJ reports, “Staffing, turnover, and workforce stability. Funders pay rate doesn’t always keep up for what we need to
pay employees to keep them. Keeping up with new rules and regulations that hare expected but not funded. Federal and state rules are
consistently in flux (Covid mask policy, vaccination policy, etc.) while we are just trying to run treatment programs for youth. New state laws and
rules that don’t necessarily help our youth but increase out workload.”
Changes that have occurred in the last 2 years: JBARJ reports, “High staff turnover. Unfunded mandates that increase workload on an already
depleted existing workforce. New law in Oregon that now can charge staff for stepping between two youth to stop a fight which in now considered a
“restraint” and staff could potentially be charged with “wrongful restraint”. This is ironic as we currently are engaged in a lawsuit against our agency,
for “failing” to intervene to protect a student that was getting hit by another student. If we fail to intervene, we face lawsuits, fi we intervene we face
lawsuits, or an already depleted workforce being charged with “wrongful restraint”. We find this is increasingly the case, whereby federal agencies,
state agencies, and the legislature, make rules in silos, without looking at the global picture. This is making it incredibly difficult to run programs to
help youth.”
Lawsuits: JBARJ reports, “As of June 30, 2021, there was a claim that was a threatened lawsuit that was then filed on July 31, 2021. This is a
personal injury lawsuit filed by a former student alleging negligence and recklessness of JBARJ Youth Services.”
Grievances and complaints filed in the last two years: JBARJ reports, “No”.
Corrective Actions and Timeframes: Please submit the following to verify compliance.
Within 45 days of receipt of this report JBARJ must submit a letter of verification indicating the agency is in compliance with the specific rules cited
above and describing how compliance will be maintained going forward. Along with the letter of verification, the agency must submit any and all
specific documentation requested in the body of this report. The letter of verification and any additional requested documents can be emailed
directly to Ed Wyller edward.wyller@dhsoha.state.or.us or sent by regular mail to the following address:
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Due to Covid-19 pandemic and working remotely the preferred method is to send directly to Ed Wyller at his email address.
Department of Human Services, Children’s Care Licensing Program
Attn: Ed Wyller
201 High St SE, Suite 500
Salem, OR 97301
Exceptions: Current and renewed exception on file for (Separation of adults and minors)
Summary of Review
Program and Services Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0011(2) Completed
Program and services are in scope of license x
Governance of the Agency Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0021 Completed
(1)(a) Minimum of 5 board members x
(2)(f) Formally evaluate the exec. Director’s x
performance annually
(2)(h) Obtain and review an annual x
independent financial review or audit of
financial records.
(2)(k) Written quality improvement program x
(2)(l) Meeting minutes x
Executive Director or Program Director Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0021 Completed
(3)(a) knowledge of requirements for x
providing care and treatment appropriate to
programs
(3)(g) Approval from BCU x
Discipline, Behavior Management, and Corrective Action
Yes No N/A Corrective Actions/Comments
Suicide Prevention 413-215-0076 Completed
(3) Agency uses appropriate and positive
methods of behavior management and
x
nationally recognized non-violent crisis
intervention
(3)(b)(C) Agency does not use chemical and
mechanical restraint (excluding medically x
necessary devices/prescriptions)
(3)(c) Agency uses appropriate time-out
rooms (adequate space, heat, light and x
ventilation and is not capable of locking) and
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documents use in child’s record when
applicable
(3)(e) Agency uses seclusion
x
appropriately/consistent with policy
(4) Agency has adequate plan in place to
x
respond to suicidal behavior/warning signs
Contractors (if applicable) Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0061(6) Completed
(a) Agency ensures the contractor meets the
requirements of this rule and Chapter 413 x
division 215
(b)(B) Contract includes the following:
(i) Services provided
(ii) Contractor fees
(iii) Disclosure of information from contractor
to agency
(iv) Lines of authority x
(v) Adherence to rules, including background
check
(vi) Any liability of the agency for acts of the
contractor, rights of indemnity and limitations
on liability
Supplemental Information Provided by Corrective Action
Yes No N/A Corrective Actions/Comments
CCA Completed
Documents as indicated on the form titled
x
“Renewal Licensing Required Documents”
Documents as indicated on form titled
“Required Financial Documents and x
Information”
All required policies and procedures as
x
identified in the “Umbrella Rules”
All required policies and procedures as
x
identified in “Agency Type Specific Rules”
Educational Services Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0611 Completed
(2) 1:15 ratio for qualified teacher/children x
(4) Secondary schools – verification provided x
that meets academic standards to obtain
admission to higher education and receive
high school diploma or GED
Physical Plant Corrective Action
Yes No N/A Corrective Actions/Comments
Completed
413-215-0046(3)(a) Foster Rights Posted (if x
children in DHS custody)
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413-215-0051(1) Sufficient safe space, x
equipment, and office equipment
413-215-0091(12) License is posted in x
common area at each facility
413-215-0001(5)(d), 0621(1) & 0618(4)(a)(J) x
Adequate furnishings and personal items
413-215-0616(2)(a) &(c) Buildings are x  Carpet in main hallway was soiled. Carpet was
smoke free, clean and in good repair installed last year and reported to have been recently
413-215-0616(2)(d) Rooms are free of x steam cleaned.
harmful drafts, odors, and excessive noise  Student bathroom sink clogged in modular bathroom.
413-215-0616(2)(e) Rooms are adequate in x
size and arrangement
413-215-0616(2)(f) System provides a x
continuous supply of hot and cold water
413-215-0616(2)(h) Building is well x
ventilated and room temperature is within a
normal comfort range
413-215-0616(2)(i)(C) Staff supervise x
children who lack ability to safely adjust
water temperature
Room and Space Requirements Corrective Action
Yes No N/A Corrective Actions/Comments
Bedrooms 413-215-0618(3) Completed
(a) Adequate furnishings and personal items x
(b) Separate from rooms used for dining, x
living, laundry, kitchen, and storage
(c) Outside room with window allowing x
egress from building
(d) Ceiling at least 90 inches x
(e) Minimum 60 SF per bed x
(f) No more than 25 if dorm style x
(g) Permanently wired fixtures x
(h) Window covering x
(i) Beds are 3 ft apart and maintained to x
ensure safety
Room and Space Requirements Yes No N/A Corrective Actions/Comments Corrective Action
Bathrooms 413-215-0618(4) Completed
(a)(A)&(B) 1:8 ratio for toilets and sinks x
(a)(D) Hot and cold running water, soap, and x
approved hand drying options
(a)(E) 1:10 ratio for shower or bathtub x
(a)(F) Individual privacy x
(a)(G) Window covering x
(a)(H) Permanently wired fixtures x
(a)(I) Adequate ventilation x
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(b)&(c) Wooden racks on floors are x
prohibited and impervious shower mats are
disinfected & dried daily
Room and Space Requirements Corrective Action
Yes No N/A Corrective Actions/Comments
Kitchen 413-215-0618 (6) Completed
(a) Used exclusively for storage, food x
preparation, dish washing and activities
related to eating
(b) Walls, floors are easily cleanable x
(c) Equipment and utensils are easily x
cleanable, durable, nontoxic, and kept clean
(d) Equipment is easy to clean beneath, x
between and behind
Room and Space Requirements Corrective Action
Yes No N/A Corrective Actions/Comments
Completed
413-215-0618(2)There is a separate living x
room or lounge area – 15 SF minimum per
child
413-215-0618 (5)There is a separate dining x
room with capacity for ½ of children in care
and 15 SF per child in care
413-215-0618 (7) Laundry is separate from x
living areas, kitchen and dining
413-215-0618 (8) Separate storage areas x
are provided for food, kitchen supplies,
utensils, clean linens, soiled linens and
clothing, cleaning supplies and equip,
poisons, chemicals, outdoor recreational and
maintenance equipment
413-215-0618 (9) Outdoor activity area is x
protected from vehicles and other hazards
and of a size and availability appropriate to
the age and needs of children in care
413-215-0218 (11) Time out rooms have x
adequate space, heat, light and ventilation
and is not capable of locking
Furnishings and Personal Items Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0621 Completed
(1) There is a bed with frame, clean mattress x
and pillow and personal storage (dresser,
closet)
(2) Linens are in good repair. There is a x
waterproof mattress cover or mattress.
Linens are appropriate and towels and
washcloths are provided
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(3) Bedding is changed weekly or when x
soiled
(4)&(5) Personal hygiene supplies and x
appropriate clothing are provided
Food Services Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0636(1)&(2) Completed
(1)(a) Meals are arranged daily, consistent x
with normal mealtimes that occur during the
hours of operation
(b) Snacks are available and provided as x
appropriate to the age and activity levels of
children.
(c) Menus are prepared in advance in x
accordance with USDA guidelines, provide a
variety of foods and are adjusted for
seasonal changes.
(c) Menus are maintained for at least 6 x
months
(d) Drinking water is freely available x
(2)(a) Food is stored, prepared & served in a x
sanitary manner
(2)(c) & (d) Food products are obtained from x
commercial suppliers (exception of fruits &
vegetables), unpasteurized juice is
prohibited, and only Grade A pasteurized
and fortified milk in appropriate container.
Safety Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0641 Completed
(2)(b) Telephone numbers for local police x
and fire are posted near all telephones
(2)(c) Operative flashlights sufficient in x
number are readily available to staff
(3)(a) Evacuation drill occurs monthly under x
varying conditions, is retained 2 yrs and
contains;
(A) identity of person conducting drill
(B) date & time
(C) notification method
(D) staff participating
(E) # of children & staff evacuated
(F) special conditions simulated
(G) problems encountered
(H) time to complete
Safety – Transportation Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0641 Completed
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(5)(b) Vehicle has insurance policy, is smoke x  Vehicles were missing fire extinguishers and current
free, safe operating condition, and has first proof of insurance.
aid kit and fire extinguisher 2-A:10-BC
Medication Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0651 Completed
(3)&(7)(e) Medications have a prescription x
and are stored in the original container with
prescription label
(4)&(5) Herbal supplements and remedies, x
medical treatments, special diets, physical
therapy, physical aides or limitations have a
written order signed by a physician or
qualified medical professional.
(8) Medications are disposed in accordance x
with state and federal law
(9) Written record of the disposal of x
medications is maintained and includes:
(a) description
(b) name
(c) reason
(d) method
(e) staff & witness signature
(10) Written record of the administration of x
medication includes:
(a) name
(b) description
(c) dates, times
(d) missed doses
(e) medication disposed
(f) method of administration
(g) ID of person administering
(h) possible adverse reactions
(i) medication taken outside facility
Minimum Staffing Requirements Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0661 Completed
(1)&(2) Supervision is adequate for the type x
of program, location, age and type of
children, ability of supervisor to respond,
electronic backup systems.
Minimum ratios are maintained:
1:10
Overnight (staff awake)
1:14
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(3)(a) When one staff on duty, there is x
additional staff immediately available with
max response time of 30 minutes.
Names of additional staff are listed on the
schedule.
Separation of Children Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0666 Completed
(1) Children 18 yrs and older are housed in x  Current and renewed exception on file for
separate bedrooms, unless parent & child (Separation of adults and minors)
are written approval
(2) There is adequate supervision of children x
if both males and females are served by the
program. Bedrooms are separated.
Personnel Files Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0061 Completed
Staff Name
Position
(3)(g) Date of Hire
(3)(a) record of education, training and
x
previous employment
(1)(b) & (3)(b) reference checks complete
x
and documented
(1)(a) & (3)(c) Background check was
x
completed and documented
(3)(d) Annual performance evaluations x
(3)(f) Record of personnel actions x
(3)(g) Termination date, reason for
x
termination
(3)(h) Current job description x
New Employee Orientation- Umbrella
Corrective Action
Requirements (30 days) Yes No N/A Corrective Actions/Comments
Completed
413-215-0061(4)
(a) Agency policies and procedures x
(b) Ethical and professional guidelines x
(c) Organizational lines of authority x
(d) Attributes of population served x
(e) & (5)(a) to (c) Mandatory reporting that
x
includes:
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(a) legal definition of child abuse ORS
419B.005, Oregon Laws 2016, chapter 106,
section 36
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to
the employee
(f) Privacy laws x
(g) Emergency procedures x
New Employee Orientation- Therapeutic
Corrective Action
(30 days) Yes No N/A Corrective Actions/Comments
Completed
413-215-0656
(1)(a) Discipline and behavior management
protocols including de-escalation skills
training, crisis prevention skills, positive x
behavior management, and non-punitive
disciplinary techniques.
(1)(b) restraint and seclusion (if applicable) x
Ongoing Training Corrective Action
Yes No N/A Corrective Actions/Comments
Completed
413-215-0636(2)(b) Employees who handle x
food served to children have a valid food
handler’s card
413-215-0061(5) Mandatory reporting
(annually) that includes:
(a) legal definition of child abuse ORS
419B.005, Oregon Laws 2016, chapter 106,
x
section 36
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to
the employee
413-215-0641(5)(a) Employees transporting
children meet the driver requirements
(current driver’s license, insurance, trained in
x
emergency procedures & behavior
management, and training for 15+
passenger vans if applicable)
413-215-0656(2)(a) Procedures for handling
x
environmental emergencies
413-215-0656(2)(b) Universal precautions x
413-215-0656(2)(c) Behavior management x
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413-215-0656(3) One staff with current
CPR/First Aid certification on site all times x
when children are in care
Comments/Corrective Actions:
Children’s Records Corrective Action
Yes No N/A Corrective Actions/Comments
Completed
Name of Child
Health Services – Medical History
413-215-0646
(2) Medical history obtained within 30 days
(significant findings, current immunizations,
history of surgical procedures-health issues-
x
injuries, allergies, dental, vision, hearing,
behavioral health, age appropriate
instruction, and physician orders)
(3) Health services are provided (information
on reproductive health, access to birth
control, prenatal care, well-baby care, fetal
alcohol syndrome, accessing child health x
insurance, screenings for breast and other
cancers, vaccinations, access to feminine
hygiene products, and preventing STD.
(4) Medical exams (3 in first year of life,
x
2,4,6,9,14)
(6) Receives services from a QMHP at least
once every 30 days, ensures follow through
x
with medical treatments and follow up
appointments.
Medication Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0651 Completed
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If applicable, there is documentation of the
continuing evaluation of the ability of the x
child to self-administer medication
Consents Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0676(1) Completed
(a) To provide routine and emergency
x
medical care
(b) To use discipline and behavior
x
management system
(c) To use restraint or seclusion (must
specify the reasons these interventions are
x
used and how staff are trained and
supervised)
 Consents were missing to allow access as required
(d) To restrict contact with persons outside in ORS418.305, OAR413-215-0091 & 0101
x
the school
(e) To allow access as required in
x
ORS418.305, OAR413-215-0091 & 0101
(f) To impose a dress code x
(g) To restrict participation in recreational or
leisure activities consistent with behavior or x
safety issues
Disclosures Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0676(2) Completed
(a) Information on personal or room
searches and protocols for confiscation of x
contraband (includes procedures)
(b) Statement of child and family rights x
(c) Grievance policies and procedures x
(e) Statement of program services x
(f) Statement that the agency may not make
limitation on contact between child and
x
parent/guardian a condition of program
participation
Authorizations Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0676(3) Completed
(b) Visitors are approved by parent/guardian x
(c) Visitation resources are pre-approved by
parent/guardian and identity of resources x
verified by agency
(d) Authorizations are pre-approved to allow
x
children to participate in potentially
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hazardous activities, including but not limited
to using motorized yard equipment,
swimming, and horseback riding.
Information about children in care
Corrective Action
413-215-0681(1) Files contain the following Yes No N/A Corrective Actions/Comments
Completed
information:
(a) The name, gender, date of birth, religious
preference and previous address of the child x
in care.
(b) Name and location of child’s previous
x
school
(c) Date of admission x
(d) Status of legal custody including name of
each person responsible for consents and x
authorizations
(e) The name, address, and telephone
number of:
(A) The child’s parents.
(B) The child's legal guardian, if different
than the parents, and legal relationship. x
(C) Other family members identified by
family as significant to child.
(D) Professionals to be involved in
service planning (if applicable)
(f) Any required signed consents and
x
authorizations.
Service Planning Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0681(2) Completed
(a) All documentation is written in terms that
x
are easily understood
(b) Intake. Document is completed the date
child accepted into care (emergency x
placement 48 hours)
(c) Child is served according to an individual
service plan that outlines goals for services x
and care coordination
(d) Assessment. Completed within 30 days
by a QMHP and;
(A) Contains relevant historical info.,
x
current behavioral observations,
identified need for services, and how
agency will provide services
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(B) Suicide potential assessed and
record of follow up actions and referrals
when risk of suicide identified
(C) Screening for presence of co-
occurring disorders and chronic medical
conditions. Documented referral for
further assessment, planning and
intervention if applicable
(D) Screening for presence of symptoms
related to physical or psychological
trauma
(e) (A)&(B) Service plan. Completed within
60 days (parent, guardian and child actively
involved). Describes how child’s issues will x
be addressed, anticipated outcomes and
reviewed by child and guardian/parent.
(e)(C)&(D) Service plan is reviewed quarterly
by QMHP and revised when information x
indicates other services should be provided
Case Management Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0681(3) Completed
(a) Services are documented, progress
x
toward achieving goals is tracked
(b)-(d) discharge planning and instructions x
(e) follow up services offered x
(f) Incident Reporting x
Financial Records Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0681(4) Completed
Records contain date, amount, source,
x
purpose, signatures
Records and Documentation Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0071 Completed
(1) Stored safely x
(2) Permanent, legible, dated, and signed x
(7) Permanent registry for each child in care
includes (name, gender, birth date, names,
x
addresses of parents or guardians, dates of
admission, and placement upon discharge)
Comments:
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Additional Findings Related to SB 710:
413-215-0077 (8)(e): Update Policy regarding restraints and seclusion
413-215-0077 (11)(e): Each child agency shall provide notice regarding how to access the quarterly reports to the parents or guardians of children in care in
the program. The child caring agency shall provide the notice upon the child in care’s admission and at least two times each year thereafter.
413-215-0078 (1) Each child in care receiving services from a child caring agency must be given the following:
(a) Instruction regarding how a child in care may report suspected inappropriate use of restraint or seclusion.
(b) Assurance that the child in care will not experience retaliation for reporting suspected inappropriate uses of restraint or involuntary seclusion.
(c) The telephone number for the toll-free child abuse hotline described in ORS 417.805 and the telephone numbers and electronic mail addresses for the
program’s licensing agency, the child in care’s caseworker, and attorney, the child in care’s court appointed special advocate and Disability Rights
Oregon.
Licensing Coordinator’s Signature: ________________________ Date: _7_-_2_5_-2_0__2_2__________
Manager Review: ______________________________________ Date: _7_-_2_2_-2__0_2_2_ ________
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facility_type: Therapeutic Boarding Schools

licensee: JBARJ Youth Programs - The Academy at Sisters Date of site visit: 7/5/2022 - 7/7/2022

program_director: Melinda Hare Jorge Pelinski

program_description:
JBARJ's website reports the following "J BAR J Youth Services promotes innovative options for at-risk youth and families
toward self-sufficiency and personal responsibilities. J BAR J Youth services is a 501c non-profit corporation founded in 1968 and is currently the
largest provider of services to youth and families in Central Oregon.
The Academy at Sister's empowering at-risk girls to lead healthy lives: A therapeutic boarding school using an approach blending both traditional
and experiential therapies, such as: Accountability-Based Cognitive Awareness helps address patterns which influence thoughts, emotions
(feelings), choices, behaviors, and decision making. Dialectical Behavioral Therapy offers additional tools and coping strategies to help manage the
behaviors and issues that are creating stress and discord. Equine Assisted Psychotherapy affords a way to engage youth who are resistant to
traditional to talk therapy through the use of horses as a medium and metaphor to treatment."

program_services:
The Academy is a Therapeutic Boarding School
Interventions:
- Individual Therapy
- Group Therapy
- Mindful Self Compassion

- Dialectical Behavioral Therapy (DBT)
- Skill Building Groups / Organic Gardening
- Community Service Projects and Volunteering
- Experiential Activities
- Family Therapy, Workshops, & Coaching
Academics:
- Accredited Academics
- Proficiency-Based Model with Semester-end Portfolio Presentations
- Experiential Learning
- College preparatory focus
- SAT/ACT Prep
- Opportunity to Transition into local high school when appropriate

capacity_age_range: Capacity 28, ages 13-18

average_length_of_stay: 12-18 months

interviews_observations:
Program has installed new flooring throughout the building. New tile in the bathrooms and new carpet as well. The
newly installed carpet in hallway easily tracks dirt and program is considering tiling as well.
I met with two Academy students. Both students reported that they feel safe and on a scale from 0-10 (0=worst program and 10=best program)
both indicated The Academy to be an 8. One student reported the family therapy to be very helpful. This student reported while being at The
Academy learning about themselves, learning goals and values, and how to communicate with their family. The other student reported attending
therapy and family therapy and working on their victim thinking and assertive communication.
Regarding food one student reported the food to be "good" and the other student reported "food has improved". Both reported that they have
enough food to eat and have options and snacks. Both students reported going on outings into the community such as shopping, farmers markets,
bowling, escape rooms, hikes, ice skating, and movies. On site recreation reported to include: crafts, cards, tv, and yoga. When asked if the
2
students could think of how to improve the program one student reported having more input in rule book by students. The other student would like
more consistency amongst the staff.

program_strengths:
JBARJ reports, "Accredited with the Council on Accreditation, as well as Cognia Accreditation for our Education systems
(schools). Leadership and Board have 10 plus years longevity. Use Evidenced Based Cognitive Behavioral treatment. Over thirty years of service
to the community, program started in 1968, the administration and treatment philosophy has been in place since 1989. Involvement in the
community and respond to community needs to continue to develop programs. Parent agency has oversight of smaller programs, thus making
insurance, fiscal oversight, marketing, human relations, and development attainable for small programs. Annual fund raiser brings financial support
in the from the region. Staff encouraged to join boards, and network with local, state, and federal agencies to continue bringing in best practices
and staying on top of new treatments, rules, and regulations."

program_challenges:
JBARJ reports, "Staffing, turnover, and workforce stability. Funders pay rate doesn't always keep up for what we need to
pay employees to keep them. Keeping up with new rules and regulations that hare expected but not funded. Federal and state rules are
consistently in flux (Covid mask policy, vaccination policy, etc.) while we are just trying to run treatment programs for youth. New state laws and
rules that don't necessarily help our youth but increase out workload."

changes_in_last_two_years:
JBARJ reports, "High staff turnover. Unfunded mandates that increase workload on an already
depleted existing workforce. New law in Oregon that now can charge staff for stepping between two youth to stop a fight which in now considered a
"restraint" and staff could potentially be charged with "wrongful restraint". This is ironic as we currently are engaged in a lawsuit against our agency,
for "failing" to intervene to protect a student that was getting hit by another student. If we fail to intervene, we face lawsuits, fi we intervene we face

lawsuits:
JBARJ reports, "As of June 30, 2021, there was a claim that was a threatened lawsuit that was then filed on July 31, 2021. This is a
personal injury lawsuit filed by a former student alleging negligence and recklessness of JBARJ Youth Services."

grievances_and_complaints: JBARJ reports, "No".

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

excerpt:
(5)(b) Vehicle has insurance policy, is smoke
free, safe operating condition, and has first
aid kit and fire extinguisher 2-A:10-BC  Vehicles were missing fire extinguishers and current
proof of insurance.  Consents were missing to allow access as required
in ORS418.305, OAR413-215-0091 & 0101

excerpt:
(e) To allow access as required in
ORS418.305, OAR413-215-0091 & 0101


state: OR

facility_name: The Academy at Sisters

summary: Unannounced - 9 findings

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Licensee: JBARJ Youth Services – The Academy at Sisters
Executive Director: Stephanie Alvstad
Program Director: Melinda Hare
Board Chairperson: Jeannette McKenzie
Date of Unannounced: November 1st, 2022 and November 2nd, 2022
Licensing Coordinator: Ed Wyller
Other Regulatory or Accrediting Agencies: National Association of Therapeutic Schools Programs, Inc (NATSAP), Council on
Accreditation, Cognia, and Sevis approved
Purpose: Per OAR 413-215-0101 (1) (b) Children’s Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Comments
Findings
Further Action
Needed
Physical Plant Yes No☐ Carpet in hallway has been removed and replaced with tile that matches tile throughout the
building. This is no longer a finding.
413-215-0616(2)(a) &(c) Buildings are
smoke free, clean and in good repair Repeated Finding: Bathroom in modular is very slow to drain, program reports a work order
will be made for that to be addressed. At time of visit the modular is not being used as all
Carpet in main hallway was soiled. Carpet students are in the main building for sleeping arrangements.
was installed last year and reported to have
been recently steam cleaned.
Student bathroom sink clogged in modular
bathroom.
Safety – Transportation 413-215-0641 Yes☐ No All vehicles were inspected and had fire extinguishers and vehicle insurance that is valid
through July 1, 2023.
(5)(b) Vehicle has insurance policy, is smoke
free, safe operating condition, and has first
1
(rev. 200115)
aid kit and fire extinguisher 2-A:10-BC
Vehicles were missing fire extinguishers and
current proof of insurance.
Consents 413-215-0676(1) Yes No☐ Repeated Finding: The Academy student charts were missing the consents to allow access
as defined in 413-215-0091 and 0101.
(e) To allow access as required in
ORS418.305, OAR413-215-0091 & 0101
Consents were missing to allow access as
required in ORS418.305, OAR413-215-0091
& 0101
Additional Findings Related to SB Yes No☐ JBARJ Agency has updated policy regarding restraints and seclusion, and this is no longer
a finding for The Academy
710:
Repeated Finding: The academy student charts did not have documentation indicating that
the info required by 413-215-0077 (11) (e) had been provided at the time of admissions.
413-215-0077 (8)(e): Update Policy regarding
JBARJ Agency has developed the required forms; however, they have not been
restraints and seclusion
implemented at The Academy.
413-215-0077 (11)(e): Each child agency shall
provide notice regarding how to access the
quarterly reports to the parents or guardians
of children in care in the program. The child
caring agency shall provide the notice upon
the child in care’s admission and at least two
times each year thereafter.
Additional Findings Related to SB Yes No☐
710:
Repeated Finding: The Academy student charts did not have documentation indicating the
information required by 413-215-0078 (1) had been given to youth in care. JBARJ Agency
413-215-0078 (1) Each child in care receiving has developed the required forms; however, they have not been implemented at The
services from a child caring agency must be Academy.
given the following:
(a) Instruction regarding how a child in care
may report suspected inappropriate use of
restraint or seclusion.
(b) Assurance that the child in care will not
experience retaliation for reporting suspected
inappropriate uses of restraint or involuntary
seclusion.
(c) The telephone number for the toll-free
child abuse hotline described in ORS 417.805
and the telephone numbers and electronic
(rev. 07/21/2022)
mail addresses for the program’s licensing
agency, the child in care’s caseworker, and
attorney, the child in care’s court appointed
special advocate and Disability Rights
Oregon.
New Findings from Site Visit Comments
N/A Good work!
Interview Summary
I interviewed two students, one at a time, in a private office away from other students and Academy staff. On a scale from 0-10 (0=worst school, 10 =best
school) they reported The Academy to be an 8.5, and a 9 on that scale. Both students reported feeling safe at The Academy. Food at The Academy was
described as amazing. Students reported that David is a Chef from five-star restaurant. He will garnish the food and takes time to make special meals for
those of need of dietary accommodations, such as dairy free and gluten free. Both students reported being involved in numerous groups, such as DBT,
feedback, equine therapy, goal setting, self-image, and real-world problems groups. One student spoke about individual counseling and family therapy that
they are in involved in. Both students spoke highly of the school and the teacher. Both reported doing better at this school academically and learning. One
student reported, “really liking the school, the math program and the different teaching style”. They also reported, “school is personalized”. Students reported
going on outings into the community to watch moves and go bowling. They also reported going shopping at Ross and, in particular, enjoy going to Dutch Bros
coffee. A recent outing was going to the Pumpkin Patch near Smith Rock. On-site, students reported playing cards, solitaire, movie night, and volunteering to
help with horses. If given a magic wand that could change the program within reason, the youth reported they would want more junk foods, extended phone
calls, and to have a bathroom in the school building.
Observations
I observed a new gas fireplace insert that was on during a staff meeting. I observed new tile in main living room. The new tile was extended down the hallway
to student bedrooms and bathrooms. At the time of the previous visit, the carpet in hallway was dirty. New additions and improvements were nicely done.
The kitchen has been remodeled, and a new refrigerated salad bar has been added as well. The wellness/yoga room had newly donated gym equipment. I
observed students in the classroom setting interacting calmly with each other and the teacher. It was reported to me that the classroom will be remodeled,
and a bathroom will be added. Later in my unannounced visit I observed students getting ready for lunch.
Corrective Actions and Timeframes:
Please submit the following to verify compliance.
Within 45 days of receipt of this report JBARJ Youth Services must submit a letter of verification indicating the agency is in compliance with the
specific rules cited above and describing how compliance will be maintained going forward. Along with the letter of verification, the agency must
(rev. 07/21/2022)
submit any and all specific documentation requested in the body of this report. The letter of verification and any additional requested documents can
be emailed directly to Ed Wyller Edward.Wyller@dhsoha.state.or.us
Licensing Coordinator’s Signature: ________________________ Date: _1_1_/_1_7_/2_0_2__2_________
Manager Review: ______________________________________ Date: _1_1_-_1_6_-_2_0_2_2_ _______
(rev. 07/21/2022)

agency_name: J Bar J Youth Services (JBJYS)

program_name: The Academy at Sisters

program_type: (TBS) Therapeutic Boarding Schools

report_type: Unannounced

view_code: TBS

licensee: JBARJ Youth Services - The Academy at Sisters

executive_director: Stephanie Alvstad

program_director: Melinda Hare

board_chairperson: Jeannette McKenzie

licensing_coordinator: Ed Wyller

purpose:
Per OAR 413-215-0101 (1) (b) Children's Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Comments
Findings
Further Action
Needed
Physical Plant Yes No[ ] Carpet in hallway has been removed and replaced with tile that matches tile throughout the
building. This is no longer a finding.
413-215-0616(2)(a) &(c) Buildings are
smoke free, clean and in good repair Repeated Finding: Bathroom in modular is very slow to drain, program reports a work order
will be made for that to be addressed. At time of visit the modular is not being used as all
Carpet in main hallway was soiled. Carpet students are in the main building for sleeping arrangements.
was installed last year and reported to have
been recently steam cleaned.
Student bathroom sink clogged in modular
bathroom.
Safety - Transportation 413-215-0641 Yes[ ] No All vehicles were inspected and had fire extinguishers and vehicle insurance that is valid
through July 1, 2023.
(5)(b) Vehicle has insurance policy, is smoke
free, safe operating condition, and has first
1

aid kit and fire extinguisher 2-A:10-BC
Vehicles were missing fire extinguishers and
current proof of insurance.
Consents 413-215-0676(1) Yes No[ ] Repeated Finding: The Academy student charts were missing the consents to allow access
as defined in 413-215-0091 and 0101.
(e) To allow access as required in
ORS418.305, OAR413-215-0091 & 0101
Consents were missing to allow access as
required in ORS418.305, OAR413-215-0091
& 0101
Additional Findings Related to SB Yes No[ ] JBARJ Agency has updated policy regarding restraints and seclusion, and this is no longer
a finding for The Academy
710:
Repeated Finding: The academy student charts did not have documentation indicating that
the info required by 413-215-0077 (11) (e) had been provided at the time of admissions.
413-215-0077 (8)(e): Update Policy regarding
JBARJ Agency has developed the required forms; however, they have not been
restraints and seclusion
implemented at The Academy.
413-215-0077 (11)(e): Each child agency shall
provide notice regarding how to access the
quarterly reports to the parents or guardians
of children in care in the program. The child
caring agency shall provide the notice upon
the child in care's admission and at least two
times each year thereafter.
Additional Findings Related to SB Yes No[ ]
710:
Repeated Finding: The Academy student charts did not have documentation indicating the
information required by 413-215-0078 (1) had been given to youth in care. JBARJ Agency
413-215-0078 (1) Each child in care receiving has developed the required forms; however, they have not been implemented at The
services from a child caring agency must be Academy.
given the following:
(a) Instruction regarding how a child in care
may report suspected inappropriate use of
restraint or seclusion.
(b) Assurance that the child in care will not
experience retaliation for reporting suspected
inappropriate uses of restraint or involuntary
seclusion.
(c) The telephone number for the toll-free
child abuse hotline described in ORS 417.805
and the telephone numbers and electronic

mail addresses for the program's licensing
agency, the child in care's caseworker, and
attorney, the child in care's court appointed
special advocate and Disability Rights
Oregon.
New Findings from Site Visit Comments
N/A Good work!
Interview Summary
I interviewed two students, one at a time, in a private office away from other students and Academy staff. On a scale from 0-10 (0=worst school, 10 =best
school) they reported The Academy to be an 8.5, and a 9 on that scale. Both students reported feeling safe at The Academy. Food at The Academy was
described as amazing. Students reported that David is a Chef from five-star restaurant. He will garnish the food and takes time to make special meals for
those of need of dietary accommodations, such as dairy free and gluten free. Both students reported being involved in numerous groups, such as DBT,
feedback, equine therapy, goal setting, self-image, and real-world problems groups. One student spoke about individual counseling and family therapy that
they are in involved in. Both students spoke highly of the school and the teacher. Both reported doing better at this school academically and learning. One
student reported, "really liking the school, the math program and the different teaching style". They also reported, "school is personalized". Students reported
going on outings into the community to watch moves and go bowling. They also reported going shopping at Ross and, in particular, enjoy going to Dutch Bros
coffee. A recent outing was going to the Pumpkin Patch near Smith Rock. On-site, students reported playing cards, solitaire, movie night, and volunteering to
help with horses. If given a magic wand that could change the program within reason, the youth reported they would want more junk foods, extended phone
calls, and to have a bathroom in the school building.
Observations
I observed a new gas fireplace insert that was on during a staff meeting. I observed new tile in main living room. The new tile was extended down the hallway
to student bedrooms and bathrooms. At the time of the previous visit, the carpet in hallway was dirty. New additions and improvements were nicely done.
The kitchen has been remodeled, and a new refrigerated salad bar has been added as well. The wellness/yoga room had newly donated gym equipment. I
observed students in the classroom setting interacting calmly with each other and the teacher. It was reported to me that the classroom will be remodeled,
and a bathroom will be added. Later in my unannounced visit I observed students getting ready for lunch.

new_findings: N/A Good work!

excerpt:
413-215-0078 (1) Each child in care receiving has developed the required forms; however, they have not been implemented at The
services from a child caring agency must be Academy.
given the following:
(a) Instruction regarding how a child in care
may report suspected inappropriate use of
restraint or seclusion.
(b) Assurance that the child in care will not
experience retaliation for reporting suspected
inappropriate uses of restraint or involuntary
seclusion.
(c) The telephone number for the toll-free
child abuse hotline described in ORS 417.805
and the telephone numbers and electronic
mail addresses for the program's licensing
agency, the child in care's caseworker, and
attorney, the child in care's court appointed
special advocate and Disability Rights
Oregon.
New Findings from Site Visit Comments
N/A Good work!
N/A Good work!


summary: Unannounced - 7 findings

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Therapeutic Board Schools
Licensee: JBARJ Youth Services – The Academy at Sisters
Executive Director: Stephanie Alvstad
Program Director: Melinda Hare
Board Chairperson: Jeannette McKenzie
Date of Unannounced: June 12th, 2023
Licensing Coordinator: Ed Wyller
Other Regulatory or Accrediting Agencies: National Association of Therapeutic Schools Programs, Inc (NATSAP), Council on
Accreditation, Cognia, and Sevis approved
Purpose: Per OAR 419-400-0240 (1)(b) Children’s Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Comments
Unannounced Site Visit 11/01/2022 – Findings
11/02/2022 Further Action
Needed
Physical Plant Yes☐ No  Entire modular building has been remodeled with a newly remodeled bathroom.
Sink now functions properly and one student is using the modular building now. In
413-215-0616(2)(a) &(c) Buildings are Compliance.
smoke free, clean and in good repair
Repeated Finding: Bathroom in modular is
very slow to drain, program reports a work
order will be made for that to be addressed.
At time of visit the modular is not being used
as all students are in the main building for
sleeping arrangements.
1 |P ag e
Form Rev. 01/23/2023
Consents 413-215-0676(1) Yes☐ No  I verified that current student charts had this consent completed. Program has
adopted the use of DocuSign which is very convenient for having parents sign
(e) To allow access as required in forms when students are coming from other States to the Academy. (In
ORS418.305, OAR413-215-0091 & 0101 Compliance)
Consents were missing to allow access as
required in ORS418.305, OAR413-215-0091
& 0101
Repeated Finding: The Academy student
charts were missing the consents to allow
access as defined in 413-215-0091 and 0101.
Additional Findings Related to SB Yes☐ No  I verified that student records contain the necessary SB 710 requirements. I found
that program has adopted the use of DocuSign for signing consents and
710:
authorizations. (In Compliance)
413-215-0077 (11)(e): Each child agency shall
provide notice regarding how to access the
quarterly reports to the parents or guardians
of children in care in the program. The child
caring agency shall provide the notice upon
the child in care’s admission and at least two
times each year thereafter.
Repeated Finding: The academy student
charts did not have documentation indicating
that the info required by 413-215-0077 (11)
(e) had been provided at the time of
admissions. JBARJ Agency has developed
the required forms; however, they have not
been implemented at The Academy.
Additional Findings Related to SB Yes☐ No  I verified that student records contain the necessary SB 710 requirements. I found
that program has adopted the use of DocuSign for signing consents and
710:
authorizations. (In Compliance)
413-215-0078 (1) Each child in care receiving
services from a child caring agency must be
given the following:
(a) Instruction regarding how a child in care
may report suspected inappropriate use of
restraint or seclusion.
(b) Assurance that the child in care will not
experience retaliation for reporting suspected
inappropriate uses of restraint or involuntary
seclusion.
2 |P ag e
Form Rev. 01/23/2023
(c) The telephone number for the toll-free
child abuse hotline described in ORS 417.805
and the telephone numbers and electronic
mail addresses for the program’s licensing
agency, the child in care’s caseworker, and
attorney, the child in care’s court appointed
special advocate and Disability Rights
Oregon.
Repeated Finding: The Academy student
charts did not have documentation indicating
the information required by 413-215-0078 (1)
had been given to youth in care. JBARJ
Agency has developed the required forms;
however, they have not been implemented at
The Academy.
New Findings from Site Visit Comments
N/A Good work!!
Interview Summary
I interviewed two students separately outside by the picnic tables adjacent to the main building. Both students reported feeling safe at The Academy. On a
scale from 0-10 (0=worst school and 10=best school) they reported The Academy to be a 7, and 8. Students reported having enough to eat and that the last
Chef was amazing. Youth reported most recent chef made authentic tacos, fillet minion. This chef has recently left, and program is looking for a new chef.
Both students reported food is currently fine and that program still makes necessary dietary accommodations for students such as tailoring food for those with
allergies, celiac disease, and diabetes. Student’s reported learning how to manage anger, coping skills, and how to say no. The other student reported,
“learned so much and has changed for the better.” One student reported EMDR (Eye Movement Desensitization Therapy) to be very helpful for her. For fun
students reported playing cards, reading, visiting the horses, movies, walks, and on-site arts and crafts. For off-site recreation students reported going
bowling, thrifting, and visiting the crystal store. Going hiking and visiting local lakes were reported as well. Both students reported going on two big trips. In
August program goes Whitewater rafting. This past Spring Break program visited Catalina Island for a Science filled spring break. The semester students
were in Oceanography class and then had hands on learning and activities such as night snorkeling while ocean had bioluminescent tides. Students reported
teachers to be great at The Academy School. Students reported having both treatment phone calls and personal phone calls with family. Both spoke about
visits with family. Each student was asked if, given a magic wand that could improve the program, what would they do. One student reported having central
air conditioning instead of window air conditioners and swamp coolers would be preferable. Another suggestion was to add more staff. The other student
reported wanting to improve staff to accept feedback from students, more snacks, and moving wake up time form 5:45am to 6am.
3 |P ag e
Form Rev. 01/23/2023
I spoke with various staff. It was reported the program continues to improve. Staffing was reported to be good. Being accredited with COA (Council on
Accreditation) has been very helpful in program improvement. The Academy reported when student transports are used, they use Right Direction. It was
reported Right Direction does a good job. Educational consultants are used for interventions when needed. The Academy is going to do a summer school
program for summertime, and students and teachers are excited about this curriculum.
Observations
When I arrived, students were doing chores, cleaning up after lunch and getting ready for school. After chores students were preparing for the end of year
presentations for school. Interactions between students and staff were observed to be both supportive and appropriate.
I observed the facility to be orderly and clean. The Kitchen remodel has been completed with student self-serve salad bar and snack area. Intake office has
been repainted and new flooring installed, offering a bright welcoming environment. I observed admissions coordinator speaking with a student that will be
arriving in the late-night hours discussing how admission / intake process will proceed. This student is transitioning from a wilderness program in another
state.
In September youth bedrooms will have carpet removed and new flooring will be installed. The transition modular has been completely remodeled and at this
time one student occupies the space.
Corrective Actions and Timeframes:
All previous findings have been addressed and no new findings were identified. Good work!
Licensing Coordinator’s Signature: ________________________ Date: _7_/0__5_/2_0_2_3__ _________
Manager Review: ______________________________________ Date: _6_-_2_8_-2__0_2_3_ ________
4 | P a g e
Form Rev. 01/23/2023

facility_type: Therapeutic Board Schools

purpose:
Per OAR 419-400-0240 (1)(b) Children's Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Comments
Unannounced Site Visit 11/01/2022 - Findings
11/02/2022 Further Action
Needed
Physical Plant Yes[ ] No - Entire modular building has been remodeled with a newly remodeled bathroom.
Sink now functions properly and one student is using the modular building now. In
413-215-0616(2)(a) &(c) Buildings are Compliance.
smoke free, clean and in good repair
Repeated Finding: Bathroom in modular is
very slow to drain, program reports a work
order will be made for that to be addressed.
At time of visit the modular is not being used
as all students are in the main building for
sleeping arrangements.

Consents 413-215-0676(1) Yes[ ] No - I verified that current student charts had this consent completed. Program has
adopted the use of DocuSign which is very convenient for having parents sign
(e) To allow access as required in forms when students are coming from other States to the Academy. (In
ORS418.305, OAR413-215-0091 & 0101 Compliance)
Consents were missing to allow access as
required in ORS418.305, OAR413-215-0091
& 0101
Repeated Finding: The Academy student
charts were missing the consents to allow
access as defined in 413-215-0091 and 0101.
Additional Findings Related to SB Yes[ ] No - I verified that student records contain the necessary SB 710 requirements. I found
that program has adopted the use of DocuSign for signing consents and
710:
authorizations. (In Compliance)
413-215-0077 (11)(e): Each child agency shall
provide notice regarding how to access the
quarterly reports to the parents or guardians
of children in care in the program. The child
caring agency shall provide the notice upon
the child in care's admission and at least two
times each year thereafter.
Repeated Finding: The academy student
charts did not have documentation indicating
that the info required by 413-215-0077 (11)
(e) had been provided at the time of
admissions. JBARJ Agency has developed
the required forms; however, they have not
been implemented at The Academy.
Additional Findings Related to SB Yes[ ] No - I verified that student records contain the necessary SB 710 requirements. I found
that program has adopted the use of DocuSign for signing consents and
710:
authorizations. (In Compliance)
413-215-0078 (1) Each child in care receiving
services from a child caring agency must be
given the following:
(a) Instruction regarding how a child in care
may report suspected inappropriate use of
restraint or seclusion.
(b) Assurance that the child in care will not
experience retaliation for reporting suspected
inappropriate uses of restraint or involuntary
seclusion.

(c) The telephone number for the toll-free
child abuse hotline described in ORS 417.805
and the telephone numbers and electronic
mail addresses for the program's licensing
agency, the child in care's caseworker, and
attorney, the child in care's court appointed
special advocate and Disability Rights
Oregon.
Repeated Finding: The Academy student
charts did not have documentation indicating
the information required by 413-215-0078 (1)
had been given to youth in care. JBARJ
Agency has developed the required forms;
however, they have not been implemented at
The Academy.
New Findings from Site Visit Comments
N/A Good work!!
Interview Summary
I interviewed two students separately outside by the picnic tables adjacent to the main building. Both students reported feeling safe at The Academy. On a
scale from 0-10 (0=worst school and 10=best school) they reported The Academy to be a 7, and 8. Students reported having enough to eat and that the last
Chef was amazing. Youth reported most recent chef made authentic tacos, fillet minion. This chef has recently left, and program is looking for a new chef.
Both students reported food is currently fine and that program still makes necessary dietary accommodations for students such as tailoring food for those with
allergies, celiac disease, and diabetes. Student's reported learning how to manage anger, coping skills, and how to say no. The other student reported,
"learned so much and has changed for the better." One student reported EMDR (Eye Movement Desensitization Therapy) to be very helpful for her. For fun
students reported playing cards, reading, visiting the horses, movies, walks, and on-site arts and crafts. For off-site recreation students reported going
bowling, thrifting, and visiting the crystal store. Going hiking and visiting local lakes were reported as well. Both students reported going on two big trips. In
August program goes Whitewater rafting. This past Spring Break program visited Catalina Island for a Science filled spring break. The semester students
were in Oceanography class and then had hands on learning and activities such as night snorkeling while ocean had bioluminescent tides. Students reported
teachers to be great at The Academy School. Students reported having both treatment phone calls and personal phone calls with family. Both spoke about
visits with family. Each student was asked if, given a magic wand that could improve the program, what would they do. One student reported having central
air conditioning instead of window air conditioners and swamp coolers would be preferable. Another suggestion was to add more staff. The other student
reported wanting to improve staff to accept feedback from students, more snacks, and moving wake up time form 5:45am to 6am.

I spoke with various staff. It was reported the program continues to improve. Staffing was reported to be good. Being accredited with COA (Council on
Accreditation) has been very helpful in program improvement. The Academy reported when student transports are used, they use Right Direction. It was
reported Right Direction does a good job. Educational consultants are used for interventions when needed. The Academy is going to do a summer school
program for summertime, and students and teachers are excited about this curriculum.
Observations
When I arrived, students were doing chores, cleaning up after lunch and getting ready for school. After chores students were preparing for the end of year
presentations for school. Interactions between students and staff were observed to be both supportive and appropriate.
I observed the facility to be orderly and clean. The Kitchen remodel has been completed with student self-serve salad bar and snack area. Intake office has
been repainted and new flooring installed, offering a bright welcoming environment. I observed admissions coordinator speaking with a student that will be
arriving in the late-night hours discussing how admission / intake process will proceed. This student is transitioning from a wilderness program in another
state.
In September youth bedrooms will have carpet removed and new flooring will be installed. The transition modular has been completely remodeled and at this
time one student occupies the space.

new_findings: N/A Good work!!

excerpt:
413-215-0078 (1)
had been given to youth in care. JBARJ
Agency has developed the required forms;
however, they have not been implemented at
The Academy.
New Findings from Site Visit Comments
N/A Good work!!
N/A Good work!!


state: AZ

facility_name: HORIZON RECOVERY DEER VALLEY, LLC

summary: Complaint - 4/27/2026

raw_content: No deficiencies were found during the on-site investigation of complaint 00165697 conducted on April 27, 2026.

inspection_type: Complaint


facility_name: ALL ABOUT KIDS

summary: Complaint;Compliance (Annual) - 3/31/2026

raw_content: The following deficiencies were found during the on-site compliance inspection and investigation of complaint 00163721 conducted on March 31, 2026:

inspection_type: Complaint;Compliance (Annual)


facility_name: ZAREPHATH YUMA HOUSE

summary: Modification - 4/14/2026

raw_content: Deficiencies were found during an off-site review to decrease the occupancy from eight to seven, conducted on April 14, 2026.

inspection_type: Modification


facility_name: MATTIES CARE HOUSE LLC

summary: Complaint;Compliance (Annual) - 3/6/2026

raw_content:
This new Statement of Deficiencies supersedes the Statement of Deficiencies sent to the licensee on March 24, 2026.

The following deficiency was found during the on-site compliance inspection and investigation of complaint 00161086 conducted on March 6, 2026:

rule: R9-10-706.H.1.a. Personnel H. An administrator shall ensure that personnel records are: 1. Maintained: a. Throughout an individual's period of providing services in or for the behavioral health residential facility, and

evidence: Based on observation, record review, and interview, the administrator failed to ensure a personnel record was maintained throughout an individual's period of providing services in or for the behavioral health residential facility. The deficient practice posed a risk as the required information could not be verified.

findings: 1. The Compliance Officers observed E4 working at the time of the inspection as a behavioral health technician. 2. The Compliance Officers requested to review the personnel record for E4. The Compliance Officers were provided a partial personnel record for E4 to include E4's date of hire, fall prevention and recovery training, a tuberculosis baseline screening, fingerprint clearance card and verification, first aid/cardiopulmonary resuscitation training card, and verification of E4's skills and knowledge. However, the Compliance Officers were not provided E4's complete personnel record, per R9-10-706,G,.1.2.3. for review. 3. In a telephonic exit interview, E2 reported E2 had been updating personnel records and was unable to locate E4's full personnel record at the time of the inspection.


facility_name: SAHARAN OASIS

summary: Complaint - 3/19/2026

raw_content: The following deficiencies were found during the on-site investigation of complaint 00162496 conducted on March 19, 2026.

rule: A.R.S. § 36-420.01.A. Health care institutions; fall prevention and fall recovery; training programs; definition A. Each health care institution shall develop and administer a training program for all staff regarding fall prevention and fall recovery. The training program shall include initial training and continued competency training in fall prevention and fall recovery. A health care institution may use information and training materials from the department's Arizona falls prevention coalition in developing the training program.

evidence: Based on record review, documentation review, and interview, the health care institution failed to administer a training program for all staff regarding fall prevention and fall recovery to include initial training and continued competency in fall prevention and fall recovery, for three of four personnel records sampled. The deficient practice posed a risk to the physical health and safety of a resident.

findings: 1. A review of E2's personnel record revealed an initial training in fall prevention dated in September 2022. However, there was no documentation of an initial training in to cover fall recovery or continued competency training in fall prevention and fall recovery. 2. A review of E3's and E4's personnel records revealed no documentation of initial training regarding fall prevention and fall recovery. 3. A review of facility documentation revealed a policy titled "Fall Policy" (dated on January 14, 2026). The procedure stated, "It is the policy of Saharan Oasis to provide a safe environment for all residents by implementing preventative measures to reduce the risk of falls and fall-related injuries. Staff will actively identify environmental hazards, monitor residents who may be at increased risk of falling, and respond appropriately to any fall incidents. Fall prevention practices shall be incorporated into daily supervision, safety checks, and resident care activities... STAFF TRAINING... Staff will receive training related to: 1. Environmental safety awareness... 2. Resident supervision and redirection... 3. Identifying medication side effects... 4. Responding to fall incidents... 5. Incident documentation procedures... This policy will be reviewed annually by Saharan Oasis management and updated as necessary to ensure compliance with safety standards and best practices in residential behavioral health care." 4. In an exit interview, the findings were discussed with E1, and no additional statements or documentation were provided.

rule: R9-10-703.C.2.a. Administration C. An administrator shall ensure that: 2. Policies and procedures for behavioral health services and physical health services are established, documented, and implemented to protect the health and safety of a resident that: a. Cover resident screening, admission, assessment, treatment plan, transport, transfer, discharge planning, and discharge;

evidence: Based on record review, documentation review, and interview, the administrator failed to ensure policies and procedures for behavioral health services were established and documented to protect the health and safety of a resident, to cover resident admission, assessment, and treatment plan. The deficient practice posed a risk if a personnel member was unable to meet a resident's needs, as the facility had not established or documented a policy and procedure to clarify the health care institution's practice.

findings: 1. A review of R1's medical record revealed a treatment plan was developed and implemented for R1 prior to the completion of a medical history and physical examination or nursing assessment required in R9-10-707(A)(6) or (E)(1)(a). 2. A review of facility documentation revealed a policy titled "Admission & Readmission" (dated on January 5, 2026). The procedure stated, "9. Physical Examination... In compliance with A.A.C. R9-10-707(A)(5)... Residents must have a physical examination completed within thirty (30) days prior to admission or within seven (7) days following admission to the residential program..." However, the policy and procedure put the facility out of compliance as residents are required to have a medical history and physical examination within 72 hours after admission, or 30 calendar days before with an interval or progress note. 3. A review of facility documentation revealed a policy titled "Treatment Plan" (dated on December 30, 2025). The procedure stated, "Treatment Plan Development... 1. Timeframes... 1. An initial treatment plan shall be developed within 48 hrs of admission... 2. Treatment plans shall be based on... Behavioral health assessments... Psychiatric evaluations (when applicable)... Developmental, educational, and psychosocial needs..." However, there was no evidence of an established and documented policy and procedure in compliance with R9-10-708.A.1 to ensure a treatment plan was developed based on a medical history and physical examination or nursing assessment. 4. In an exit interview, the findings were discussed with E1, and no additional statements or documentation were provided.

rule: R9-10-716.B.2. Behavioral Health Services B. An administrator shall ensure that counseling is: 2. Provided according to the frequency and number of hours identified in the resident's treatment plan, and

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure counseling was provided according to the number of hours identified in a resident's treatment plan, for one of two medical records sampled. The deficient practice posed a risk as a treatment plan was not completed to articulate decisions and agreements of services to be provided.

findings: 1. A review of facility documentation revealed a policy titled "Treatment Plan" (dated on December 30, 2025). The procedure stated, "4. Interventions and Services... Specific therapeutic interventions aligned with each goal... Frequency, duration, and type of services (e.g., individual therapy, group therapy, family therapy, skill-building)..." 2. A review of R2's medical record revealed a treatment plan, dated in January 2025, which stated, "OBJECTIVE 6... Client will meet with the therapist weekly and complete groups... OBJECTIVE 7... Client will complete individual therapy to move towards family therapy..." However, R2's treatment plan did not identify the frequency and number of hours of group and individual counseling to be provided for each goal. 3. In an exit interview, the findings were discussed with E1, and no additional statements or documentation were provided.


facility_name: PROGRESSIVE HEALTH ALLIANCE

summary: Complaint - 3/17/2026

raw_content: The following deficiencies were found during the on-site investigation of complaint 00162222 conducted on March 17, 2026:

rule: R9-10-113.A.2.a-f. Tuberculosis Screening A. If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that: 2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, baseline screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1); b. If an individual may have a latent tuberculosis infection, as defined in A.A.C. R9-6-1201: i. Referring the individual for assessment or treatment; and ii. Annually obtaining documentation of the individual's freedom from symptoms of infectious tuberculosis, signed by a medical practitioner, occupational health provider, as defined in A.A.C. R9-6-801, or local health agency, as defined in A.A.C. R9-6-101; c. Annually providing training and education related to recognizing the signs and symptoms of tuberculosis to individuals employed by or providing volunteer services for the health care institution; d. Annually assessing the health care institution's risk of exposure to infectious tuberculosis; e. Reporting, as specified in A.A.C. R9-6-202, an individual who is suspected of exposure to infectious tuberculosis; and f. If an exposure to infectious tuberculosis occurs in the health care institution, coordinating and sharing information with the local health agency, as defined in A.A.C. R9-6-101, for identifying, locating, and investigating contacts, as defined in A.A.C. R9-6-101.

evidence: Based on documentation review, record review, and interview, the chief administrative officer failed to establish, document, and implement tuberculosis (TB) infection control activities to include baseline screening consisting of assessing risks of prior exposure to infectious TB and determining if the individual had signs or symptoms of TB, for one of three personnel records sampled. The deficient practice posed a potential TB exposure risk to residents.

findings: 1. A review of facility documentation revealed an undated policy titled "Section 19: Infection Control." The policy stated, "1. All personnel and residents of this facility are required to provide one of the following on admission/hire and annually thereafter; a. A report of a negative Mantoux Tuberculin (TB) skin test within 6 months of the date of employment or residence in the facility; or b. A written physician's statement dated within 6 months of employment or residence in the facility indicating freedom from pulmonary tuberculosis, if the individual has a positive skin test for tuberculosis..." However, the requirements in (A)(2)(a)(i)(ii)(iii), for baseline screening, were not established and documented in this policy regarding TB infection control activities. 2. A review of E2's personnel record revealed a negative PPD skin test dated November 14, 2024, and January 14, 2026. However, no documentation of a baseline screening consisting of assessing risks of prior exposure to infectious TB and determining if E2 had signs or symptoms of TB was available. 3. In an exit interview, E1 and E2 reviewed the findings and E2 reported E2 was asked the questions at the clinic and wasn't provided documentation of the baseline screening.

rule: R9-10-706.G.3.a. Personnel G. An administrator shall ensure that a personnel record is maintained for each personnel member, employee, volunteer, or student that includes: 3. Documentation of: a. The individual's qualifications, including skills and knowledge applicable to the individual's job duties;

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure a personnel record was maintained for each personnel member to include documentation of the individual's qualifications, including skills and knowledge applicable to the individual's job duties, for one of three personnel records sampled. The deficient practice posed a risk if E2 was unable to meet the needs of the residents.

findings: 1. A review of facility documentation revealed a policy titled "Verification of Skills and Knowledge," dated March 12, 2024. The policy stated, "Verification of skills and knowledge will be checked prior to starting employment... There is a form used for verification of skills and knowledge." 2. A review of E2's personnel record revealed no documentation of the verification of E2's qualifications, skills and knowledge was available. 3. In an exit interview, E1 and E2 reviewed the findings and E2 reported E2 was in the process of moving all physical documents to an electronic health record and discarded the documentation of the verification of E2's qualifications, including skills and knowledge. E2 reported E2 would have E2's verification of qualifications, including skills and knowledge documented again.

rule: R9-10-706.G.3.c. Personnel G. An administrator shall ensure that a personnel record is maintained for each personnel member, employee, volunteer, or student that includes: 3. Documentation of: c. The individual's completed orientation and in-service education as required by policies and procedures;

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure a personnel record was maintained for each personnel member to include documentation of the individual's completed orientation and in-service education as required by policies and procedures, for one of three personnel records sampled. The deficient practice posed a risk if as the repeated violation shows a pattern of noncompliance to ensure the health and safety of residents.

findings: 1. A review of facility documentation revealed a policy titled "Personnel Orientation," dated March 17, 2024. The policy stated, "A. Orientation/Training prior to providing services includes..." 2. A review of facility documentation revealed a policy titled "Personnel In-Service Training," dated March 12, 2024. The policy stated, "... Requirement Timeline for Completion Re-Certification... Crisis management within first 90 days annually..." 3. A review of facility documentation revealed an undated policy titled "Behavior Management/Emergency Safety Response." The policy stated, "... If an emergency situation arises, other residents will be separated from the situation and crisis and/or police will be called if verbal de-escalation is unsuccessful..." 4. A review of facility documentation revealed an undated policy titled "Seclusion or Restraint." The policy stated, "Our organization prides itself in strongly refraining from the use of physical interventions to manage behaviors. However, our staff is thoroughly trained to manage behaviors via verbal redirection, de-escalation. Our staff is educated to recognize when residents become a danger to self or others, and to intervene appropriately via verbal de-escalation techniques or coordination with the crisis team/police." 5. A review of E2's personnel record revealed no documentation of completed orientation was available. 6. A review of E2's personnel record revealed no documentation of training in the use of verbal de-escalation was available. 7. In an exit interview, E1 and E2 reviewed the findings and E2 reported E2 was in the process of moving all physical documents to an electronic health record and discarded the orientation documentation. E2 also reported E2 would complete another orientation and complete the training on the use of verbal redirection, de-escalation, and crisis management. This is a repeated violation from the February 28, 2024 complaint and compliance inspection.

rule: R9-10-706.G.3.e. Personnel G. An administrator shall ensure that a personnel record is maintained for each personnel member, employee, volunteer, or student that includes: 3. Documentation of: e. The individual's compliance with requirements in A.R.S. §§ 36-411, 36-411.01, and 36-425.03, as applicable;

evidence: Based on record review and interview, the administrator failed to ensure a personnel record was maintained for each personnel member to include documentation of the individual's compliance with requirements in A.R.S. § 36-411.C.3. and 36-425.03, for one of three personnel records sampled. The deficient practice posed a risk if E3 was a risk to a vulnerable population.

findings: A.R.S. § 36-411.C. Each residential care institution, nursing care institution and home health agency shall make documented, good faith efforts to: 3. Beginning January 1, 2025, verify that a potential employee is not on the adult protective services registry pursuant to section 46-459. If a potential employee is found to be on the adult protective services registry, the residential care institution, nursing care institution or home health agency may not hire the potential employee. A.R.S. § 36-425.03.E. Children's behavioral health program personnel shall certify on forms that are provided by the department and notarized that they are not awaiting trial on or have never been convicted of or admitted in open court or pursuant to a plea agreement to committing any of the offenses listed in section 41-1758.03, subsection B or C in this state or similar offenses in another state or jurisdiction. 1. A review of E3's personnel record revealed no documentation of an adult protective services (APS) registry check was available. 2. A review of E3's personnel record revealed no documentation of a notarized form certifying E3 was not awaiting trial or has been convicted of or admitted in open court or pursuant to a plea agreement to committing any of the offenses listed in section 41-1758.03 subsection B or C was available. 3. In an exit interview, E1 and E2 reviewed the findings and reported E1 and E2 were unaware E3 needed the forms prior to providing services.

rule: R9-10-706.G.3.f. Personnel G. An administrator shall ensure that a personnel record is maintained for each personnel member, employee, volunteer, or student that includes: 3. Documentation of: f. The individual ' s compliance with the requirements in A.R.S. § 8-804, if applicable;

evidence: Based on record review and interview, the administrator failed to ensure a personnel record was maintained for each personnel member to include documentation of the individual's compliance with the requirements in A.R.S. § 8-804(B)(2), for one of three personnel records sampled. The deficient practice posed a risk if E3 was a danger to a vulnerable population, and the repeated violation shows a pattern of noncompliance to ensure the health and safety of residents.

findings: A.R.S. § 8-804.B. The department shall conduct central registry background checks and shall use the information contained in the central registry only for the following purposes: 2. As a factor to determine qualifications for persons who are employed or who are applying for employment with this state in positions that provide direct service to children or vulnerable adults. 1. A review of E3's personnel record revealed no documentation of a department of child safety central registry check was available. 2. In an exit interview, E1 and E2 reviewed the findings and reported E1 and E2 were unaware E3 needed the forms prior to providing services. This is a repeated violation from the February 28, 2024 complaint and compliance inspection.

rule: R9-10-718.C.3. Medication Services C. If a behavioral health residential facility provides assistance in the self-administration of medication, an administrator shall ensure that: 3. Policies and procedures for assistance in the self-administration of medication are reviewed and approved by a medical practitioner or registered nurse;

evidence: Based on documentation review and interview, the administrator failed to ensure policies and procedures for assistance in the self-administration of medication were reviewed and approved by a medical practitioner or registered nurse. The deficient practice posed a risk as policies and procedures reinforce and clarify standards expected of personnel members.

findings: 1. A review of facility documentation revealed an undated policy titled "18. Medication Services." However, no evidence the policies and procedures were reviewed and approved by a medical practitioner or registered nurse was available. 2. In an exit interview, E1 and E2 reviewed the findings and no additional statements or documentation were provided for review.

rule: R9-10-718.C.4.b.i. Medication Services C. If a behavioral health residential facility provides assistance in the self-administration of medication, an administrator shall ensure that: 4. Training for a personnel member, other than a medical practitioner or registered nurse, in assistance in the self-administration of medication: b. Includes: i. A demonstration of the personnel member's skills and knowledge necessary to provide assistance in the self-administration of medication,

evidence: Based on record review and interview, the administrator failed to ensure training for a personnel member, other than a medical practitioner or registered nurse, in assistance in the self-administration of medication included a demonstration of the personnel member's skills and knowledge necessary to provide assistance in the self-administration of medication, for two of three personnel records sampled. The deficient practice posed a risk if the resident experienced a change in condition due to improper assistance in the self-administration of medication.

findings: 1. A review of E1's personnel record revealed assistance in the self-administration of medication training dated October 16, 2025. However, the training did not document a demonstration of E1's skills and knowledge necessary to provide assistance in the self-administration of medication. 2. A review of E2's personnel record revealed assistance in the self-administration of medication training dated February 10, 2026. However, the training did not document a demonstration of E2's skills and knowledge necessary to provide assistance in the self-administration of medication. 3. In an exit interview, E1 and E2 reviewed the findings and no additional statements or documentation were provided for review.

rule: R9-10-718.C.4.b.ii. Medication Services C. If a behavioral health residential facility provides assistance in the self-administration of medication, an administrator shall ensure that: 4. Training for a personnel member, other than a medical practitioner or registered nurse, in assistance in the self-administration of medication: b. Includes: ii. Identification of medication errors and medical emergencies related to medication that require emergency medical intervention, and

evidence: Based on record review and interview, the administrator failed to ensure training for a personnel member, other than a medical practitioner or registered nurse, in assistance in the self-administration of medication included identification of medication errors and medical emergencies related to a medication that require emergency medical intervention, for two of three personnel records sampled. The deficient practice posed a risk if the employees were unable to meet a resident's needs.

findings: 1. A review of E1's personnel record revealed assistance in the self-administration of medication training dated October 16, 2025. However, the training did include the identification of medical emergencies related to a medication requiring emergency medical intervention. 2. A review of E2's personnel record revealed assistance in the self-administration of medication training dated February 10, 2026. However, the training did not include the identification of medical emergencies related to a medication requiring emergency medical intervention. 3. In an exit interview, E1 and E2 reviewed the findings and no additional statements or documentation were provided for review.

rule: R9-10-718.C.4.b.iii. Medication Services C. If a behavioral health residential facility provides assistance in the self-administration of medication, an administrator shall ensure that: 4. Training for a personnel member, other than a medical practitioner or registered nurse, in assistance in the self-administration of medication: b. Includes: iii. The process for notifying the appropriate entities when an emergency medical intervention is needed;

evidence: Based on record review and interview, the administrator failed to ensure training for a personnel member, other than a medical practitioner or registered nurse, in assistance in the self-administration of medication included the process for notifying the appropriate entities when an emergency medical intervention is needed, for two of three personnel records sampled. The deficient practice posed a risk if the employees were unable to meet a resident's needs.

findings: 1. A review of E1's personnel record revealed assistance in the self-administration of medication training dated October 16, 2025. However, the training did include the process for notifying the appropriate entities when an emergency medical intervention is needed. 2. A review of E2's personnel record revealed assistance in the self-administration of medication training dated February 10, 2026. However, the training did not include the process for notifying the appropriate entities when an emergency medical intervention is needed. 3. In an exit interview, E1 and E2 reviewed the findings and no additional statements or documentation were provided for review.


facility_name: SUNFLOWER LIVING LLC

summary: Complaint - 4/9/2026

raw_content: No deficiencies were found during the on-site investigation of complaints 00162990, 00163188, and 00163192 conducted on April 9, 2026.


facility_name: PTL BEHAVIORAL HEALTH, LLC

summary: Compliance (Annual) - 4/2/2026

raw_content: The following deficiencies were found during the on-site compliance inspection conducted on April 2, 2026:

inspection_type: Compliance (Annual)

evidence: Based on documentation review, record review, and interview, the health care institution failed to administer a training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a risk as organized instruction and information related to resident care and safety were not implemented.

findings: 1. A review of facility documentation revealed a Policy titled "FALL PREVENTION AND FALL RECOVERY," dated May 1, 2024. The policy stated, "Ongoing Training will be provided at least once every 12 months for all personnel." 2. A review of E2's personnel record revealed a continued competency training in fall prevention and fall recovery dated in November 2024, and no training for November 2025 was available for review. 3. In an exit interview, the findings were discussed with E1, and no further statements or documentation were provided.

rule: R9-10-711.E.3.b. Resident Rights E. A resident has the following rights: 3. To receive privacy in treatment and care for personal needs, including the right not to be fingerprinted, photographed, or recorded without consent, except: b. For a resident receiving treatment according to A.R.S. Title 36, Chapter 37; or

evidence: Based on observation and interview, the administrator failed to ensure a resident had the right to receive privacy in treatment. The deficient practice posed a risk if the administrator was unable to ensure confidentiality in treatment as well as a resident’s right to privacy in treatment and visitation.

findings: R9-10-101.52.a. “Common area” means licensed space in health care institution that is: Not a resident’s bedroom or a residential unit, R9-10-722.B.1.a.b. An administrator shall ensure that: A behavioral health residential facility has a Room that provides privacy for a resident to receive treatment or visitors; and Common area and a dining area that contain furniture and materials to accommodate the recreational and socialization needs of the residents and other individuals in the behavioral health residential facility; 1. The Compliance Officer observed an office E1 identified as a privacy room used for visitation and counseling. The designated privacy room contained video monitoring systems that recorded and displayed on a screen in the facility's privacy room. 2. The Compliance Officer observed a letter taped to the designated privacy room door which stated, " No RESIDENTS beyond this point without staff supervision." 3. In an interview, E1 reported counseling sessions were being conducted in the primary bedroom. 4. The Compliance Officer observed three beds in the primary bedroom. 5. In an interview, E1 reported the facility census was two for the last 12 months, and neither of the residents were residing in the primary bedroom. 6. In an exit interview, the findings were discussed with E1 who reported the designated privacy room contained video monitoring due to medications being stored in the designated medication cabinet.

evidence: Based on documentation review and interview, the administration failed to ensure policies and procedures for assistance in the self-administration of medication were reviewed and approved by a medical practitioner or registered nurse. The deficient practice posed a risk as policies and procedures reinforce and clarify standards expected of employees.

findings: 1. A review of facility documentation revealed a policy and procedure titled "Section 16: Medication Services" (dated May 2024). However, there was no evidence the policy and procedure was not reviewed and approved by a medical practitioner or registered nurse. 2. In an exit interview, the findings were discussed with E1, and no further statements or documentation were provided.