summary: Unannounced - 32 findings

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Licensee: Jasper Mountain
Executive Director: Beau Garner
Program Directors: Sarah Huff and Taryne Roberts
Date of Unannounced: 11/2/22
Licensing Coordinator: Mary Torres, accompanied by co-worker, Jorge Pelinski
Other Regulatory or Accrediting Agencies: Oregon Health Authority (OHA), Oregon Department of Education (ODE) Private Alternative School,
Council on Accreditation (COA) for Services to Children and Families. Jasper Mountain’s COA’s review is scheduled for 2023.
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 from Review dated Repeat Comments
Findings
Further Action
Needed
Supplemental Information Provided by Yes☐ No The program provided photo proof on 6/14/22 via email that verified improvements were
CCA Documents as indicated on the form made to the playground’s fence as required by the Health Inspection.
titled “Renewal Licensing Required
Documents”
Completed health inspection of the Castle
indicates that improvements are needed to
the fenced area around the playground.
CORRECTIVE ACTION: Complete
recommended tasks and submit pictures of
those improvements to Licensing.
Supplemental Information Provided by Yes No☐ REPEAT FINDING: The program’s Fire Marshall inspection is scheduled for November of
CCA Documents as indicated on the form 2022 due to budget shortfalls experienced by the county. It is requested that the program
titled “Renewal Licensing Required submit a copy of the 2022 Fire Marshal Report once completed in November. Any noted
Documents” violations will be abated and approved by the Fire Marshal inspector.
1
(rev. 200115)
Updated Fire Marshal reports for The Castle
and the SAFE Center were not submitted at
the time of the review. Previous inspections
completed in Nov of 2020 were submitted.
CORRECTIVE ACTION: Schedule updated
fire marshal inspections for The Castle and
SAFE Center and forward those completed
inspections to Licensing for review.
Supplemental Information Provided by Yes☐ No The approved Tax Compliance Certificate was submitted via email on 11/16/22.
CCA Documents as indicated on form titled
“Required Financial Documents and
Information”
Agency did not submit a Tax Compliance
Certificate issued from the Department of
Revenue but did submit a copy of the
application filled out.
CORRECTIVE ACTON: Submit completed
Tax Compliance Certificate signed by a
representative of the Department of Revenue
to Licensing once received.
Supplemental Information Provided by Yes☐ No Revised Conflict of Interest that meets Licensing Rule was submitted via email on 6/14/22.
CCA All required policies and procedures as
identified in the “Umbrella Rules”
Submitted Conflict of Interest policy 3.C.5
Protections Against Nepotism requires
revision to meet Licensing rule.
CORRECTIVE ACTION: Revise Conflict of
Interest to include the required information
and resubmit to Licensing for review.
Supplemental Information Provided by Yes☐ No Revised Grievance Policy that meets Licensing Rule was submitted via email on 8/23/22.
CCA All required policies and procedures as
identified in the “Umbrella Rules”
Submitted grievance policy 2.H.6 Consumer
Grievance Procedure requires revision to
meet Licensing rule.
CORRECTIVE ACTION: Revise grievance
procedure to include the required information
and resubmit to Licensing for review.
(rev. 200115)
Supplemental Information Provided by Yes☐ No Revised Mandatory Reporting Policy that meets Licensing Rule was submitted via email on
CCA All required policies and procedures as 6/14/22.
identified in the “Umbrella Rules”
Submitted mandatory reporting policy 3.E.2
Reporting of Child Abuse requires revision to
meet Licensing Rule.
CORRECTIVE ACTION: Revise child abuse
reporting policy to include the required
information and resubmit to Licensing for
review.
Supplemental Information Provided by Yes☐ No Revised policy was submitted to Licensing on
CCA All required policies and procedures as
identified in the “Umbrella Rules”
Submitted personnel policies 3.C Recruitment
and Selection require revision to meet
Licensing rules.
CORRECTIVE ACTION: Revise personnel
policies to include required information and
resubmit to Licensing for review.
Supplemental Information Provided by Yes☐ No The correct information was located on the program’s website.
CCA All required policies and procedures as
identified in the “Umbrella Rules”
Submitted privacy policy 2.G Confidentiality
requires revision to meet Licensing rules.
CORRECTIVE ACTION: Revise privacy
policy to include the highlighted information
and resubmit to Licensing for review.
Supplemental Information Provided by Yes☐ No Revised policy submitted via email on 7/19/22.
CCA All required policies and procedures as
identified in the “Umbrella Rules”
Submitted behavior management policy 2.A.4
Jasper Mountain Interventions – Clinically
Appropriate Interventions requires revision to
meet licensing rules.
CORRECTIVE ACTIVE: Revise behavior
management policy to include the required
(rev. 200115)
information and resubmit to Licensing for
review.
Supplemental Information Provided by Yes No☐ REPEAT FINDING: A final draft of the program’s revised Suicide Prevention Policy is still
CCA All required policies and procedures as required. The last draft submitted on 9/19/22 requires final timeframe as to when
identified in the “Umbrella Rules” notifications to both Licensing and legal guardians will be made by the program.
Submitted Suicide Prevention Policy 2.A.6.02
Enhanced Supervision to Prevent Self Harm
requires revision to meet Licensing rule.
CORRECTIVE ACTION: Revise suicide
prevention policy to include the highlighted
information and resubmit to Licensing for
review.
Supplemental Information Provided by Yes☐ No This policy was later located in the program’s Policy and Procedure packet.
CCA All required policies and procedures as
identified in the “Umbrella Rules”
A policy regarding Searches was not
submitted at the time of the review.
CORRECTIVE ACTION: Review the
Licensing rule related to searches. Create or
modify program’s Search Policy to include the
required information and submit to Licensing
for review.
Supplemental Information Provided by Yes☐ No Revised policy meeting Licensing Rule was submitted via email on 6/14/22 and 8/23/22.
CCA All required policies and procedures as
identified in the “Umbrella Rules”
Newly added information regarding restraints
in the program’s policies does not reflect
required information.
CORRECTIVE ACTION: Include the
following information in the program’s restraint
section of their policy packet and resubmit to
Licensing for review.
Supplemental Information Provided by Yes☐ No Revised policy submitted via email on 9/5/22.
CCA All required policies and procedures as
identified in “Agency Type Specific Rules”
Foster Care Medication Policy requires
revision to meet Licensing rule
(rev. 200115)
CORRECTIVE ACTION: Include the
following item missing from existing policy
Requirements Regarding Child’s Medical
Care and Notifications Requirements and
resubmit to Licensing for review.
Supplemental Information Provided by Yes☐ No The program’s policy was corrected and resubmitted via email on 6/14/22.
CCA All required policies and procedures as
identified in “Agency Type Specific Rules”
Foster Care Policy subtitled Requirements
Regarding the Number of Children Placed by
JM (page11) includes incorrect information
CORRECTIVE ACTION: Update this section
with the correct information as stated in
Licensing rule and resubmit to Licensing for
review.
Supplemental Information Provided by Yes☐ No The program’s policy was corrected and resubmitted via email on 6/14/22.
CCA All required policies and procedures as
identified in “Agency Type Specific Rules”
Foster Care Policy subtitled Responsibilities
to Monitor Certification Compliance (page21)
includes incorrect information.
CORRECTIVE ACTION: Update this section
with the correct information as stated in
Licensing rule and resubmit to Licensing for
review.
Physical Plant Yes☐ No The program provided photo proof on 6/14/22 and 7/13/22 via email reflecting the required
413-215-0511(2)(a) &(c) Buildings are smoke repairs.
free, clean and in good repair
Second wooden step from the bottom of the
stairway located between the admin office and
the boardroom office is broken
CORRECTIVE ACTION: Repair/replace
wooden step that is broken
Physical Plant Yes☐ No The program provided photo proof on 6/14/22 and 7/13/22 via email reflecting the required
413-215-0511(2)(a) &(c) Buildings are smoke repairs
free, clean and in good repair
(rev. 200115)
Boys’ bathroom located in the Castle has a
hole in the wall behind the door and a burnt-
out light bulb.
CORRECTIVE ACTION: Repair hole behind
bathroom door and replace light bulb.
Safety Yes☐ No During the review, the program modified the evacuation drill to include the total number of
(3)(a) Evacuation drill occurs monthly under children evacuated.
varying conditions 413-215-0541
During the 2020 year, both the Castle and As per the program, the importance of the monthly drills has been reiterated & both sites
SAFE Center missed multiple monthly are back on track moving forward. Both sites are documenting their monthly drills.
evacuation drills. The Castle missed 4 drills.
The SAFE Center missed 2 drills. All monthly
drills were completed for the 2021 year. In
addition, the program’s evacuation form was
missing the total number of children
evacuated.
CORRECTIVE ACTION: Ensure that
evacuation drills are completed and
documented on a monthly basis.
Health Services Yes☐ No The program has modified their health assessment intake form, adding a section to record
413-215-0546 (Res.) and 413-215-0376 the completion of age-appropriate instruction taught to each resident. A copy of this
(Foster Care) modified form was submitted via email on 7/25/22.
(2)(e) Documentation of age-appropriate
instruction – pregnancy prevention, nutrition,
prevention of HIV & AIDS, and prevention and
treatment of sexually transmitted disease
Age-appropriate instruction is reportedly
occurring when residents meet with nursing
staff, but that instruction is not being recorded.
CORRECTIVE ACTION: Ensure that
documentation of this age-appropriate
instruction is recorded in the youths’ files from
this point forward.
Consents Yes☐ No Updated intake form submitted via email on 6/14/22.
413-215-0576(1) (Res) and 413-215-0391(1)
(Foster Care)
(e) Allow access as defined in 413-215-0091
& 0101
(rev. 200115)
Five out of the five youth files reviewed did not
have a written consent related to allowing
access to youth as defined by OAR.
CORRRECTIVE ACTION: Add this consent to
existing intake paperwork.
Consents Yes☐ No Updated intake form submitted via email on 6/14/22.
413-215-0576(1) (Res) and 413-215-0391(1)
(Foster Care)
(f) Impose a dress code
Five out of the five youth files reviewed did not
have a written consent related to imposing a
dress code.
CORRECTIVE ACTION: Add this consent to
existing intake paperwork.
Information about Children in Care Yes☐ No Updated intake form submitted via email on 6/14/22.
413-215-0581(1) (Res) and 413-215-0396(1)
(Foster Care) Summary sheet contains the
following:
(b) Name and location of previous and current
school
(c) Date of admission
(d) Legal custody
(e) The name, address, and telephone
number of:
(A) The child in care's parents.
(B) The child in care's legal guardian, if
different than the parents, and a copy of the
document that provides for his or her authority
over the child in care.
(C) Other persons significant to child
(D) Other professionals to be involved
in service planning (if applicable)
Summary sheet does not allow space for
residents’ previous school setting.
CORRECTIVE ACTION: Add space where a
residents’ previous school and school’s
location can be added to the summary sheet.
(rev. 200115)
Information about Children in Care Yes☐ No Updated intake form submitted via email on 6/14/22.
413-215-0581(1) (Res) and 413-215-0396(1)
(Foster Care) Summary sheet contains the
following:
Youth’s date of admission is unclear on the
summary sheet.
CORRECTIVE ACTION: Modify the summary
sheet to include admission date.
Information about Children in Care Yes☐ No Updated intake form submitted via email on 6/14/22.
413-215-0581(1) (Res) and 413-215-0396(1)
(Foster Care) Summary sheet contains the
following:
Summary sheet does not clearly document
who has legal custody of the admitted youth.
CORRECTIVE ACTION: Modify the
summary sheet to confirm who has legal
custody of youth once admitted.
Information about Children in Care Yes☐ No Updated intake form submitted via email on 6/14/22.
413-215-0581(1) (Res) and 413-215-0396(1)
(Foster Care) Summary sheet contains the
following:
Files where youth were under the legal
custody of a guardian different form their
parent did not reflect the document to confirm
this authority.
CORRECTIVE ACTION: Modify the intake
process where documentation to confirm the
legal authority of a youth if not the parent.
Financial Records 413-215-0581(4) Yes☐ No A new form for tracking/recording youth financial records was generated and shared at the
Records contain date, amount, source, time of the program’s review. Since then, this new tracking is being utilized and stored in
purpose, signatures each youth’s respective file.
Youth financial records are not being
individually maintained nor kept in the youths’
files. Monthly records with the entire milieu’s
spending are physically stored in the program
and required information is missing.
(rev. 200115)
Information is later entered into a separate
electronic account record that is being kept by
the main admin office.
CORRECTIVE ACTION: Solidify a process
where financial records for each youth are
maintained and reflect all necessary
information listed to include youth and staff
signatures for each entry.
Personal Possessions Records Yes☐ No The program’s newly appointed support services coordinator digitized all of the inventory
413-215-0581(5) lists for youth. Hard copies of these inventory lists are placed in each youth’s respective
Individual written inventory of all personal files on a monthly basis or when inventory changes occur.
possessions is maintained and updated as
needed
Youth files did not reflect consistent
documentation of youths’ personal
possessions.
CORRECTIVE ACTION: Ensure that
individual written inventory of personal
possessions is recorded and updated to
include the addition of possessions and/or
when items are discarded, lost, destroyed,
etc.
Records of Proctor Foster Homes Yes☐ No The program created a template letter to reflect either the acceptance or denial of a foster
413-215-0351 parents’ foster care application. A copy of this letter was submitted via email on 6/14/22.
(2)(b) & 413-215-0316(4) Notification of
acceptance or denial of application. If denial is
due to substantiated abuse, the reason for
denial is disclosed to applicant.
Files reviewed did not reflect documentation
of acceptance or denial of application
CORRECTIVE ACTION: Implement a
process where applicants are notified in
writing of either the program’s acceptance or
denial of application
Records of Proctor Foster Homes Yes☐ No A new tracking form was generated to ensure documentation of all routine home visits.
413-215-0351 This new form was submitted via email on 6/14/22.
(2)(g) Documentation of home visit (every 90
days)
(rev. 200115)
Documentation of home visits every 90 days
is not consistent or clear in the files reviewed
CORRECTIVE ACTION: Implement a
process where home visits are conducted
every 90 day and clearly documented in each
foster family’s files
Assessment and Approval of Proctor Yes☐ No Once the TFC program has been reinstated, the newly hired foster care coordinator will
Foster Homes Written Assessment ensure all signatures are captured.
413-215-0316
(2)(a) Application signed by all applicants
One out of the two foster parent files did not
have an application signed by both providers
CORRECTIVE ACTION: Ensure that all
applicants sign the required application from
this point forward.
Annual Review and Approval Yes☐ No Once the TFC program has been reinstated, the newly hired foster care coordinator will
413-215-0331(2) ensure all signatures are captured.
(e) Documentation that home remains in
compliance with safety standards 413-215-
0318
One out of the two foster parents’ files did not
reflect documentation of safety standards
(CF0979) signed by both applicants.
CORRECTIVE ACTION: Ensure that safety
standards (CF0979) form is signed by both
applicants
Training for Parents in Proctor Foster Care Yes☐ No The program has recently hired a new foster care coordinator who will be generating a new
Written Training Plan includes: training plan to utilize once the TFC program has been reinstated.
413-215-0326(1)
(c)(A) Characteristics and needs of children
who are placed
Training plan is not clear in documentation to
ensure this specific training topic is covered
CORRECTIVE ACTION: Ensure
documentation of specific topic as required by
Licensing rule
(rev. 200115)
Training for Parents in Proctor Foster Care Yes☐ No The program has recently hired a new foster care coordinator who will be generating a new
Written Training Plan includes: training plan to utilize once the TFC program has been reinstated.
413-215-0326(1)
(c)(B) Ways to effectively parent children,
including application of the reasonable and
prudent parent standard
Training plan is not clear in documentation to
ensure this specific training topic is covered
CORRECTIVE ACTION: Ensure
documentation of specific topic as required by
Licensing rule
Training for Parents in Proctor Foster Care Yes☐ No The program has recently hired a new foster care coordinator who will be generating a new
Written Training Plan includes: training plan to utilize once the TFC program has been reinstated.
413-215-0326(1)
(c)(D) Importance of family of the child and
working with the family
Training plan is not clear in documentation to
ensure this specific training topic is covered
CORRECTIVE ACTION: Ensure
documentation of specific topic as required by
Licensing rule
Training for Parents in Proctor Foster Care Yes☐ No The program has recently hired a new foster care coordinator who will be generating a new
Written Training Plan includes: training plan to utilize once the TFC program has been reinstated.
413-215-0326(1)
(c)(E) Importance of age-appropriate or
developmentally appropriate extracurricular,
enrichment, cultural, and social activities
Training plan is not clear in documentation to
ensure this specific training topic is covered
CORRECTIVE ACTION: Ensure
documentation of specific topic as required by
Licensing rule
(rev. 200115)
Training for Parents in Proctor Foster Care Yes☐ No The program has recently hired a new foster care coordinator who will be generating a new
Written Training Plan includes: training plan to utilize once the TFC program has been reinstated.
413-215-0326(1)
(c)(F) Preparation of child for independence
based on age, stage of development, and
child’s needs
Training plan is not clear in documentation to
ensure this specific training topic is covered
CORRECTIVE ACTION: Ensure
documentation of specific topic as required by
Licensing rule
Training for Parents in Proctor Foster Care Yes☐ No The program has recently hired a new foster care coordinator who will be generating a new
Written Training Plan includes: training plan to utilize once the TFC program has been reinstated.
413-215-0326(1)
(2) Training is documented
Training is not uniformly documented in the
foster families’ files
CORRECTIVE ACTION: Ensure clear,
consistent documentation of training from this
point forward
Disclosures 413-215-0391(2) Yes☐ No Updated intake form submitted via email on 6/14/22.
Parent/guardian has acknowledged in writing:
(e) Any policies and procedures upon request
Three out of three youth files reviewed did not
have a disclosure related to policies and
procedures upon request. The intake forms
used were outdated.
CORRECTIVE ACTION: Use the program’s
updated intake forms where this disclosure
exists.
Authorizations 413-215-0391(3) Yes☐ No Updated intake form submitted via email on 6/14/22.
(b) Child specific visitors
(rev. 200115)
Authorizations regarding child specific visitors
were absent in two out of the three files
reviewed
CORRECTIVE ACTION: Ensure that child
specific visitors authorization is in the youths’
files
Authorizations 413-215-0391(3) Yes☐ No Updated intake form submitted via email on 6/14/22.
(c) Visitation resources are pre-approved
Authorizations regarding pre-approved
visitation resources were absent in two out of
the three files reviewed
CORRECTIVE ACTION: Ensure that pre-
approved visitation resources authorization is
in the youths’ files
New Findings from Site Visit Comments
Physical Plant The Castle:
413-215-0511(2)(a) &(c) Buildings are - 1st floor bathroom recently had mirror removed
smoke free, clean and in good repair - 1st floor bathroom’s ceiling has the possible beginnings of moisture damage/mold
- 1st floor – bedroom #4 has broken window blinds
The Safe Center:
- Bathtub needs recaulking
- Bathroom ceiling has the possible beginnings of moisture damage/mold
CORRECTIVE ACTION:
- Replace mirror or repair and paint wall where the mirror once hung
- Assess and treat the bathroom ceilings in both facilities if moisture damage/mold is found
- Replace window blinds in bedroom #4
- Re caulk along bathtub
413-215-0091 Licensing Umbrella Rules: Recent promotions may warrant an updated CCA Contact Information Form
Responsibilities of Licensees
(11) Notify the Department in the following CORRECTIVE ACTION:
circumstances: Review current CCA Contact Information Form and submit updated document given recent promotions.
(a) Immediately when information on the
"CCA Contact Information Form" changes.
An updated form may be submitted
electronically, or the change may be
(rev. 200115)
communicated directly to a department
licensing coordinator.
Interview Summary
The following information was shared and gathered during the unannounced site visit:
- Both programs, The Castle, and The Safe Center, currently have 12 residents in their respective buildings. Four youth were recently discharged from
the program due to ongoing behavioral issues.
- There are plans to reopen Crystal Creek in the upcoming new year.
- The program is exploring having additional staff members attending and become certified in advanced CPI training.
- The majority of all meals for both facilities are being prepared in Crystal Creek’s industrial kitchen and transported to each site.
- Staffing status and changes were discussed.
Several staff members were met with during this site visit. The program continues to take active steps to remain in compliance with SB710 and has been
working collaboratively with Licensing, OTIS, CPI instructors and their Senator, inviting ongoing discussions and seeking to understand the intent behind this
new legislation.
Four youth were interviewed individually. Although all youth reported feeling safe in the program, two youth disclosed concerns related to one specific staff
member. The concerns reported were sufficient for Licensing to report to the Child Abuse Hotline. Strengths identified by youth include the program meeting
youth needs, craft activities, breakfast meal options, frequent contact with family members and former foster parents. No areas of improvement were
reported, but two recommendations that were made were more nature walks and youth having their own rooms. Staff support youth in various ways. This
support includes hugs, space, talking to youth, sitting with staff and staff checking in with youth. All youth were able to provide a list of staff whom they had a
good relationship with and could report issues to. Treatment goals were understood by youth and progress is measured by staff and summarized on daily
point sheets.
Observations
Tour of Crystal Creek was unremarkable. No concerns regarding the building’s physical space were noted.
Corrective Actions and Timeframes:
Please submit the following to verify compliance.
Within 45 days of receipt of this report Jasper Mountain 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
(rev. 200115)
and all specific documentation requested in the body of this report. The letter of verification and any additional requested documents can be emailed
directly to Mary Torres at mary.torres@odhsoha.oregon.gov or sent by regular mail to the following address:
Department of Human Services
Children’s Care Licensing Program
Attn: Mary Torres
201 High St. SE Suite 500
Salem, OR 97301
Licensing Coordinator’s Signature: ________________________ Date: _ _ _1_2_/0_8_/_2_2_ _________
Manager Review: ______________________________________ Date: _1_2_-8_-_2_0_2_2_ _________
(rev. 200115)

other_regulatory_agencies: Oregon Health Authority (OHA), Oregon Department of Education (ODE) Private Alternative School, Council on Accreditation (COA) for Services to Children and Families. Jasper Mountain's COA's review is scheduled for 2023.

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 from Review dated Repeat Comments
Findings
Further Action
Needed
Supplemental Information Provided by Yes[ ] No The program provided photo proof on 6/14/22 via email that verified improvements were
CCA Documents as indicated on the form made to the playground's fence as required by the Health Inspection.
titled "Renewal Licensing Required
Documents"
Completed health inspection of the Castle
indicates that improvements are needed to
the fenced area around the playground.
CORRECTIVE ACTION: Complete
recommended tasks and submit pictures of
those improvements to Licensing.
Supplemental Information Provided by Yes No[ ] REPEAT FINDING: The program's Fire Marshall inspection is scheduled for November of
CCA Documents as indicated on the form 2022 due to budget shortfalls experienced by the county. It is requested that the program
titled "Renewal Licensing Required submit a copy of the 2022 Fire Marshal Report once completed in November. Any noted
Documents" violations will be abated and approved by the Fire Marshal inspector.
1

Updated Fire Marshal reports for The Castle
and the SAFE Center were not submitted at
the time of the review. Previous inspections
completed in Nov of 2020 were submitted.
CORRECTIVE ACTION: Schedule updated
fire marshal inspections for The Castle and
SAFE Center and forward those completed
inspections to Licensing for review.
Supplemental Information Provided by Yes[ ] No The approved Tax Compliance Certificate was submitted via email on 11/16/22.
CCA Documents as indicated on form titled
"Required Financial Documents and
Information"
Agency did not submit a Tax Compliance
Certificate issued from the Department of
Revenue but did submit a copy of the
application filled out.
CORRECTIVE ACTON: Submit completed
Tax Compliance Certificate signed by a
representative of the Department of Revenue
to Licensing once received.
Supplemental Information Provided by Yes[ ] No Revised Conflict of Interest that meets Licensing Rule was submitted via email on 6/14/22.
CCA All required policies and procedures as
identified in the "Umbrella Rules"
Submitted Conflict of Interest policy 3.C.5
Protections Against Nepotism requires
revision to meet Licensing rule.
CORRECTIVE ACTION: Revise Conflict of
Interest to include the required information
and resubmit to Licensing for review.
Supplemental Information Provided by Yes[ ] No Revised Grievance Policy that meets Licensing Rule was submitted via email on 8/23/22.
CCA All required policies and procedures as
identified in the "Umbrella Rules"
Submitted grievance policy 2.H.6 Consumer
Grievance Procedure requires revision to
meet Licensing rule.
CORRECTIVE ACTION: Revise grievance
procedure to include the required information
and resubmit to Licensing for review.

Supplemental Information Provided by Yes[ ] No Revised Mandatory Reporting Policy that meets Licensing Rule was submitted via email on
CCA All required policies and procedures as 6/14/22.
identified in the "Umbrella Rules"
Submitted mandatory reporting policy 3.E.2
Reporting of Child Abuse requires revision to
meet Licensing Rule.
CORRECTIVE ACTION: Revise child abuse
reporting policy to include the required
information and resubmit to Licensing for
review.
Supplemental Information Provided by Yes[ ] No Revised policy was submitted to Licensing on
CCA All required policies and procedures as
identified in the "Umbrella Rules"
Submitted personnel policies 3.C Recruitment
and Selection require revision to meet
Licensing rules.
CORRECTIVE ACTION: Revise personnel
policies to include required information and
resubmit to Licensing for review.
Supplemental Information Provided by Yes[ ] No The correct information was located on the program's website.
CCA All required policies and procedures as
identified in the "Umbrella Rules"
Submitted privacy policy 2.G Confidentiality
requires revision to meet Licensing rules.
CORRECTIVE ACTION: Revise privacy
policy to include the highlighted information
and resubmit to Licensing for review.
Supplemental Information Provided by Yes[ ] No Revised policy submitted via email on 7/19/22.
CCA All required policies and procedures as
identified in the "Umbrella Rules"
Submitted behavior management policy 2.A.4
Jasper Mountain Interventions - Clinically
Appropriate Interventions requires revision to
meet licensing rules.
CORRECTIVE ACTIVE: Revise behavior
management policy to include the required

information and resubmit to Licensing for
review.
Supplemental Information Provided by Yes No[ ] REPEAT FINDING: A final draft of the program's revised Suicide Prevention Policy is still
CCA All required policies and procedures as required. The last draft submitted on 9/19/22 requires final timeframe as to when
identified in the "Umbrella Rules" notifications to both Licensing and legal guardians will be made by the program.
Submitted Suicide Prevention Policy 2.A.6.02
Enhanced Supervision to Prevent Self Harm
requires revision to meet Licensing rule.
CORRECTIVE ACTION: Revise suicide
prevention policy to include the highlighted
information and resubmit to Licensing for
review.
Supplemental Information Provided by Yes[ ] No This policy was later located in the program's Policy and Procedure packet.
CCA All required policies and procedures as
identified in the "Umbrella Rules"
A policy regarding Searches was not
submitted at the time of the review.
CORRECTIVE ACTION: Review the
Licensing rule related to searches. Create or
modify program's Search Policy to include the
required information and submit to Licensing
for review.
Supplemental Information Provided by Yes[ ] No Revised policy meeting Licensing Rule was submitted via email on 6/14/22 and 8/23/22.
CCA All required policies and procedures as
identified in the "Umbrella Rules"
Newly added information regarding restraints
in the program's policies does not reflect
required information.
CORRECTIVE ACTION: Include the
following information in the program's restraint
section of their policy packet and resubmit to
Licensing for review.
Supplemental Information Provided by Yes[ ] No Revised policy submitted via email on 9/5/22.
CCA All required policies and procedures as
identified in "Agency Type Specific Rules"
Foster Care Medication Policy requires
revision to meet Licensing rule

CORRECTIVE ACTION: Include the
following item missing from existing policy
Requirements Regarding Child's Medical
Care and Notifications Requirements and
resubmit to Licensing for review.
Supplemental Information Provided by Yes[ ] No The program's policy was corrected and resubmitted via email on 6/14/22.
CCA All required policies and procedures as
identified in "Agency Type Specific Rules"
Foster Care Policy subtitled Requirements
Regarding the Number of Children Placed by
JM (page11) includes incorrect information
CORRECTIVE ACTION: Update this section
with the correct information as stated in
Licensing rule and resubmit to Licensing for
review.
Supplemental Information Provided by Yes[ ] No The program's policy was corrected and resubmitted via email on 6/14/22.
CCA All required policies and procedures as
identified in "Agency Type Specific Rules"
Foster Care Policy subtitled Responsibilities
to Monitor Certification Compliance (page21)
includes incorrect information.
CORRECTIVE ACTION: Update this section
with the correct information as stated in
Licensing rule and resubmit to Licensing for
review.
Physical Plant Yes[ ] No The program provided photo proof on 6/14/22 and 7/13/22 via email reflecting the required
413-215-0511(2)(a) &(c) Buildings are smoke repairs.
free, clean and in good repair
Second wooden step from the bottom of the
stairway located between the admin office and
the boardroom office is broken
CORRECTIVE ACTION: Repair/replace
wooden step that is broken
Physical Plant Yes[ ] No The program provided photo proof on 6/14/22 and 7/13/22 via email reflecting the required
413-215-0511(2)(a) &(c) Buildings are smoke repairs
free, clean and in good repair

Boys' bathroom located in the Castle has a
hole in the wall behind the door and a burnt-
out light bulb.
CORRECTIVE ACTION: Repair hole behind
bathroom door and replace light bulb.
Safety Yes[ ] No During the review, the program modified the evacuation drill to include the total number of
(3)(a) Evacuation drill occurs monthly under children evacuated.
varying conditions 413-215-0541
During the 2020 year, both the Castle and As per the program, the importance of the monthly drills has been reiterated & both sites
SAFE Center missed multiple monthly are back on track moving forward. Both sites are documenting their monthly drills.
evacuation drills. The Castle missed 4 drills.
The SAFE Center missed 2 drills. All monthly
drills were completed for the 2021 year. In
addition, the program's evacuation form was
missing the total number of children
evacuated.
CORRECTIVE ACTION: Ensure that
evacuation drills are completed and
documented on a monthly basis.
Health Services Yes[ ] No The program has modified their health assessment intake form, adding a section to record
413-215-0546 (Res.) and 413-215-0376 the completion of age-appropriate instruction taught to each resident. A copy of this
(Foster Care) modified form was submitted via email on 7/25/22.
(2)(e) Documentation of age-appropriate
instruction - pregnancy prevention, nutrition,
prevention of HIV & AIDS, and prevention and
treatment of sexually transmitted disease
Age-appropriate instruction is reportedly
occurring when residents meet with nursing
staff, but that instruction is not being recorded.
CORRECTIVE ACTION: Ensure that
documentation of this age-appropriate
instruction is recorded in the youths' files from
this point forward.
Consents Yes[ ] No Updated intake form submitted via email on 6/14/22.
413-215-0576(1) (Res) and 413-215-0391(1)
(Foster Care)
(e) Allow access as defined in 413-215-0091
& 0101

Five out of the five youth files reviewed did not
have a written consent related to allowing
access to youth as defined by OAR.
CORRRECTIVE ACTION: Add this consent to
existing intake paperwork.
Consents Yes[ ] No Updated intake form submitted via email on 6/14/22.
413-215-0576(1) (Res) and 413-215-0391(1)
(Foster Care)
(f) Impose a dress code
Five out of the five youth files reviewed did not
have a written consent related to imposing a
dress code.
CORRECTIVE ACTION: Add this consent to
existing intake paperwork.
Information about Children in Care Yes[ ] No Updated intake form submitted via email on 6/14/22.
413-215-0581(1) (Res) and 413-215-0396(1)
(Foster Care) Summary sheet contains the
following:
(b) Name and location of previous and current
school
(c) Date of admission
(d) Legal custody
(e) The name, address, and telephone
number of:
(A) The child in care's parents.
(B) The child in care's legal guardian, if
different than the parents, and a copy of the
document that provides for his or her authority
over the child in care.
(C) Other persons significant to child
(D) Other professionals to be involved
in service planning (if applicable)
Summary sheet does not allow space for
residents' previous school setting.
CORRECTIVE ACTION: Add space where a
residents' previous school and school's
location can be added to the summary sheet.

Information about Children in Care Yes[ ] No Updated intake form submitted via email on 6/14/22.
413-215-0581(1) (Res) and 413-215-0396(1)
(Foster Care) Summary sheet contains the
following:
Youth's date of admission is unclear on the
summary sheet.
CORRECTIVE ACTION: Modify the summary
sheet to include admission date.
Information about Children in Care Yes[ ] No Updated intake form submitted via email on 6/14/22.
413-215-0581(1) (Res) and 413-215-0396(1)
(Foster Care) Summary sheet contains the
following:
Summary sheet does not clearly document
who has legal custody of the admitted youth.
CORRECTIVE ACTION: Modify the
summary sheet to confirm who has legal
custody of youth once admitted.
Information about Children in Care Yes[ ] No Updated intake form submitted via email on 6/14/22.
413-215-0581(1) (Res) and 413-215-0396(1)
(Foster Care) Summary sheet contains the
following:
Files where youth were under the legal
custody of a guardian different form their
parent did not reflect the document to confirm
this authority.
CORRECTIVE ACTION: Modify the intake
process where documentation to confirm the
legal authority of a youth if not the parent.
Financial Records 413-215-0581(4) Yes[ ] No A new form for tracking/recording youth financial records was generated and shared at the
Records contain date, amount, source, time of the program's review. Since then, this new tracking is being utilized and stored in

interview_summary:
The following information was shared and gathered during the unannounced site visit:
- Both programs, The Castle, and The Safe Center, currently have 12 residents in their respective buildings. Four youth were recently discharged from
the program due to ongoing behavioral issues.
- There are plans to reopen Crystal Creek in the upcoming new year.
- The program is exploring having additional staff members attending and become certified in advanced CPI training.
- The majority of all meals for both facilities are being prepared in Crystal Creek's industrial kitchen and transported to each site.
- Staffing status and changes were discussed.
Several staff members were met with during this site visit. The program continues to take active steps to remain in compliance with SB710 and has been
working collaboratively with Licensing, OTIS, CPI instructors and their Senator, inviting ongoing discussions and seeking to understand the intent behind this
new legislation.
Four youth were interviewed individually. Although all youth reported feeling safe in the program, two youth disclosed concerns related to one specific staff
member. The concerns reported were sufficient for Licensing to report to the Child Abuse Hotline. Strengths identified by youth include the program meeting
youth needs, craft activities, breakfast meal options, frequent contact with family members and former foster parents. No areas of improvement were
reported, but two recommendations that were made were more nature walks and youth having their own rooms. Staff support youth in various ways. This
support includes hugs, space, talking to youth, sitting with staff and staff checking in with youth. All youth were able to provide a list of staff whom they had a
good relationship with and could report issues to. Treatment goals were understood by youth and progress is measured by staff and summarized on daily
point sheets.

observations: Tour of Crystal Creek was unremarkable. No concerns regarding the building's physical space were noted.

previous_findings:
from Review dated Repeat Comments
Findings
Further Action
Needed
Supplemental Information Provided by Yes[ ] No The program provided photo proof on 6/14/22 via email that verified improvements were
CCA Documents as indicated on the form made to the playground's fence as required by the Health Inspection.
titled "Renewal Licensing Required
Documents"
Completed health inspection of the Castle
indicates that improvements are needed to
the fenced area around the playground.
CORRECTIVE ACTION: Complete
recommended tasks and submit pictures of
those improvements to Licensing.
Supplemental Information Provided by Yes No[ ] REPEAT FINDING: The program's Fire Marshall inspection is scheduled for November of
CCA Documents as indicated on the form 2022 due to budget shortfalls experienced by the county. It is requested that the program
titled "Renewal Licensing Required submit a copy of the 2022 Fire Marshal Report once completed in November. Any noted
Documents" violations will be abated and approved by the Fire Marshal inspector.
1

Updated Fire Marshal reports for The Castle
and the SAFE Center were not submitted at
the time of the review. Previous inspections
completed in Nov of 2020 were submitted.
CORRECTIVE ACTION: Schedule updated
fire marshal inspections for The Castle and
SAFE Center and forward those completed
inspections to Licensing for review.
Supplemental Information Provided by Yes[ ] No The approved Tax Compliance Certificate was submitted via email on 11/16/22.
CCA Documents as indicated on form titled
"Required Financial Documents and
Information"
Agency did not submit a Tax Compliance
Certificate issued from the Department of
Revenue but did submit a copy of the
application filled out.
CORRECTIVE ACTON: Submit completed
Tax Compliance Certificate signed by a
representative of the Department of Revenue
to Licensing once received.
Supplemental Information Provided by Yes[ ] No Revised Conflict of Interest that meets Licensing Rule was submitted via email on 6/14/22.
CCA All required policies and procedures as
identified in the "Umbrella Rules"
Submitted Conflict of Interest policy 3.C.5
Protections Against Nepotism requires
revision to meet Licensing rule.
CORRECTIVE ACTION: Revise Conflict of
Interest to include the required information
and resubmit to Licensing for review.
Supplemental Information Provided by Yes[ ] No Revised Grievance Policy that meets Licensing Rule was submitted via email on 8/23/22.
CCA All required policies and procedures as
identified in the "Umbrella Rules"
Submitted grievance policy 2.H.6 Consumer
Grievance Procedure requires revision to
meet Licensing rule.
CORRECTIVE ACTION: Revise grievance
procedure to include the required information
and resubmit to Licensing for review.

Supplemental Information Provided by Yes[ ] No Revised Mandatory Reporting Policy that meets Licensing Rule was submitted via email on
CCA All required policies and procedures as 6/14/22.
identified in the "Umbrella Rules"
Submitted mandatory reporting policy 3.E.2
Reporting of Child Abuse requires revision to
meet Licensing Rule.
CORRECTIVE ACTION: Revise child abuse
reporting policy to include the required
information and resubmit to Licensing for
review.
Supplemental Information Provided by Yes[ ] No Revised policy was submitted to Licensing on
CCA All required policies and procedures as
identified in the "Umbrella Rules"
Submitted personnel policies 3.C Recruitment
and Selection require revision to meet
Licensing rules.
CORRECTIVE ACTION: Revise personnel
policies to include required information and
resubmit to Licensing for review.
Supplemental Information Provided by Yes[ ] No The correct information was located on the program's website.
CCA All required policies and procedures as
identified in the "Umbrella Rules"
Submitted privacy policy 2.G Confidentiality
requires revision to meet Licensing rules.
CORRECTIVE ACTION: Revise privacy
policy to include the highlighted information
and resubmit to Licensing for review.
Supplemental Information Provided by Yes[ ] No Revised policy submitted via email on 7/19/22.
CCA All required policies and procedures as
identified in the "Umbrella Rules"
Submitted behavior management policy 2.A.4
Jasper Mountain Interventions - Clinically
Appropriate Interventions requires revision to
meet licensing rules.
CORRECTIVE ACTIVE: Revise behavior
management policy to include the required

information and resubmit to Licensing for
review.
Supplemental Information Provided by Yes No[ ] REPEAT FINDING: A final draft of the program's revised Suicide Prevention Policy is still
CCA All required policies and procedures as required. The last draft submitted on 9/19/22 requires final timeframe as to when
identified in the "Umbrella Rules" notifications to both Licensing and legal guardians will be made by the program.
Submitted Suicide Prevention Policy 2.A.6.02
Enhanced Supervision to Prevent Self Harm
requires revision to meet Licensing rule.
CORRECTIVE ACTION: Revise suicide
prevention policy to include the highlighted
information and resubmit to Licensing for
review.
Supplemental Information Provided by Yes[ ] No This policy was later located in the program's Policy and Procedure packet.
CCA All required policies and procedures as
identified in the "Umbrella Rules"
A policy regarding Searches was not
submitted at the time of the review.
CORRECTIVE ACTION: Review the
Licensing rule related to searches. Create or
modify program's Search Policy to include the
required information and submit to Licensing
for review.
Supplemental Information Provided by Yes[ ] No Revised policy meeting Licensing Rule was submitted via email on 6/14/22 and 8/23/22.
CCA All required policies and procedures as
identified in the "Umbrella Rules"
Newly added information regarding restraints
in the program's policies does not reflect
required information.
CORRECTIVE ACTION: Include the
following information in the program's restraint
section of their policy packet and resubmit to
Licensing for review.
Supplemental Information Provided by Yes[ ] No Revised policy submitted via email on 9/5/22.
CCA All required policies and procedures as
identified in "Agency Type Specific Rules"
Foster Care Medication Policy requires
revision to meet Licensing rule

CORRECTIVE ACTION: Include the
following item missing from existing policy
Requirements Regarding Child's Medical
Care and Notifications Requirements and
resubmit to Licensing for review.
Supplemental Information Provided by Yes[ ] No The program's policy was corrected and resubmitted via email on 6/14/22.
CCA All required policies and procedures as
identified in "Agency Type Specific Rules"
Foster Care Policy subtitled Requirements
Regarding the Number of Children Placed by
JM (page11) includes incorrect information
CORRECTIVE ACTION: Update this section
with the correct information as stated in
Licensing rule and resubmit to Licensing for
review.
Supplemental Information Provided by Yes[ ] No The program's policy was corrected and resubmitted via email on 6/14/22.
CCA All required policies and procedures as
identified in "Agency Type Specific Rules"
Foster Care Policy subtitled Responsibilities
to Monitor Certification Compliance (page21)
includes incorrect information.
CORRECTIVE ACTION: Update this section
with the correct information as stated in
Licensing rule and resubmit to Licensing for
review.
Physical Plant Yes[ ] No The program provided photo proof on 6/14/22 and 7/13/22 via email reflecting the required
413-215-0511(2)(a) &(c) Buildings are smoke repairs.
free, clean and in good repair
Second wooden step from the bottom of the
stairway located between the admin office and
the boardroom office is broken
CORRECTIVE ACTION: Repair/replace
wooden step that is broken
Physical Plant Yes[ ] No The program provided photo proof on 6/14/22 and 7/13/22 via email reflecting the required
413-215-0511(2)(a) &(c) Buildings are smoke repairs
free, clean and in good repair

Boys' bathroom located in the Castle has a
hole in the wall behind the door and a burnt-
out light bulb.
CORRECTIVE ACTION: Repair hole behind
bathroom door and replace light bulb.
Safety Yes[ ] No During the review, the program modified the evacuation drill to include the total number of
(3)(a) Evacuation drill occurs monthly under children evacuated.
varying conditions 413-215-0541
During the 2020 year, both the Castle and As per the program, the importance of the monthly drills has been reiterated & both sites
SAFE Center missed multiple monthly are back on track moving forward. Both sites are documenting their monthly drills.
evacuation drills. The Castle missed 4 drills.
The SAFE Center missed 2 drills. All monthly
drills were completed for the 2021 year. In
addition, the program's evacuation form was
missing the total number of children
evacuated.
CORRECTIVE ACTION: Ensure that
evacuation drills are completed and
documented on a monthly basis.
Health Services Yes[ ] No The program has modified their health assessment intake form, adding a section to record
413-215-0546 (Res.) and 413-215-0376 the completion of age-appropriate instruction taught to each resident. A copy of this
(Foster Care) modified form was submitted via email on 7/25/22.
(2)(e) Documentation of age-appropriate
instruction - pregnancy prevention, nutrition,
prevention of HIV & AIDS, and prevention and
treatment of sexually transmitted disease
Age-appropriate instruction is reportedly
occurring when residents meet with nursing
staff, but that instruction is not being recorded.
CORRECTIVE ACTION: Ensure that
documentation of this age-appropriate
instruction is recorded in the youths' files from
this point forward.
Consents Yes[ ] No Updated intake form submitted via email on 6/14/22.
413-215-0576(1) (Res) and 413-215-0391(1)
(Foster Care)
(e) Allow access as defined in 413-215-0091
& 0101

Five out of the five youth files reviewed did not
have a written consent related to allowing
access to youth as defined by OAR.
CORRRECTIVE ACTION: Add this consent to
existing intake paperwork.
Consents Yes[ ] No Updated intake form submitted via email on 6/14/22.
413-215-0576(1) (Res) and 413-215-0391(1)
(Foster Care)
(f) Impose a dress code
Five out of the five youth files reviewed did not
have a written consent related to imposing a
dress code.
CORRECTIVE ACTION: Add this consent to
existing intake paperwork.
Information about Children in Care Yes[ ] No Updated intake form submitted via email on 6/14/22.
413-215-0581(1) (Res) and 413-215-0396(1)
(Foster Care) Summary sheet contains the
following:
(b) Name and location of previous and current
school
(c) Date of admission
(d) Legal custody
(e) The name, address, and telephone
number of:
(A) The child in care's parents.
(B) The child in care's legal guardian, if
different than the parents, and a copy of the
document that provides for his or her authority
over the child in care.
(C) Other persons significant to child
(D) Other professionals to be involved
in service planning (if applicable)
Summary sheet does not allow space for
residents' previous school setting.
CORRECTIVE ACTION: Add space where a
residents' previous school and school's
location can be added to the summary sheet.

Information about Children in Care Yes[ ] No Updated intake form submitted via email on 6/14/22.
413-215-0581(1) (Res) and 413-215-0396(1)
(Foster Care) Summary sheet contains the
following:
Youth's date of admission is unclear on the
summary sheet.
CORRECTIVE ACTION: Modify the summary
sheet to include admission date.
Information about Children in Care Yes[ ] No Updated intake form submitted via email on 6/14/22.
413-215-0581(1) (Res) and 413-215-0396(1)
(Foster Care) Summary sheet contains the
following:
Summary sheet does not clearly document
who has legal custody of the admitted youth.
CORRECTIVE ACTION: Modify the
summary sheet to confirm who has legal
custody of youth once admitted.
Information about Children in Care Yes[ ] No Updated intake form submitted via email on 6/14/22.
413-215-0581(1) (Res) and 413-215-0396(1)
(Foster Care) Summary sheet contains the
following:
Files where youth were under the legal
custody of a guardian different form their
parent did not reflect the document to confirm
this authority.
CORRECTIVE ACTION: Modify the intake
process where documentation to confirm the
legal authority of a youth if not the parent.
Financial Records 413-215-0581(4) Yes[ ] No A new form for tracking/recording youth financial records was generated and shared at the
Records contain date, amount, source, time of the program's review. Since then, this new tracking is being utilized and stored in
purpose, signatures each youth's respective file.
Youth financial records are not being
individually maintained nor kept in the youths'
files. Monthly records with the entire milieu's
spending are physically stored in the program
and required information is missing.

Information is later entered into a separate
electronic account record that is being kept by
the main admin office.
CORRECTIVE ACTION: Solidify a process
where financial records for each youth are
maintained and reflect all necessary
information listed to include youth and staff
signatures for each entry.
Personal Possessions Records Yes[ ] No The program's newly appointed support services coordinator digitized all of the inventory
413-215-0581(5) lists for youth. Hard copies of these inventory lists are placed in each youth's respective
Individual written inventory of all personal files on a monthly basis or when inventory changes occur.
possessions is maintained and updated as
needed
Youth files did not reflect consistent
documentation of youths' personal
possessions.
CORRECTIVE ACTION: Ensure that
individual written inventory of personal
possessions is recorded and updated to
include the addition of possessions and/or
when items are discarded, lost, destroyed,
etc.
Records of Proctor Foster Homes Yes[ ] No The program created a template letter to reflect either the acceptance or denial of a foster
413-215-0351 parents' foster care application. A copy of this letter was submitted via email on 6/14/22.
(2)(b) & 413-215-0316(4) Notification of
acceptance or denial of application. If denial is
due to substantiated abuse, the reason for
denial is disclosed to applicant.
Files reviewed did not reflect documentation
of acceptance or denial of application
CORRECTIVE ACTION: Implement a
process where applicants are notified in
writing of either the program's acceptance or
denial of application
Records of Proctor Foster Homes Yes[ ] No A new tracking form was generated to ensure documentation of all routine home visits.
413-215-0351 This new form was submitted via email on 6/14/22.
(2)(g) Documentation of home visit (every 90
days)

Documentation of home visits every 90 days
is not consistent or clear in the files reviewed
CORRECTIVE ACTION: Implement a
process where home visits are conducted
every 90 day and clearly documented in each
foster family's files
Assessment and Approval of Proctor Yes[ ] No Once the TFC program has been reinstated, the newly hired foster care coordinator will
Foster Homes Written Assessment ensure all signatures are captured.
413-215-0316
(2)(a) Application signed by all applicants
One out of the two foster parent files did not
have an application signed by both providers
CORRECTIVE ACTION: Ensure that all
applicants sign the required application from
this point forward.
Annual Review and Approval Yes[ ] No Once the TFC program has been reinstated, the newly hired foster care coordinator will
413-215-0331(2) ensure all signatures are captured.
(e) Documentation that home remains in
compliance with safety standards 413-215-
0318
One out of the two foster parents' files did not
reflect documentation of safety standards
(CF0979) signed by both applicants.
CORRECTIVE ACTION: Ensure that safety
standards (CF0979) form is signed by both
applicants
Training for Parents in Proctor Foster Care Yes[ ] No The program has recently hired a new foster care coordinator who will be generating a new
Written Training Plan includes: training plan to utilize once the TFC program has been reinstated.
413-215-0326(1)
(c)(A) Characteristics and needs of children
who are placed
Training plan is not clear in documentation to
ensure this specific training topic is covered
CORRECTIVE ACTION: Ensure
documentation of specific topic as required by
Licensing rule

Training for Parents in Proctor Foster Care Yes[ ] No The program has recently hired a new foster care coordinator who will be generating a new
Written Training Plan includes: training plan to utilize once the TFC program has been reinstated.
413-215-0326(1)
(c)(B) Ways to effectively parent children,
including application of the reasonable and
prudent parent standard
Training plan is not clear in documentation to
ensure this specific training topic is covered
CORRECTIVE ACTION: Ensure
documentation of specific topic as required by
Licensing rule
Training for Parents in Proctor Foster Care Yes[ ] No The program has recently hired a new foster care coordinator who will be generating a new
Written Training Plan includes: training plan to utilize once the TFC program has been reinstated.
413-215-0326(1)
(c)(D) Importance of family of the child and
working with the family
Training plan is not clear in documentation to
ensure this specific training topic is covered
CORRECTIVE ACTION: Ensure
documentation of specific topic as required by
Licensing rule
Training for Parents in Proctor Foster Care Yes[ ] No The program has recently hired a new foster care coordinator who will be generating a new
Written Training Plan includes: training plan to utilize once the TFC program has been reinstated.
413-215-0326(1)
(c)(E) Importance of age-appropriate or
developmentally appropriate extracurricular,
enrichment, cultural, and social activities
Training plan is not clear in documentation to
ensure this specific training topic is covered
CORRECTIVE ACTION: Ensure
documentation of specific topic as required by
Licensing rule

Training for Parents in Proctor Foster Care Yes[ ] No The program has recently hired a new foster care coordinator who will be generating a new
Written Training Plan includes: training plan to utilize once the TFC program has been reinstated.
413-215-0326(1)
(c)(F) Preparation of child for independence
based on age, stage of development, and
child's needs
Training plan is not clear in documentation to
ensure this specific training topic is covered
CORRECTIVE ACTION: Ensure
documentation of specific topic as required by
Licensing rule
Training for Parents in Proctor Foster Care Yes[ ] No The program has recently hired a new foster care coordinator who will be generating a new
Written Training Plan includes: training plan to utilize once the TFC program has been reinstated.
413-215-0326(1)
(2) Training is documented
Training is not uniformly documented in the
foster families' files
CORRECTIVE ACTION: Ensure clear,
consistent documentation of training from this
point forward
Disclosures 413-215-0391(2) Yes[ ] No Updated intake form submitted via email on 6/14/22.
Parent/guardian has acknowledged in writing:
(e) Any policies and procedures upon request
Three out of three youth files reviewed did not
have a disclosure related to policies and
procedures upon request. The intake forms
used were outdated.
CORRECTIVE ACTION: Use the program's
updated intake forms where this disclosure
exists.
Authorizations 413-215-0391(3) Yes[ ] No Updated intake form submitted via email on 6/14/22.
(b) Child specific visitors

Authorizations regarding child specific visitors
were absent in two out of the three files
reviewed
CORRECTIVE ACTION: Ensure that child
specific visitors authorization is in the youths'
files
Authorizations 413-215-0391(3) Yes[ ] No Updated intake form submitted via email on 6/14/22.
(c) Visitation resources are pre-approved
Authorizations regarding pre-approved
visitation resources were absent in two out of
the three files reviewed
CORRECTIVE ACTION: Ensure that pre-
approved visitation resources authorization is
in the youths' files
New Findings from Site Visit Comments
Physical Plant The Castle:
413-215-0511(2)(a) &(c) Buildings are - 1st floor bathroom recently had mirror removed
smoke free, clean and in good repair - 1st floor bathroom's ceiling has the possible beginnings of moisture damage/mold
- 1st floor - bedroom #4 has broken window blinds
The Safe Center:
- Bathtub needs recaulking
- Bathroom ceiling has the possible beginnings of moisture damage/mold
CORRECTIVE ACTION:
- Replace mirror or repair and paint wall where the mirror once hung
- Assess and treat the bathroom ceilings in both facilities if moisture damage/mold is found
- Replace window blinds in bedroom #4
- Re caulk along bathtub
413-215-0091 Licensing Umbrella Rules: Recent promotions may warrant an updated CCA Contact Information Form
Responsibilities of Licensees
(11) Notify the Department in the following CORRECTIVE ACTION:
circumstances: Review current CCA Contact Information Form and submit updated document given recent promotions.
(a) Immediately when information on the
"CCA Contact Information Form" changes.
An updated form may be submitted
electronically, or the change may be

communicated directly to a department
licensing coordinator.

excerpt:
413-215-0091 Licensing Umbrella Rules: Recent promotions may warrant an updated CCA Contact Information Form
Responsibilities of Licensees
(11) Notify the Department in the following CORRECTIVE ACTION:
circumstances: Review current CCA Contact Information Form and submit updated document given recent promotions.
(a) Immediately when information on the
"CCA Contact Information Form" changes.
An updated form may be submitted
electronically, or the change may be
communicated directly to a department
licensing coordinator.
Physical Plant The Castle


state: OR

facility_name: Jasper Mountain

summary: 6-month - 08/23/2023

raw_content:
Licensed Child Caring Agency 6 Month Review
Residential Care
Licensee: Jasper Mountain – Crystal Creek Board Chairperson: Frank Papagani
Interim Executive Director: Nicole Roberts Date of site visit: 8/23/23
Program Director: Sarah Huff Licensing Coordinator: Mary Torres
Interviews, Observations: Construction of Crystal Creek was completed in 2020 and was initially inspected by Licensing on 9/1/20. A 6-month
temporary license was granted on 11/30/20 for Crystal Creek. After being open for only a few months and prior to expiration of its’ 6-month
temporary license, the program decided to briefly close their newest building due to ongoing staffing shortages. In the summer of 2023, the program
resubmitted all necessary paperwork to re-open and relicense Crystal Creek.
A tour of the building was led by the program’s newest Residential Assistant dedicated to Crystal Creek. The building remains in excellent physical
condition. There are currently 6 youth at Crystal Creek. The program is only able to house 6 youth currently due to staffing levels. When more staff
are hired, Crystal Creek will be able to serve more youth. The youth are currently on summer break. On campus school will resume in September.
All instructors are hired internally by Jasper Mountain. There are six teachers in total. Three on the Jasper Mountain campus and three at the Safe
Center. Youth currently in program have reportedly all done well. One youth is scheduled to return home in October and another youth will follow
soon after. The building recently added door codes to their main entrance. This additional safety measure was approved in writing by the Fire
Marshal’s office. There is a nearby forest fire that the program is monitoring. Evacuation packs are at the ready should the campus move to a
Level II evacuation notice.
Three youth were interviewed during this site visit. All three youth had previously resided in another one of the program’s buildings before moving
into Crystal Creek in April and May of this year. Youth report feeling safe in Crystal Creek. Two youth share feeling unsafe when peers have
escalated. In both situations, staff reportedly handled the situation well, moving youth to another area and moving the escalated youth outside.
Crystal Creek was developed as a step down/transitional program for youth who are ready to return home or transition to lower-level care such as
foster care. When asked how staff support youth at Crystal Creek, one youth stated that staff will provide “space” either outside or on the bench
located downstairs. Another youth reports not needing support since arriving at Crystal Creek and that seeing an assigned therapist twice a week
meets the youth’s need for support currently. The food is described as “good” and “healthy.” Youth are able to help out in the kitchen if it’s part of
their assigned chore. When asked about available snacks, the youth report that during summer, snacks are not offered as mealtimes are modified
during the summer months. Residents sleep in so meals start later in the day (8:45 am, 1:00 pm, 6:00 pm). Contact with family is described as
frequent. Contact occurs via phone within the milieu or over zoom during family therapy sessions. Strengths of Crystal Creek include time spent
P a g e 1 | 18
Form Rev. 08/03/2023
10/6/23
10-6-2023

agency_name: Jasper Mountain (JM)

program_name: Castle

program_type: (RC) Residential Care Programs

view_code: RC

facility_type: Residential Care

licensee: Jasper Mountain - Crystal Creek Board Chairperson: Frank Papagani Interim Executive Director: Nicole Roberts Date of site visit: 8/23/23

licensing_coordinator: Mary Torres

interviews_observations:
Construction of Crystal Creek was completed in 2020 and was initially inspected by Licensing on 9/1/20. A 6-month
temporary license was granted on 11/30/20 for Crystal Creek. After being open for only a few months and prior to expiration of its' 6-month
temporary license, the program decided to briefly close their newest building due to ongoing staffing shortages. In the summer of 2023, the program
resubmitted all necessary paperwork to re-open and relicense Crystal Creek.
A tour of the building was led by the program's newest Residential Assistant dedicated to Crystal Creek. The building remains in excellent physical
condition. There are currently 6 youth at Crystal Creek. The program is only able to house 6 youth currently due to staffing levels. When more staff
are hired, Crystal Creek will be able to serve more youth. The youth are currently on summer break. On campus school will resume in September.
All instructors are hired internally by Jasper Mountain. There are six teachers in total. Three on the Jasper Mountain campus and three at the Safe
Center. Youth currently in program have reportedly all done well. One youth is scheduled to return home in October and another youth will follow
soon after. The building recently added door codes to their main entrance. This additional safety measure was approved in writing by the Fire
Marshal's office. There is a nearby forest fire that the program is monitoring. Evacuation packs are at the ready should the campus move to a
Level II evacuation notice.
Three youth were interviewed during this site visit. All three youth had previously resided in another one of the program's buildings before moving
into Crystal Creek in April and May of this year. Youth report feeling safe in Crystal Creek. Two youth share feeling unsafe when peers have
escalated. In both situations, staff reportedly handled the situation well, moving youth to another area and moving the escalated youth outside.
Crystal Creek was developed as a step down/transitional program for youth who are ready to return home or transition to lower-level care such as
foster care. When asked how staff support youth at Crystal Creek, one youth stated that staff will provide "space" either outside or on the bench
located downstairs. Another youth reports not needing support since arriving at Crystal Creek and that seeing an assigned therapist twice a week
meets the youth's need for support currently. The food is described as "good" and "healthy." Youth are able to help out in the kitchen if it's part of
their assigned chore. When asked about available snacks, the youth report that during summer, snacks are not offered as mealtimes are modified
during the summer months. Residents sleep in so meals start later in the day (8:45 am, 1:00 pm, 6:00 pm). Contact with family is described as
frequent. Contact occurs via phone within the milieu or over zoom during family therapy sessions. Strengths of Crystal Creek include time spent
P a g e 1 | 18

10/6/23
10-6-2023


summary: Unannounced - 3 findings

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Licensee: Jasper Mountain
Executive Director: Nicole Roberts
Program Directors: Sarah Huff, Taryne Roberts, Melanie Bernabe
Date of Unannounced: 9/20/23
Licensing Coordinator: Mary Torres
Other Regulatory or Accrediting Agencies: Oregon Health Authority (OHA), Oregon Department of Education (ODE) Private Alternative School,
Council on Accreditation (COA) for Services to Children and Families.
Purpose: Per OAR 419-400-0240 (1)(b) Children’s Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings from Unannounced Visit Repeat Comments
dated 11/2/22 Findings
Further Action
Needed
Physical Plant Yes☐ No✓ This on-site visit confirmed the program has addressed repairs.
413-215-0511(2)(a) &(c) Buildings are
smoke free, clean and in good repair
The Castle:
- 1st floor bathroom had mirror removed
- 1st floor bathroom ceiling has the possible
beginnings of moisture damage/mold
- 1st floor bedroom #4 has broken window
blinds
The Safe Center:
- Bathtub needs recaulking
- Bathroom ceiling has the possible
beginnings of moisture damage/mold
CORRECTIVE ACTION:
1| P age
Form Rev. 01/23/2023
- Replace mirror or repair and paint wall
where the mirror once hung
- Assess and treat the bathroom ceilings in
both facilities if moisture damage/mold is
found
- Replace window blinds in bedroom #4
- Re caulk along bathtub
413-215-0091 Licensing Umbrella Rules: Yes☐ No✓ The program submitted an updated CCA Contact Form to reflect staff changes.
Responsibilities of Licensees
(11) Notify the Department in the following
circumstances:
(a) Immediately when information on the
"CCA Contact Information Form" changes.
Recent promotions may warrant an updated
CCA Contact Information Form
CORRECTIVE ACTION:
Review current CCA Contact Information
Form and submit updated document given
recent promotions.
Supplemental Information Provided by Yes☐ No✓ The Fire Marshal completed the program’s 2022 inspection on 11/14/22. A copy of this
CCA Documents as indicated on the form approved inspection was provided to Licensing via email on 12/17/22.
titled “Renewal Licensing Required
Documents”
Updated Fire Marshal reports for The Castle
and the SAFE Center were not submitted at
the time of the review. Previous inspections
completed in Nov of 2020 were submitted.
REPEAT FINDING: The program’s Fire
Marshall inspection is scheduled for
November of 2022 due to budget shortfalls
experienced by the county. It is requested that
the program submit a copy of the 2022 Fire
Marshal Report once completed in November.
Any noted violations will be abated and
approved by the Fire Marshal inspector.
CORRECTIVE ACTION: Schedule updated
fire marshal inspections for The Castle and
SAFE Center and forward those completed
inspections to Licensing for review.
2| P age
Form Rev. 01/23/2023
Supplemental Information Provided by Yes☐ No✓ A revised copy of the program’s Suicide Prevention Policy meeting Licensing Rule was
CCA All required policies and procedures as submitted to Licensing via email on 1/10/23.
identified in the “Umbrella Rules”
Submitted Suicide Prevention Policy 2.A.6.02
Enhanced Supervision to Prevent Self Harm
requires revision to meet Licensing rule.
REPEAT FINDING: A final draft of the
program’s revised Suicide Prevention Policy is
still required. The last draft submitted on
9/19/22 requires final timeframe as to when
notifications to both Licensing and legal
guardians will be made by the program.
CORRECTIVE ACTION: Revise suicide
prevention policy to include the highlighted
information and resubmit to Licensing for
review.
New Findings from Site Visit Comments
Physical Plant Safe Center:
413-215-0511(2)(a) &(c) Buildings are - Mold found in back bathroom at the base of the floor, just behind the door.
smoke free, clean and in good repair - Bedroom #5 – window is hard to open and close. Extra force/pressure must be used to fully close.
- Bedroom windows facing the front of building have a buildup of condensation.
The Castle
- Discarded extension cord found at the base of the stairs located near the main parking lot.
- Outside wooden stairs leading to the entry have deteriorated boards on multiple steps.
- Bedroom #3 has adhesive debris on the wall as well as a blue splotch near the upper bunk.
- Broken window blinds in bedrooms #1 and #7.
- Carpet in the Great Room and on the same floor is worn and stained.
- Heavy insect webbing located on outside windows, blocking view, and reducing daylight.
CORRECTIVE ACTION:
- Until the scheduled renovation of the bathroom occurs, treat/clean mold found at the base of the floor
just behind the door.
- Assess and remedy the cause for the difficulty in opening and closing the window in bedroom #5.
- Assess and address the source of condensation for bedrooms facing the front of the building. Clean
dark spots around the windows’ caulking.
- Remove extension cord from base of stairs.
3| P age
Form Rev. 01/23/2023
- Replace or cover wooden boards that are showing obvious signs of deterioration. This includes the
edge of the landing where the tables are located and the stairs leading to the entry of the Castle.
- Remove the adhesive and re paint the wall located in the bedroom #3.
- Replace the broken blinds in bedrooms #1 and #7.
- Replace the carpet on the entire floor where the Great Room and living room is located.
- Clean the outside of all the windows.
Interview Summary
Tours of both campuses were led by staff members. There are currently 12 residents at the Safe Center, plus one crisis respite placement. The “front
bathroom” at the Safe Center is in the midst of a total renovation. Mold was found in the bathroom and a decision was made to gut the shower/tub to prevent
further spread. The renovation which started on 9/18/23, is scheduled to take 2 – 3 weeks to complete. The facility has extra bathrooms that youth can access
to help meet bathroom to resident ratio during this period of time. The “back bathroom” will also go through a renovation once the front bathroom has been
completed. The program also has plans to have the main doors to the covered structure replaced with funds obtained through a grant. Census for the Castle is
currently low.
Youth from both sites were interviewed for a total of 4 youth. All youth report currently feeling safe in the program with two residents feeling uneasy when
peers become escalated. One youth also added feeling unsafe at the time of his first hold as he was unaware that the program practiced restraints when
initially placed at Jasper Mountain. Since then, one of the program directors explained why youth are placed in a restraint and the youth understands that this
is done to “keep kids safe.” Staff are described as well trained and are there to help the residents. Staff offer one on one support, structure, give youth space
and encourage youth to breathe. Feedback regarding the program’s food varied from youth to youth. One youth reports that the program offers “too much
salad” while another says the food is “good”, but youth are only allowed seconds. A third youth admits not liking the flavor of many main dishes, preferring to
only eat side dishes. Family contact is reported as being frequent and positive. Strengths of the program include staff’s help to do what’s right, fun activities,
giving youth space and attending a recent Duck’s game. Areas of weakness included the food and the volume of the room alarms at the Safe Center.
Observations
During both tours of the campuses, the overall environments were calm. Youth randomly selected for interviews were engaging and pleasant.
The Castle is beginning to show signs of wear. Larger repairs were noted above for this facility.
4| P age
Form Rev. 01/23/2023
Corrective Actions and Timeframes:
Please submit the following to verify compliance.
Within 45 days of receipt of this report Jasper Mountain must submit a letter of verification indicating the agency is in compliance with the specific
rules cited above and describing how compliance will be maintained going forward. Along with the letter of verification, the agency must submit any
and all specific documentation requested in the body of this report. The letter of verification and any additional requested documents can be emailed
directly to Licensing Coordinator, Mary Torres, at mary.torres@odhsoha.oregon.gov.
Licensing Coordinator’s Signature: ________________________ Date: _1_0_/2_7_/_2_3_ ___________
Manager Review: ______________________________________ Date: _1_0_-_2_7_-_2_0_2_3_ _______
5| P age
Form Rev. 01/23/2023

report_type: Unannounced

licensee: Jasper Mountain

executive_director: Nicole Roberts

purpose:
Per OAR 419-400-0240 (1)(b) Children's Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings from Unannounced Visit Repeat Comments
dated 11/2/22 Findings
Further Action
Needed
Physical Plant Yes[ ] No✓ This on-site visit confirmed the program has addressed repairs.
413-215-0511(2)(a) &(c) Buildings are
smoke free, clean and in good repair
The Castle:
- 1st floor bathroom had mirror removed
- 1st floor bathroom ceiling has the possible
beginnings of moisture damage/mold
- 1st floor bedroom #4 has broken window
blinds
The Safe Center:
- Bathtub needs recaulking
- Bathroom ceiling has the possible
beginnings of moisture damage/mold
CORRECTIVE ACTION:

- Replace mirror or repair and paint wall
where the mirror once hung
- Assess and treat the bathroom ceilings in
both facilities if moisture damage/mold is
found
- Replace window blinds in bedroom #4
- Re caulk along bathtub
413-215-0091 Licensing Umbrella Rules: Yes[ ] No✓ The program submitted an updated CCA Contact Form to reflect staff changes.
Responsibilities of Licensees
(11) Notify the Department in the following
circumstances:
(a) Immediately when information on the
"CCA Contact Information Form" changes.
Recent promotions may warrant an updated
CCA Contact Information Form
CORRECTIVE ACTION:
Review current CCA Contact Information
Form and submit updated document given
recent promotions.
Supplemental Information Provided by Yes[ ] No✓ The Fire Marshal completed the program's 2022 inspection on 11/14/22. A copy of this
CCA Documents as indicated on the form approved inspection was provided to Licensing via email on 12/17/22.
titled "Renewal Licensing Required
Documents"
Updated Fire Marshal reports for The Castle
and the SAFE Center were not submitted at
the time of the review. Previous inspections
completed in Nov of 2020 were submitted.
REPEAT FINDING: The program's Fire
Marshall inspection is scheduled for
November of 2022 due to budget shortfalls
experienced by the county. It is requested that
the program submit a copy of the 2022 Fire
Marshal Report once completed in November.
Any noted violations will be abated and
approved by the Fire Marshal inspector.
CORRECTIVE ACTION: Schedule updated
fire marshal inspections for The Castle and
SAFE Center and forward those completed
inspections to Licensing for review.

Supplemental Information Provided by Yes[ ] No✓ A revised copy of the program's Suicide Prevention Policy meeting Licensing Rule was
CCA All required policies and procedures as submitted to Licensing via email on 1/10/23.
identified in the "Umbrella Rules"
Submitted Suicide Prevention Policy 2.A.6.02
Enhanced Supervision to Prevent Self Harm
requires revision to meet Licensing rule.
REPEAT FINDING: A final draft of the
program's revised Suicide Prevention Policy is
still required. The last draft submitted on
9/19/22 requires final timeframe as to when
notifications to both Licensing and legal
guardians will be made by the program.
CORRECTIVE ACTION: Revise suicide
prevention policy to include the highlighted
information and resubmit to Licensing for
review.
New Findings from Site Visit Comments
Physical Plant Safe Center:
413-215-0511(2)(a) &(c) Buildings are - Mold found in back bathroom at the base of the floor, just behind the door.
smoke free, clean and in good repair - Bedroom #5 - window is hard to open and close. Extra force/pressure must be used to fully close.
- Bedroom windows facing the front of building have a buildup of condensation.
The Castle
- Discarded extension cord found at the base of the stairs located near the main parking lot.
- Outside wooden stairs leading to the entry have deteriorated boards on multiple steps.
- Bedroom #3 has adhesive debris on the wall as well as a blue splotch near the upper bunk.
- Broken window blinds in bedrooms #1 and #7.
- Carpet in the Great Room and on the same floor is worn and stained.
- Heavy insect webbing located on outside windows, blocking view, and reducing daylight.
CORRECTIVE ACTION:
- Until the scheduled renovation of the bathroom occurs, treat/clean mold found at the base of the floor
just behind the door.
- Assess and remedy the cause for the difficulty in opening and closing the window in bedroom #5.
- Assess and address the source of condensation for bedrooms facing the front of the building. Clean
dark spots around the windows' caulking.
- Remove extension cord from base of stairs.

- Replace or cover wooden boards that are showing obvious signs of deterioration. This includes the
edge of the landing where the tables are located and the stairs leading to the entry of the Castle.
- Remove the adhesive and re paint the wall located in the bedroom #3.
- Replace the broken blinds in bedrooms #1 and #7.
- Replace the carpet on the entire floor where the Great Room and living room is located.
- Clean the outside of all the windows.
Interview Summary
Tours of both campuses were led by staff members. There are currently 12 residents at the Safe Center, plus one crisis respite placement. The "front
bathroom" at the Safe Center is in the midst of a total renovation. Mold was found in the bathroom and a decision was made to gut the shower/tub to prevent
further spread. The renovation which started on 9/18/23, is scheduled to take 2 - 3 weeks to complete. The facility has extra bathrooms that youth can access
to help meet bathroom to resident ratio during this period of time. The "back bathroom" will also go through a renovation once the front bathroom has been
completed. The program also has plans to have the main doors to the covered structure replaced with funds obtained through a grant. Census for the Castle is
currently low.
Youth from both sites were interviewed for a total of 4 youth. All youth report currently feeling safe in the program with two residents feeling uneasy when
peers become escalated. One youth also added feeling unsafe at the time of his first hold as he was unaware that the program practiced restraints when
initially placed at Jasper Mountain. Since then, one of the program directors explained why youth are placed in a restraint and the youth understands that this
is done to "keep kids safe." Staff are described as well trained and are there to help the residents. Staff offer one on one support, structure, give youth space
and encourage youth to breathe. Feedback regarding the program's food varied from youth to youth. One youth reports that the program offers "too much
salad" while another says the food is "good", but youth are only allowed seconds. A third youth admits not liking the flavor of many main dishes, preferring to
only eat side dishes. Family contact is reported as being frequent and positive. Strengths of the program include staff's help to do what's right, fun activities,
giving youth space and attending a recent Duck's game. Areas of weakness included the food and the volume of the room alarms at the Safe Center.
Observations
During both tours of the campuses, the overall environments were calm. Youth randomly selected for interviews were engaging and pleasant.
The Castle is beginning to show signs of wear. Larger repairs were noted above for this facility.

excerpt:
413-215-0511(2)(a) &(c) Buildings are - Mold found in back bathroom at the base of the floor, just behind the door.
smoke free, clean and in good repair - Bedroom #5 - window is hard to open and close. Extra force/pressure must be used to fully close.
- Bedroom windows facing the front of building have a buildup of condensation.
The Castle
- Discarded extension cord found at the base of the stairs located near the main parking lot.
- Outside wooden stairs leading to the entry have deteriorated boards on multiple steps.
- Bedroom #3 has adhesive debris on the wall as well as a blue splotch near the upper bunk.
- Broken window blinds in bedrooms #1 and #7.
- Carpet in the Great Room and on the same floor is worn and stained.
- Heavy insect webbing located on outside windows, blocking view, and reducing daylight.
CORRECTIVE ACTION:
- Until the scheduled renovation of the bathroom occurs, treat/clean mold found at the base of the floor
just behind the door.
- Assess and remedy the cause for the difficulty in opening and closing the window in bedroom #5.
- Assess and address the source of condensation for bedrooms facing the front of the building. Clean
dark spots around the windows' caulking.
- Remove extension cord from base of stairs.
- Replace or cover wooden boards that are showing obvious signs of deterioration. This includes the
edge of the landing where the tables are located and the stairs leading to the entry of the Castle.
- Remove the adhesive and re paint the wall located in the bedroom #3.
- Replace the broken blinds in bedrooms #1 and #7.
- Replace the carpet on the entire floor where the Great Room and living room is located.
- Clean the outside of all the windows.
Physical Plant Safe Center


facility_name: Turning Point

summary: Unannounced - 10/19/2021

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Licensee: Josephine County Turning Point
Executive Director: James Goodwin
Program Director(s): Jennifer Horst
Date of Unannounced: 10/19/2021
Licensing Coordinator: Todd Cooley
Other Regulatory or Accrediting Agencies: OYA and ODHS Treatment Services
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
No previous findings to review Yes☐ No☐
New Findings from Site Visit Comments
No new identified findings
Interview Summary
During the unannounced review I met with one youth and Program Manager Jennifer Horst.
Youth had been at the program for 5 ½ months and was scheduled to discharge in the upcoming month. They stated they felt safe at the program and felt
comfortable talking with staff if they had any issues. Youth said the food was really good and they get plenty to eat. They get phone calls whenever the
phones are available and are allowed home visits based on their level. The higher the level, the longer the home visit they are afforded. They stated they
were aware of their service plan and family was involved when developing and reviewing it. Youth was aware of their discharge time frame and goals that
1
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 200115)
were needed to be met in order to discharge to home on schedule. They said there are groups they participate in and topics include anger management and
controlling emotions, both areas the youth said they needed work on. Youth said the groups have been very helpful, and they feel they have a good chance of
being successful when they go home. They said school was going okay, and they were mostly caught up on credits for when they return to their school. They
were ahead in science credits, but a little behind in math. Youth stated they get plenty of time for rec and go on lots of outings. They said they play a lot of
basketball and have been to Table Rock hiking, parks, and all the youth were getting ready to leave for a pumpkin patch at the time of the interview. Youth
said they could not think of anything the program or staff could improve on. They said the staff are really good at talking with the clients during and after they
are upset or escalated. They stated staff are caring and are able talk and listen in a way that makes them feel heard.
There were three other youth present, but no other interviews were conducted as to not delay their trip to the pumpkin patch.
When speaking with Horst, she said things were going good with the program. There were ongoing general staffing concerns that are typical across all
programs. Locally it has been difficult to compete with a local correctional facility, state offices and the high rate potential employees can still earn on
unemployment. On the day of the visit there was one youth discharging to their PO and another youth ready for intake.
Turning point has also partnered with a community program that allows youth to learn skills in small engine repair and other shop-related activities. Youth will
be able to get school credit through this program as well as a certificate identifying their competency in the skills learned. This will be helpful when seeking
employment.
Observations
Program was clean and in good repair. After leaving the program an incident report was forwarded containing pictures of damage to a door frame and window
of one of the bedrooms. It was not seen during the review and unknown if it had already been repaired or just overlooked. Overall the youth are doing a good
job of maintaining their rooms, and two of them had very impressive beds made.
Other areas of the program had received some updates in the kitchen from a grant to include new gas range, commercial dishwasher and milk fridge. Other
funding also allowed the program to purchase around $3000 in art supplies and equipment. The youth seemed excited about a multi-step art project they had
been working on that went from choosing an animal, sketching the animal and then painting the animal.
There were currently four male and one female client in the program and milieu levels have been pretty stable.
No other notable observations made during the unannounced visit.
Corrective Actions and Timeframes:
Please submit the following to verify compliance.
Within 45 days of receipt of this report Josephine County Turning Point 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:
Department of Human Services
2
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 200115)
Children’s Care Licensing Program
Attn: Ed Wyller
201 High St. SE Suite 500
Salem, OR 97301
10-28-2021
Licensing Coordinator’s Signature: ________________________ Date: ___________________
10-28-2021
Manager Review: ______________________________________ Date: __________________
3
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 200115)

agency_name: Josephine County Juvenile Dept (JOSEPHINECJD)

program_name: Turning Point

licensee: Josephine County Turning Point

executive_director: James Goodwin

program_director: Jennifer Horst

licensing_coordinator: Todd Cooley

other_regulatory_agencies: OYA and ODHS Treatment Services

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
No previous findings to review Yes[ ] No[ ]
New Findings from Site Visit Comments
No new identified findings
Interview Summary
During the unannounced review I met with one youth and Program Manager Jennifer Horst.
Youth had been at the program for 5 ½ months and was scheduled to discharge in the upcoming month. They stated they felt safe at the program and felt
comfortable talking with staff if they had any issues. Youth said the food was really good and they get plenty to eat. They get phone calls whenever the
phones are available and are allowed home visits based on their level. The higher the level, the longer the home visit they are afforded. They stated they
were aware of their service plan and family was involved when developing and reviewing it. Youth was aware of their discharge time frame and goals that
1

were needed to be met in order to discharge to home on schedule. They said there are groups they participate in and topics include anger management and
controlling emotions, both areas the youth said they needed work on. Youth said the groups have been very helpful, and they feel they have a good chance of
being successful when they go home. They said school was going okay, and they were mostly caught up on credits for when they return to their school. They
were ahead in science credits, but a little behind in math. Youth stated they get plenty of time for rec and go on lots of outings. They said they play a lot of
basketball and have been to Table Rock hiking, parks, and all the youth were getting ready to leave for a pumpkin patch at the time of the interview. Youth
said they could not think of anything the program or staff could improve on. They said the staff are really good at talking with the clients during and after they
are upset or escalated. They stated staff are caring and are able talk and listen in a way that makes them feel heard.
There were three other youth present, but no other interviews were conducted as to not delay their trip to the pumpkin patch.
When speaking with Horst, she said things were going good with the program. There were ongoing general staffing concerns that are typical across all
programs. Locally it has been difficult to compete with a local correctional facility, state offices and the high rate potential employees can still earn on
unemployment. On the day of the visit there was one youth discharging to their PO and another youth ready for intake.
Turning point has also partnered with a community program that allows youth to learn skills in small engine repair and other shop-related activities. Youth will
be able to get school credit through this program as well as a certificate identifying their competency in the skills learned. This will be helpful when seeking
employment.
Observations
Program was clean and in good repair. After leaving the program an incident report was forwarded containing pictures of damage to a door frame and window
of one of the bedrooms. It was not seen during the review and unknown if it had already been repaired or just overlooked. Overall the youth are doing a good
job of maintaining their rooms, and two of them had very impressive beds made.
Other areas of the program had received some updates in the kitchen from a grant to include new gas range, commercial dishwasher and milk fridge. Other
funding also allowed the program to purchase around $3000 in art supplies and equipment. The youth seemed excited about a multi-step art project they had
been working on that went from choosing an animal, sketching the animal and then painting the animal.
There were currently four male and one female client in the program and milieu levels have been pretty stable.
No other notable observations made during the unannounced visit.

new_findings: No new identified findings