summary: 2nd Unannounced

raw_content: Checklist 577577: Census: 10; Contact: Steve Demille; Licensor: Larry Black


state: UT

facility_name: Three Peaks Ascent

summary: Follow-Up Inspection, Non On-Site Inspection


summary: Unannounced, Annual Inspection (1 finding)

raw_content:
R501-19-3(8): Direct supervision only by direct care staff — The provider was out of compliance with this rule by not conducting line of sight check in's every 15 minutes. During the inspection it was observed that for a period of 30 minutes staff did not go check on clients.
Checklist 552107: Census: 5; Contact: McCabe Peterson; Licensor: :

Inspection Type: Unannounced, Annual Inspection


facility_name: Treatment Solutions LLC, DBA Kaizen Academy; Heritage Youth Services

summary: Unannounced, Annual Inspection

raw_content: Checklist 824161: Census: 19; Capacity: 24; Contact: Kris Kilpatrick; Licensor: MeRee Jacobsen


summary: Announced, Annual Inspection

raw_content: Checklist 776819: Census: 17; Capacity: 24; Contact: Kris Kilpatrick and Janis Taylor; Licensor: MeRee Jacobsen

Inspection Type: Announced, Annual Inspection


summary: Follow-Up Inspection

Inspection Type: Follow-Up Inspection


summary: 3rd Unannounced

raw_content: Checklist 661899: Census: 21; Capacity: 24; Contact: Kris Kilpatrick; Licensor: MeRee Jacobsen

Inspection Type: 3rd Unannounced


summary: Investigation Inspection

Inspection Type: Investigation Inspection


summary: 2nd Unannounced

raw_content: Checklist 646957: Census: 20; Capacity: 24; Contact: Kris Kilpatrick 04/17/2025; Licensor: MeRee Jacobsen

Inspection Type: 2nd Unannounced


summary: Unannounced, Annual Inspection

raw_content: Checklist 631021: Census: 17; Capacity: 24; Contact: Kris Kilpatrick 01/08/2025; Licensor: MeRee Jacobsen


summary: Announced, Annual Inspection

raw_content: Checklist 627066: Census: 16; Capacity: 24; Contact: Kris Kilpatrick 12-5-24; Licensor: MeRee Jacobsen


summary: 2nd Unannounced

raw_content: Checklist 615290: Census: 18; Capacity: 24; Contact: Kris Kilpatrick; Licensor: Heather Guanajuato


summary: Unannounced, Annual Inspection

raw_content: Checklist 603064: Census: 20; Capacity: 24; Contact: Kevin Bailey; Licensor: Kacee Arrington


summary: Announced, Annual Inspection


summary: Non On-Site Inspection

Inspection Type: Non On-Site Inspection


summary: 3rd Unannounced

raw_content: Checklist 551564: Contact: Licensor(s) Conducting this Inspection: OL Staff Observing Inspection:; Licensor: :


facility_name: Triumph Youth Services/Triumph Academy dba Expeditions

summary: Announced, Annual Inspection

raw_content: Checklist 980671: Census: 0; Capacity: 20; Contact: Tom Filipe; Michelle Young; Licensor: Josilyn Bertrand; Mary Bokinskie


summary: 3rd Unannounced

raw_content: Checklist 817839: Census: 27; Contact: Bruce Humphries; Licensor: Josilyn Bertrand


summary: 2nd Unannounced

raw_content: Checklist 697271: Census: 0; Capacity: 20; Contact: Tom FIlipe; Bruce Humphries; Licensor: Josilyn Bertrand


summary: Unannounced, Annual Inspection

raw_content: Checklist 659939: Census: 0; Capacity: 20; Contact: Bruce Humphries; Licensor: Josilyn Bertrand


summary: Announced, Annual Inspection

raw_content: Checklist 644909: Census: 0; Capacity: 20; Contact: Michelle Young; Licensor: Josilyn Bertrand, Mary Bokinskie


summary: 3rd Unannounced


summary: 2nd Unannounced

raw_content: Checklist 619421: Census: 0; Capacity: 20; Contact: Tom Filipe, Bruce Humphries; Licensor: Josilyn Bertrand


summary: Unannounced, Annual Inspection

raw_content: Checklist 610809: Census: 0; Capacity: 20; Contact: Michelle Young; Licensor: Josilyn Bertrand


summary: Announced, Annual Inspection

raw_content: Checklist 595775: Census: 0; Capacity: 20; Contact: Michelle Young, Tom Filipe; Licensor: Josilyn Bertrand, Mary Bokinskie


summary: 3rd Unannounced

raw_content: Checklist 573788: Contact: Tom Filipe; Licensor: Josilyn Bertrand


summary: 2nd Unannounced

raw_content: Checklist 549218: Contact: Licensor(s) Conducting this Inspection: OL Staff Observing Inspection:; Licensor: :


facility_name: Turning Point Family Care, Inc. - Residential Treatment

summary: 3rd Unannounced

raw_content: Checklist 987032: Census: 27; Capacity: 29; Contact: Morgan Gomez; Licensor: Larry Black


summary: Investigation Inspection


summary: 2nd Unannounced

raw_content: Checklist 855320: Census: 26; Capacity: 29; Contact: Morgan Gomez; Licensor: Larry Black


summary: Unannounced, Annual Inspection

raw_content: Checklist 694215: Census: 24; Capacity: 29; Contact: Morgan Gomez; Licensor: Larry Black


summary: Announced, Annual Inspection (2 findings)

raw_content:
R501-1-16(1)(a)-(u): Pre-service training requirements — The Licensee was out of compliance with R501-1-16(1)(o)(p)(q) by not completing required preservice training within 30 days of hire. During the employee file inspection staff member was found to have not completed preservice training with first 30 days of hire.
R501-14-5(2)(a)-(f): Submitting application for an initial background screening — The Licensee was out of compliance with R501-14-5(2)(a) by not associating background screening with the program within 2 weeks of hire. During the employee file inspection a staff member had not had there background check associated with the program within 2 weeks of hire.
Checklist 659301: Census: 25; Capacity: 29; Contact: Morgan Gomez; Licensor: Larry Black


summary: 3rd Unannounced

raw_content: Checklist 651221: Census: 28; Capacity: 29; Contact: Morgan Gomez; Licensor: Larry Black


summary: Non On-Site Inspection


summary: 2nd Unannounced (1 finding)

raw_content:
R501-1-8(1)(a)-(i): Facility and safety requirements — The provider was out of compliance with this rule by not maintaining the building so that's it free of health and safety issues. During the inspection in Pod A - Broken Door handle in laundry room. Hole in client bedroom. Pod B - Base board broken in bathroom. Bathroom sink not attached to wall. Light fixture cover missing in laundry room. Light fixture cover broken in common area. Pod C - Hole in room 9 wall. Door to room 10 broken. This is a repeat non-compliance.
Checklist 634163: Census: 25; Contact: Morgan Gomez; Licensor: Larry Black


summary: Unannounced, Annual Inspection

raw_content: Checklist 620250: Census: 26; Contact: Morgan Gomez; Licensor: Larry Black


summary: Announced, Annual Inspection (1 finding)

raw_content:
R501-1-15(4): Residential program unsupervised staff requirements — The provider was out of compliance with this rule by not providing supervision to staff who have a background check requiring supervision. During the inspection on 7/16/24, the licensor observed a staff member requiring supervision not being supervised.
Checklist 605434: Census: 24; Contact: Morgan Gomez; Licensor: Larry Black


summary: 3rd Unannounced

raw_content: Checklist 602237: Contact: Morgan Gomez; Licensor: Larry Black


summary: Follow-Up Inspection


summary: 3rd Unannounced

raw_content: Checklist 581356: Census: 27; Contact: Morgan Gomez; Licensor: Larry Black


summary: 2nd Unannounced

raw_content: Checklist 571265: Census: 25; Contact: Larry Black McCabe Peterson; Licensor: :


facility_name: UHS Of Provo Canyon dba Provo Campus

summary: Investigation Inspection


summary: Unannounced, Annual Inspection

raw_content: Checklist 859479: Census: 106; Contact: Ann Bowen; Licensor: Heather Guanajuato


summary: Announced, Annual Inspection

raw_content: Checklist 756659: Census: 65; Capacity: 130; Contact: Ann Bowen; Licensor: Heather Guanajuato


summary: 3rd Unannounced

raw_content: Checklist 662483: Census: 22; Capacity: 130; Contact: Tim Marshall; Licensor: Heather Guanajuato


summary: 2nd Unannounced

raw_content: Checklist 649715: Census: 32; Capacity: 106; Contact: Tim Marshall; Licensor: Heather Guanajuato


summary: Follow-Up Inspection


summary: Unannounced, Annual Inspection

raw_content: Checklist 636892: Census: 106; Contact: Ann Bowen; Licensor: Heather Guanajuato


summary: Announced, Annual Inspection

raw_content: Checklist 624832: Census: 40; Capacity: 130; Contact: Ann Bowen; Licensor: Heather Guanajuato


summary: 2nd Unannounced

raw_content: Checklist 613084: Census: 35; Capacity: 106; Contact: Patricia Martinez; Licensor: Heather Guanajuato


summary: Unannounced, Annual Inspection

raw_content: Checklist 602148: Census: 30; Capacity: 106; Contact: Ann Bowen; Licensor: Heather Holbrook


summary: Non On-Site Inspection


summary: Announced, Annual Inspection

raw_content: Checklist 577052: Census: 106; Contact: of this; Licensor: Jennifer Buss


summary: 2nd Unannounced

raw_content: Checklist 557150: Contact: Licensor(s) Conducting this Inspection: OL Staff Observing Inspection:; Licensor: :


summary: Unannounced, Annual Inspection

raw_content: Checklist 558107: Contact: Licensor(s) Conducting this Inspection: OL Staff Observing Inspection:; Licensor: :


facility_name: UHS Of Provo Canyon dba Springville Campus

summary: Unannounced, Annual Inspection

raw_content: Checklist 864279: Census: 70; Capacity: 120; Contact: Ann Bowen; Licensor: Heather Guanajuato


summary: Investigation Inspection


summary: Announced, Annual Inspection

raw_content: Checklist 761400: Census: 75; Capacity: 120; Contact: Ann Bowen; Licensor: Heather Guanajuato


summary: 3rd Unannounced

raw_content: Checklist 662298: Census: 115; Capacity: 120; Contact: Licensor(s) Conducting this Inspection: Heather Guanajuato OL Staff Observing Inspection:; Licensor: Heather Guanajuato


summary: Follow-Up Inspection


summary: Conditional, Monitoring Inspection

Inspection Type: Conditional, Monitoring Inspection


summary: 2nd Unannounced


summary: 2nd Unannounced

raw_content: Checklist 650255: Census: 100; Capacity: 120; Contact: Ann Bowen; Licensor: Heather Guanajuato


summary: Investigation Inspection (2 findings)

raw_content:
R380-80-6(1)(a)-(i): Client rights — The provider was out of compliance with R380-80-6(1)(c) by failing to keep a client free from acts of harm. During an investigation inspection, the investigator discovered that during a restraint on April 13, 2025, a staff member, through physical contact with the client, caused an injury to a client's face.
R380-80-5(3): Provider shall comply with policies and safe practices — The provider was out of compliance with R380-80-5(3) by not complying with applicable written policies and safe practices that address the appropriate treatment of clients. During the investigation inspection, it was determined a staff member did not implement  the Handle With Care behavior management policy on which they were trained per the documentation provided.  As a result of the failure to follow the policy, a client was injured.


summary: Conditional, Monitoring Inspection, Follow-Up Inspection


facility_name: Uinta Academy RTC LLC - ADULT NORTH

summary: Announced, Annual Inspection

raw_content: Checklist 660728: Census: 0; Capacity: 10; Contact: Daryn Reiner; Licensor: Josilyn Bertrand, Mary Bokinskie


summary: Non On-Site Inspection


summary: Announced, Annual Inspection

raw_content: Checklist 603210: Census: 0; Capacity: 10; Contact: Daryn Reiner; Licensor: Josilyn Bertrand, Mary Bokinskie


summary: Announced, Annual Inspection

raw_content: Checklist 547339: Contact: Licensor(s) Conducting this Inspection: OL Staff Observing Inspection:; Licensor: :


facility_name: Uinta Academy RTC LLC - Achievement

summary: Announced, Annual Inspection

raw_content: Checklist 660727: Contact: Daryn Reiner; Licensor: Josilyn Bertrand, Mary Bokinskie


summary: Non On-Site Inspection


summary: Announced, Annual Inspection

raw_content: Checklist 603205: Census: 6; Capacity: 16; Contact: Daryn Reiner; Licensor: Josilyn Bertrand, Mary Bokinskie


summary: Announced, Annual Inspection

raw_content: Checklist 549584: Contact: Licensor(s) Conducting this Inspection: OL Staff Observing Inspection:; Licensor: :


facility_name: Uinta Academy RTC LLC - Adult

summary: Announced, Annual Inspection

raw_content: Checklist 660722: Census: 3; Capacity: 10; Contact: Daryn Reiner; Licensor: Josilyn Bertrand, Mary Bokinskie


summary: Non On-Site Inspection


summary: Announced, Annual Inspection

raw_content: Checklist 603209: Census: 0; Capacity: 10; Contact: Daryn Reiner; Licensor: Josilyn Bertrand, Mary Bokinskie


summary: Announced, Annual Inspection

raw_content: Checklist 547132: Contact: Licensor(s) Conducting this Inspection: OL Staff Observing Inspection:; Licensor: :


facility_name: Uinta Academy RTC LLC - East

summary: Focus, Non On-Site (1 finding)

raw_content: R380-600-7(16)(a)-(e): Critical incidents reporting requirements — The Licensee was out of compliance with R380-600-7(16)(a) by not reporting a critical incident to the Office within one business day. During review of critical incidents it was identified that the incident occurred on 4/14/2026 and was not reported until 4/17/2026.

Inspection Type: Focus, Non On-Site


summary: 3rd Unannounced

raw_content: Checklist 967412: Census: 7; Capacity: 16; Contact: Daryn Reiner; Licensor: Josilyn Bertrand


summary: Investigation Inspection (1 finding)

raw_content: R501-19-4(4)(a)-(j): Supervision and ratio requirements — The provider was out of compliance with R501-19-4(4)(f) for failing to conduct required 15 minute line of sight supervision checks on February 23, 2026. A review of the facility’s night logs revealed that mandatory 15-minute line-of-sight safety checks were neither performed nor documented for at least one client for a duration of 4.75 hours. During this lapse in supervision, a door alarm was left disengaged, allowing the client to escape from the facility. The client remained unaccounted for by facility staff for approximately 3.5 hours. During the elopement, the client walked to a convenience store and reported sustaining a leg injury from a fall. The client was eventually supervised by local police and convenience store staff until being transported to a hospital for evaluation, where the facility eventually resumed custody. This is a repeat noncompliance as noted on 10/08/2024.


summary: 2nd Unannounced

raw_content: Checklist 825179: Census: 7; Capacity: 16; Contact: Daryn Reiner; Licensor: Josilyn Bertrand


summary: Investigation Inspection


summary: Unannounced, Annual Inspection

raw_content: Checklist 702427: Census: 9; Capacity: 16; Contact: Daryn Reiner; Licensor: Josilyn Bertrand


summary: Announced, Annual Inspection

raw_content: Checklist 660684: Census: 12; Capacity: 16; Contact: Daryn Reiner; Licensor: Josilyn Bertrand, Mary Bokinskie


summary: 3rd Unannounced

raw_content: Checklist 643705: Census: 9; Capacity: 16; Contact: Samantha Powell; Licensor: Josilyn Bertrand, Mary Bokinskie


summary: 2nd Unannounced

raw_content: Checklist 630852: Census: 11; Capacity: 16; Contact: Daryn Reiner; Licensor: Josilyn Bertrand


summary: Unannounced, Annual Inspection

raw_content: Checklist 618758: Census: 10; Capacity: 16; Contact: Samantha Powell; Licensor: Josilyn Bertrand


summary: Non On-Site Inspection


summary: Announced, Annual Inspection

raw_content: Checklist 603212: Census: 10; Capacity: 16; Contact: Daryn Reiner; Licensor: Josilyn Bertrand, Mary Bokinskie


summary: 3rd Unannounced

raw_content: Checklist 590136: Census: 10; Capacity: 16; Contact: Daryn Reiner; Licensor: Josilyn Bertrand


summary: 2nd Unannounced

raw_content: Checklist 573778: Contact: Daryn Reiner; Licensor: Josilyn Bertrand


summary: Investigation Inspection, Unannounced, Annual Inspection


summary: Announced, Annual Inspection

raw_content: Checklist 545429: Contact: Licensor(s) Conducting this Inspection: OL Staff Observing Inspection:; Licensor: :


facility_name: Uinta Academy RTC LLC- West

summary: 3rd Unannounced

raw_content: Checklist 967411: Census: 0; Capacity: 16; Contact: Daryn Reiner; Licensor: Josilyn Bertrand


summary: 2nd Unannounced

raw_content: Checklist 825219: Census: 6; Capacity: 16; Contact: Daryn Reiner; Licensor: Josilyn Bertrand


summary: Unannounced, Annual Inspection

raw_content: Checklist 704469: Census: 7; Capacity: 16; Contact: Daryn Reiner; Licensor: Josilyn Bertrand


summary: Announced, Annual Inspection

raw_content: Checklist 660682: Census: 7; Capacity: 16; Contact: Daryn Reiner; Licensor: Josilyn Bertrand, Mary Bokinskie


Inspection Type: Follow-Up Inspection, Non On-Site Inspection


summary: 3rd Unannounced

raw_content: Checklist 644139: Census: 8; Capacity: 16; Contact: Samantha Powell; Licensor: Josilyn Bertrand, Mary Bokinskie


summary: 2nd Unannounced

raw_content: Checklist 630851: Census: 4; Capacity: 16; Contact: Daryn Reiner; Licensor: Josilyn Bertrand


summary: Unannounced, Annual Inspection

raw_content: Checklist 618756: Census: 8; Capacity: 16; Contact: Samantha Powell; Licensor: Josilyn Bertrand


summary: Non On-Site Inspection


summary: Announced, Annual Inspection

raw_content: Checklist 603192: Census: 8; Capacity: 16; Contact: Daryn Reiner; Licensor: Josilyn Bertrand, Mary Bokinskie


summary: 3rd Unannounced

raw_content: Checklist 590137: Census: 7; Capacity: 16; Contact: Daryn Reiner; Licensor: Josilyn Bertrand


summary: Unannounced, Annual Inspection

raw_content: Checklist 573765: Contact: Daryn Reiner; Licensor: Josilyn Bertrand


summary: Announced, Annual Inspection

raw_content: Checklist 547049: Contact: Licensor(s) Conducting this Inspection: OL Staff Observing Inspection:; Licensor: :


facility_name: Utah Healing House Youth Crisis Center

summary: Investigation Inspection


summary: Announced, Annual Inspection

raw_content: Checklist 847462: Census: 12; Contact: Mady Weight; Licensor: MeRee Jacobsen


summary: 3rd Unannounced (1 finding)

raw_content: R501-1-8(1)(a)-(i): Facility and safety requirements — The licensee was out of compliance with R501-1-8(1) (a)(f) for not having the appearance and cleanliness of the facility maintained. During the inspection the licensor observed all client bedrooms had clothing and miscellaneous items covering most of the bedroom floors and client bathrooms did not have paper towels or a dryer. This is a repeat noncompliance as noted on 05/29/2025. Technical assistance was provided on 07/30/2025.


summary: Conditional, Monitoring Inspection


summary: 2nd Unannounced

raw_content: Checklist 661987: Census: 5; Capacity: 16; Contact: Ashley Halversen; Licensor: MeRee Jacobsen


summary: Complaint, Focus Inspection (3 findings)

raw_content:
R380-80-4(2): Report abuse or neglect — The provider is out of compliance with R380-80-4(2) by the provider failing to notify Child Protective Services when they suspect that a child is being subjected to abuse. The investigator conducted a phone interview with the provider on 6/6/2025 and it was reported that they did not know that they had to report the incident of the client being slammed on the floor, to Child Protective Services.
R380-80-6(1)(a)-(i): Client rights — The provider is out of compliance with R380-80-6(1)(c) by staff failing to keep client free from potential harm. The investigator was on site 6/3/2025 and observed video footage of an incident that occurred on 5/27/2025. It was observed in the footage that staff was using aggressive restraint techniques including a knee across the clients abdomen with the staff’s weight pressuring down and slamming the client to the ground.
R380-80-6(1)(a)-(i): Client rights — The provider is out of compliance with R380-80-6(1)(b) by staff failing to treat the clients with dignity. On 6/3/2025 the investigator reviewed video footage that included audio. The investigator observed through the audio that the staff was yelling at the client and appeared to be antagonizing the client by saying “Are you going to fucking hit me? Hit me!,” while slapping his own chin.

Inspection Type: Complaint, Focus Inspection


summary: Unannounced, Annual Inspection

raw_content: Checklist 653167: Census: 8; Capacity: 16; Contact: Ashley Halverson; Licensor: MeRee Jacobsen


raw_content:
R501-1-8(3): Medication and hazardous items maintenance and storage — The licensee was out of compliance with R501-1-8(3) by not maintaining potentially hazardous items in a locked storage. During the inspection the licensor observed potentially hazardous items were not maintained in a locked storage and accessible to clients. This is a repeat noncompliance.
Checklist 641395: Census: 7; Capacity: 16; Contact: Madalyn Weight; Licensor: MeRee Jacobsen


facility_name: Utah Health Operations LLC dba Newport Academy

summary: Investigation Inspection


summary: 2nd Unannounced

raw_content: Checklist 857279: Census: 52; Capacity: 64; Contact: Robert Owens; Licensor: Heather Holbrook


summary: Unannounced, Annual Inspection

raw_content: Checklist 756999: Census: 61; Capacity: 64; Contact: Gary Broadbent; Licensor: Heather Holbrook


summary: Non On-Site Inspection


summary: Announced, Annual Inspection

raw_content: Checklist 660013: Census: 50; Capacity: 64; Contact: Christan Gillespie; Licensor: Heather Holbrook


summary: 3rd Unannounced

raw_content: Checklist 652620: Census: 56; Capacity: 64; Contact: Christan Gillespie; Licensor: Heather Holbrook


summary: 3rd Unannounced (1 finding)

raw_content:
R501-1-6(2)(a)-(g): Required posted documents — The licensor was out of compliance with this rule by not having the client's rights, abuse reporting and ADA posters in a conspicuous place where each visitor, staff and client may view them in the female house. During the walk through inspection, the civil rights and code of conduct posters were posted, but the abuse reporting, ADA and client's rights posters were missing.
Checklist 637832: Census: 50; Capacity: 64; Contact: Robert Owens; Licensor: Heather Holbrook


summary: 2nd Unannounced

raw_content: Checklist 628996: Census: 47; Capacity: 64; Contact: Christan Gillespie; Licensor: Heather Holbrook


summary: Follow-Up Inspection


summary: Unannounced, Annual Inspection

raw_content: Checklist 615596: Census: 32; Capacity: 64; Contact: Brendan Gallagher; Licensor: Kacee Arrington


summary: Focus, Non On-Site (1 finding)

raw_content:
R380-600-7(16)(a)-(d): Critical incidents reporting requirements — The provider was out of compliance with this rule by not reporting a critical incident to the Office within one business day. During review of critical incidents it was identified that the incident occurred on 08/28/2024 and was not reported until 09/04/2024.
This rule was previously found out of complaince on the following dates: 12/09/2022, 03/09/2023, 10/26/2023, & 03/05/2024.


summary: Focus Inspection (1 finding)

raw_content: R380-80-6(1)(a)-(i): Client rights — The Provider was out of compliance with this rule by failing to protect a client from acts of violence and mistreatment. During an incident in a client bedroom, a client pushed a staff member. The staff member pushed the client causing the client to fall into a bed frame. The client was injured.

Inspection Type: Focus Inspection


facility_name: Utah Youth Village (AA-BR)

summary: 3rd Unannounced

raw_content: Checklist 978031: Census: 8; Capacity: 11; Contact: Lisa Bryant; Licensor: Heather Holbrook


summary: 2nd Unannounced

raw_content: Checklist 867100: Census: 7; Capacity: 11; Contact: Lisa Bryant; Licensor: Heather Holbrook


summary: Unannounced, Annual Inspection

raw_content: Checklist 701408: Census: 7; Capacity: 11; Contact: Lisa Bryant; Licensor: Heather Holbrook


summary: Announced, Annual Inspection

raw_content: Checklist 663459: Census: 3; Capacity: 11; Contact: Lisa Bryant; Licensor: Heather Holbrook and Rob Jones


summary: Non On-Site Inspection


summary: 3rd Unannounced

raw_content: Checklist 653517: Census: 6; Capacity: 11; Contact: Lisa Bryant; Licensor: Heather Holbrook


summary: 3rd Unannounced

raw_content: Checklist 638351: Census: 0; Capacity: 11; Contact: Lisa Bryant; Licensor: Heather Holbrook


summary: 2nd Unannounced

raw_content: Checklist 629734: Census: 0; Capacity: 11; Contact: Lisa Bryant; Licensor: Heather Holbrook and Rob Jones


summary: Unannounced, Annual Inspection

raw_content: Checklist 613137: Census: 3; Capacity: 11; Contact: Lisa Bryant; Licensor: Heather Holbrook, Rob Jones, Kacee Arrington


summary: Announced, Annual Inspection

raw_content: Checklist 611229: Census: 11; Contact: Lisa Bryant; Licensor: Heather Holbrook assisted by Rob Jones


summary: Follow-Up Inspection


summary: Investigation Inspection


summary: 2nd Unannounced (1 finding)

raw_content:
R501-1-10(2)(a)-(f): Requirements for licensees providing meals — The provider was out of compliance with this rule by not having the kitchen rules posted. During the walk through, the licensor observed the kitchen rules were not posted in the kitchen of Boulder Ridge Home.

This is a repeat non-compliance.
Checklist 586343: Census: 4; Capacity: 11; Contact: Lisa Bryant; Licensor: Heather Holbrook


summary: Unannounced, Annual Inspection

raw_content: Checklist 564456: Census: 5; Contact: Heather Holbrook Rob Jones; Licensor: :


facility_name: Utah Youth Village (AA-CC)

summary: 3rd Unannounced

raw_content: Checklist 978091: Census: 11; Contact: Lisa Bryant; Licensor: Heather Holbrook


summary: 2nd Unannounced

raw_content: Checklist 867239: Census: 7; Capacity: 11; Contact: Lisa Bryant; Licensor: Heather Holbrook


summary: Unannounced, Annual Inspection

raw_content: Checklist 701527: Census: 4; Capacity: 11; Contact: Lisa Bryant; Licensor: Heather Holbrook


summary: Investigation Inspection


summary: Non On-Site Inspection


raw_content:
R501-1-8(1)(a)-(i): Facility and safety requirements — The licensee was out of compliance with Rule R501-1-8(1)(i) by having a student's med box with two loose inhalers without the original pharmacy packaging in it. During the inspection, the licensor observed one of the student med boxes had two loose inhalers without the original pharmacy packaging in it. This is a repeat noncompliance.
Checklist 663501: Census: 3; Capacity: 11; Contact: Lisa Bryant; Licensor: Heather Holbrook and Rob Jones


summary: 3rd Unannounced

raw_content: Checklist 653524: Census: 6; Capacity: 11; Contact: Lisa Bryant; Licensor: Heather Holbrook


summary: 3rd Unannounced (1 finding)

raw_content:
R501-1-8(3): Medication and hazardous items maintenance and storage — The provider was out of compliance with rule R501-1-8(3) by not maintaining medication and potentially hazardous items on-site lawfully, responsibly, and with consideration of the safety and risk level of the population served to include locked storage for each medication and hazardous chemical that is not in active use. During the walk through inspection, the licensor observed one student bathroom had a bottle of sea salt hair spray left out which contains alcohol. The licensor also observed another student bathroom had aerosol deodorant left out. And the licensor observed one student bathroom had prescription eczema cream left out. This is a repeat non-compliance as noted on 3/20/2024; 2/12/2024; 7/19/2023; 3/15/2023; 3/1/2023; 11/16/2022.
Checklist 638378: Census: 10; Capacity: 11; Contact: Lisa Bryant; Licensor: Heather Holbrook


summary: 2nd Unannounced

raw_content: Checklist 629735: Census: 0; Capacity: 11; Contact: Lisa Bryant; Licensor: Heather Holbrook and Rob Jones


summary: Unannounced, Annual Inspection

raw_content: Checklist 613138: Census: 5; Capacity: 11; Contact: Lisa Bryant; Licensor: Heather Holbrook, Rob Jones, Kacee Arrington


summary: Announced, Annual Inspection

raw_content: Checklist 611205: Census: 11; Contact: Lisa Bryant; Licensor: Heather Holbrook assisted by Rob Jones


summary: Follow-Up Inspection


summary: 2nd Unannounced (1 finding)

raw_content:
R501-1-8(3): Medication and hazardous items maintenance and storage — The provider was out of compliance with this rule by having potentially hazardous items left out in the bathrooms while not in active use including hair oil with a warning label and beard spray aerosol. These items were not maintained with consideration of safety the risk level of the population being served.  During the walk through, the licensor observed hair oil and beard spray were in two of the student's bathrooms. This is a repeat citation.
Checklist 586356: Census: 5; Capacity: 11; Contact: Lisa Bryant; Licensor: Heather Holbrook


summary: Focus Inspection (3 findings)

raw_content:
R501-1-8(3): Medication and hazardous items maintenance and storage — The provider was out of compliance with this rule by staff members failing to lock the supply and hazardous chemical closet. During an investigation inspection on 03/15/2024 a video review for 02/12/2024, OL investigators observed the door remaining open after showers and unattended by staff for more than an hour. This is a repeat citation.
R501-19-3(3)(a)-(j): Supervision and ratio requirements — The provider was out of compliance with this rule by staff members failing to perform direct supervision with line-of-sight check-ins every 15 minutes. During an investigation inspection on 02/12/2024, video footage documented staff failing to conduct 15-minute checks on 02/07/2024 for nearly 50 minutes. This continued during the night shift with most of the checks being conducted hourly or more. This is a repeat citation.
R380-80-5(4): Provider shall protect clients from abuse, prevent abuse — The provider was out of compliance with this rule by staff members failing to protect the client’s health and safety. During an investigation inspection on 02/12/2024 a video review for 02/07/2024, OL investigators observed staff members’ actions including transporting an unresponsive client via program van to the hospital rather than calling 911 or Emergency Services.


summary: Focus Inspection (1 finding)

raw_content: R380-80-6(1)(a)-(i): Client rights — The provider was out of compliance with this rule by failing to keep clients free from potential harm and/or acts of violence during an incident on 01/24/2024.  During the inspection on 01/31/2024, the investigators reviewed video footage of the 01/24/2024 incident and observed a client assaulting other clients and staff with a fire extinguisher while staff did not physically intervene.


facility_name: Utah Youth Village (AA-CW)

summary: 3rd Unannounced

raw_content: Checklist 977931: Census: 7; Capacity: 11; Contact: Lisa Bryant; Licensor: Heather Holbrook


summary: Investigation Inspection


summary: 2nd Unannounced

raw_content: Checklist 867279: Census: 8; Capacity: 11; Contact: Lisa Bryant; Licensor: Heather Holbrook


summary: Unannounced, Annual Inspection

raw_content: Checklist 701567: Census: 9; Capacity: 11; Contact: Lisa Bryant; Licensor: Heather Holbrook


summary: Announced, Annual Inspection

raw_content: Checklist 663460: Census: 4; Capacity: 11; Contact: Lisa Bryant; Licensor: Heather Holbrook and Rob Jones


summary: 3rd Unannounced

raw_content: Checklist 651492: Census: 4; Capacity: 11; Contact: Licensor(s) Conducting this Inspection: Heather Holbrook OL Staff Observing Inspection:; Licensor: Heather Holbrook


summary: 3rd Unannounced

raw_content: Checklist 638354: Census: 5; Capacity: 11; Contact: Lisa Bryant; Licensor: Heather Holbrook


summary: 2nd Unannounced

raw_content: Checklist 629737: Contact: Lisa Bryant; Licensor: Heather Holbrook and Rob Jones


summary: Unannounced, Annual Inspection

raw_content: Checklist 613115: Census: 4; Capacity: 11; Contact: Lisa Bryant; Licensor: Heather Holbrook, Rob Jones, Kacee Arrington


summary: Non On-Site Inspection


summary: Announced, Annual Inspection

raw_content: Checklist 611196: Census: 7; Capacity: 11; Contact: Lisa Bryant; Licensor: Heather Holbrook assisted by Rob Jones


summary: 2nd Unannounced

raw_content: Checklist 584126: Census: 11; Contact: Lisa Bryant; Licensor: Heather Holbrook


summary: Unannounced, Annual Inspection

raw_content: Checklist 564433: Census: 6; Contact: Heather Holbrook Rob Jones; Licensor: :


summary: Announced, Annual Inspection

raw_content: Checklist 545580: Census: 8; Contact: Heather Holbrook; Licensor: :


facility_name: Utah Youth Village (AA-GH)

summary: 3rd Unannounced

raw_content: Checklist 977771: Census: 7; Capacity: 11; Contact: Lisa Bryant; Licensor: Heather Holbrook


summary: Investigation Inspection


summary: 2nd Unannounced

raw_content: Checklist 867299: Census: 6; Capacity: 11; Contact: Lisa Bryant; Licensor: Heather Holbrook


summary: Unannounced, Annual Inspection

raw_content: Checklist 701548: Census: 8; Capacity: 11; Contact: Lisa Bryant; Licensor: Heather Holbrook


summary: Non On-Site Inspection


summary: Announced, Annual Inspection

raw_content: Checklist 663904: Census: 6; Capacity: 11; Contact: Lisa Bryant; Licensor: Heather Holbrook and Rob Jones


summary: 3rd Unannounced (1 finding)

raw_content:
R501-1-8(1)(a)-(i): Facility and safety requirements — The licensee was out of compliance with rule (R501-1-8(1)(f)) by not having paper towels in several of the student's bathrooms. During the walk through inspection, the licensor observed several of the student bathrooms did not have paper towels in them. This is a repeat non-compliance as noted on 11/9/2023 and 2/27/2025.
Checklist 653526: Census: 6; Capacity: 11; Contact: Lisa Bryant; Licensor: Heather Holbrook


summary: 3rd Unannounced (1 finding)

raw_content:
R501-1-8(1)(a)-(i): Facility and safety requirements — The provider was out of compliance with rule R501-1-8(1)(f) by not having many of the student bathrooms properly equipped with towels to dry their hands with. During the walk through inspection, the licensor observed most of the student bathrooms were not equipped with towels for the students to dry their hands with. This is a repeat non-compliance as noted on 11/9/2023.
Checklist 638390: Census: 10; Capacity: 11; Contact: Lisa Bryant; Licensor: Heather Holbrook


summary: 2nd Unannounced

raw_content: Checklist 629738: Contact: Lisa Bryant; Licensor: Heather Holbrook and Rob Jones


raw_content:
R501-1-8(3): Medication and hazardous items maintenance and storage — The provider was out of compliance with this rule by having potentially hazardous items out while not in use including aerosol deodorant. This item was not kept in locked storage with consideration of the safety and risk level of the population served. During the walk through, the licensor observed an aerosol can of deodorant was left out in a student bathroom. This is a repeat citation.
Checklist 613143: Census: 4; Capacity: 11; Contact: Lisa Bryant; Licensor: Heather Holbrook, Rob Jones, Kacee Arrington


summary: Announced, Annual Inspection

raw_content: Checklist 611231: Census: 11; Contact: Lisa Bryant; Licensor: Heather Holbrook assisted by Rob Jones


summary: 2nd Unannounced (1 finding)

raw_content: R501-1-8(3): Medication and hazardous items maintenance and storage — The provider was out of compliance with this rule by having potentially hazardous items out while not in active use including mouthwash with alcohol and face toner. These items were not kept in locked storage with consideration of the safety and risk level of the population served. During the walk through, the licensor observed a small bottle of mouthwash with alcohol and liquid facial toner were left out in student bathrooms. This is a repeat citation.


summary: Unannounced, Annual Inspection

raw_content: Checklist 564473: Census: 6; Contact: Heather Holbrook Rob Jones; Licensor: :


summary: Pre-Inspection

raw_content: Checklist 545039: Contact: Licensor(s) Conducting this Inspection: OL Staff Observing Inspection:; Licensor: :

Inspection Type: Pre-Inspection


facility_name: Utah Youth Village (AA-MB)

summary: 3rd Unannounced

raw_content: Checklist 977751: Census: 4; Capacity: 11; Contact: Lisa Bryant; Licensor: Heather Holbrook


summary: 2nd Unannounced

raw_content: Checklist 867399: Census: 0; Capacity: 11; Contact: Lisa Bryant; Licensor: Heather Holbrook


summary: Unannounced, Annual Inspection

raw_content: Checklist 701394: Census: 0; Capacity: 11; Contact: Lisa Bryant; Licensor: Heather Holbrook


summary: Announced, Annual Inspection

raw_content: Checklist 663461: Census: 1; Capacity: 11; Contact: Lisa Bryant; Licensor: Heather Holbrook and Rob Jones


summary: 3rd Unannounced

raw_content: Checklist 651497: Census: 0; Capacity: 11; Contact: Licensor(s) Conducting this Inspection: Heather Holbrook OL Staff Observing Inspection:; Licensor: Heather Holbrook


summary: 3rd Unannounced

raw_content: Checklist 638397: Census: 0; Capacity: 11; Contact: Lisa Bryant; Licensor: Heather Holbrook


summary: 2nd Unannounced

raw_content: Checklist 629740: Census: 0; Capacity: 11; Contact: Lisa Bryant; Licensor: Heather Holbrook and Rob Jones


summary: Non On-Site Inspection


raw_content:
R501-1-8(3): Medication and hazardous items maintenance and storage — The provider was out of compliance with this rule by not maintaining potentially  hazardous items in a lawful and responsible manner. During the walk through inspection, the licensor observed a aerosol can of body spray in one of the student bathrooms. The body spray was locked up immediately. This is a repeat non-compliance.
Checklist 611193: Census: 5; Capacity: 11; Contact: Lisa Bryant; Licensor: Heather Holbrook assisted by Rob Jones


summary: Investigation Inspection


summary: 2nd Unannounced

raw_content: Checklist 584111: Census: 11; Contact: Lisa Bryant; Licensor: Heather Holbrook


summary: Unannounced, Annual Inspection

raw_content: Checklist 564439: Census: 7; Contact: Heather Holbrook Rob Jones; Licensor: :


summary: Follow-Up, Additional Follow-Up Inspection


summary: Focus Inspection (1 finding)

raw_content: R501-19-3(8): Direct supervision only by direct care staff — The provider is out of compliance with this rule by failing to actively supervise the client with line-of-sight check-ins no less than every 15 minutes. At the facility, during the investigation inspection the Director of Operation confirmed that staff conduct a check every hour and their Roles and Responsibility indicates “seven walkthroughs are done each night”.


facility_name: Utah Youth Village (AA-OR)

summary: 3rd Unannounced

raw_content: Checklist 977991: Census: 8; Capacity: 11; Contact: Lisa Bryant; Licensor: Heather Holbrook


summary: 2nd Unannounced

raw_content: Checklist 867419: Census: 7; Capacity: 11; Contact: Lisa Bryant; Licensor: Heather Holbrook


summary: Unannounced, Annual Inspection

raw_content: Checklist 701587: Census: 6; Capacity: 11; Contact: Lisa Bryant; Licensor: Heather Holbrook


summary: Non On-Site Inspection


summary: Announced, Annual Inspection

raw_content: Checklist 663502: Census: 6; Capacity: 11; Contact: Lisa Bryant; Licensor: Heather Holbrook and Rob Jones


summary: 3rd Unannounced

raw_content: Checklist 651493: Census: 8; Capacity: 11; Contact: Licensor(s) Conducting this Inspection: Heather Holbrook OL Staff Observing Inspection:; Licensor: Heather Holbrook


summary: 3rd Unannounced

raw_content: Checklist 638392: Census: 9; Capacity: 11; Contact: Lisa Bryant; Licensor: Heather Holbrook


summary: 2nd Unannounced

raw_content: Checklist 629742: Contact: Lisa Bryant; Licensor: Heather Holbrook and Rob Jones


summary: Investigation Inspection


summary: Follow-Up Inspection


summary: Focus, Non On-Site (1 finding)

raw_content:
R380-600-7(16)(a)-(d): Critical incidents reporting requirements — The provider was out of compliance with this rule by not reporting a critical incident to the Office within one business day. During review of critical incidents it was identified that the incident occurred on 10/07/2024 and was not reported until 10/09/2024.
This is a repeat noncompliance.


summary: Unannounced, Annual Inspection

raw_content: Checklist 613147: Census: 8; Capacity: 11; Contact: Lisa Bryant; Licensor: Heather Holbrook, Rob Jones, Kacee Arrington


summary: Announced, Annual Inspection

raw_content: Checklist 611215: Census: 8; Capacity: 11; Contact: Lisa Bryant; Licensor: Heather Holbrook assisted by Rob Jones


summary: 2nd Unannounced

raw_content: Checklist 584127: Census: 11; Contact: Lisa Bryant; Licensor: Heather Holbrook


summary: Unannounced, Annual Inspection

raw_content: Checklist 564441: Census: 6; Contact: Heather Holbrook Rob Jones; Licensor: :


facility_name: Utah Youth Village (AA-PC)

summary: 3rd Unannounced

raw_content: Checklist 977791: Census: 9; Capacity: 10; Contact: Lisa Bryant; Licensor: Heather Holbrook


summary: Investigation Inspection


summary: 2nd Unannounced

raw_content: Checklist 867440: Census: 9; Capacity: 10; Contact: Lisa Bryant; Licensor: Heather Holbrook


summary: Unannounced, Annual Inspection

raw_content: Checklist 701508: Census: 6; Capacity: 10; Contact: Lisa Bryant; Licensor: Heather Holbrook


summary: Announced, Annual Inspection

raw_content: Checklist 663463: Census: 8; Capacity: 10; Contact: Lisa Bryant; Licensor: Heather Holbrook and Rob Jones


summary: 3rd Unannounced

raw_content: Checklist 651639: Census: 7; Capacity: 10; Contact: Licensor(s) Conducting this Inspection: Heather Holbrook OL Staff Observing Inspection:; Licensor: Heather Holbrook


summary: 3rd Unannounced

raw_content: Checklist 638398: Census: 6; Capacity: 10; Contact: Lisa Bryant; Licensor: Heather Holbrook


summary: Follow-Up Inspection


summary: 2nd Unannounced

raw_content: Checklist 629743: Census: 0; Capacity: 10; Contact: Lisa Bryant; Licensor: Heather Holbrook and Rob Jones


summary: Unannounced, Annual Inspection

raw_content: Checklist 613149: Census: 5; Capacity: 10; Contact: Lisa Bryant; Licensor: Heather Holbrook, Rob Jones, Kacee Arrington


summary: Non On-Site Inspection


raw_content:
R501-1-8(3): Medication and hazardous items maintenance and storage — The provider was out of compliance with this rule by not maintaining potentially hazardous material lawfully and responsibly. During the walk through inspection, the licensor observed aerosol cans of bug spray and sun screen in the vehicle first aid kit which the students have access to while riding in the van. This was corrected during the inspection. This is a repeat non-compliance.
Checklist 611217: Census: 9; Capacity: 10; Contact: Lisa Bryant; Licensor: Heather Holbrook assisted by Rob Jones


summary: 2nd Unannounced

raw_content: Checklist 584128: Census: 10; Contact: Lisa Bryant; Licensor: Heather Holbrook


facility_name: Utah Youth Village (AA-WC)

summary: 3rd Unannounced

raw_content: Checklist 977811: Census: 0; Capacity: 11; Contact: Lisa Bryant; Licensor: Heather Holbrook


summary: 2nd Unannounced

raw_content: Checklist 867499: Census: 0; Capacity: 11; Contact: Lisa Bryant; Licensor: Heather Holbrook


summary: Unannounced, Annual Inspection

raw_content: Checklist 701607: Census: 2; Capacity: 11; Contact: Lisa Bryant; Licensor: Heather Holbrook


summary: Investigation Inspection


summary: Announced, Annual Inspection

raw_content: Checklist 659218: Census: 0; Capacity: 11; Contact: Lisa Bryant; Licensor: Heather Holbrook and Rob Jones


summary: 3rd Unannounced (1 finding)

raw_content:
R501-1-8(3): Medication and hazardous items maintenance and storage — The licensee was out of compliance with rule R501-1-8(3) by having an unconnected propane tank left out in the backyard. During the walk through inspection, the licensor observed an unconnected propane tank in the backyard where the students could have access to it. This is a repeat non compliance as cited on 09/03/2024, 06/06/2024, 03/07/2024 and 02/15/2023.
Checklist 651532: Census: 4; Capacity: 11; Contact: Licensor(s) Conducting this Inspection: Heather Holbrook OL Staff Observing Inspection:; Licensor: Heather Holbrook


summary: Non On-Site Inspection


summary: 3rd Unannounced

raw_content: Checklist 638400: Census: 6; Capacity: 11; Contact: Lisa Bryant; Licensor: Heather Holbrook


summary: 2nd Unannounced

raw_content: Checklist 629745: Contact: Lisa Bryant; Licensor: Heather Holbrook and Rob Jones


summary: Focus, Non On-Site (1 finding)

raw_content: R380-600-7(16)(a)-(d): Critical incidents reporting requirements — The provider was out of compliance with this rule by not reporting a critical incident to the Office within one business day. During review of critical incidents it was identified that the incident occurred on 11/09/2024 and was not reported until 11/13/2024.


raw_content:
R501-1-8(3): Medication and hazardous items maintenance and storage — The provider was out of compliance with this rule by having potentially hazardous items not maintained lawfully, responsibly and with consideration of the population served by having a propane tank left out on the back porch and cleaning chemicals in an unlocked cupboard under the kitchen sink. During the walk through inspection, the licensor observed a propane tank sitting on the back porch and the cupboard under the sink containing cleaning chemicals was unlocked.
Checklist 613119: Census: 6; Capacity: 11; Contact: Lisa Bryant; Licensor: Heather Holbrook, Rob Jones, Kacee Arrington


raw_content:
R501-1-8(3): Medication and hazardous items maintenance and storage — The provider was out of compliance with this rule by not maintaining potentially hazardous items lawfully and responsibly. During the walk through inspection, the licensor observed an aerosol can of dry shampoo and piercing aftercare spray were left out in student bathrooms. These items were locked up immediately. This is a repeat non-compliance.
Checklist 611222: Census: 7; Capacity: 11; Contact: Lisa Bryant; Licensor: Heather Holbrook assisted by Rob Jones


summary: Follow-Up Inspection


summary: Focus Inspection (1 finding)

raw_content: R501-19-3(3)(a)-(j): Supervision and ratio requirements — The provider was out of compliance with this rule by not performing a 15 minute check-in with a client on 04/06/2024.  During an inspection on 04/11/2024, this non-compliance was confirmed by reviewing video footage of the client locking themselves in a bathroom and staff not being able to complete a line of sight check-in for 31 minutes.


summary: 2nd Unannounced

raw_content: Checklist 584112: Census: 11; Contact: Lisa Bryant; Licensor: Heather Holbrook


facility_name: Vive Adolescent Care

summary: Announced, Annual Inspection

raw_content: Checklist 955672: Contact: Justin Day; Licensor: Larry Black


summary: 3rd Unannounced

raw_content: Checklist 819940: Census: 20; Capacity: 20; Contact: Justin Day; Licensor: Larry Black


summary: 2nd Unannounced

raw_content: Checklist 747619: Census: 20; Capacity: 20; Contact: Nicole Marro; Licensor: OL Staff Observing Inspection:


summary: Unannounced, Annual Inspection

raw_content: Checklist 664427: Census: 14; Capacity: 20; Contact: Justin Day; Licensor: Larry Black


summary: Investigation Inspection


summary: Investigation Inspection (1 finding)

raw_content: R380-600-7(16)(a)-(e): Critical incidents reporting requirements — The provider was out of compliance with R380-600-7(16)(1)(b) by not ensuring an allegation of abuse of a client was reported to Child Protective Services. During the investigation inspection, the information gathered substantiated that the provider did not report a client’s allegation of abuse to Child Protective Services.


summary: Announced, Annual Inspection (3 findings)

raw_content:
R501-1-16(2)(a)-(q): Program policy and training — The Licensee was out of compliance with R501-1-16 (2)(b)(f)(o)(v) by not conducting required annual trainings.. During the employee file inspection not all of the annual trainings had be conducted. This is a repeat noncompliance as noted on 4/18/24.
R501-1-16(1)(a)-(u): Pre-service training requirements — The Licensee was out of compliance with R501-1-16 (1)(j) by not completing required preservice training within a staffs first 30 days of hire. During the employee file inspection  there was no training on background checks.	 This is a repeat noncompliance as noted on 4/18/24.
R501-1-12(4)(a)-(c): Required signed agreements — The Licensee was out of compliance with R501-1-12 (4)(c)(v) by by not having all the required signed documents part of the client records.. During the client file inspection client files didn't have documentation that parents or guardians were receiving clients rights. This is a repeat noncompliance as noted on 5/25/23.
Checklist 650103: Census: 8; Capacity: 20; Contact: Justin Day; Licensor: Larry Black


summary: Investigation Inspection (3 findings)

raw_content:
R380-80-6(1)(a)-(i): Client rights — The licensee was out of compliance with R380-80-6(1)(b) by not ensuring each client had a right to be treated with dignity. During an investigation, the information gathered substantiated that a client who engaged in self-harm with contraband was not permitted to wear an undergarment for multiple days. The client reported they felt uncomfortable, humiliated, and self-conscious.
R380-80-5(4): Provider shall protect clients from abuse, prevent abuse — The licensee was out of compliance with R380-80-6(1)(c) by not protecting clients from harm. During an investigation, multiple high acuity clients were not protected from harm by accessing needles from a medical supply closet that was left unlocked, and used the needles to harm themselves.
R501-19-3(3)(a)-(j): Supervision and ratio requirements — The provider was out of compliance with R501-19-3(3)(f) by direct care staff members not performing direct supervision with line of sight check-ins every 15 minutes. During the investigation inspection, provider records documented multiple incidents in which staff members conducted line of sight check-ins that were over the 15-minute requirement.


summary: Follow-Up Inspection


summary: 3rd Unannounced (1 finding)

raw_content:
R501-1-8(1)(a)-(i): Facility and safety requirements — The provider was out of compliance with this rule by not maintaining the building and grounds so they are free from health and fire hazards. During the inspection there was exposed wiring in boys stairwell, light not working in client bedroom, broken shower in client bathroom, hole in wall in client bedroom, exposed wires from missing fire alarm in two client bedrooms. This is a repeat non-compliance.
Checklist 631835: Census: 15; Contact: Justin Day; Licensor: Larry Black


summary: Follow-Up Inspection

raw_content: Checklist 618097: Contact: Justin Day; Licensor: Larry Black


facility_name: Wasatch Behavioral Health Special Service District dba Aspire Academy

summary: Unannounced, Annual Inspection

raw_content: Checklist 892759: Census: 8; Capacity: 16; Contact: Licensor(s) Conducting this Inspection: Heather Guanajuato OL Staff Observing Inspection:; Licensor: Heather Guanajuato


summary: Announced, Annual Inspection

raw_content: Checklist 783661: Census: 9; Capacity: 16; Contact: Kent Downs; Licensor: Heather Guanajuato


summary: 3rd Unannounced

raw_content: Checklist 668001: Census: 10; Capacity: 16; Contact: Licensor(s) Conducting this Inspection: Heather Guanajuato OL Staff Observing Inspection:; Licensor: Heather Guanajuato


summary: 2nd Unannounced

raw_content: Checklist 654124: Census: 9; Capacity: 16; Contact: Licensor(s) Conducting this Inspection: Heather Guanajuato OL Staff Observing Inspection: NA; Licensor: Heather Guanajuato


summary: Unannounced, Annual Inspection

raw_content: Checklist 639269: Census: 7; Capacity: 16; Contact: Brooke Hudson; Licensor: Heather Guanajuato


summary: Announced, Annual Inspection

raw_content: Checklist 626330: Census: 7; Capacity: 16; Contact: Brooke Hudson; Licensor: Heather Guanajuato


summary: 3rd Unannounced

raw_content: Checklist 613978: Census: 6; Capacity: 16; Contact: Brooke Hudson; Licensor: Heather Guanajuato


summary: Non On-Site Inspection


summary: 2nd Unannounced

raw_content: Checklist 602502: Census: 7; Capacity: 12; Contact: Haley Sindt; Licensor: Mary Bokinskie


summary: Unannounced, Annual Inspection

raw_content: Checklist 586375: Census: 5; Capacity: 16; Contact: Brooke Hudson; Licensor: Kacee Arrington


summary: Investigation Inspection


summary: Follow-Up Inspection


summary: Announced, Annual Inspection

raw_content: Checklist 576462: Census: 7; Capacity: 16; Contact: of this; Licensor: Jennifer Buss


summary: 3rd Unannounced

raw_content: Checklist 562355: Contact: Licensor(s) Conducting this Inspection: OL Staff Observing Inspection:; Licensor: :


Inspection Type: Investigation Inspection, Unannounced, Annual Inspection


summary: Investigation Inspection, Non On-Site Inspection


facility_name: Weber Recovery Center, LLC (RT, SD, OT)

summary: Announced, Annual Inspection

raw_content: Checklist 871261: Census: 38; Contact: Patricia Cardwell; Licensor: Mary Bokinskie; Josilyn Bertrand


summary: Investigation Inspection


summary: Non On-Site Inspection


raw_content:
R501-1-16(2)(a)-(q): Program policy and training — The provider was out of compliance with this rule by not having all training completed for staff. During the inspection, 4 staff did not have training completed. This was a repeat rule noncompliance.
R501-1-15(10)(a)-(f): Required personnel information — The provider was out of compliance with this rule by not documenting training with the topic, date, and signature of staff and not having proof of qualifications and experience for all staff. During the inspection, 3 staff did not have signed training acknowledgements and 3 staff did not have proof of qualifications and experience or job descriptions. This was a repeat rule non compliance.
R501-1-8(1)(a)-(i): Facility and safety requirements — The provider was out of compliance with this rule by not having all electrical and plumbing in operating order and in clean and safe condition. During the inspection, 2 electrical outlets did not have cover plates and one sink was clogged. This was a repeat non compliance.
Checklist 635936: Census: 38; Contact: Patricia Cardwell; Licensor: Shelisa York


summary: Follow-Up Inspection


summary: Complaint, Investigation Inspection (1 finding)

raw_content: R501-1-8(1)(a)-(i): Facility and safety requirements — The provider was out of compliance with this rule by not properly equipping bathrooms with paper towels or a dryer.  During the inspection, the investigators observed multiple bathrooms throughout the facility without paper towels or a dryer.  This was a repeat rule non-compliance.

Inspection Type: Complaint, Investigation Inspection


raw_content:
R501-1-8(1)(a)-(i): Facility and safety requirements — The provider was out of compliance with this rule by not having a clean and maintained facility. During the inspection, the licensor found 4 detox rooms missing hand soap and/or paper towels/dryer; basement bathrooms have no ventilation system or heat; east building rooms 2 and 4 were missing outlet covers. This was a repeat rule non-compliance.
R501-1-15(4): Residential program unsupervised staff requirements — The provider was out of compliance with this rule by not having all staff in DACS. During the inspection, the licensor saw that 1 staff member did not have a background check.
Checklist 576018: Contact: Patricia Cardwell; Licensor: Shelisa York


facility_name: White River Academy Foundation

summary: Non On-Site Inspection


summary: Announced, Annual Inspection

raw_content: Checklist 908939: Census: 18; Capacity: 36; Contact: Loren Pence; Licensor: Larry Black


summary: 3rd Unannounced

raw_content: Checklist 701509: Census: 24; Capacity: 36; Contact: Loren Pence; Licensor: Larry Black


summary: 2nd Unannounced

raw_content: Checklist 666050: Census: 24; Capacity: 36; Contact: Loren Pence; Licensor: Larry Black


summary: Investigation Inspection (1 finding)

raw_content: R380-80-6(1)(a)-(i): Client rights — The provider is out of compliance with R380-80-6(1)(c) by the staff failing to keep clients free from potential harm. While on site for interviews on 6/24/2025, it was reported that during a restraint, a staff member placed their hands on the neck of a client and proceeded to squeeze with enough force to leave a red mark on the client’s neck afterwards.


summary: Investigation Inspection


summary: Unannounced, Annual Inspection

raw_content: Checklist 649451: Census: 23; Capacity: 36; Contact: Loren Pence; Licensor: Larry Black


summary: Announced, Annual Inspection (6 findings)

raw_content:
R501-1-16(2)(a)-(q): Program policy and training — The Licensee was out of compliance with R501-1-16 (2) by not completing annual training. During the employee file inspection there was missing required annual training. This a repeat non-compliance cited on 5/9/24.
R501-1-16(1)(a)-(u): Pre-service training requirements — The Licensee was out of compliance with R501-1-16(1) by ensure that each staff receives pre-serving training within 30-days of hire. During the employee file inspection  a staff member hadn't received the required preservice training. This a repeat non-compliance cited on 5/9/24.
R501-1-15(4): Residential program unsupervised staff requirements — The Licensee was out of compliance with R501-1-15(4) by having a staff work unsupervised without a approved background clearance. During the employee file inspection a staff member was discovered to have worked without having an approved background check.
R501-1-8(3): Medication and hazardous items maintenance and storage — The Licensee was out of compliance with rule R501-1-8(3) by not maintaining hazardous items with consideration of the safety and risk level of the population served. During the inspection, chemicals were not in locked cabinets when not in use. This a repeat non-compliance cited on 9/24/24.
R501-1-8(1)(a)-(i): Facility and safety requirements — The Licensee was out of compliance with R501-1-8 (1)(a) by not maintaining the building so its clean and free from fire and health hazards. During the inspection the licensor observed broken electrical outlet covers and an area that wasn't clean. This is a repeat noncompliance as noted on 9/24/24, 3/26/24, 12/12/23, 8/24/23, 4/27/23, 1/20/23
R501-14-5(2)(a)-(f): Submitting application for an initial background screening — The Licensee was out of compliance with R501-14-5 (2)(A) by not submitting an application for an initial background screening no later than two weeks from the applicant becoming associated with the licensee. During the inspection while doing employee document review they had 2 staff missing background checks who had not been associated with program in DACS..
Checklist 641878: Census: 24; Capacity: 36; Contact: Loren Pence; Licensor: Larry Black


summary: 3rd Unannounced

raw_content: Checklist 628595: Census: 23; Contact: Loren Pence; Licensor: Larry Black


summary: 2nd Unannounced (1 finding)

raw_content:
R501-1-8(1)(a)-(i): Facility and safety requirements — The provider was out of compliance with this rule by not having an electrical outlet in safe condition. During the onsite inspection this licensor observed that several outlets and switches were missing its face and one was not secured to the wall. This is a repeat noncompliance
Checklist 618521: Census: 25; Capacity: 36; Contact: Loren Pence; Licensor: Rob Jones


summary: Unannounced, Annual Inspection

raw_content: Checklist 601687: Census: 23; Capacity: 36; Contact: Sidney Anderson; Licensor: Rob Jones


summary: Follow-Up Inspection


raw_content:
R501-1-8(1)(a)-(i): Facility and safety requirements — The provider was out of compliance with this rule by having an accessible light fixture in a client bedroom that did not have an intact cover and light bulb leaving an exposed socket.
Checklist 590303: Census: 26; Capacity: 36; Contact: Loren Pence; Licensor: Rob Jones


facility_name: Wildflower Mountain Ranch Inc.

summary: Announced, Annual Inspection

raw_content: Checklist 901100: Census: 0; Capacity: 7; Contact: Bridget Kilgrow; Licensor: Mary Bokinskie; Josilyn Bertrand


summary: Follow-Up Inspection


summary: 3rd Unannounced

raw_content: Checklist 767699: Census: 4; Capacity: 7; Contact: Bridget Kilgrow; Licensor: Mary Bokinskie


summary: 2nd Unannounced

raw_content: Checklist 663970: Census: 5; Capacity: 7; Contact: Bridget Kilgrow; Jeff Kilgrow; Licensor: Mary Bokinskie


summary: Investigation Inspection, Non On-Site Inspection (1 finding)

raw_content: R380-600-7(16)(a)-(e): Critical incidents reporting requirements — The Licensee was out of compliance with R380-600-7(16)(a-d) by not reporting a critical incident to the Office within one business day. During review of critical incidents it was identified that the incident occurred on 6/29/2025 and was not reported until 7/7/2025.


summary: Unannounced, Annual Inspection

raw_content: Checklist 651770: Census: 3; Capacity: 7; Contact: Bridget Kilgrow, Veronica Kasprzak-Bratcher; Licensor: Mary Bokinskie


Inspection Type: Follow-Up, Additional Follow-Up Inspection


summary: Announced, Annual Inspection (5 findings)

raw_content:
R501-1-8(1)(a)-(i): Facility and safety requirements — The Licensee was out of compliance with R501-1-8(1)(a) by not ensuring the building is free from health hazards. During the inspection, the licensor observed three cans of paint were in a closet attached to the clients bedroom where the cans could be accessed by the clients. This was a repeat noncompliance as noted on 10/17/2023 and 10/29/2024.
R501-1-12(4)(a)-(c): Required signed agreements — The Licensee was out of compliance with R501-1-12(4)(a)-(c) by not ensuring that all required agreements are signed and maintained as part of the client record. During the inspection, one of the client files reviewed did not contain the required signed agreements as part of the client record. This was a repeat noncompliance as noted on 02/22/2024.
R501-1-15(10)(a)-(f): Required personnel information — The Licensee was out of compliance with R501-1-15(10)(f) by not ensuring that personnel information includes each crisis intervention or critical incident report involving the individual. During the inspection, it was observed that staff files did not contain critical incidents that the individual staff members were involved in. This was a repeat noncompliance as noted on 02/22/2024.
R501-1-16(1)(a)-(u): Pre-service training requirements — The Licensee was out of compliance with R501-1-16(1)(a)-(u) by not ensuring each staff receives pre-serving training on all required topics within 30-days of being hired. During the inspection, it was observed that staff had not received training on multiple required topics within 30-days of their hire date. This was a repeat noncompliance as noted on 02/22/2024.
R501-1-16(2)(a)-(q): Program policy and training — The Licensee was out of compliance with R501-1-16(2)(a)-(q) by not ensuring each staff member completes the required training topics each year. At the time of inspection, multiple staff members were missing required annual training. This was a repeat noncompliance as noted on 05/06/2024.
Checklist 640933: Census: 3; Capacity: 7; Contact: Bridget Kilgrow, Veronica Kasprzak-Bratcher; Licensor: Mary Bokinskie, Josilyn Bertrand


summary: Non On-Site Inspection


summary: 3rd Unannounced

raw_content: Checklist 621582: Census: 4; Capacity: 7; Contact: Bridget Kilgrow/Jeffrey Kilgrow/Veronica Bratcher; Licensor: Mary Bokinskie


summary: 2nd Unannounced

raw_content: Checklist 616331: Census: 7; Capacity: 7; Contact: Bridget Kilgrow/Jeffrey Kilgrow/Veronica Bratcher; Licensor: Mary Bokinskie


summary: Unannounced, Annual Inspection

raw_content: Checklist 602520: Census: 5; Capacity: 6; Contact: Bridget Kilgrow; Licensor: Mary Bokinskie


summary: Investigation Inspection


summary: Announced, Annual Inspection

raw_content: Checklist 581990: Census: 6; Capacity: 6; Contact: Bridget Kilgrow/Veronica Kasprzak Bratcher; Licensor: Mary Bokinskie/Josilyn Bertrand


summary: Unannounced, Annual Inspection


facility_name: Wildflower Mountain Ranch Residential Treatment Center for Girls

summary: Announced, Annual Inspection

raw_content: Checklist 901059: Census: 1; Capacity: 4; Contact: Bridget Kilgrow; Licensor: Mary Bokinskie; Josilyn Bertrand


summary: 3rd Unannounced

raw_content: Checklist 767159: Census: 0; Capacity: 4; Contact: Bridget Kilgrow ; Lacy Rasmussen; Licensor: Mary Bokinskie


summary: 2nd Unannounced

raw_content: Checklist 663971: Census: 0; Capacity: 4; Contact: Bridget Kilgrow; Licensor: Mary Bokinskie


summary: Unannounced, Annual Inspection

raw_content: Checklist 651768: Census: 0; Capacity: 4; Contact: Bridget Kilgrow, Veronica Kasprzak-Bratcher; Licensor: Mary Bokinskie


summary: Announced, Annual Inspection

raw_content: Checklist 640959: Census: 0; Capacity: 4; Contact: Bridget Kilgrow, Veronica Kasprzak-Bratcher; Licensor: Mary Bokinskie, Josilyn Bertrand


summary: Unannounced, Annual Inspection

raw_content: Checklist 621583: Census: 3; Capacity: 4; Contact: Bridget Kilgrow/Jeffrey Kilgrow/Veronica Bratcher; Licensor: Mary Bokinskie


summary: Pre-Inspection

raw_content: Checklist 606286: Census: 0; Capacity: 4; Contact: Veronica Bratcher; Licensor: Kacee Arrington


facility_name: Young Women's Empowerment Center

summary: 3rd Unannounced

raw_content: Checklist 897779: Census: 10; Capacity: 12; Contact: Justice Roberts; Licensor: Rob Jones


summary: 2nd Unannounced

raw_content: Checklist 720339: Census: 11; Capacity: 12; Contact: Justice Roberts; Licensor: Rob Jones


summary: Unannounced, Annual Inspection

raw_content: Checklist 665676: Census: 9; Capacity: 12; Contact: Justice Roberts; Licensor: Rob Jones


summary: Announced, Annual Inspection

raw_content: Checklist 651501: Census: 9; Capacity: 12; Contact: Justice Roberts; Licensor: Rob Jones


summary: 3rd Unannounced

raw_content: Checklist 636069: Census: 8; Capacity: 12; Contact: Justice Roberts; Licensor: Rob Jones


summary: 2nd Unannounced

raw_content: Checklist 626646: Census: 9; Capacity: 12; Contact: Jen Cook; Licensor: Rob Jones


summary: Follow-Up Inspection


summary: Unannounced, Annual Inspection

raw_content: Checklist 609229: Census: 10; Capacity: 12; Contact: Justice Roberts; Licensor: Rob Jones


summary: Announced, Annual Inspection

raw_content: Checklist 597325: Census: 9; Capacity: 12; Contact: Justice Roberts; Licensor: Rob Jones


summary: Investigation Inspection


summary: 3rd Unannounced

raw_content: Checklist 583618: Census: 10; Capacity: 12; Contact: Jennifer Cook; Licensor: Rob Jones


summary: 3rd Unannounced

raw_content: Checklist 567683: Licensor: :


summary: 2nd Unannounced

raw_content: Checklist 553743: Contact: Licensor(s) Conducting this Inspection: OL Staff Observing Inspection:; Licensor: :


facility_name: Youth Futures Shelter- Ogden

summary: Unannounced, Annual Inspection

raw_content: Checklist 993631: Census: 1; Capacity: 16; Contact: Angel Perez; Licensor: Josilyn Bertrand


summary: Announced, Annual Inspection

raw_content: Checklist 859219: Census: 6; Capacity: 16; Contact: Heidi Rugg, Angela Perez; Licensor: Josilyn Bertrand, Mary Bokinskie


summary: 3rd Unannounced

raw_content: Checklist 684255: Census: 9; Capacity: 16; Contact: Heidi Rugg; Licensor: Josilyn Bertrand


summary: 2nd Unannounced

raw_content: Checklist 659036: Census: 6; Capacity: 16; Contact: Angela Perez; Licensor: Josilyn Bertrand


summary: Unannounced, Annual Inspection

raw_content: Checklist 643788: Census: 6; Capacity: 16; Contact: Angela Perez; Licensor: Josilyn Bertrand


summary: Non On-Site Inspection


summary: Announced, Annual Inspection

raw_content: Checklist 632738: Census: 7; Capacity: 16; Contact: Heidi Rugg; Licensor: Josilyn Bertrand, Mary Bokinskie


summary: Investigation Inspection


summary: 3rd Unannounced

raw_content: Checklist 620558: Census: 4; Capacity: 16; Contact: Angel Perez; Licensor: Josilyn Bertrand


summary: 2nd Unannounced

raw_content: Checklist 604259: Census: 6; Capacity: 16; Contact: Angel Perez; Licensor: Josilyn Bertrand


summary: Unannounced, Annual Inspection

raw_content: Checklist 590952: Census: 2; Capacity: 16; Contact: Kristen Mitchell, Heidi Rugg; Licensor: Josilyn Bertrand


summary: Focus Inspection (1 finding)

raw_content: R380-80-6(1)(a)-(i): Client rights — The provider was out of compliance with this rule by mistreating and/or exploiting a client. During an inspection and in staff interviews that followed, it was reported that a staff member told a client how to make an inappropriate drawing. The staff member described how to make the drawing look like the staff member. The same staff member also had the same client translate and respond to inappropriate voice text messages between the staff member and their friend.


summary: Announced, Annual Inspection

raw_content: Checklist 578823: Census: 6; Capacity: 16; Contact: Heidi Rugg; Licensor: Josilyn Bertrand, Mary Bokinskie


summary: 2nd Unannounced

raw_content: Checklist 551642: Contact: Licensor(s) Conducting this Inspection: OL Staff Observing Inspection:; Licensor: :


facility_name: Youth Health Associates Inc dba Bridges Academy

summary: 3rd Unannounced

raw_content: Checklist 933631: Census: 8; Capacity: 12; Contact: Monie Riddle; Jason English; Gilbert Smalls; Licensor: Mary Bokinskie


summary: Investigation Inspection


summary: 2nd Unannounced

raw_content: Checklist 806899: Census: 7; Capacity: 12; Contact: Monie Riddle; Gilbert Smalls; Licensor: Mary Bokinskie


summary: Unannounced, Annual Inspection

raw_content: Checklist 667573: Census: 5; Capacity: 12; Contact: Monie Riddle; Jason English; Licensor: Mary Bokinskie


raw_content:
R501-1-13(5)(a)-(b): Private placement reporting — The Licensee was out of compliance with R501-1-13(5)(a) by not reporting private placements to the office by completing the congregate care out of state placement survey prior to the fifth business day of each month. During the inspection, it was observed that the month of February 2025 had not been reported through the required survey. This was a repeat noncompliance as noted on 05/21/2024.
Checklist 656859: Census: 8; Capacity: 12; Contact: Monie Riddle; Jason English; Licensor: Mary Bokinskie; Josilyn Bertrand


summary: Focus, Non On-Site (1 finding)

raw_content: R380-600-7(16)(a)-(d): Critical incidents reporting requirements — The provider was out of compliance with this rule by not reporting a critical incident to the Office within one business day. During review of critical incidents it was identified that the incident occurred on 2/6/2025 and was not reported until 2/8/2025.


summary: 3rd Unannounced

raw_content: Checklist 635259: Census: 5; Capacity: 12; Contact: Jason English; Licensor: Mary Bokinskie


summary: 2nd Unannounced

raw_content: Checklist 629202: Census: 5; Capacity: 12; Contact: Jonathan Snyder; Jason English; Licensor: Mary Bokinskie/Josilyn Bertrand


summary: Unannounced, Annual Inspection

raw_content: Checklist 615537: Census: 10; Capacity: 12; Contact: Jason English; Licensor: Mary Bokinskie


summary: Non On-Site Inspection


summary: Announced, Annual Inspection

raw_content: Checklist 599686: Census: 5; Capacity: 12; Contact: Jason English; Licensor: Mary Bokinskie, Josilyn Bertrand


summary: Complaint, Investigation Inspection (2 findings)

raw_content:
R380-600-7(16)(a)-(d): Critical incidents reporting requirements — The provider was out of compliance with this rule by failing to report a critical incident. During the investigation it was found that a staff member was fired for sharing a vape with clients. The vaping  incidents and subsequent firing of the employee were not reported to licensing. This is a repeat citation.
R380-80-6(1)(a)-(i): Client rights — The provider was out of compliance with this rule by a staff member sharing their vape with 3 clients and putting those clients in potential harm and mistreatment. During an inspection on 3-18-24, staff and clients were interviewed. Documents were later gathered. Staff confirmed a former staff member provided a vape for clients use. This is a repeat citation.


summary: 2nd Unannounced

raw_content: Checklist 578824: Census: 5; Capacity: 12; Contact: Jason English; Licensor: Mary Bokinskie


summary: Focus Inspection (1 finding)

raw_content: R380-80-6(1)(a)-(i): Client rights — The provider was out of compliance with this rule by a staff member sharing their vape with a client, which led to at least 3 clients using the vape and putting those clients in potential harm and mistreatment. During an inspection on 2-5-24, staff and clients were interviewed. Staff and clients confirmed a former staff provided a vape for clients use.


facility_name: Youth Health Associates Inc dba Manti Academy

summary: Announced, Annual Inspection

raw_content: Checklist 945131: Census: 16; Contact: Devin Frischknecht; Licensor: Kacee Arrington


summary: 3rd Unannounced

raw_content: Checklist 711399: Census: 15; Capacity: 16; Contact: Devin Frischknecht; Licensor: MeRee Jacobsen


summary: Investigation Inspection


summary: 2nd Unannounced

raw_content: Checklist 663118: Census: 15; Contact: Devin Frischknecht; Licensor: MeRee Jacobsen


summary: Unannounced, Annual Inspection

raw_content: Checklist 647902: Census: 15; Capacity: 16; Contact: Devin Frischknecht; Licensor: MeRee Jacobsen


summary: Announced, Annual Inspection

raw_content: Checklist 641852: Census: 15; Capacity: 16; Contact: Devin Frischknecht 03/18/2025; Licensor: MeRee Jacobsen


summary: 3rd Unannounced

raw_content: Checklist 628952: Census: 16; Capacity: 16; Contact: Devin Frischknecht; Licensor: MeRee Jacobsen


summary: 2nd Unannounced

raw_content: Checklist 606290: Census: 16; Capacity: 16; Contact: Devin Frischknecht; Licensor: MeRee Jacobsen


summary: Unannounced, Annual Inspection


summary: Non On-Site Inspection


summary: 2nd Unannounced

raw_content: Checklist 570393: Census: 15; Capacity: 16; Contact: Devin Frischknecht; Licensor: MeRee Jacobsen


summary: Focus Inspection (1 finding)

raw_content: R495-876-4(2): Report abuse or neglect — The provider was out of compliance with this rule by failing to report the alleged sexual misconduct to Child Protective Services. During an investigation inspection on 08/16/2023, the provider admitted the alleged sexual misconduct was not reported to Child Protective Services.


summary: Investigation Inspection

raw_content: Checklist 550731: Contact: Licensor(s) Conducting this Inspection: OL Staff Observing Inspection:; Licensor: :


facility_name: Youth Health Associates dba Cedar Valley Ranch

raw_content:
R501-1-8(1)(a)-(i): Facility and safety requirements — The Licensee was out of compliance with R501-1-8 (a, b) by not maintaining the appearance and cleanliness of the building so it's free from health and safety concerns. During the inspection, the building was in disrepair with broken window, holes in walls, and missing electrical outlet covers. This is a repeat noncompliance as noted on 10/22/25, 4/1/25, 1/16/25, 7/23/24, 4/8/24, 2/8/24, 10/5/23, 5/3/23. On-Site Technical Assistance was given on 7/21/25.
Checklist 987052: Census: 16; Capacity: 16; Contact: Breanna; Licensor: Larry Black


summary: Focus, Non On-Site (1 finding)

raw_content:
R380-600-7(16)(a)-(e): Critical incidents reporting requirements — The Licensee was out of compliance with R380-600-7(16)(a) by not reporting a critical incident to the Office within one business day. During review of critical incidents it was identified that the incident occurred on 2/17/2026 and was not reported until 2/23/2026.
This is a repeat noncompliance.


summary: Announced, Annual Inspection

raw_content: Checklist 826219: Census: 14; Capacity: 16; Contact: Nathan Giles; Licensor: Larry Black


summary: Investigation Inspection


summary: 3rd Unannounced (1 finding)

raw_content:
R501-1-8(1)(a)-(i): Facility and safety requirements — The Licensee was out of compliance with R501-1-8 (a)(b)(f) by not maintaining the appearance and cleanliness of the building and grounds so they are free from health hazards; electrical, HVAC, and furnishings are maintained in operating order and in a clean and safe condition. During the walkthrough inspection broken light fixtures, holes in wall of buildings, furnishing broken and unsafe. This is a repeat noncompliance as noted on 4/1/25, 1/16/25, 7/23/24, 4/8/24, 2/8/24, 10/5/23, 5/3/23. On-Site Technical Assistance was given on 7/21/25.
Checklist 715560: Census: 15; Capacity: 16; Contact: Breann; Licensor: Larry Black


summary: Complaint, Follow-Up Inspection (1 finding)

raw_content: R501-19-3(3)(a)-(j): Supervision and ratio requirements — The provider was out of compliance with R501-19-3(3)(f) by not conducting line of sight check-ins every 15 minutes. During the inspection two clients left the facility, without the provider being aware, even though staff was checking the bedroom. This is a repeat noncompliance as noted on 2/18/2025.

Inspection Type: Complaint, Follow-Up Inspection


summary: 2nd Unannounced

raw_content: Checklist 660485: Census: 14; Capacity: 16; Contact: James Carling; Licensor: Larry Black


summary: Investigation Inspection (1 finding)

raw_content: R501-14-5(2)(a)-(f): Submitting application for an initial background screening — The licensee was out of compliance with R501-14-5(2)(b) by not directly supervising a staff member without a cleared background. During the inspection a staff member whose determination had not been made was left unsupervised with clients.


raw_content:
R501-1-8(1)(a)-(i): Facility and safety requirements — The Licensee was out of compliance with R501-1-8 (a, b) by not maintaining the appearance and cleanliness of the building so it's free from health and safety concerns. During the inspection, the building was in disrepair with multiple broken windows, holes in walls, and client areas were not clean.
Checklist 644297: Census: 12; Capacity: 16; Contact: James Carling; Licensor: Larry Black

Inspection Type: Unannounced, Annual Inspection


summary: Investigation Inspection (1 finding)

raw_content: R380-600-7(16)(a)-(d): Critical incidents reporting requirements — The licensee was out of compliance with R380-600-7(16)(a) by not reporting a critical incident within one business day. During the inspection the licensee was aware of a critical incident on 3/3/2025 but did not submit a report until 3/7/2025. This was a repeat noncompliance as noted on 7/3/2024, 10/5/2023, 8/22/2023, and 8/21/2023.


summary: Non On-Site Inspection


facility_name: Youth Health Associates Inc dba Eagle Academy

summary: 3rd Unannounced

raw_content: Checklist 925679: Census: 16; Capacity: 16; Contact: Monie Riddle; Rachel Mays; Licensor: Mary Bokinskie


summary: Investigation Inspection


summary: 2nd Unannounced

raw_content: Checklist 806919: Census: 16; Capacity: 16; Contact: Licensor(s) Conducting this Inspection: Mary Bokinskie OL Staff Observing Inspection:; Licensor: Mary Bokinskie


summary: Unannounced, Annual Inspection

raw_content: Checklist 679343: Census: 16; Capacity: 16; Contact: Monie Riddle; Matt Clark; Licensor: Mary Bokinskie


raw_content:
R501-1-13(5)(a)-(b): Private placement reporting — The Licensee was out of compliance with R501-1-13(5)(a) by not reporting private placements to the office by completing the congregate care out of state placement survey prior to the fifth business day of each month. During the inspection, it was observed that multiple months in the last year had not been reported through the required survey. This was a repeat noncompliance as noted on 09/12/2023 and 05/21/2024.
Checklist 656827: Census: 16; Capacity: 16; Contact: Monie Riddle; Matt Clark; Licensor: Mary Bokinskie; Josilyn Bertrand

Inspection Type: Announced, Annual Inspection


summary: 3rd Unannounced (1 finding)

raw_content:
R501-1-8(1)(a)-(i): Facility and safety requirements — The provider was out of compliance with this rule by not ensuring all prescription medications stored on site are stored in original pharmacy packaging or individual pharmacy bubble pack together with the pharmacy label, directions, and warnings. At the time of inspection, a prescription medication was outside of the required pharmacy packaging. This is a repeat rule noncompliance.
Checklist 636616: Census: 16; Capacity: 16; Contact: Matt Clark; Licensor: Mary Bokinskie


summary: 2nd Unannounced (1 finding)

raw_content:
R501-1-8(1)(a)-(i): Facility and safety requirements — The provider was out of compliance with this rule by not ensuring all prescription medications stored on site are stored in original pharmacy packaging or individual pharmacy bubble pack together with the pharmacy label, directions, and warnings. At the time of inspection some of the prescription medications were observed in a plastic bag and not contained in packaging with the pharmacy label, directions, and warnings. This is a repeat rule noncompliance.
Checklist 629425: Census: 16; Capacity: 14; Contact: Gianluca Conti; Licensor: Mary Bokinskie/Josilyn Bertrand


summary: Unannounced, Annual Inspection

raw_content: Checklist 615534: Census: 16; Capacity: 16; Contact: Matt Clark; Licensor: Mary Bokinskie


summary: Non On-Site Inspection


summary: Announced, Annual Inspection

raw_content: Checklist 598023: Census: 16; Capacity: 16; Contact: Matt Clark; Licensor: Mary Bokinskie, Josilyn Bertrand


facility_name: Youth Health Associates Inc dba Lakeside Academy

summary: 3rd Unannounced

raw_content: Checklist 940291: Census: 16; Capacity: 16; Contact: Licensor(s) Conducting this Inspection: Mary Bokinskie OL Staff Observing Inspection:; Licensor: Mary Bokinskie


summary: 2nd Unannounced

raw_content: Checklist 796299: Census: 16; Capacity: 16; Contact: Licensor(s) Conducting this Inspection: Mary Bokinskie OL Staff Observing Inspection:; Licensor: Mary Bokinskie


summary: Unannounced, Annual Inspection

raw_content: Checklist 661808: Census: 16; Capacity: 16; Contact: Monie Riddle; Mike Norvang; Licensor: Mary Bokinskie


summary: Investigation Inspection


summary: Announced, Annual Inspection

raw_content: Checklist 656828: Census: 16; Capacity: 16; Contact: Monie Riddle; Mike Norvang; Licensor: Mary Bokinskie; Josilyn Bertrand


summary: 3rd Unannounced

raw_content: Checklist 632246: Census: 16; Capacity: 16; Contact: Lewis Lofton/Lori Christensen; Licensor: Mary Bokinskie


summary: 2nd Unannounced

raw_content: Checklist 620572: Census: 15; Capacity: 16; Contact: Lewis Lofton/Lori Christensen; Licensor: Mary Bokinskie


summary: Unannounced, Annual Inspection

raw_content: Checklist 612329: Census: 16; Capacity: 16; Contact: Lewis Lofton; Licensor: Mary Bokinskie


summary: Non On-Site Inspection


raw_content:
R501-1-16(2)(a)-(q): Program policy and training — The provider was out of compliance with this rule by not ensuring each staff completes annual training on general provisions and applicable categorical licensing rule, as well as training on managing funds for clients and identifying signs and symptoms of clients under the influence of substances and alcohol. At the time of inspection staff files did not contain any documentation showing they had been trained on these required topics. This is a repeat noncompliance.
Checklist 598089: Census: 15; Capacity: 16; Contact: Lewis Lofton; Licensor: Mary Bokinskie, Josilyn Bertrand


summary: 3rd Unannounced

raw_content: Checklist 584529: Census: 16; Capacity: 16; Contact: Lewis Lofton; Licensor: Mary Bokinskie


summary: 2nd Unannounced


summary: Unannounced, Annual Inspection

raw_content: Checklist 556523: Contact: Licensor(s) Conducting this Inspection: OL Staff Observing Inspection:; Licensor: :


facility_name: Youth Health Associates dba Lakeview

summary: Follow-Up Inspection

raw_content: Checklist 836079: Census: 16; Capacity: 16; Contact: Cam Christenson; Licensor: MeRee Jacobsen

Inspection Type: Follow-Up Inspection


summary: 2nd Unannounced

raw_content: Checklist 786622: Licensor: observed downstairs client bathroom #2 did not have a mirror attached to the wall.


summary: Unannounced, Annual Inspection

raw_content: Checklist 665796: Census: 16; Capacity: 16; Contact: Camron Christensen; Licensor: MeRee Jacobsen


summary: Announced, Annual Inspection

raw_content: Checklist 655826: Census: 16; Capacity: 16; Contact: Nathan Giles; Licensor: MeRee Jacobsen


summary: Investigation Inspection


summary: 3rd Unannounced

raw_content: Checklist 642331: Census: 16; Capacity: 16; Contact: Nathan Giles 3-24-25; Licensor: MeRee Jacobsen

Inspection Type: 3rd Unannounced


summary: Investigation Inspection (2 findings)

raw_content:
R380-80-5(4): Provider shall protect clients from abuse, prevent abuse — The provider was out of compliance with R380-80-5(4) by compromising the health and safety of the clients. During the inspection, it was reported by clients that the staff were not present in the basement, where the clients were able to engage in sexual misconduct. This is a repeat noncompliance.
R380-80-5(3): Provider shall comply with policies and safe practices — The provider was out of compliance with R380-80-5(3) by failing to comply with applicable written policies. During the inspection, it was reported by clients that they were able to engage in misconduct without appropriate supervision as stated in the provider’s policies. This is a repeat noncompliance.

Inspection Type: Investigation Inspection


summary: Investigation Inspection (1 finding)

raw_content: R380-80-6(1)(a)-(i): Client rights — The provider is out of compliance with rule by failing to keep clients free from acts of violence. While on site 01/07/2025, it was reported by staff and clients that a client had been harmed by staff. The investigator observed a bruise on the client’s ear.


summary: 2nd Unannounced

raw_content: Checklist 624768: Census: 16; Capacity: 16; Contact: Jacob Westercamp 11/19/2024; Licensor: MeRee Jacobsen

Inspection Type: 2nd Unannounced


summary: Unannounced, Annual Inspection

raw_content: Checklist 615840: Census: 16; Capacity: 16; Contact: Nathan Giles; Licensor: Heather Guanajuato


summary: Non On-Site Inspection

Inspection Type: Non On-Site Inspection


summary: Focus, Non On-Site (1 finding)

raw_content:
R380-600-7(16)(a)-(d): Critical incidents reporting requirements — The provider was out of compliance with this rule by not reporting a critical incident to the Office within one business day. During review of critical incidents it was identified that the incident occurred on 08/04/2024 and was not reported until 08/06/2024.
This rule was previously out of compliance on: 02/14/2023, 06/06/2024, 10/05/2023, 11/13/2024, and 04/01/2024.

This is a repeat noncompliance.


facility_name: Youth Health Associates Inc dba Stepping Stones

summary: Follow-Up Inspection


summary: 3rd Unannounced

raw_content: Checklist 933632: Census: 16; Capacity: 16; Contact: Monie Riddle; Nathan Larson; Licensor: Mary Bokinskie


summary: Investigation Inspection (2 findings)

raw_content:
R380-80-5(5): Provider shall refrain from corporal punishment and use restrain as intervention — The provider was out of compliance with R380-80-5(5) by utilizing an unjustified restraint. During an inspection on 2/12/2026, it was determined that a staff member initiated a physical restraint while the client was engaged in a healthy coping skill, which posed no threat of self-harm, harm to others, or property damage. Consequently, the client required medical attention due to the inappropriate behavior management technique.
R501-1-4(5)(a)-(l): Congregate care behavior management policy — The provider was out of compliance with R501-1-4(5)(b) by failing to use behavior management techniques that emphasize de-escalation. During an inspection on 2/12/2026, it was determined that a staff member instigated a client who was non-responsive to verbal prompts. The staff member failed to promote the client's self-control and instead contributed to the client's frustration. This failure to de-escalate directly resulted in a physical restraint and an injury to the client.


summary: 2nd Unannounced

raw_content: Checklist 751599: Census: 16; Capacity: 16; Contact: Monie Riddle; Nathan Larson; Licensor: Mary Bokinskie


summary: Investigation Inspection


summary: Unannounced, Annual Inspection

raw_content: Checklist 663339: Census: 16; Capacity: 16; Contact: Monie Riddle; Nathan Larson; Licensor: Mary Bokinskie


summary: Announced, Annual Inspection

raw_content: Checklist 656845: Census: 16; Capacity: 16; Contact: Monie Riddle; Nathan Larson; Licensor: Mary Bokinskie; Josilyn Bertrand


summary: 3rd Unannounced

raw_content: Checklist 636622: Census: 16; Capacity: 16; Contact: Nathan Larson; Licensor: Mary Bokinskie


summary: 2nd Unannounced

raw_content: Checklist 629203: Census: 16; Capacity: 16; Contact: Nathan Larson; Licensor: Mary Bokinskie/Josilyn Bertrand


summary: Unannounced, Annual Inspection

raw_content: Checklist 615536: Census: 16; Capacity: 16; Contact: Kody Burrell; Licensor: Mary Bokinskie


summary: Non On-Site Inspection


summary: Announced, Annual Inspection

raw_content: Checklist 598022: Census: 16; Capacity: 16; Contact: Nathan Larson; Licensor: Mary Bokinskie, Josilyn Bertrand


summary: 3rd Unannounced (1 finding)

raw_content:
R501-1-8(1)(a)-(i): Facility and safety requirements — The provider was out of compliance with this rule by not maintaining the appearance and cleanliness of the building. At the time of inspection, one of the client showers had a build up of residue and grime. This was a repeat non-compliance.
Checklist 586557: Census: 16; Capacity: 16; Contact: Nathan Larson; Licensor: Mary Bokinskie


summary: 2nd Unannounced


facility_name: Zion Hills Inc.

summary: Announced, Annual Inspection

raw_content: Checklist 966791: Census: 11; Capacity: 16; Contact: Janie Sabin; Licensor: Larry Black


summary: 2nd Unannounced

raw_content: Checklist 836540: Census: 10; Capacity: 16; Contact: Janie Sabin; Licensor: Larry Black


summary: Unannounced, Annual Inspection

raw_content: Checklist 714982: Census: 6; Capacity: 16; Contact: Janie Sabin; Licensor: Larry Black


summary: Announced, Annual Inspection

raw_content: Checklist 658954: Census: 4; Capacity: 12; Contact: Janie Sabin; Licensor: Larry Black


summary: Investigation Inspection (1 finding)

raw_content: R380-80-6(1)(a)-(i): Client rights — The provider was out of compliance with R380-80-6(1(c) by a client being exposed to potential harm. During the inspection a client was able to take a staff members vape and prescription pills unnoticed.


summary: 3rd Unannounced

raw_content: Checklist 647132: Census: 4; Capacity: 12; Contact: Janie Sabin; Licensor: Larry Black


summary: 2nd Unannounced

raw_content: Checklist 632992: Census: 4; Contact: Janie Sabin; Licensor: Larry Black


summary: Unannounced, Annual Inspection

raw_content: Checklist 620544: Census: 6; Contact: Janie Sabin; Licensor: Larry Black


summary: Unannounced, Annual Inspection

raw_content: Checklist 603351: Census: 0; Contact: Janie Sabin; Licensor: Larry Black


summary: Announced, Annual Inspection

raw_content: Checklist 588264: Census: 0; Contact: Janie Sabin; Licensor: Larry Black


summary: 3rd Unannounced

raw_content: Checklist 580366: Census: 0; Contact: Janie Sabin; Licensor: Larry Black


summary: 2nd Unannounced


state: NC

facility_name: Falcon Crest Residential Care 3 Inc.

summary: Statement of Deficiency - MHLCS Annual

raw_content:
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

MHL001-103 B. WING

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
3309-A NC HIGHWAY 49

FALCON CREST RESIDENTIAL CARE 3 INC BURLINGTON, NC 27217

PRINTED: 09/26/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

09/23/2025

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES iD
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG
DEFICIENCY)

PROVIDER'S PLAN OF CORRECTION (x5)
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE DATE

COMPLETE

V 000} INITIAL COMMENTS Vv 000

An annual survey was completed on September
23, 2025. A deficiency was cited.

This facility is licensed for the following service
category: 10A NCAC 27G .1700 Residential
Treatment Staff Secure for Children or
Adolescents.

This facility is licensed for four and has a current
census of three. The survey sample consisted of
audits of three current clients.

V 118] 27G .0209 (C) Medication Requirements V 118

10A NCAC 27G .0209 MEDICATION
REQUIREMENTS

(c) Medication administration:

(1) Prescription or non-prescription drugs shall
only be administered to a client on the written
order of a person authorized by law to prescribe
drugs.
(2) Medications shall be self-administered by
clients only when authorized in writing by the
client's physician.
(3) Medications, including injections, shall be
administered only by licensed persons, or by
unlicensed persons trained by a registered nurse,
pharmacist or other legally qualified person and
privileged to prepare and administer medications.
(4) A Medication Administration Record (MAR) of
all drugs administered to each client must be kept
current. Medications administered shall be
recorded immediately after administration. The
MAR is to include the following:

(A) client's name;

(B) name, strength, and quantity of the drug;

(C) instructions for administering the drug;

(D) date and time the drug is administered; and
(E) name or initials of person administering the

Division of Health Service Regulation
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE

(X6) DATE

STATE FORM 6899 AMEN

If continuation sheet 1 of 3

Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL001-103 B. WING

NAME OF PROVIDER OR SUPPLIER
3309-A NC HIGHWAY 49

FALCON CREST RESIDENTIAL CARE 3 INC BURLINGTON, NC 27217

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 09/26/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

09/23/2025

drug.

(5) Client requests for medication changes or
checks shall be recorded and kept with the MAR
file followed up by appointment or consultation
with a physician.

This Rule is not met as evidenced by:

Based on record reviews and interview, the

acility failed to keep the MAR current affecting
one of three audited clients (#3). The findings are:

Review on 9/23/25 of Client #3's record revealed:
-Admission date of 1/26/24.
-Diagnoses of Borderline Intellectual Functioning;
Attention Deficit Hyperactivity Disorder,
Predominantly Inattentive Presentation; Major
Depressive Disorder, Recurrent Episode,
Moderate; Other Specified Trauma and Stressor
Related Disorder, Complex Post Traumatic
Stress Disorder; Generalized Anxiety Disorder.
-Physician's order dated 3/11/25:

-Ketoconazole Shampoo (anti-dandruff)- Use
3 times a week when active-Reduce to once
weekly when controlled.
-Physician's order dated 9/11/25:

-Clobetasol 0.05% Shampoo anti-dandruff)-
Apply topically to affected area every other day.

Observation on 9/23/25 at about 2:35 pm of

Client #3's medications revealed:
-Ketoconazole Shampoo was available.
-Clobetasol 0.05% Shampoo was available.

Review on 9/23/25 of Client #3's MARs for July

Division of Health Service Regulation

STATE FORM 6899

411E11

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 118] Continued From page 1 V 118

If continuation sheet 2 of 3

PRINTED: 09/26/2025

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL001-103 B. WING 09/23/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
3309-A NC HIGHWAY 49
FALCON CREST RESIDENTIAL CARE 3 INC
BURLINGTON, NC 27217
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 118| Continued From page 2 V 118
2025 through September 23, 2025 revealed:
-July:

-Ketoconazole Shampoo- Facility staff
marked the shampoo as being administered
daily.
-Clobetasol 0.05% Shampoo- There were no
markings from staff indicating that the shampoo
had been administered.

-August:
-Ketoconazole Shampoo- Facility staff
marked the shampoo as being administered
daily.
-Clobetasol 0.05% Shampoo- Facility staff
marked the shampoo as being administered
daily.
-September:

-Ketoconazole Shampoo- Facility staff
marked the shampoo as being administered
daily.
-Clobetasol 0.05% Shampoo- Facility staff
marked the shampoo as being administered
daily.

Interview on 9/23/25 with the program Director
revealed:
-He was not aware that staff were marking the
shampoos wrong on the MAR for Client #3.

-He would review the MARs with staff to make
sure they were to be inputting the correct marks
on the right days.

-He confirmed the MARs was not kept current for
Client #3.

Due to the failure to accurately document
medication administration for Client #3, it could
not be determined if he received the medicated
shampoos as ordered by his physician.

Division of Health Service Regulation
STATE FORM 6899 411E11 If continuation sheet 3 of 3

inspection_type: MHLCS Annual

document_type: Statement of Deficiency


summary: Statement of Deficiency - MHLCS Annual

raw_content:
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION

PRINTED: 09/03/2024
FORM APPROVED

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL001-103 B. WING 08/30/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
3309-A NC HIGHWAY 49
FALCON CREST RESIDENTIAL CARE 3 INC BURLINGTON, NC 27217
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 000) INITIAL COMMENTS V 000
An annual survey was completed on August 30,
2024. No deficiencies were cited.
This facility is licensed for the following service
category: 27G NCAC .1700 Residential
Treatment Staff Secure for Children or
Adolescents.
This facility is licensed for 4 and has a current
census of 3. The survey sample consisted of
audits of 3 current clients.
Division of Health Service Regulation
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

STATE FORM

6899 E5WP11 If continuation sheet 1 of 1