summary: 6-month - 62 findings

raw_content:
Licensed Child Caring Agency Site Visit Report
Residential Care - 6-Month
Licensee: Klamath Basin Behavioral Health (KBBH) Board Chairperson: Edward Horvath
Residential Programs: Sage and Yarrow Date of site visit: 4/7/25
Executive Director: Kendall Alexander Licensing Coordinator: Mary Torres
Other Regulatory or Accrediting Agencies: Oregon Department of Human Services (ODHS) - Treatment Services, Child Welfare
Program compliance: The program was found to be compliant or will be compliant with OAR 419-400-0005 to 419-400-0310,
Licensing Umbrella Rules, and OAR 419-470-0010 to 419-470-0180, Licensing Residential Care Agencies Rules. Personnel records
were reviewed and compliance with required background checks was documented for employees in all programs.
Program description(s): As per the CCA's website; The youth residential facilities provide behavioral rehabilitation services to youth in
DHS custody who are experiencing a severe behavioral health episode. Services are provided to male and female adolescents ages
10-17 years.
Program type and services: As per the CCA's website; Services provided include 24/7 supervision, intensive weekly skills building,
medication management, and care coordination. Temporary crisis respite services are available for non-qualifying youth who need
mental health supervision while waiting for less restrictive services.
Capacity and age range: 10 youth total, 4 youth at Yarrow, 6 youth at Sage, ages 10 - 17 years
Funding sources: Oregon Department of Human Services (ODHS)
Contracts and sources for referrals: Oregon Department of Human Services (ODHS)
Average length of stay: To be determined over the upcoming 2-year licensing period.
Form revised 3/12/2025 Page 1 of 32
Average daily population served: To be determined over the upcoming 2-year licensing period.
Number of children served annually: To be determined over the upcoming 2-year licensing period.
Use of seclusion or restraint: The CCA does not currently utilize seclusion nor restraint. Although the program expresses a strong
desire to refrain from the use of restraints, a recent decision to train staff in safety holds through Crisis Prevention Institute (CPI) has
been made. This will provide staff with the tools needed to safely and effectively implement a hold should circumstances warrant a
physical intervention by staff to lower risk and maximize safety.
Interviews/observations: Licensing completed a tour of the building and conducted both staff and youth interviews. At the time of this
6 month review, the program was servicing two youth with a third expected to arrive the same evening. Since the program's opening in
November of 2024, the program has served 15 youth total. Both buildings were clean and showed no signs of previous damage done
only a few weeks prior by a prevoius milieu. The agency's maintenance team was quick to repair walls, doors, doorframes, etc.
Three direct care staff were interviewed. All staff were able to identify essential training topics covered in during their new employee
orientation. One staff suggested breaking up the three week training course as it was difficult to retain so much new information.
Strengths identified by staff include the Program Manager's "good communication" with staff, quick responses to questions and
situations and their "open door policy." The teams cohesiveness was also appreciated. Areas where staff would like to see
improvement are having all staff trained to administer medication to youth and finding "a balance" when intaking youth to prevent the
need for discharging youth on an emergency basis due to an inbalance of needs within the milieu. The program will soon implement a
12 hour work schedule, allowing staff to have three consecutive days to recharge. Those inteviewed are excited about this change and
feel it will reap positive results.
One youth was open to being interviewed. Youth reports feeling safe within the program and feels that staff are adequately trained to
provide care and supervision of youth. The current miliue is diverse and although the youth is experiencing issues with a peer, there is
opportunity to create space from the peer and staff are able to provide individual support. A program positive, in the youth's
perspective, is the amount of free time allowed and there are not too many required groups that youth must attend. A change to the TV
and video game use was recommended. Currently, screen time is only allowed after 4:00 pm or later, depending on what is happening
Form revised 3/12/2025 Page 2 of 32
in the milieu. Outings regularly occur and include trips to the park, swimming at the Y, and library. With summer approaching, the
program is planning on more outside activities. The youth has met with the program's therapist and treatment goals have been
established. The in house therapist has offered this youth with support and the youth verbalizes a commitment to stay in program.
Program strengths: A common strength identified by staff is the support and positive communication provided by the Program
Manager. Staff report that the Program Manager is quick to respond and encourages staff to utilize critical thinking when dealing with
difficult youth behaviors.
Program challenges: Staff identify program challenges as difficult youth behaviors that result in emergency discharges and the lack of
medication adminstration for all staff. Enrolling new youth into school within a timely manner has proven to be difficult. School
administrators have been apprehensive in accepting newly placed youth without requested school history and documentation, delaying
enrollment by weeks. Youth behaviors within the milieu and in the community coming to the attention of law enforcement are creating
tension with local police. The program is assessing their reporting practices and making changes as needed to avoid taxing police
resources.
Changes that have occurred in the last two years: None reported by the program.
Lawsuits: None reported by the program.
Grievances and complaints filed in the last two years: None reported by the program.
Corrective actions and timeframes: Please submit the following to verify compliance.
Within 45 days of receipt of this report Klamath Basin Behavioral Health (KBBH) must submit a letter of verification indicating the
agency is in compliance with the specific rules cited above and describing how compliance will be maintained going forward. Along
with the letter of verification, the agency must submit any and all specific documentation requested in the body of this report. The letter
of verification and any additional requested documents can be emailed directly to Mary Torres at mary.torres@odhsoha.oregon.gov.
Exceptions: None
Form revised 3/12/2025 Page 3 of 32
Changes in license: The residential programs were added to the CCA's 2-year license on November 19. 2024. A review for the CCA
is scheduled to occur before the license's expiration on September 30, 2025.
Summary of review
Program and services Yes/No Corrective actions/comments
419-400-0020 (2) or N/A
Program and services are in scope of Yes
license
Governance of the agency Yes/No Corrective actions/comments
419-400-0040 or N/A
(1)(a) Minimum of 5 board members Yes
(2)(f) Formally evaluate the Executive N/A Item to be audited at the upcoming license renewal.
Director’s performance annually
(2)(g) Approves annual budget N/A Item to be audited at the upcoming license renewal.
(2)(h) Obtain and review an annual N/A Item to be audited at the upcoming license renewal.
independent financial review or audit
of financial records.
(2)(k) Written quality improvement No A quality improvement plan was not submitted.
program
CORRECTIVE ACTION: Submit a written quality improvement plan to
Licensing for review.
(2)(l) Meeting minutes N/A Item to be audited at the upcoming license renewal.
Form revised 3/12/2025 Page 4 of 32
Executive Director or Program Yes/No Corrective actions/comments
Director or N/A
419-400-0040
(3)(a) knowledge of requirements for Yes
providing care and treatment
appropriate to programs
(3)(g) Approval from BCU Yes Approved background check from 2023 license renewal on file with
Licensing. This background check will be renewed for the next licensing
period due fall of 2025.
Installation and use of video Yes/No Corrective actions/comments
equipment used to monitor or or N/A
record children in care
419-400-0145
(1) If a child-caring agency installs Yes
video equipment to monitor or record
a child in care, all employees,
volunteers, parents or guardians and
children in care must be informed
about the intended use and locations
of the equipment.
Discipline, behavior management Yes/No Corrective actions/comments
and suicide prevention or N/A
419-400-0150
(3) Agency uses appropriate and Yes The program utlizes Dialectical Behavior Therapy (DBT) and Cognitive
positive methods of behavior Behavioral Therapy (CBT) when assisting youth regulate. There was a
management and nationally recent decision to extend CPI training to include training on safety holds.
recognized non-violent crisis Once this occurs, the program will need to revise their current behavior
intervention mamagement policy to reflect these changes.
(3)(b)(C) Agency does not use N/A The program does not utilize chemical or mechanical restraints.
chemical and mechanical restraint
Form revised 3/12/2025 Page 5 of 32
Discipline, behavior management Yes/No Corrective actions/comments
and suicide prevention or N/A
419-400-0150
(excluding medically necessary
devices/prescriptions)
(3)(c) Agency uses appropriate time- N/A The program does not utilize the use of time out rooms.
out rooms (adequate space, heat,
light and ventilation and is not capable
of locking) and documents use in
child’s record when applicable
(3)(e) Agency uses seclusion N/A The program does not utilize seclusion.
appropriately/consistent with policy
(4) Agency has adequate plan in Yes
place to respond to suicidal
behavior/warning signs
Contractors (if applicable) Yes/No Corrective actions/comments
419-400-0120(6) or N/A
(a) Agency ensures the contractor N/A Item to be audited at the upcoming license renewal
meets the requirements of this rule
and Chapter 413 division 215
(b)(B) Contract includes the following: N/A Item to be audited at the upcoming license renewal
(i) Services provided
(ii) Contractor fees
(iii) Disclosure of information from
contractor to agency
(iv) Lines of authority
(v) Adherence to rules, including
background check
(vi) Any liability of the agency for acts
of the contractor, rights of indemnity
and limitations on liability
Form revised 3/12/2025 Page 6 of 32
Restraints and Involuntary Yes/No Corrective actions/comments
Seclusion or N/A
419-400-0180
(13)(d) Each child caring agency that No Although the program has submitted a copy of the program's most recent
submits a report under this section quarterly report to Licensing for public posting, a copy of the report has not
shall make its quarterly report been uploaded to the CCA's own website.
available to the public upon request at
the child caring agency’s main office CORRECTIVE ACTION: Upload most recent and future quarterly reports
and on the child caring agency’s onto the CCA's own website for public review.
website if applicable.
Supplemental information provided Yes/No Corrective actions/comments
by CCA or N/A
Documents as indicated on the form Yes These items were checked prior to the program receiving its' license and
titled “Renewal Licensing Required was not audited during this 6-month review.
Documents”
Documents as indicated on form titled Yes These items were checked prior to the program receiving its' license and
“Required Financial Documents and was not audited during this 6-month review
Information”
All required policies and procedures Yes These items were checked prior to the program receiving its' license and
as identified in the “Umbrella Rules” was not audited during this 6-month review
All required policies and procedures Yes These items were checked prior to the program receiving its' license and
as identified in “Agency Type Specific was not audited during this 6-month review
Rules”
Physical plant Yes/No Corrective actions/comments
or N/A
419-400-0090(3)(a) Foster Rights No Foster Rights was not posted.
Posted (if children in ODHS custody)
Form revised 3/12/2025 Page 7 of 32
Physical plant Yes/No Corrective actions/comments
or N/A
CORRECTIVE ACTION: Post youth Foster Rights in the common area of
each facility. Send a picure to Licensing showing the posted page as proof.
419-400-0100(1) Sufficient safe Yes
space, equipment and office
equipment
419-400-0230(12) License is posted No License was not posted.
in common area at each facility
CORRECTIVE ACTION: Post a copy of the CCA's license in each facility in
the common area. Send a picture to Licensing showing the posted license
as proof.
419-470-0020(2)(a) and (c) Buildings Yes
are smoke free, clean and in good
repair
419-470-0020 (2)(d) Rooms are free Yes
of harmful drafts, odors and excessive
noise
419-470-0020 (2)(e) Rooms are Yes
adequate in size and arrangement
419-470-0020 (2)(f) System provides Yes
a continuous supply of hot and cold
water to taps located throughout the
facility
419-470-0020 (2)(h) Building is well Yes
ventilated, and room temperature is
within a normal comfort range
419-470-0030 (1) All parts of the Yes
facility ensure the safety of children
Form revised 3/12/2025 Page 8 of 32
Room and space requirements Yes/No Corrective actions/comments
419-470-0030 or N/A
(2) There is a separate living room or Yes
lounge area – 15 SF minimum per
child
(5) There is a separate dining room Yes
with capacity for ½ of children in care
and 15 SF per child in care
(7) Laundry is separate from living, Yes
kitchen and dining areas
(8) Separate storage areas are Yes
provided for food, kitchen supplies,
utensils, clean linens, soiled linens
and clothing, cleaning supplies and
equipment, poisons, chemicals,
outdoor recreational and maintenance
equipment. (Hazardous materials are
properly labeled, in original container
and locked)
(9) Outdoor activity area is protected Yes
from vehicles and other hazards and
of a size and availability appropriate to
the age and needs of children in care
(11) Time-out rooms: Rooms used for N/A The program does not use time out rooms.
time out or quiet time must have
adequate space, heat, light and
ventilation and must not be capable of
locking.
Form revised 3/12/2025 Page 9 of 32
Room and space requirements - Yes/No Corrective actions/comments
bedrooms or N/A
419-470-0030(3)
(a) Adequate furnishings and personal Yes
items
(b) Separate from rooms used for Yes
dining, living, laundry, kitchen and
storage
(c) Meet Oregon Fire Code Yes
Requirements
(d) Be an outside room, with a window Yes
that operates as designed. If the
window is modified from its original
design, the fire marshal must approve
the modification and indicate this
room still meets applicable Oregon
Fire Code.
(d) Ceiling at least 90 inches Yes
(e) Minimum 60 SF per occupant Yes
(f) No more than 25 if dorm style N/A The program provides youth with single room occupancy.
(g) Permanently wired fixtures Yes
(h) Window covering Yes
Room and space requirements - Yes/No Corrective actions/comments
bathrooms or N/A
419-470-0030(4)
(a)(A) and (B) 1:8 ratio for toilets and Yes
sinks
(a)(D) Hot and cold running water, Yes
soap and approved hand drying
options
(a)(E) 1:10 ratio for shower or bathtub Yes
Form revised 3/12/2025 Page 10 of 32
Room and space requirements - Yes/No Corrective actions/comments
bathrooms or N/A
419-470-0030(4)
(a)(E) Individual privacy Yes
(a)(F) Window covering Yes
(a)(G) Permanently wired fixtures Yes
(a)(H) Adequate ventilation Yes
(b) and (c) Wooden racks on floors are Yes The program will be using an impervious shower mat in each shower. The
prohibited and impervious shower development of a procedure, ensuring the mats are disinfected and dried
mats are disinfected and dried daily be on a daily basis is being requested by Licensing. ***Please note, this is not
in good condition and free of mold a corrective action.***
Room and space requirements - Yes/No Corrective actions/comments
kitchen or N/A
419-470-0030(6)
(a) Used exclusively for storage, food Yes
preparation, dishwashing and
activities related to eating and food
preparation activities
(b) Walls, floors are easily cleanable Yes
(c) Equipment and utensils are easily Yes
cleanable, durable, nontoxic and kept
clean
(e) Equipment is easy to clean Yes
beneath, between and behind
Furnishings and personal items Yes/No Corrective actions/comments
419-470-0040 or N/A
(1) There is a bed with frame Yes
Form revised 3/12/2025 Page 11 of 32
Furnishings and personal items Yes/No Corrective actions/comments
419-470-0040 or N/A
(1)(b) clean mattress in good Yes
condition, with a minimum thickness
of five inches
(1)(c) a pillow in good condition Yes
(1)(d) a private dresser, closet, or Yes
similar storage area for personal
belongings that is readily accessible
(2) Linens are in good repair. There is Yes
a waterproof mattress cover or
mattress. Linens are appropriate and
towels and washcloths are provided
(3) Bedding is changed weekly or Yes
when soiled
(4) and (5) Personal hygiene supplies Yes
and appropriate clothing are provided
Food services Yes/No Corrective actions/comments
419-470-0070 or N/A
(1)(a) Meals are arranged daily, Yes
consistent with normal mealtimes that
occur during the hours of operation
and provide snacks between
mealtimes
(1)(b) Menus are prepared in advance Yes Snacks are to be listed on each monthly menu. Snacks options can be listed
in accordance with USDA guidelines, for each day or listed for each week. ***Please note, this is not a finding.***
provide a variety of foods and are
adjusted for seasonal changes
including snacks
(1)(b) Menus are kept for at least 6 Yes
months
Form revised 3/12/2025 Page 12 of 32
Food services Yes/No Corrective actions/comments
419-470-0070 or N/A
(1)(c) Drinking water is freely available Yes
(2)(a) Food is stored, prepared and Yes
served in a sanitary manner
(2)(c) and (d) Food products are Yes
obtained from commercial suppliers
(exception of fruits and vegetables),
unpasteurized juice is prohibited, and
only Grade A pasteurized and fortified
milk in appropriate container.
Residential care safety Yes/No Corrective actions/comments
419-470-0080 or N/A
(2) Written emergency plan that Yes
includes
(a) Identifying the types of Yes
emergencies most likely to happen
where the residential care agency is
located
(b) Identifying a place to meet for Yes
each type of emergency identified
(c) Identifying an alternate shelter if Yes
necessary
(d) Ensuring access to necessary Yes
medications or medical equipment
(e) How to help each child in care Yes
recover after a disaster
(3) Telephone numbers for local Yes
police, fire department, poison control,
after hours medical advice and other
Form revised 3/12/2025 Page 13 of 32
Residential care safety Yes/No Corrective actions/comments
419-470-0080 or N/A
appropriate emergency numbers must
be posted near all telephones.
(4) Operative flashlights sufficient in Yes
number are readily available to staff
(5)(a) Evacuation drill occurs monthly No Although evacuations have occurred monthly since the program's opening,
under varying conditions, is retained 2 the documentation for these drills do not reflect the required information as
years and contains: listed to the side of this narrative.
(A) identify of person conducting drill
(B) date and time CORRECTIVE ACTION: Revise the existing evacuation sheet to include the
(C) notification method required information and implement the use of the revised form moving
(D) staff participating forward. If further assistance is needed, the program will reach out to the
(E) number of children and staff Licensing Coordinator.
evacuated
(F) special conditions simulated
(G) problems encountered
(H) time to complete
Umbrella safety Yes/No Corrective actions/comments
419-400-0200 or N/A
(5)(b) Vehicle has insurance policy, is Yes
smoke free, safe operating condition,
and has first aid kit and fire
extinguisher 2-A:10-BC
(1)(b)(A) Each vehicle used to Yes A copy of the vehicle's current registration issued by the DMV is requested
transport a child in care must be: to be kept in the vehicle moving forward. ***Please note, this is not a
properly registered, finding.***
covered by an insurance policy in full
force and effect, maintained in safe
operating condition and smoke-free.
Form revised 3/12/2025 Page 14 of 32
Umbrella safety Yes/No Corrective actions/comments
419-400-0200 or N/A
(3) If a child-caring agency has a N/A The program does not have a pool on site. If the program has plans to have
swimming pool on the premises that is youth engage in swimming off site, then a policy addressing disclosures and
accessible to children in care or if a obtaiing consents as well as assessing the swimming ability of each chilld in
child-caring agency plans to have care will need to be submitted to Licensing. ***Please note, this is not a
children in care engage in swimming, finding.***
the child-caring agency must have
and adhere to policies and procedures
that address, at a minimum, providing
disclosures and obtaining consents,
assessing swimming ability of children
in care and ensuring the safety of pool
access.
(4)(a) The program protects children Yes
from potentially harmful items and
materials.
(4)(b) Direct supervision of children Yes
who do not have the ability to adjust
and control water temperature
(4)(c) Light fixtures have protective Yes
covers unless designed to be used
without one
Medication Yes/No Corrective actions/comments
419-470-0100 or N/A
(3) and (7)(e) Medications have a Yes
prescription and are stored in the
original container with prescription
label
(4) and (5) Herbal supplements and Yes
remedies, medical treatments, special
Form revised 3/12/2025 Page 15 of 32
Medication Yes/No Corrective actions/comments
419-470-0100 or N/A
diets, physical therapy, physical aides
or limitations have a written order
signed by a physician or qualified
medical professional. A written order,
signed by a physician or qualified
medical professional, is also required
before a restriction on diet or physical
activity is imposed.
(7)(c) Medications are inaccessible to Yes
children and stored behind at least
two locking mechanisms. This does
not apply to Naloxone.
(8) Medications are disposed in Yes
accordance with state and federal law
(9) Written record of the disposal of No Disposal log is missing two staff signatures.
medications is maintained and
includes: CORRECTIVE ACTION: Ensure that all required informaition is noted on the
(a) description and amount disposal log to include two staff signatures. Submit revised document to
(b) name Licensing.
(c) reason
(d) method
(e) staff and witness signature
(10) Written record of the Yes
administration of medication includes:
(a) name
(b) description
(c) dates and times
(d) missed doses
(e) medication disposed
(f) method of administration
(g) ID of person administering
Form revised 3/12/2025 Page 16 of 32
Medication Yes/No Corrective actions/comments
419-470-0100 or N/A
(h) possible adverse reactions
(i) medication taken outside facility
Extracurricular, enrichment, Yes/No Corrective actions/comments
cultural and social activities or N/A
419-470-0110
(2) Children have ongoing Yes
opportunities to participate in at least
one age-appropriate or
developmentally appropriate activity
Minimum staffing requirements Yes/No Corrective actions/comments
419-470-0130 or N/A
(1) and (2) Supervision is adequate Yes
for the type of program, location, age
and type of children, ability of
supervisor to respond, electronic
back-up systems.
Minimum ratios are maintained:
Under 30 months of age: 1:4
30 months to ˃ 6 years or non-
ambulatory: 1:6
Ages 6 and older: 1:7
Overnight (staff awake)
1:10
(4)(a) When one staff on duty, there is Yes
additional staff immediately available
with max response time of 30 minutes
Form revised 3/12/2025 Page 17 of 32
Minimum staffing requirements Yes/No Corrective actions/comments
419-470-0130 or N/A
(5) There is at least one on-site No A review of staff files does not reflect reasonable and prudent parent
employee authorized to apply the standard training being offered to residential staff.
reasonable and prudent parent
standard CORRECTIVE ACTION: Train all staff in this area and submit proof in
writing to Licensing.
Sleeping arrangements Yes/No Corrective actions/comments
419-470-0140 or N/A
(1) Children are in separate bedrooms N/A The program's age range is 10 - 17 years.
than adults, unless parent and child,
or there is written approval from
guardian/parent and licensing
coordinator
(2) There is adequate supervision of Yes
children when sleeping
(3) When assigning bedrooms a Yes
residential care agency must consider
all of the following:
(a) Chronological age
(b) Developmental age
(c) Gender identity
(d) Personal history, including
medical, mental health, behavioral
health and past adverse experiences
including any physical or sexual
abuse
Form revised 3/12/2025 Page 18 of 32
Personnel files Yes/No Corrective actions/comments
419-400-0120 or N/A
Staff name/position Yes
(3)(g) Date of hire Yes
(3)(a) record of education, training Yes
and previous employment
(1)(b) and (3)(b) reference checks Yes
completed and documented
(1)(a) and (3)(c) Background check Yes
completed and documented
(3)(d) Annual performance N/A Evaluations for residential staff are scheduled for June 2025. Item to be
evaluations audited at the upcoming license renewal.
(3)(f) Record of personnel actions Yes
(3)(g) Termination date, reason for Yes
termination
(3)(h) Current job description (1)(c) Yes
Employee meets minimum
qualifications stated in current job
description
New employee orientation – Yes/No Corrective actions/comments
Umbrella Requirements (30 days) or N/A
419-400-0120(4)
(a) Agency policies and procedures Yes
(b) Ethical and professional Yes
guidelines
(c) Suicide prevention and No One personnel file reviewed reflected partial training in this area.
intervention
CORRECTIVE ACTION: Ensure that the staff member completes this
training. Submit proof that this training was completed to Licensing.
Licensing is able to identify the staff member to the program upon request.
Form revised 3/12/2025 Page 19 of 32
New employee orientation – Yes/No Corrective actions/comments
Umbrella Requirements (30 days) or N/A
419-400-0120(4)
(d) Attributes of population served Yes
(e) and (5)(a) to (c) Mandatory Yes
reporting that includes:
(a) legal definition of child abuse in
ORS 418.257 and 419B.005
(b) legal responsibility to immediately
report
(c) legal responsibility to report is
personal to the employee
(f) Privacy laws Yes
(g) Emergency procedures Yes
New employee orientation Yes/No Corrective actions/comments
residential (prior to working alone or N/A
and within 30 days)
419-470-0120(1)
(a) Discipline and behavior Yes
management including de-escalation,
crisis prevention, positive behavior
management and disciplinary
techniques that are non-punitive in
nature
(b) CPR and First Aid sufficient to Yes
retain a current certification
(c) Universal precautions and hygiene Yes
(d) Application of the reasonable and No Reasonable and prudent parent standard training is not being offered to
prudent parent standard residential staff.
Form revised 3/12/2025 Page 20 of 32
New employee orientation Yes/No Corrective actions/comments
residential (prior to working alone or N/A
and within 30 days)
419-470-0120(1)
CORRECTIVE ACTION: Implement a process where this required training
is a part of the new employee onboarding process and existing staff are
trained in this area. Submit completion of this training to Licensing.
(e) Training on the agency’s policy on No Although the program provides training in suicide prevention and
suicide prevention and suicide risk intervention to staff, it is unclear how and which staff are trained to
assessment tool administer a suicide risk assessment.
CORRECTIVE ACTION: Clarify what suicide risk assessment tool is used,
which staff are trained to administer the assessment and how staff are
trained in the use of this tool.
Crisis intervention training Yes/No Corrective actions/comments
standards and certification or N/A
419-400-0160(4) (as applicable)
(a)Complete a minimum of 12 hours N/A The program does not currently utilize physical restraint as a behavior
of initial training in person from a intervention
certified instructor, including but not
limited to a minimum of six hours of
training focused on positive behavior
support, nonviolent crisis intervention
and other methods of nonphysical
intervention to support children in
care during a crisis
(d) Receive a certificate that states: N/A The program does not currently utilize physical restraint as a behavior
(A) The dates during which the intervention
certification is current
Form revised 3/12/2025 Page 21 of 32
Crisis intervention training Yes/No Corrective actions/comments
standards and certification or N/A
419-400-0160(4) (as applicable)
(B) The type of restraint which the
individual is certified to perform if
applicable
(C) The type of training the individual
is certified to conduct if applicable
(D) Any special endorsements earned
by the individual
(E) The level of training
(F) The name of the certified
instructor who conducted the training
and administered the assessment of
proficiency.
(e) A certification issued: N/A The program does not currently utilize physical restraint as a behavior
(A) Must be personal to the individual intervention
certified by the training provider
(B) May be valid for no more than two
years with recertification
Ongoing training Yes/No Corrective actions/comments
or N/A
419-470-0070(2)(b) Employees who N/A The program is less than a year in existence.
handle food served to children have a
valid food handler’s card
419-400-0200 (1) Employees N/A The program is less than a year in existence.
transporting children have: current
driver’s license, insurance, trained in
emergency procedures and behavior
Form revised 3/12/2025 Page 22 of 32
Ongoing training Yes/No Corrective actions/comments
or N/A
management and training for 15+
passenger vans if applicable)
419-470-0120 (2)(a) Environmental N/A The program is less than a year in existence.
emergencies
419-470-0120 (2)(b) Universal N/A The program is less than a year in existence.
precautions
419-470-0120 (2)(c) Discipline and N/A The program is less than a year in existence.
behavior management
419-470-0120 (2)(d) Agency’s policy N/A The program is less than a year in existence.
on suicide prevention and risk
assessment tool
419-470-0120 (3) Staff providing N/A The program is less than a year in existence.
direct care must maintain current
CPR/First Aid certification
419-470-0120 (4) Designated staff N/A The program is less than a year in existence.
authorized to apply reasonable and
prudent parent standard are trained in
application of the standard
419-400-0120(5) Mandatory reporting N/A The program is less than a year in existence.
(annually) that includes:
(a) legal definition of child abuse in
ORS 418.257 and 419B.005
(b) legal responsibility to immediately
report
(c) legal responsibility to report is
personal to the employee
419-400-0160(4)(b) Receive N/A The program is less than a year in existence.
continuing education (as applicable
Form revised 3/12/2025 Page 23 of 32
Ongoing training Yes/No Corrective actions/comments
or N/A
on crisis intervention training) from a
certified instructor on an annual basis
Children’s records Yes/No Corrective actions/comments
health services or N/A
419-470-0090
(2) Medical history obtained within 30 Yes Currently the program utilizes the Child Welfare referral packet (1055)
days (significant findings, current submitted for each child the program considers and takes into care. For
immunizations, history of surgical now, the information captured in this packet adequately addresses a
procedures-health issues-injuries, youth's medical history. Licensing will offer technical assistance in this area
allergies, dental, vision, hearing, should the program decide to independently obtain and document a youth's
behavioral health and physician medical history in additon to the referral packet.
orders)
(4)(a) to (f) Medical exams (3 in first Yes
year of life, 2,4,6,9,14)
(g) Have a physical examination within Yes The program is establishing partnerships within the medical community and
the first 60 days after admission of a is striving to have all youth fast tracked through Sky Lakes for a well child
child in care. Documentation of a check within 2 weeks of their arrival. Vision and dental appointments are
physical examination having occurred taking longer to schedule than 2 weeks.
within the calendar year will meet this
requirement.
Consents Yes/No Corrective actions/comments
419-470-0160(1) or N/A
(a) Provide routine and emergency Yes
medical care
(b) Use the discipline and behavior Yes
management system
Form revised 3/12/2025 Page 24 of 32
Consents Yes/No Corrective actions/comments
419-470-0160(1) or N/A
(c) Use restraint or seclusion (if N/A The program does not practice restraint or seculsion. This may change
applicable). Must specify the reasons once staff are fully trained in safety holds through CPI.
for the intervention and how staff are
trained and supervised
(d) Restrict contact with persons Yes
outside of the agency
(e) Allow access as defined in 419- No This required consent is missing from the program's intake packet.
400-0230 and 0240
CORRECTIVE ACTION: Create and implement the use of this consent that
allows the following:
419-400-0230 Licensing Umbrella Rules: Responsibilities of Licensees
A Licensee is responsible to do all of the following:
(10) Permit immediate access to a child in care and access to any area of
the premises in which the child in care receives care or services to the
following:
(a) Employees and representatives of the Department;
(b) The child in care's attorney;
(c) The child in care's court-appointed special advocate;
(d) The parent or legal guardian of the child in care if the child in care has
not been committed to the custody of the Department or the Oregon Youth
Authority;
(e) Any governmental agency or unit that has a contract with the child-
caring agency to provide care or services to the child in care; and
(f) Any other person authorized by the Department
(f) Impose a dress code Yes
(g) Apply the reasonable and prudent No This required consent is missing from the program's intake packet.
parent standard
CORRECTIVE ACTION: Create and implement the use of this consent that
allows the program to apply the reasonable and prudent parent standard to
determine whether the child in care is allowed to participate in age-
Form revised 3/12/2025 Page 25 of 32
Consents Yes/No Corrective actions/comments
419-470-0160(1) or N/A
appropriate or developmentally appropriate activities including
extracurricular, enrichment, cultural, and social activities.
Disclosures Yes/No Corrective actions/comments
419-470-0160(2) or N/A
Parent/guardian has acknowledged in
writing:
(a) Information regarding personal or Yes
room searches and protocols for
confiscation of contraband
(b) Statement of Rights of Children Yes
and Parents/Guardians
(c) Any policies and procedures upon No This required disclosure is missing from the program's intake packet.
request
CORRECTIVE ACTION: Create and implement the use of this disclosure
stating that a parent/guardian will be provided any of the program's policies
and/or procedures upon request.
Authorizations Yes/No Corrective actions/comments
419-470-0160(3) or N/A
(a) Disclose or exchange information Yes
with others
(b) Child specific visitors Yes
(c) Visitation resources are pre- Yes
approved
(d) Activity specific authorizations are Yes
pre-approved to allow children to
participate in potentially hazardous
activities, including but not limited to
Form revised 3/12/2025 Page 26 of 32
Authorizations Yes/No Corrective actions/comments
419-470-0160(3) or N/A
using motorized yard equipment,
swimming and horseback riding.
Information about children in care Yes/No Corrective actions/comments
419-400-0190(1) or N/A
Summary sheet contains the
following:
(a)The name, gender, date of birth, Yes The program will make an active effort to document a youth's most recent
religious preference and previous placement and address, if known, as part of the intake process for new
address youth moving forward. This may warrant a revision to the program's
existing intake packet. ***Please note, this is not a finding.***
(b) Name and location of previous and No The program's existing intake packet does not have a dedicated space to
current school document a youth's previous and current school setting.
CORRECTIVE ACTION: Revise the existing intake packet to include a
youth's previous and current school name and address.
(c) Date of admission Yes
(d) Legal custody Yes
(e) The name, address and telephone Yes
number of:
(A) The child in care's parents.
(B) The child in care's legal
guardian, if different than the
parents and a copy of the
document that provides for his or
her authority over the child in care.
(C) Other persons significant to
child
(D) Other professionals to be involved
in service planning (if applicable)
Form revised 3/12/2025 Page 27 of 32
Service planning Yes/No Corrective actions/comments
419-470-0170(2) or N/A
(b) Intake document is completed the Yes
date child accepted into care
(emergency placement 48 hours)
(d) Assessment is completed within 30 No Youth assessments have not been completed as the program did not have
days and contains relevant historical an active mental health therapist available until one was hired on 3/3/25.
information, current behavioral
observations, identified need for CORRECTIVE ACTION: Submit a plan as to how the newly hired therapist
services and how agency will provide will meet this 30 day requirement moving forward.
services
(e) (A) and (B) Service plan within 60 No Service plans have not been completed as the program did not have an
days (parent, guardian and child active mental health therapist available until one was hired on 3/3/25.
actively involved). Describes how
child’s issues will be addressed, CORRECTIVE ACTION: Submit a plan as to how the newly hired therapist
anticipated outcomes and reviewed by will meet this 60 day requirement moving forward.
child and guardian/parent.
(e)(C) and (D) Service plan is No It is unknown how often the program plans to review service plans.
reviewed quarterly and revised when
information indicates other services CORRECTIVE ACTION: Submit a plan as to how often service plans are to
should be provided be reviewed and by who.
Case management Yes/No Corrective actions/comments
419-470-0170(3) or N/A
(a) Services are documented, No Services nor progress toward achieving goals are not documented.
progress toward achieving goals is
tracked CORRECTIVE ACTION: Submit a plan as to how services are documented
and how progress toward achieving goals is tracked.
(c) Discharge summary must include: No The program has yet to develop a discharge summary that captures the
(A)Current medications required information located to the side of this narrative.
Form revised 3/12/2025 Page 28 of 32
Case management Yes/No Corrective actions/comments
419-470-0170(3) or N/A
(B)Name of the physician or qualified
medical professional who prescribed CORRECTIVE ACTION: Create and implement a discharge summary that
each medication addresses the required information. Submit a copy of this document to
(C)Any outstanding medical or other Licensing for review.
appointments
(D)Summary of the child’s
participation in the program and
progress achieved
(E)Results of evaluations
(F)Recommendations regarding
services
(G)Discharge destination
(e) Follow up services No Youth that have exited the program thus far, have been discharged under
emergency circumstances. Examples of a planned discharge with
identified follow up services are nonexistent.
CORRECTIVE ACTION: Provide a summary as to how the program plans
to offer and provide transitional or aftercare service coordination to youth
upon their discharge from the program.
(f) Incident reports Yes Licensing will continue to offer support in this area to ensure that all
pertinent information is appropriately documented in these incident reports.
Records relating to Restraint and Yes/No Corrective actions/comments
Involuntary Seclusion or N/A
419-400-0180 (12) Records N/A The program does not utilize restraint or seclusion.
419-400-0180(13)(e) Each child No It is unknown how this notice is provided to parents/guardians at the time of
caring agency shall provide notice admission.
regarding how to access the quarterly
reports to the parents or guardians of CORRECTIVE ACTION: Submit how this information is provided to
children in care in the program. The Licening.
Form revised 3/12/2025 Page 29 of 32
Records relating to Restraint and Yes/No Corrective actions/comments
Involuntary Seclusion or N/A
child caring agency shall provide the
notice upon the child in care’s
admission and at least two times each
year thereafter.
419-400-0190(1) Information provided No The program accepts youth from ODHS - Child Welfare. Although it is the
to children in care relating to Restraint responsibility of ODHS to provide children in care with this required
and Involuntary Seclusion information, the program also provides crisis respite services to the county
youth who must also be provided the same informaiton.
CORRECTIVE ACTION: Create and implement a plan as to how non
ODHS youth will receive the following informaiton as required through rule:
(1) Each child in care receiving services from a child-caring agency must
be given the following:
(a) Instruction regarding how a child in care may report suspected
inappropriate use of restraint or involuntary seclusion;
(b) Assurance that the child in care will not experience retaliation for
reporting suspected inappropriate uses of restraint or involuntary seclusion
and;
(c) The telephone number for the toll-free child abuse hotline (855-503-
7233) described in ORS 417.805 and the telephone numbers and
electronic mail addresses for the program’s Licensing Agency (Mary Torres
503-798-5300, mary.torres@odhsoha.oregon.gov, the child in care’s
caseworker and attorney, the child in care’s court appointed special
advocate and Disability Rights Oregon (503-243-2081).
(2) The information must be provided by:
(a) The Oregon Department of Human Services if the department placed
the child in care in the child-caring agency;
(b) The Oregon Youth Authority if the child in care has been committed to
the custody of the authority; or
(c) The child-caring agency for all other children in care.
Form revised 3/12/2025 Page 30 of 32
Financial records Yes/No Corrective actions/comments
419-470-0170(4) or N/A
Records contain date, amount, N/A Any monetary items (cash, gift cards) that the youth arrive with are locked
source, purpose, signatures up and given to the caseworker upon discharge. There is no need for youth
to access their money during their stay. The program is encouraged to
document the amount of money that is secured at the time of arrival as well
as the amount upon discharge to include staff and youth signatures at both
times. ***Please note, this is not a finding.***
Personal possessions records Yes/No Corrective actions/comments
419-470-0170 (5) or N/A
Individual written inventory of all Yes Although the files reviewed had written inventories, the lists were
personal possessions is maintained inconsistent with the information documented (i.e., not updated, not dated,
and updated as needed not signed, not specific). The program is encouraged to develop a uniform
way for staff to document a youth's belongings and set the expection that
all fields in the document are addressed.
Records and documentation Yes/No Corrective actions/comments
419-400-0140 or N/A
(1) Stored safely Yes
(2) Permanent, legible, dated and Yes
signed
(3) and (4) Uniform in organization, No The program is currently utilizing a drop file system.
readily identifiable and accessible,
current and complete, containing all CORRECTIVE ACTION: The program will develop and implement a filing
required info. No eraser tape or white system that enhances organization, accessibility and ensures that all
out. required information is in each respective file. A checklist or a standard
table of contents has proven helpful for the CCAs in reaching this goal.
(7) Permanent registry for each child Yes
includes:
Name
Form revised 3/12/2025 Page 31 of 32
Records and documentation Yes/No Corrective actions/comments
419-400-0140 or N/A
Gender
Birth date
Names, addresses of parents or
guardians
Dates of admission
Placement upon discharge
5-19-2025 5-19-2025
Mary Torres Tom van der Veen
Licensing Coordinator's signature Manager Review
Form revised 3/12/2025 Page 32 of 32

report_title: Licensed Child Caring Agency Site Visit Report

facility_type: Residential Care - 6-Month

executive_director: Kendall Alexander Licensing Coordinator: Mary Torres

board_chairperson: Edward Horvath Residential Programs: Sage and Yarrow Date of site visit: 4/7/25

licensing_coordinator: Mary Torres

other_regulatory_agencies: Oregon Department of Human Services (ODHS) - Treatment Services, Child Welfare

capacity_age_range: 10 youth total, 4 youth at Yarrow, 6 youth at Sage, ages 10 - 17 years

funding_sources: Oregon Department of Human Services (ODHS)

contracts_and_referrals: Oregon Department of Human Services (ODHS)

average_length_of_stay: To be determined over the upcoming 2-year licensing period. Form revised 3/12/2025 Page 1 of 32

average_daily_population_served: To be determined over the upcoming 2-year licensing period.

number_of_children_served_annually: To be determined over the upcoming 2-year licensing period.

changes_in_last_two_years: None reported by the program.

lawsuits: None reported by the program.

grievances_and_complaints: None reported by the program.

exceptions:
None
Form revised 3/12/2025 Page 3 of 32

observations:
, identified need for CORRECTIVE ACTION: Submit a plan as to how the newly hired therapist
services and how agency will provide will meet this 30 day requirement moving forward.
services
(e) (A) and (B) Service plan within 60 No Service plans have not been completed as the program did not have an
days (parent, guardian and child active mental health therapist available until one was hired on 3/3/25.
actively involved). Describes how
child's issues will be addressed, CORRECTIVE ACTION: Submit a plan as to how the newly hired therapist
anticipated outcomes and reviewed by will meet this 60 day requirement moving forward.
child and guardian/parent.
(e)(C) and (D) Service plan is No It is unknown how often the program plans to review service plans.
reviewed quarterly and revised when
information indicates other services CORRECTIVE ACTION: Submit a plan as to how often service plans are to
should be provided be reviewed and by who.
Case management Yes/No Corrective actions/comments
419-470-0170(3) or N/A
(a) Services are documented, No Services nor progress toward achieving goals are not documented.
progress toward achieving goals is
tracked CORRECTIVE ACTION: Submit a plan as to how services are documented
and how progress toward achieving goals is tracked.
(c) Discharge summary must include: No The program has yet to develop a discharge summary that captures the
(A)Current medications required information located to the side of this narrative.
Form revised 3/12/2025 Page 28 of 32
Case management Yes/No Corrective actions/comments
419-470-0170(3) or N/A
(B)Name of the physician or qualified
medical professional who prescribed CORRECTIVE ACTION: Create and implement a discharge summary that
each medication addresses the required information. Submit a copy of this document to
(C)Any outstanding medical or other Licensing for review.
appointments
(D)Summary of the child's
participation in the program and
progress achieved
(E)Results of evaluations
(F)Recommendations regarding
services
(G)Discharge destination
(e) Follow up services No Youth that have exited the program thus far, have been discharged under
emergency circumstances. Examples of a planned discharge with
identified follow up services are nonexistent.
CORRECTIVE ACTION: Provide a summary as to how the program plans
to offer and provide transitional or aftercare service coordination to youth
upon their discharge from the program.
(f) Incident reports Yes Licensing will continue to offer support in this area to ensure that all
pertinent information is appropriately documented in these incident reports.
Records relating to Restraint and Yes/No Corrective actions/comments
Involuntary Seclusion or N/A
419-400-0180 (12) Records N/A The program does not utilize restraint or seclusion.
419-400-0180(13)(e) Each child No It is unknown how this notice is provided to parents/guardians at the time of
caring agency shall provide notice admission.
regarding how to access the quarterly
reports to the parents or guardians of CORRECTIVE ACTION: Submit how this information is provided to
children in care in the program. The Licening.
Form revised 3/12/2025 Page 29 of 32
Records relating to Restraint and Yes/No Corrective actions/comments
Involuntary Seclusion or N/A
child caring agency shall provide the
notice upon the child in care's
admission and at least two times each
year thereafter.
419-400-0190(1) Information provided No The program accepts youth from ODHS - Child Welfare. Although it is the
to children in care relating to Restraint responsibility of ODHS to provide children in care with this required
and Involuntary Seclusion information, the program also provides crisis respite services to the county
youth who must also be provided the same informaiton.
CORRECTIVE ACTION: Create and implement a plan as to how non
ODHS youth will receive the following informaiton as required through rule:
(1) Each child in care receiving services from a child-caring agency must
be given the following:
(a) Instruction regarding how a child in care may report suspected
inappropriate use of restraint or involuntary seclusion;
(b) Assurance that the child in care will not experience retaliation for
reporting suspected inappropriate uses of restraint or involuntary seclusion
and;
(c) The telephone number for the toll-free child abuse hotline (855-503-
7233) described in ORS 417.805 and the telephone numbers and
electronic mail addresses for the program's Licensing Agency (Mary Torres
503-798-5300, mary.torres@odhsoha.oregon.gov, the child in care's
caseworker and attorney, the child in care's court appointed special
advocate and Disability Rights Oregon (503-243-2081).
(2) The information must be provided by:
(a) The Oregon Department of Human Services if the department placed
the child in care in the child-caring agency;
(b) The Oregon Youth Authority if the child in care has been committed to
the custody of the authority; or
(c) The child-caring agency for all other children in care.
Form revised 3/12/2025 Page 30 of 32
Financial records Yes/No Corrective actions/comments
419-470-0170(4) or N/A
Records contain date, amount, N/A Any monetary items (cash, gift cards) that the youth arrive with are locked
source, purpose, signatures up and given to the caseworker upon discharge. There is no need for youth
to access their money during their stay. The program is encouraged to
document the amount of money that is secured at the time of arrival as well
as the amount upon discharge to include staff and youth signatures at both
times. ***Please note, this is not a finding.***
Personal possessions records Yes/No Corrective actions/comments
419-470-0170 (5) or N/A
Individual written inventory of all Yes Although the files reviewed had written inventories, the lists were
personal possessions is maintained inconsistent with the information documented (i.e., not updated, not dated,
and updated as needed not signed, not specific). The program is encouraged to develop a uniform
way for staff to document a youth's belongings and set the expection that
all fields in the document are addressed.
Records and documentation Yes/No Corrective actions/comments
419-400-0140 or N/A
(1) Stored safely Yes
(2) Permanent, legible, dated and Yes
signed
(3) and (4) Uniform in organization, No The program is currently utilizing a drop file system.
readily identifiable and accessible,
current and complete, containing all CORRECTIVE ACTION: The program will develop and implement a filing
required info. No eraser tape or white system that enhances organization, accessibility and ensures that all
out. required information is in each respective file. A checklist or a standard
table of contents has proven helpful for the CCAs in reaching this goal.
(7) Permanent registry for each child Yes
includes:
Name
Form revised 3/12/2025 Page 31 of 32
Records and documentation Yes/No Corrective actions/comments
419-400-0140 or N/A
Gender
Birth date
Names, addresses of parents or
guardians
Dates of admission
Placement upon discharge
5-19-2025 5-19-2025
Mary Torres Tom van der Veen

excerpt:
419-400-0040 or N/A
(1)(a) Minimum of 5 board members Yes
(2)(f) Formally evaluate the Executive N/A Item to be audited at the upcoming license renewal.
Director's performance annually
(2)(g) Approves annual budget N/A Item to be audited at the upcoming license renewal.
(2)(h) Obtain and review an annual N/A Item to be audited at the upcoming license renewal.
independent financial review or audit
of financial records.
(2)(k) Written quality improvement No A quality improvement plan was not submitted.
program
CORRECTIVE ACTION: Submit a written quality improvement plan to
Licensing for review.
(2)(l) Meeting minutes N/A Item to be audited at the upcoming license renewal.
Form revised 3/12/2025 Page 4 of 32
Executive Director or Program Yes/No Corrective actions/comments
Director or N/A

rule: 419-400-0150 (excluding medically necessary devices/prescriptions) (3)(c)

excerpt:
419-400-0150
(excluding medically necessary
devices/prescriptions)
(3)(c) Agency uses appropriate time- N/A The program does not utilize the use of time out rooms.
out rooms (adequate space, heat,
light and ventilation and is not capable
of locking) and documents use in
child's record when applicable
(3)(e) Agency uses seclusion N/A The program does not utilize seclusion.
appropriately/consistent with policy
(4) Agency has adequate plan in Yes
place to respond to suicidal
behavior/warning signs
Contractors (if applicable) Yes/No Corrective actions/comments

excerpt:
419-400-0180
(13)(d) Each child caring agency that No Although the program has submitted a copy of the program's most recent
submits a report under this section quarterly report to Licensing for public posting, a copy of the report has not
shall make its quarterly report been uploaded to the CCA's own website.
available to the public upon request at
the child caring agency's main office CORRECTIVE ACTION: Upload most recent and future quarterly reports
and on the child caring agency's onto the CCA's own website for public review.
website if applicable.
Supplemental information provided Yes/No Corrective actions/comments
by CCA or N/A
Documents as indicated on the form Yes These items were checked prior to the program receiving its' license and
titled "Renewal Licensing Required was not audited during this 6-month review.
Documents"
Documents as indicated on form titled Yes These items were checked prior to the program receiving its' license and
"Required Financial Documents and was not audited during this 6-month review
Information"
All required policies and procedures Yes These items were checked prior to the program receiving its' license and
as identified in the "Umbrella Rules" was not audited during this 6-month review
All required policies and procedures Yes These items were checked prior to the program receiving its' license and
as identified in "Agency Type Specific was not audited during this 6-month review
Rules"
Physical plant Yes/No Corrective actions/comments
or N/A

excerpt:
419-400-0100(1) Sufficient safe Yes
space, equipment and office
equipment

excerpt:
419-470-0020(2)(a) and (c) Buildings Yes
are smoke free, clean and in good
repair

excerpt:
419-470-0020 (2)(d) Rooms are free Yes
of harmful drafts, odors and excessive
noise

excerpt:
419-470-0020 (2)(e) Rooms are Yes
adequate in size and arrangement

excerpt:
419-470-0020 (2)(h) Building is well Yes
ventilated, and room temperature is
within a normal comfort range

excerpt:
419-470-0030 or N/A
(2) There is a separate living room or Yes
lounge area - 15 SF minimum per
child
(5) There is a separate dining room Yes
with capacity for ½ of children in care
and 15 SF per child in care
(7) Laundry is separate from living, Yes
kitchen and dining areas
(8) Separate storage areas are Yes
provided for food, kitchen supplies,
utensils, clean linens, soiled linens
and clothing, cleaning supplies and
equipment, poisons, chemicals,
outdoor recreational and maintenance
equipment. (Hazardous materials are
properly labeled, in original container
and locked)
(9) Outdoor activity area is protected Yes
from vehicles and other hazards and
of a size and availability appropriate to
the age and needs of children in care
(11) Time-out rooms: Rooms used for N/A The program does not use time out rooms.
time out or quiet time must have
adequate space, heat, light and
ventilation and must not be capable of
locking.
Form revised 3/12/2025 Page 9 of 32
Room and space requirements - Yes/No Corrective actions/comments
bedrooms or N/A

excerpt:
419-400-0120 or N/A
Staff name/position Yes
(3)(g) Date of hire Yes
(3)(a) record of education, training Yes
and previous employment
(1)(b) and (3)(b) reference checks Yes
completed and documented
(1)(a) and (3)(c) Background check Yes
completed and documented
(3)(d) Annual performance N/A Evaluations for residential staff are scheduled for June 2025. Item to be
evaluations audited at the upcoming license renewal.
(3)(f) Record of personnel actions Yes
(3)(g) Termination date, reason for Yes
termination
(3)(h) Current job description (1)(c) Yes
Employee meets minimum
qualifications stated in current job
description
New employee orientation - Yes/No Corrective actions/comments
Umbrella Requirements (30 days) or N/A

excerpt:
419-400-0120(4)
(a) Agency policies and procedures Yes
(b) Ethical and professional Yes
guidelines
(c) Suicide prevention and No One personnel file reviewed reflected partial training in this area.
intervention
CORRECTIVE ACTION: Ensure that the staff member completes this
training. Submit proof that this training was completed to Licensing.
Licensing is able to identify the staff member to the program upon request.
Form revised 3/12/2025 Page 19 of 32
New employee orientation - Yes/No Corrective actions/comments
Umbrella Requirements (30 days) or N/A

excerpt:
419-470-0120(1)
CORRECTIVE ACTION: Implement a process where this required training
is a part of the new employee onboarding process and existing staff are
trained in this area. Submit completion of this training to Licensing.
(e) Training on the agency's policy on No Although the program provides training in suicide prevention and
suicide prevention and suicide risk intervention to staff, it is unclear how and which staff are trained to
assessment tool administer a suicide risk assessment.
CORRECTIVE ACTION: Clarify what suicide risk assessment tool is used,
which staff are trained to administer the assessment and how staff are
trained in the use of this tool.
Crisis intervention training Yes/No Corrective actions/comments
standards and certification or N/A

excerpt:
419-470-0070(2)(b) Employees who N/A The program is less than a year in existence.
handle food served to children have a
valid food handler's card

excerpt:
419-400-0200 (1) Employees N/A The program is less than a year in existence.
transporting children have: current
driver's license, insurance, trained in
emergency procedures and behavior
Form revised 3/12/2025 Page 22 of 32
Ongoing training Yes/No Corrective actions/comments
or N/A
management and training for 15+
passenger vans if applicable)

excerpt:
419-470-0120 (2)(a) Environmental N/A The program is less than a year in existence.
emergencies

excerpt:
419-470-0120 (2)(b) Universal N/A The program is less than a year in existence.
precautions

excerpt:
419-470-0120 (2)(c) Discipline and N/A The program is less than a year in existence.
behavior management

excerpt:
419-470-0120 (2)(d) Agency's policy N/A The program is less than a year in existence.
on suicide prevention and risk
assessment tool

excerpt:
419-400-0160(4)(b) Receive N/A The program is less than a year in existence.
continuing education (as applicable
Form revised 3/12/2025 Page 23 of 32
Ongoing training Yes/No Corrective actions/comments
or N/A
on crisis intervention training) from a
certified instructor on an annual basis
Children's records Yes/No Corrective actions/comments
health services or N/A


state: OR

facility_name: Madrona Recovery Date of site visit: 04/28/2025

summary: License Renewals - 4 findings

raw_content:
Licensed Child Caring Agency Site Visit Report
Residential Care
Licensee: Madrona Recovery Date of site visit: 2-10-21
Executive Director: Charley Downing Licensing Coordinator: Todd Cooley
Board Chairperson: Michael Knapp
Other Regulatory or Accrediting Agencies: OHA, ODHS Treatment Services
Program Compliance: The program was found to be compliant or will be compliant with OAR 413-215-0001 to 413-215-0131, Licensing Umbrella
Rules, and OAR 413-215-0501 to 413-215-0586, Licensing Residential Care Agencies Rules. Personnel records were reviewed and compliance
with required background checks was documented for employees in all programs.
Program Description(s): Madrona Recovery’s residential program focus on community, accountability, and relationships. The residential program
has an inter-disciplinary clinically grounded team, who work closely with Qualified Mental Health Associates and Certified Recovery Mentors who
provide a therapeutic milieu where youth are challenged to develop skills to prevent relapse and provided education to best equip them to support
their own mental health and recovery needs.
Program type and services: Residential and BRS
Capacity (gender and ages): 26 – ages 13-17
Funding sources: Kaiser, MHN, BCBS, 1st Choice, PacSource, Optum, Providence, Good Sam, Healthnet
Contracts and sources for referrals: Emergency Departments, community providers, website, alumni
Average length of stay: Residential – 21 days; BRS – 45 days
Average daily population served: 13
Number of children served annually: 155
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 08/13/2020)
Use of seclusion or restraint: No seclusion. Use therapeutic holds by staff trained in CPI
Interviews, Observations: During the review the Founder/CEO John Thornton, Exec. Dir. Charley Downing and COO/CFO Micah Brathwaite were
on hand for entrance interviews, exit interviews and available for any questions throughout the day. Three residents were also interviewed during
this review.
The residents had been in the program 1-2 weeks and one of them had been a resident prior for approximately a month. There were some
common themes among the residents during the interviews. All stated they felt safe in the program and did not have any concerns around safety.
They felt most staff really cared and all had staff they were comfortable talking with if they had any concerns. All felt the food was good and
portions were plentiful with snacks available if they got hungry between meals.
There were mixed opinions on recreation. While all felt there was plenty of free time, some stated outside activities were limited due to basketballs
being flat and not having access to the goats unless you were in crisis. There did not seem to be clear messaging around interacting with the
program’s goats as some residents felt you could interact with them whenever, but this particular resident chose not to, and others felt only those
residents in crisis had the opportunity to feed or pet the goats. It was suggested items like sidewalk chalk might make outdoor rec more enjoyable
for some who don’t like to participate in things like basketball. Weather was also a factor and the residents said they choose not to go outside just
because it is really cold.
Another common theme was overall chaos and lack of structure. The residents stated with the current milieu there are a lot of loud and strong
personalities who enjoying engaging in drama for the sake of drama. This occurs during the day as well as at night sometimes making it difficult to
sleep or find a quiet space. Residents felt staff did not do a good job of calming things down a lot of times when it would get loud which made it feel
chaotic. This gave some residents the impression as well that some of their peers were “rewarded” for acting up because there were really no
consequences for their actions. They got this impression because staff had to dedicate much of their time to those residents who were acting out
and that would take time away from those participating and sometimes cause them to miss out on things they were supposed to do because staff
were not available. As far as structure, there is a set schedule but one of the residents interviewed said the schedule was rarely kept to due to
peers acting out and not being able to transition. This resident gave the impression they came from a very structured household as they thought in
addition to a more rigid schedule the residents should also have a lot more chores and responsibilities during their stay.
All interviewed residents agreed the groups (therapy) were really good. They felt the topics were on point and they were learning something in
every group. The groups were all found to be helpful towards reaching their goals. They did state they could get sidetracked by peers being
obnoxious and talking a lot but were still able to focus and take away something positive.
John and Charley also provided the tour of the facility which was found to be clean and in good repair. The bedrooms appeared well kept and the
common areas and bathrooms were all very clean. Lunch was being prepared in the kitchen at the time of the tour and there were no concerns
over food prep or storage that were immediately apparent. The outdoor recreation area is now about twice the size it originally was as Madrona
Recovery has recently acquired the adjacent building for their outpatient program and have been able to fence the area in between. This is a
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marked improvement in the outdoor recreation area providing more space for basketball, additions of some raised garden beds and a new space for
the programs two goats.
One observation of note during the tour, and discussed at the exit interview with management, was an observed interaction with a group of three
residents and one staff. While moving through the hallway there were three female residents with high energy in close proximity to a male staff.
The three residents seemed to be feeding off each other’s energy and the staff appeared to not be setting boundaries and possibly a bit flustered at
the situation. Another staff was observed down the hall just watching the interaction and not making an attempt to intervene or calm the situation.
Our group moved on past the commotion in the hall, but the scene made an impact on licensing and other regulators. It was brought to
managements attention that staff might benefit from some additional training and support around boundaries. This observation was in line with what
was heard during the resident interviews about high energy and “chaos”. For context it is also understood the behavior, energy level and tone of a
milieu is always in flux as residents come and go, and the group in care at the time of the review was particularly challenging.
Program Strengths, as identified by the program: Resilience. We are in our 3rd year. Staff retention has improved more recently. Groups. The
quality of the content is high, client engagement has increased, according to our surveys, clients find our groups/group leaders relavent and
valuable to their treatment experiences. Therapeutic alliance is strong. By design, we have low caseloads, highly qualified professionals and a
(relatively) small population of clients. These are ingredients that produce positive outcomes.
Program Challenges, as identified by the program: The population of clients we serve is very challenging. Generally speaking, we are up for
this challenge; we sign up for it. However, turnover is high when staff express they do not feel safe. We have had several assaults on the unit that
have resulted in valuable staff leaving. This puts additional stress on staff who remain. Assaultive clients who remain in our program due to limits
of available community options has been cited as a main reason for staff expressing this safety concern.
Covid-19. We've had two cases. This makes staff, parents, everyone anxious. We've lost good staff and have had to press pause on admissions,
which puts a stress on the agency’s finances.
Attempting a much-needed outpatient program has proven challenging to begin and grow during this time.
Medical Leadership was highly problematic. That concern has been resolved.
Changes that have occurred in the last 2 years, as described by the program: Contracting with DHS to provide BRS services to a larger
number of teenagers in the CW system. Medical Director changed within the last two years. We are well served by Dr. Joel Suckow since this
change occurred.
We received our Intensive Outpatient Services and Support (IOSS) license and began serving families in an outpatient capacity in December of
2020.
Lawsuits: No lawsuits to date
Grievances and complaints filed in the last two years: No significant grievances. Documentation provided and on file.
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Corrective Actions and Timeframes: Please submit the following to verify compliance.
Within 45 days of receipt of this report Madrona Recovery must submit a letter of verification indicating the agency is in compliance with the specific
rules cited above and describing how compliance will be maintained going forward. Along with the letter of verification, the agency must submit any
and all specific documentation requested in the body of this report. The letter of verification and any additional requested documents can be emailed
directly to Todd Cooley, todd.cooley@dhsoha.state.or.us , or sent by regular mail to the following address:
Department of Human Services, Children’s Care Licensing Program
Attn: Todd Cooley
201 High St SE, Suite 500
Salem, OR 97301
Exceptions: Exception on file for no window egress in bedrooms. Exception on file for the annual financial review or audit.
Changes in License: None
Summary of Review
Program and Services Corrective Action
Yes No N/A Corrective Actions
413-215-0011(2) Completed
Program and services are in scope of license
X
Governance of the Agency Corrective Action
Yes No N/A Corrective Actions
413-215-0021 Completed
(1)(a) Minimum of 5 board members X
(2)(f) Formally evaluate the exec. Director’s
X
performance annually
(2)(g) Approves annual budget X
(2)(h) Obtain and review an annual  Exception on file for audit
independent financial review or audit of X
financial records.
(2)(k) Written quality improvement program X
(2)(l) Meeting minutes X
Executive Director or Program Director Corrective Action
Yes No N/A Corrective Actions
413-215-0021 Completed
(3)(a) knowledge of requirements for
providing care and treatment appropriate to X
programs
(3)(g) Approval from BCU X
Discipline, Behavior Management, and Corrective Action
Yes No N/A Comments
Suicide Prevention 413-215-0076 Completed
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(3) Agency uses appropriate and positive
methods of behavior management and
X
nationally recognized non-violent crisis
intervention
(3)(b)(C) Agency does not use chemical and
mechanical restraint (excluding medically X
necessary devices/prescriptions)
(3)(c) Agency uses appropriate time-out
rooms (adequate space, heat, light and
ventilation and is not capable of locking) and X
documents use in child’s record when
applicable
(3)(e) Agency uses seclusion
X
appropriately/consistent with policy
(4) Agency has adequate plan in place to
X
respond to suicidal behavior/warning signs
Physical Plant Corrective Action
Yes No N/A Corrective Actions
Completed
413-215-0046(3)(a) Foster Rights Posted (if
X
children in DHS custody)
413-215-0051(1) Sufficient safe space,
X
equipment, and office equipment
413-215-0091(12) License is posted in
X
common area at each facility
413-215-0001(5)(d), 0516(4(a)(I) & 0521(1)
X
Adequate furnishings and personal items
413-215-0511(2)(a) &(c) Buildings are
X
smoke free, clean and in good repair
413-215-0511(2)(d) Rooms are free of
X
harmful drafts, odors, and excessive noise
413-215-0511(2)(e) Rooms are adequate in
X
size and arrangement
413-215-0511(2)(f) System provides a
continuous supply of hot and cold water to X
taps located throughout the facility
413-215-0511(2)(h) Building is well
ventilated and room temperature is within a X
normal comfort range
413-215-0516(1) All parts of the facility
X
ensure the safety of children
Room and Space Requirements Corrective Action
Yes No N/A Corrective Actions
Bedrooms 413-215-0516(3) Completed
(a) Adequate furnishings and personal items X
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(b) Separate from rooms used for dining,
X
living, laundry, kitchen, and storage
(c) Outside room with window allowing
X
egress from building
(d) Ceiling at least 90 inches X
(e) Minimum 60 SF per bed X  Exception on file for window egress.
(f) No more than 25 if dorm style X
(g) Permanently wired fixtures X
(h) Window covering X
(i) Beds are 3 feet apart and maintained to
X
ensure safety
Room and Space Requirements Corrective Action
Yes No N/A Corrective Actions
Bathrooms 413-215-0516(4) Completed
(a)(A)&(B) 1:8 ratio for toilets and sinks X
(a)(D) Hot and cold running water, soap, and
X
approved hand drying options
(a)(E) 1:10 ratio for shower or bathtub X
(a)(E) Individual privacy X
(a)(F) Window covering X
(a)(G) Permanently wired fixtures X
(a)(H) Adequate ventilation X
(b)&(c) Wooden racks on floors are
prohibited and impervious shower mats are X
disinfected & dried daily
Room and Space Requirements Corrective Action
Yes No N/A Corrective Actions
Kitchen 413-215-0516(6) Completed
(a) Used exclusively for storage, food
preparation, dish washing and activities X
related to eating
(b) Walls, floors are easily cleanable X
(c) Equipment and utensils are easily
X
cleanable, durable, nontoxic, and kept clean
(e) Equipment is easy to clean beneath,
X
between and behind
Room and Space Requirements Corrective Action
Yes No N/A Corrective Actions
413-215-0516 Completed
(2) There is a separate living room or lounge
X
area – 15 SF minimum per child
(5) There is a separate dining room with
capacity for ½ of children in care and 15 SF X
per child in care
(7) Laundry is separate from living areas,
X
kitchen and dining
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(8) Separate storage areas are provided for
food, kitchen supplies, utensils, clean linens,
soiled linens and clothing, cleaning supplies X
and equip, poisons, chemicals, outdoor
recreational and maintenance equipment
(9) Outdoor activity area is protected from
vehicles and other hazards and of a size and
X
availability appropriate to the age and needs
of children in care
(11) & 413-215-0076(3)(c)(C)Time out rooms
have adequate space, heat, light and X
ventilation and is not capable of locking
Furnishings and Personal Items Corrective Action
Yes No N/A Corrective Actions
413-215-0521 Completed
(1) There is a bed with frame, clean mattress
and pillow and personal storage (dresser, X
closet)
(2) Linens are in good repair. There is a
waterproof mattress cover or mattress.
X
Linens are appropriate and towels and
washcloths are provided
(3) Bedding is changed weekly or when
X
soiled
(4)&(5) Personal hygiene supplies and
X
appropriate clothing are provided
Food Services Corrective Action
Yes No N/A Corrective Actions
413-215-0536(1)&(2) Completed
(1)(a) Meals are arranged daily, consistent
with normal mealtimes that occur during the X
hours of operation
(1)(b) Menus are prepared in advance in
accordance with USDA guidelines, provide a
X
variety of foods and are adjusted for
seasonal changes.
(1)(b) Menus are kept for at least 6 months X
(1)(c) Drinking water is freely available X
(2)(a) Food is stored, prepared & served in a
X
sanitary manner
(2)(c) & (d) Food products are obtained from
commercial suppliers (exception of fruits &
vegetables), unpasteurized juice is X
prohibited, and only Grade A pasteurized
and fortified milk in appropriate container.
Safety Corrective Action
Yes No N/A Corrective Actions
413-215-0541 Completed
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(2)(a) Written emergency plan X
(2)(b) Telephone numbers for local police
X
and fire are posted near all telephones
(2)(c) Operative flashlights sufficient in
X
number are readily available to staff
(3)(a) Evacuation drill occurs monthly under
varying conditions, is retained 2 yrs and
contains;
(A) identify of person conducting drill
(B) date & time
(C) notification method X
(D) staff participating
(E) # of children & staff evacuated
(F) special conditions simulated
(G) problems encountered
(H) time to complete
Safety – Transportation Corrective Action
Yes No N/A Corrective Actions
413-215-0541 Completed
(5)(b) Vehicle has insurance policy, is smoke
free, safe operating condition, and has first X
aid kit and fire extinguisher 2-A:10-BC
Medication Corrective Action
Yes No N/A Corrective Actions
413-215-0551 Completed
(3)&(7)(e) Medications have a prescription
and are stored in the original container with X
prescription label
(4)&(5) Herbal supplements and remedies,
medical treatments, special diets, physical
therapy, physical aides or limitations have a X
written order signed by a physician or
qualified medical professional.
(7)(c) Medications are inaccessible to
X
children
(8) Medications are disposed in accordance
X
with state and federal law
(9) Written record of the disposal of
medications is maintained and includes:
(a) description and amount
(b) name X
(c) reason
(d) method
(e) staff & witness signature
(10) Written record of the administration of
medication includes: X
(a) name
8
(b) description
(c) dates and times
(d) missed doses
(e) medication disposed
(f) method of administration
(g) ID of person administering
(h) possible adverse reactions
(i) medication taken outside facility
Extracurricular, Enrichment, Cultural &
Corrective Action
Social Activities Yes No N/A Corrective Actions
Completed
413-215-0554
(2) Children have ongoing opportunities to
participate in at least one age-appropriate or X
developmentally appropriate activity
Minimum Staffing Requirements Corrective Action
Yes No N/A Corrective Actions
413-215-0561 Completed
(1)&(2) Supervision is adequate for the type
of program, location, age and type of
children, ability of supervisor to respond,
electronic back-up systems.
Minimum ratios are maintained:
Under 30 months of age: 1:4 X
30 months to ˃ 6 yrs or non-ambulatory: 1:6
Ages 6 and older: 1:7
Overnight (staff awake)
1:10
(4)(a) When one staff on duty, there is
additional staff immediately available with X
max response time of 30 minutes
(5) There is at least one on-site employee
authorized to apply the reasonable and X
prudent parent standard
Separation of Residents Corrective Action
Yes No N/A Corrective Actions
413-215-0566 Completed
(1) Children are in separate bedrooms than
adults, unless parent and child, or there is
X
written approval from guardian/parent and
licensing coordinator
(2) There is adequate supervision of children
if both males and females are served by the X
program
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Supplemental Information Provided by Corrective Action
Yes No N/A Comments
CCA Completed
Documents as indicated on the form titled
X
“Renewal Licensing Required Documents”
Documents as indicated on form titled
“Required Financial Documents and X
Information”
All required policies and procedures as
X See Comments
identified in the “Umbrella Rules”
All required policies and procedures as
X
identified in “Agency Type Specific Rules”
Comments:
Madrona Recovery provided all required policies and procedures. During the interview process it was discovered their practice was not in alignment with their
policy on rights of children and families. Residents disclosed having a 72-hour restriction on phone calls/contact with their guardians upon being admitted to the
program. Management confirmed this practice and stated both residents and guardians were made aware prior to entry into the program. Licensing informed
Madrona Recovery this practice is in violation of rule and their own policy and requested the practice be stopped immediately. Licensing is working with
Madrona Recovery to ensure practices match policy.
OAR 413-215-0081- Application for License, Renewal, or to Add a Program: (B) Written policies regarding the rights of children and families the child caring
agency would serve upon being licensed that meets the requirements of OAR 413-215-0046.
413-215-0046
Licensing Umbrella Rules: Children and Families Rights Policy and Grievance Procedures
(1) Rights of children in care and families served by the child-caring agency. A child-caring agency must guarantee the rights of children in care and the families
the child-caring agency serves. A child-caring agency must enact and adhere to a policy ensuring those rights. A written copy must be distributed to all children
in care and families served by the child-caring agency, and afford the following rights:
(a) Except as provided in paragraph (B) of this subsection, the child in care's right to uncensored communication with legal guardians, caseworkers, legal
representatives, and other persons approved for communication by the legal guardian or as provided in a court order.
(A) This right cannot be waived, including voluntarily. Restriction on communication between a child in care and his or her legal guardian may not be a condition
of participation in the program.
(B) A child-caring agency may place reasonable limits on communication, but only as provided in the child-caring agency's policy. Reasonable limits include, but
are not limited to, having set time periods during the day for visitation and phone calls and imposing moderate limits on the duration of calls or visits. However, a
limitation is not considered reasonable if it prevents the ability to meaningfully communicate, such as not allowing contact with a child in care's attorney during
regular business hours.
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Personnel Files Corrective Action
Yes No N/A Corrective Actions
413-215-0061 Completed
Staff Name/Position X
(3)(g) Date of Hire X
(3)(a) record of education, training and
X
previous employment
(1)(b) & (3)(b) reference checks completed
X
and documented
(1)(a) & (3)(c) Background check completed  One of the files reviewed included staff who had
X
and documented received a promotion and a new background check
had not been conducted per rule.
(3)(d) Annual performance evaluations X
(3)(f) Record of personnel actions X
(3)(g) Termination date, reason for
X
termination
(3)(h) Current job description (1)(c)
Employee meets minimum qualifications X
stated in current job description
New Employee Orientation – Umbrella
Corrective Action
Requirements (30 days) Yes No N/A Corrective Actions
Completed
413-215-0061(4)
(a) Agency policies and procedures X
(b) Ethical and professional guidelines X
(c) Organizational lines of authority X
(d) Attributes of population served X
(e) & (5)(a) to (c) Mandatory reporting that
includes:
(a) legal definition of child abuse ORS
419B.005, Oregon Laws 2016, chapter 106,
X
section 36
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to
the employee
(f) Privacy laws X
(g) Emergency procedures X
New Employee Orientation – Residential
Corrective Action
(30 days) Yes No N/A Corrective Actions
Completed
413-215-0556
(1)(a) Discipline and behavior management
X
including de-escalation, crisis prevention,
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positive behavior management, and
disciplinary techniques that are non-punitive
in nature
(1)(b) Restraint and seclusion (if applicable) X
Ongoing Training Corrective Action
Yes No N/A Corrective Actions
Completed
413-215-0536(2)(b) Employees who handle
food served to children have a valid food X
handler’s card
413-215-0541(5)(a) Employees transporting
children have: current driver’s license,
insurance, trained in emergency procedures X
and behavior management, and training for
15+ passenger vans if applicable)
413-215-0556(2)(a) Environmental
X
emergencies
413-215-0556(2)(b) Universal Precautions X
413-215-0556(2)(c) Discipline and Behavior
X
Management
413-215-0556(3) Staff providing direct care
must maintain current CPR/First Aid X
certification
413-215-0556(4) Designated staff authorized
to apply reasonable and prudent parent
X
standard are trained in application of the
standard
413-215-0061(5) Mandatory reporting
(annually) that includes:
(a) legal definition of child abuse ORS
419B.005, Oregon Laws 2016, chapter 106,
X
section 36
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to
the employee
Contractors (if applicable) Corrective Action
Yes No N/A Corrective Actions
413-215-0061(6) Completed
(a) Agency ensures the contractor meets the
requirements of this rule and Chapter 413 X
division 215
(b)(B) Contract includes the following:
X
(i) Services provided
12
(ii) Contractor fees
(iii) Disclosure of information from contractor
to agency
(iv) Lines of authority
(v) Adherence to rules, including background
check
(vi) Any liability of the agency for acts of the
contractor, rights of indemnity and limitations
on liability
Comments:
Children’s Records Corrective Action
Yes No N/A Corrective Actions
Completed
Health Services
413-215-0546
(2) Medical history obtained within 30 days
(significant findings, current immunizations,
history of surgical procedures-health issues- X
injuries, allergies, dental, vision, hearing,
behavioral health, and physician orders)  There was no documentation of age appropriate
(2)(e) Documentation of age appropriate instruction. Madrona Recovery plans to add this to
instruction – pregnancy prevention, nutrition, the nursing assessment at intake so any concerns
prevention of HIV & AIDS, and prevention X around diet, pregnancy prevention, STDs, etc. can
and treatment of sexually transmitted be discussed with the nursing staff.
disease
(4)(a) to (f) Medical exams (3 in first year of
life, 2,4,6,9,14) X
Consents Corrective Action
Yes No N/A Corrective Actions
413-215-0576(1) Completed
(a) Provide routine and emergency medical
X
care
(b) Use the discipline and behavior
X
management system
(c) Use restraint or seclusion (if applicable).
Must specify the reasons for the intervention X
and how staff are trained and supervised
(d) Restrict contact with persons outside of
X
the agency
13
(e) Allow access as defined in 413-215-0091
X
& 0101
(f) Impose a dress code X
(g) Apply the reasonable and prudent parent
X
standard
Disclosures
Corrective Action
413-215-0576(2) Parent/guardian has Yes No N/A Corrective Actions
Completed
acknowledged in writing:
(a) Information regarding personal or room
searches and protocols for confiscation of X
contraband
(b) Statement of Rights of Children and
X
Parents/Guardians
(c) Any policies and procedures upon
X
request
Authorizations Corrective Action
Yes No N/A Corrective Actions
413-215-0576(3) Completed
(a) Disclose or exchange information with
X
others
(b) Child specific visitors X
(c) Visitation resources are pre-approved X
(d) Activity specific authorizations are pre-
approved to allow children to participate in
potentially hazardous activities, including but X
not limited to using motorized yard
equipment, swimming, and horseback riding.
Information about Children in Care
Corrective Action
413-215-0581(1) Summary sheet contains Yes No N/A Corrective Actions
Completed
the following:
(a)The name, gender, date of birth, religious
X
preference, and previous address
(b) Name and location of previous and
X
current school
(c) Date of admission X
(d) Legal custody X
(e) The name, address, and telephone
number of:
(A) The child in care's parents.
(B) The child in care's legal guardian, if X
different than the parents, and a copy of
the document that provides for his or her
authority over the child in care.
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(C) Other persons significant to child
(D) Other professionals to be involved in
service planning (if applicable)
Service Planning Corrective Action
Yes No N/A Corrective Actions
413-215-0581(2) Completed
(b) Intake document is completed the date
child accepted into care (emergency X
placement 48 hours)
(d) Assessment is completed within 30 days
and contains relevant historical info., current
behavioral observations, identified need for X
services, and how agency will provide
services
(e) (A)&(B) Service plan within 60 days
(parent, guardian and child actively
involved). Describes how child’s issues will X
be addressed, anticipated outcomes and
reviewed by child and guardian/parent.
(e)(C)&(D) Service plan is reviewed quarterly
and revised when information indicates other X
services should be provided
Case Management Corrective Action
Yes No N/A Corrective Actions
413-215-0581(3) Completed
(a) Services are documented, progress
X
toward achieving goals is tracked
(b)-(d) discharge planning and instructions X
(f) Incident Reports X
Financial Records Corrective Action
Yes No N/A Corrective Actions
413-215-0581(4) Completed
Records contain date, amount, source,
X
purpose, signatures
Personal Possessions Records Corrective Action
Yes No N/A Corrective Actions
413-215-0581(5) Completed
Individual written inventory of all personal
possessions is maintained and updated as X
needed
Records and Documentation Corrective Action
Yes No N/A Corrective Actions
413-215-0071 Completed
(1) Stored safely X
(2) Permanent, legible, dated, and signed X
15
(3)&(4) Uniform in organization, readily
identifiable and accessible, current, and
X
complete, containing all required info. No
eraser tape or white out.
(7) Permanent registry for each child
includes:
Name
Gender
X
Birth date
Names, addresses of parents or guardians
Dates of admission
Placement upon discharge
Comments:
Consents were originally vague around use of the discipline and behavior management and essentially only stated they would use the discipline and behavior
management system. Program Director Downing expanded this section to identify the system being used, the Crisis Prevention Institute (CPI) system, which
will enable clients and guardians to find additional information if they choose.
Residents at Madrona Recovery do not participate in off-site recreational activities, and the activities on site are not high-risk, so a disclosure and consent for
these types of activities isn’t required and isn’t part of the intake process.
Due to the nature of the program and length of average stays, none of the files reviewed belonged to residents who had been in the program long enough to
require a 60-day service plan or quarterly review of the service plan.
3-1-2021
Licensing Coordinator’s Signature: ________________________ Date: ___________________
02-26-2021
Manager Review: ______________________________________ Date: __________________
16

agency_name: Madrona Recovery (MR)

program_type: (RC) Residential Care Programs

report_type: License Renewals

view_code: RC

facility_type: Residential Care

board_chairperson: Michael Knapp

licensing_coordinator: Todd Cooley

other_regulatory_agencies: OHA, ODHS Treatment Services

program_description:
Madrona Recovery's residential program focus on community, accountability, and relationships. The residential program
has an inter-disciplinary clinically grounded team, who work closely with Qualified Mental Health Associates and Certified Recovery Mentors who
provide a therapeutic milieu where youth are challenged to develop skills to prevent relapse and provided education to best equip them to support
their own mental health and recovery needs.

program_services:
Residential and BRS
Capacity (gender and ages): 26 - ages 13-17

average_length_of_stay: Residential - 21 days; BRS - 45 days

interviews_observations:
During the review the Founder/CEO John Thornton, Exec. Dir. Charley Downing and COO/CFO Micah Brathwaite were
on hand for entrance interviews, exit interviews and available for any questions throughout the day. Three residents were also interviewed during
this review.
The residents had been in the program 1-2 weeks and one of them had been a resident prior for approximately a month. There were some
common themes among the residents during the interviews. All stated they felt safe in the program and did not have any concerns around safety.
They felt most staff really cared and all had staff they were comfortable talking with if they had any concerns. All felt the food was good and
portions were plentiful with snacks available if they got hungry between meals.
There were mixed opinions on recreation. While all felt there was plenty of free time, some stated outside activities were limited due to basketballs
being flat and not having access to the goats unless you were in crisis. There did not seem to be clear messaging around interacting with the
program's goats as some residents felt you could interact with them whenever, but this particular resident chose not to, and others felt only those
residents in crisis had the opportunity to feed or pet the goats. It was suggested items like sidewalk chalk might make outdoor rec more enjoyable
for some who don't like to participate in things like basketball. Weather was also a factor and the residents said they choose not to go outside just
because it is really cold.
Another common theme was overall chaos and lack of structure. The residents stated with the current milieu there are a lot of loud and strong
personalities who enjoying engaging in drama for the sake of drama. This occurs during the day as well as at night sometimes making it difficult to
sleep or find a quiet space. Residents felt staff did not do a good job of calming things down a lot of times when it would get loud which made it feel
chaotic. This gave some residents the impression as well that some of their peers were "rewarded" for acting up because there were really no
consequences for their actions. They got this impression because staff had to dedicate much of their time to those residents who were acting out
and that would take time away from those participating and sometimes cause them to miss out on things they were supposed to do because staff
were not available. As far as structure, there is a set schedule but one of the residents interviewed said the schedule was rarely kept to due to
peers acting out and not being able to transition. This resident gave the impression they came from a very structured household as they thought in
addition to a more rigid schedule the residents should also have a lot more chores and responsibilities during their stay.
All interviewed residents agreed the groups (therapy) were really good. They felt the topics were on point and they were learning something in
every group. The groups were all found to be helpful towards reaching their goals. They did state they could get sidetracked by peers being
obnoxious and talking a lot but were still able to focus and take away something positive.
John and Charley also provided the tour of the facility which was found to be clean and in good repair. The bedrooms appeared well kept and the
common areas and bathrooms were all very clean. Lunch was being prepared in the kitchen at the time of the tour and there were no concerns
over food prep or storage that were immediately apparent. The outdoor recreation area is now about twice the size it originally was as Madrona
Recovery has recently acquired the adjacent building for their outpatient program and have been able to fence the area in between. This is a
2
marked improvement in the outdoor recreation area providing more space for basketball, additions of some raised garden beds and a new space for
the programs two goats.
One observation of note during the tour, and discussed at the exit interview with management, was an observed interaction with a group of three
residents and one staff. While moving through the hallway there were three female residents with high energy in close proximity to a male staff.
The three residents seemed to be feeding off each other's energy and the staff appeared to not be setting boundaries and possibly a bit flustered at
the situation. Another staff was observed down the hall just watching the interaction and not making an attempt to intervene or calm the situation.
Our group moved on past the commotion in the hall, but the scene made an impact on licensing and other regulators. It was brought to
managements attention that staff might benefit from some additional training and support around boundaries. This observation was in line with what
was heard during the resident interviews about high energy and "chaos". For context it is also understood the behavior, energy level and tone of a
milieu is always in flux as residents come and go, and the group in care at the time of the review was particularly challenging.

lawsuits: No lawsuits to date

excerpt:
(2)(h) Obtain and review an annual
independent financial review or audit of
financial records.

excerpt:
(c) Outside room with window allowing
egress from building

excerpt: See Comments

excerpt:
(1)(a) & (3)(c) Background check completed
and documented  There was no documentation of age appropriate
instruction. Madrona Recovery plans to add this to
the nursing assessment at intake so any concerns
around diet, pregnancy prevention, STDs, etc. can
be discussed with the nursing staff.