summary: Unannounced - 8 findings

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Residential Care
Licensee: Family Solutions – Cascade House Date of Unannounced: March 13, 2024
Executive Director: Dorothy Provencio Licensing Coordinator: Robin DuVal
Program Manager: Susan Shorey
Board Chairperson: Roy Lindsay
Other Regulatory or Accrediting Agencies: Oregon Health Authority (OHA) and Oregon Department of Human Services Child Welfare Treatment
Services (ODHS).
Purpose: Per OAR 419-400-0240 (1)(b) Children’s Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Findings Comments
Unannounced Site Visit 08/23/2023 Further Action
Needed
Medication 419-470-0100(9) Written record of the disposal of medications Yes☐ No☐ N/A✓ The last documented disposal was from August
is maintained and includes: 2023, therefore nothing new to review.
(a) description and amount
(b) name This area will be reviewed at a future visit.
(c) reason
(d) method The agencies corrective action response from the
(e) staff & witness signature 8/23/2023 visit is on record.
(9)(e) The agency shall ensure staff and witness provide a signature, not
initials.
Note: This licensor and staff discussed ways to update documentation and
processes. The agency is working on updating policies and procedures to
be clearer and reduce potential errors.
Requirement (9)(e) remains unmet: initials instead of signatures; and
several instances with only one staff person without a witness.
Form Rev. 11/14/2023 P age 1 | 5
Some disposed medications are disposed on-site utilizing the Rx Destroyer
product, however other disposed medications were in a bin labeled
“disposal” with no tracking document within said bin, creating a risk of
mismanagement or theft.
When speaking to several staff and the program manager, there was a lack
of clarity on the process of medication administration documentation and
medication disposal and disposal documentation. There have been recent
staff changes, and new hires that may not have received required training.
Corrective Action. The Agency shall:
1) Ensure staff and a witness provide a signature, not initials.
2) Ensure two staff (one staff and one staff witness) are disposing
medications and signing the disposal record.
3) Review medication policies and procedures to ensure it meets
requirements in related OARs and the practices set forth by Family
Solutions.
4) Ensure all staff who handle medications are provided medication policies
and procedures, are trained, and demonstrate competency before
administering and disposing medications as well as proper documentation.
5) Ensure management oversight for quality check and assurances and any
follow-up training needed.
**This is a repeat finding.**
Medication 419-470-0100(10) Written record of the administration of Yes✓ No☐ (d) There were several blank areas on the medication
medication includes: administration record with no corresponding notes to
(a) name document the circumstances where space is provided
(b) description for such notes on the back of the sheet. **This is a
(c) dates and times repeat finding.**
(d) missed doses
(e) medication disposed (e) There was no noted medication disposed,
(f) method of administration therefore nothing new to review. This area will be
(g) ID of person administering reviewed at a future visit.
(h) possible adverse reactions
(i) medication taken outside facility
The agencies corrective action response from the
Requirements (10)(d) and (e) are unmet. The agency shall ensure all 8/23/2023 visit is on record.
requirements are included on the medication administration record.
Note: This licensor and staff discussed ways to update documentation and
processes. The agency is working on updating policies and procedures to
be clearer and reduce potential errors.
Form Rev. 11/14/2023 P age 2 | 5
There were several blank areas on the medication administration record
with no corresponding notes to document the circumstances where space
is provided for such notes on the back of the sheet.
When speaking to several staff and the program manager, there was a lack
of clarity on the process of medication administration documentation and
medication disposal and disposal documentation. There have been recent
staff changes, and new hires that may not have received required training.
Corrective Action – The Agency shall:
1) The agency shall ensure the written record of the medication
administration are filled out accurately with no blanks, indicating missed
doses or medication disposed.
• Medication errors, or anomalies in documentation or administration,
can be documented by adding a notation to the medication
administration record.
2) Review medication policies and procedures to ensure it meets
requirements in related OARs and the practices set forth by Family
Solutions.
3) Ensure all staff who handle medications are provided medication policies
and procedures, are trained, and demonstrate competency before
administering and disposing medications as well as proper documentation.
4) Ensure management oversight for quality check and assurances and any
follow-up training needed.
**This is a repeat finding.**
Physical Plant Requirements 419-470-0020(2)(c) All areas of buildings Yes☐ No✓ Correction #1: The toilet bowls were observed to be
where children in care are present must be kept clean and in good repair. averagely clean. The agency noted in their Corrective
Major appliances and heating, ventilation, plumbing, and electrical systems Action response from 8/23/2023 that per the Medford
must be functional and in good repair. Water Commission, the Medford water chemical
make-up tends to react with materials in some toilets
All upstairs toilets had various levels of rings in the toilet indicating a deep creating ongoing staining that is difficult to remove.
cleaning and regular upkeep was lacking. It’s recommended that the
agency utilize Collaborative Problem Solving techniques to encourage the Correction #2: It was discovered the toilet ring was
youth to meet cleaning expectations. causing leaking and needed to be replaced. The under
• Corrective Action #1: The agency is ultimately responsible and flooring was treated and the toilet ring and flooring
must ensure agency staff are completing necessary cleaning. were replaced on 9/7/2023. This bathroom was
observed and has been corrected.
There is dark discolored flooring around one of the upstairs toilets indicating
a potential water leak, mold, rotting floor, or other unknown reason. Mold is There is no further corrective action needed at this
a health hazard, and a rotting floor structure is a safety concern. time.
• Corrective Action #2: The agency shall seek out a professional
assessment and remedy the problem.
Form Rev. 11/14/2023 P age 3 | 5
New Findings from Site Visit Corrective Actions
419-470-0100(3) A prescription, signed by a Staff discovered a pharmacy error (AM vs. PM) on the label of a refill medication, they called the physician
physician or qualified medical professional, is to confirm the exact time for administration and handwrote the change on the Medication Administration
required before any prescription medication is Record (MAR), however there was no documented evidence to verify.
administered to a child in care. • Corrective Action: The agency shall ensure such documentation is retained.
419-470-0100(10) Medication records. Sticky notes were on several youth’s MARs, indicating various notes or instructions with no corresponding
notes to document the circumstances where space is provided for such notes on the back of the sheet.
• Corrective Action: The agency shall ensure any errors, or anomalies in documentation or
administration, are documented by adding a notation to the medication administration record. Note:
use of sticky notes is allowed as long as the information is documented on the MAR as well.
419-470-0030(4)(a)(G) Bathrooms: A window There was no window covering in one of the upstairs bathrooms. The window size is large, and placement
covering on each window to ensure privacy. is lower to the floor which is directly next to the toilet and faces a main street outside.
When this licensor brought this concern forward, the agency gathered information and discovered the
window covering had fallen down the night prior. The agency remedied this later that day and sent a picture
to confirm.
• Corrective Action: The agency shall ensure a bathroom window covering is always in place.
419-470-0030(3)(i) Bedrooms: A window One youth’s bedroom was missing a window covering. This youth was out of the program at the time.
covering to ensure privacy.
• Corrective Action: The agency shall ensure this window covering is in place prior to the youth
returning, as well as ensuring all bedroom window coverings are always in place.
Physical Plant Requirements Toilet seats had various levels of uncleanliness. The agency is ultimately responsible to ensure agency
419-470-0020(2)(c) All areas of buildings where staff are completing necessary and routine cleaning.
children in care are present must be kept clean • Corrective Action: The agency shall ensure oversight to ensure cleanliness.
and in good repair. Major appliances and
heating, ventilation, plumbing, and electrical
systems must be functional and in good repair.
Interview Summary
Two youth were individually interviewed, both ages 15, and they have been in the program approximately 6 months and 8 months, respectively. Both youth
reported that they are not gaining anything or benefiting from the program services. Although they noted the program efforts, they said the efforts don’t match
their needs. They report feeling safe here, peers are tolerable, some staff are trusting and there’s no issues getting their medications as prescribed. The food is
good, consisting of prepared meals for dinner and occasionally heated up frozen food. Rules and expectations are always changing, and communication is poor
and inconsistent, making it hard to know what the rules and expectations are day-to-day, staff-to-staff, and shift-to-shift. They reported frustrations with staff
inconsistences regarding youth losing privileges and when to expect to gain them back. Both youth report that the program therapist was not a good fit, and they
both see an outside therapist. Outings are mainly on Saturdays: going to the park, shopping, or on a drive, and going to the YMCA during the week for swimming
or working out. School is boring, but they get help. Youth report wanting to do more activities, both in and out of the program. Their daily routine consists of
room time, classroom, meals, living room for tv or gaming, which is a lot of sitting around and no regular physical activity or fresh air. They reported a recent
rule change where youth can no longer “take space” on the porch outside. Outside walks rarely happen due to staffing and staff ratios, and if youth are split
Form Rev. 11/14/2023 P age 4 | 5
about going on a walk or not, it just doesn’t happen. They report that it feels “suffocating”. Groups haven’t happened in a long time; they guessed since January.
They report having regular phone calls with approved persons; however, they haven’t been getting privacy for these calls. The kitchen phone (where most private
calls are conducted) was removed for reasons they don’t know, and the cordless phone doesn’t always work downstairs. They reported the agency does well at
“check-ins” with the youth. If they could change anything about the program, it would be better communication, less changing of rules, and more consistency
among staff. It’s not often they see the program manager. One youth submitted a grievance about the program manager to the Executive Director, but they
didn’t receive a response so they just “dropped it.” There is one staff person who is part-time and is one of the main staff for outings, who can be disrespectful,
which makes the outing days less enjoyable.
Agency follow-up from youth interviews
1) Assess the situation regarding youth privacy for phone calls and make any adjustments to ensure privacy is occurring. Provide a written response to
this licensor.
2) Provide documentation of the grievance noted above to this licensor and the agency response.
Observations
The facility is an aging building that was originally built as a house. It has original or aging bathrooms and some areas appear more worn down. One upstairs
bathroom is out of order, the upstairs “quad” room is not in use, and both are locked and not accessible to youth. There are two other bathrooms, and this is
sufficient for their current census. The agency works at keeping the facility maintained and clean. One upstairs bathroom floor was replaced, as noted above.
One bathroom was missing a window covering, as noted above. Youth bedrooms were observed, and there were various levels of tidiness, and one bedroom
window missing a window covering, as noted above. Food was observed in the kitchen cupboards and in refrigerators and freezers. The walk-through consisted
of bedrooms, bathrooms, kitchen, dining room, living room, and the staff and medication office. Youth had just recently ended their on-site school day and were
either in their bedrooms or hanging out in the hallway with two staff. One youth was on a call to their sibling, on speaker, while sitting in the hallway with staff.
Corrective Actions and Timeframes: Please submit the following to verify compliance.
Within 45 days of receipt of this report Family Solutions 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 are to be emailed directly to Robin DuVal
at robin.m.duval@odhsoha.oregon.gov.
Licensing Coordinator’s Signature: ________________________ Date: _3_/_2_5_/2_0_2__4__________
Manager Review: ______________________________________ Date: _3_-2_5_-_2_0_2_4__________
Form Rev. 11/14/2023 P age 5 | 5

board_chairperson: Roy Lindsay

purpose:
Per OAR 419-400-0240 (1)(b) Children's Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Findings Comments
Unannounced Site Visit 08/23/2023 Further Action
Needed
Medication 419-470-0100(9) Written record of the disposal of medications Yes[ ] No[ ] N/A✓ The last documented disposal was from August
is maintained and includes: 2023, therefore nothing new to review.
(a) description and amount
(b) name This area will be reviewed at a future visit.
(c) reason
(d) method The agencies corrective action response from the
(e) staff & witness signature 8/23/2023 visit is on record.
(9)(e) The agency shall ensure staff and witness provide a signature, not
initials.
Note: This licensor and staff discussed ways to update documentation and
processes. The agency is working on updating policies and procedures to
be clearer and reduce potential errors.
Requirement (9)(e) remains unmet: initials instead of signatures; and
several instances with only one staff person without a witness.

Some disposed medications are disposed on-site utilizing the Rx Destroyer
product, however other disposed medications were in a bin labeled
"disposal" with no tracking document within said bin, creating a risk of
mismanagement or theft.
When speaking to several staff and the program manager, there was a lack
of clarity on the process of medication administration documentation and
medication disposal and disposal documentation. There have been recent
staff changes, and new hires that may not have received required training.
Corrective Action. The Agency shall:
1) Ensure staff and a witness provide a signature, not initials.
2) Ensure two staff (one staff and one staff witness) are disposing
medications and signing the disposal record.
3) Review medication policies and procedures to ensure it meets
requirements in related OARs and the practices set forth by Family
Solutions.
4) Ensure all staff who handle medications are provided medication policies
and procedures, are trained, and demonstrate competency before
administering and disposing medications as well as proper documentation.
5) Ensure management oversight for quality check and assurances and any
follow-up training needed.
**This is a repeat finding.**
Medication 419-470-0100(10) Written record of the administration of Yes✓ No[ ] (d) There were several blank areas on the medication
medication includes: administration record with no corresponding notes to
(a) name document the circumstances where space is provided
(b) description for such notes on the back of the sheet. **This is a
(c) dates and times repeat finding.**
(d) missed doses
(e) medication disposed (e) There was no noted medication disposed,
(f) method of administration therefore nothing new to review. This area will be
(g) ID of person administering reviewed at a future visit.
(h) possible adverse reactions
(i) medication taken outside facility
The agencies corrective action response from the
Requirements (10)(d) and (e) are unmet. The agency shall ensure all 8/23/2023 visit is on record.
requirements are included on the medication administration record.
Note: This licensor and staff discussed ways to update documentation and
processes. The agency is working on updating policies and procedures to
be clearer and reduce potential errors.

There were several blank areas on the medication administration record
with no corresponding notes to document the circumstances where space
is provided for such notes on the back of the sheet.
When speaking to several staff and the program manager, there was a lack
of clarity on the process of medication administration documentation and
medication disposal and disposal documentation. There have been recent
staff changes, and new hires that may not have received required training.
Corrective Action - The Agency shall:
1) The agency shall ensure the written record of the medication
administration are filled out accurately with no blanks, indicating missed
doses or medication disposed.
- Medication errors, or anomalies in documentation or administration,
can be documented by adding a notation to the medication
administration record.
2) Review medication policies and procedures to ensure it meets
requirements in related OARs and the practices set forth by Family
Solutions.
3) Ensure all staff who handle medications are provided medication policies
and procedures, are trained, and demonstrate competency before
administering and disposing medications as well as proper documentation.
4) Ensure management oversight for quality check and assurances and any
follow-up training needed.
**This is a repeat finding.**
Physical Plant Requirements 419-470-0020(2)(c) All areas of buildings Yes[ ] No✓ Correction #1: The toilet bowls were observed to be
where children in care are present must be kept clean and in good repair. averagely clean. The agency noted in their Corrective
Major appliances and heating, ventilation, plumbing, and electrical systems Action response from 8/23/2023 that per the Medford
must be functional and in good repair. Water Commission, the Medford water chemical
make-up tends to react with materials in some toilets
All upstairs toilets had various levels of rings in the toilet indicating a deep creating ongoing staining that is difficult to remove.
cleaning and regular upkeep was lacking. It's recommended that the
agency utilize Collaborative Problem Solving techniques to encourage the Correction #2: It was discovered the toilet ring was
youth to meet cleaning expectations. causing leaking and needed to be replaced. The under
- Corrective Action #1: The agency is ultimately responsible and flooring was treated and the toilet ring and flooring
must ensure agency staff are completing necessary cleaning. were replaced on 9/7/2023. This bathroom was
observed and has been corrected.
There is dark discolored flooring around one of the upstairs toilets indicating
a potential water leak, mold, rotting floor, or other unknown reason. Mold is There is no further corrective action needed at this
a health hazard, and a rotting floor structure is a safety concern. time.
- Corrective Action #2: The agency shall seek out a professional
assessment and remedy the problem.

New Findings from Site Visit Corrective Actions
419-470-0100(3) A prescription, signed by a Staff discovered a pharmacy error (AM vs. PM) on the label of a refill medication, they called the physician
physician or qualified medical professional, is to confirm the exact time for administration and handwrote the change on the Medication Administration
required before any prescription medication is Record (MAR), however there was no documented evidence to verify.
administered to a child in care. - Corrective Action: The agency shall ensure such documentation is retained.
419-470-0100(10) Medication records. Sticky notes were on several youth's MARs, indicating various notes or instructions with no corresponding
notes to document the circumstances where space is provided for such notes on the back of the sheet.
- Corrective Action: The agency shall ensure any errors, or anomalies in documentation or
administration, are documented by adding a notation to the medication administration record. Note:
use of sticky notes is allowed as long as the information is documented on the MAR as well.
419-470-0030(4)(a)(G) Bathrooms: A window There was no window covering in one of the upstairs bathrooms. The window size is large, and placement
covering on each window to ensure privacy. is lower to the floor which is directly next to the toilet and faces a main street outside.
When this licensor brought this concern forward, the agency gathered information and discovered the
window covering had fallen down the night prior. The agency remedied this later that day and sent a picture
to confirm.
- Corrective Action: The agency shall ensure a bathroom window covering is always in place.
419-470-0030(3)(i) Bedrooms: A window One youth's bedroom was missing a window covering. This youth was out of the program at the time.
covering to ensure privacy.
- Corrective Action: The agency shall ensure this window covering is in place prior to the youth
returning, as well as ensuring all bedroom window coverings are always in place.
Physical Plant Requirements Toilet seats had various levels of uncleanliness. The agency is ultimately responsible to ensure agency
419-470-0020(2)(c) All areas of buildings where staff are completing necessary and routine cleaning.
children in care are present must be kept clean - Corrective Action: The agency shall ensure oversight to ensure cleanliness.
and in good repair. Major appliances and
heating, ventilation, plumbing, and electrical
systems must be functional and in good repair.
Interview Summary
Two youth were individually interviewed, both ages 15, and they have been in the program approximately 6 months and 8 months, respectively. Both youth
reported that they are not gaining anything or benefiting from the program services. Although they noted the program efforts, they said the efforts don't match
their needs. They report feeling safe here, peers are tolerable, some staff are trusting and there's no issues getting their medications as prescribed. The food is
good, consisting of prepared meals for dinner and occasionally heated up frozen food. Rules and expectations are always changing, and communication is poor
and inconsistent, making it hard to know what the rules and expectations are day-to-day, staff-to-staff, and shift-to-shift. They reported frustrations with staff
inconsistences regarding youth losing privileges and when to expect to gain them back. Both youth report that the program therapist was not a good fit, and they
both see an outside therapist. Outings are mainly on Saturdays: going to the park, shopping, or on a drive, and going to the YMCA during the week for swimming
or working out. School is boring, but they get help. Youth report wanting to do more activities, both in and out of the program. Their daily routine consists of
room time, classroom, meals, living room for tv or gaming, which is a lot of sitting around and no regular physical activity or fresh air. They reported a recent
rule change where youth can no longer "take space" on the porch outside. Outside walks rarely happen due to staffing and staff ratios, and if youth are split

about going on a walk or not, it just doesn't happen. They report that it feels "suffocating". Groups haven't happened in a long time; they guessed since January.
They report having regular phone calls with approved persons; however, they haven't been getting privacy for these calls. The kitchen phone (where most private
calls are conducted) was removed for reasons they don't know, and the cordless phone doesn't always work downstairs. They reported the agency does well at
"check-ins" with the youth. If they could change anything about the program, it would be better communication, less changing of rules, and more consistency
among staff. It's not often they see the program manager. One youth submitted a grievance about the program manager to the

interview_summary:
Two youth were individually interviewed, both ages 15, and they have been in the program approximately 6 months and 8 months, respectively. Both youth
reported that they are not gaining anything or benefiting from the program services. Although they noted the program efforts, they said the efforts don't match
their needs. They report feeling safe here, peers are tolerable, some staff are trusting and there's no issues getting their medications as prescribed. The food is
good, consisting of prepared meals for dinner and occasionally heated up frozen food. Rules and expectations are always changing, and communication is poor
and inconsistent, making it hard to know what the rules and expectations are day-to-day, staff-to-staff, and shift-to-shift. They reported frustrations with staff
inconsistences regarding youth losing privileges and when to expect to gain them back. Both youth report that the program therapist was not a good fit, and they
both see an outside therapist. Outings are mainly on Saturdays: going to the park, shopping, or on a drive, and going to the YMCA during the week for swimming
or working out. School is boring, but they get help. Youth report wanting to do more activities, both in and out of the program. Their daily routine consists of
room time, classroom, meals, living room for tv or gaming, which is a lot of sitting around and no regular physical activity or fresh air. They reported a recent
rule change where youth can no longer "take space" on the porch outside. Outside walks rarely happen due to staffing and staff ratios, and if youth are split

about going on a walk or not, it just doesn't happen. They report that it feels "suffocating". Groups haven't happened in a long time; they guessed since January.
They report having regular phone calls with approved persons; however, they haven't been getting privacy for these calls. The kitchen phone (where most private
calls are conducted) was removed for reasons they don't know, and the cordless phone doesn't always work downstairs. They reported the agency does well at
"check-ins" with the youth. If they could change anything about the program, it would be better communication, less changing of rules, and more consistency
among staff. It's not often they see the program manager. One youth submitted a grievance about the program manager to the Executive Director, but they
didn't receive a response so they just "dropped it." There is one staff person who is part-time and is one of the main staff for outings, who can be disrespectful,
which makes the outing days less enjoyable.
Agency follow-up from youth interviews
1) Assess the situation regarding youth privacy for phone calls and make any adjustments to ensure privacy is occurring. Provide a written response to
this licensor.
2) Provide documentation of the grievance noted above to this licensor and the agency response.

observations:
The facility is an aging building that was originally built as a house. It has original or aging bathrooms and some areas appear more worn down. One upstairs
bathroom is out of order, the upstairs "quad" room is not in use, and both are locked and not accessible to youth. There are two other bathrooms, and this is
sufficient for their current census. The agency works at keeping the facility maintained and clean. One upstairs bathroom floor was replaced, as noted above.
One bathroom was missing a window covering, as noted above. Youth bedrooms were observed, and there were various levels of tidiness, and one bedroom
window missing a window covering, as noted above. Food was observed in the kitchen cupboards and in refrigerators and freezers. The walk-through consisted
of bedrooms, bathrooms, kitchen, dining room, living room, and the staff and medication office. Youth had just recently ended their on-site school day and were
either in their bedrooms or hanging out in the hallway with two staff. One youth was on a call to their sibling, on speaker, while sitting in the hallway with staff.


state: OR

facility_name: Homestead Youth & Family

summary: Unannounced - 3 findings

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Licensee: Homestead
Executive Director: Elisa Doebler-Irvine
Date of Unannounced: March 15th, 2021
Licensing Coordinator: Ed Wyller
Other Regulatory or Accrediting Agencies: Oregon Youth Authority
Purpose: Per OAR 413-215-0101 (1) (b) Children’s Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings: Repeat Comments
Unannounced Site Visit 10/13/2020 Findings
Further Action
Residential Care
Needed
413-215-0021(2)(f) Formally evaluate the Yes☐ No Joan Howard Board Chair for Homestead Youth and Family Services completed a
exec. Director’s performance annually: performance evaluation on Executive Director Elisa Doebler-Irvine. DHS CCLP received
Executive Director Elisa Doebler-Irvine has the evaluation regarding Elisa Doebler-Irvine on 12/15/2020. This is no longer a finding.
informed the Board that this is a requirement.
At time of unannounced visit, the Board has
yet to provide a formal evaluation of Elisa
Doebler-Irvine’s performance.
Missing completed Tax Compliance Yes☐ No Homestead Youth and Family Services provided a completed tax compliance certificate
Certification: Homestead Youth and Family dated 1/21/21. This is no longer a finding.
Services has not provided DHS CCLP with a
completed tax compliance certificate.
1
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 200115)
New Findings from Site Visit Comments
413-215-0516  One bedroom was missing bedroom window covering. Other bedroom coverings had holes. It
Residential Care Agencies: Room and appears youth may have made these holes to look out. During youth interviews one youth indicated
Space Requirements that it was scary having a room without curtains. 413-215-0516 (3) (h) states each bedroom should
have a window covering on each window to ensure privacy.
A residential care agency must meet all the
following room and space requirements:
(3) Bedrooms. Bedrooms for children in care
may not be exposed to drafts, odors, or
noises that interfere with the health or safety
of the occupants. Each bedroom must
comply with all of the following
requirements:(h) Have a window covering on
each window to ensure privacy.
Interview Summary
I interviewed three youth on March 15th, 2021 onsite at Homestead Youth and Family Services. All three-youth reported that they feel safe in the program.
One youth indicated that “not having curtains on windows is scary”. This was a finding identified during the tour and confirmed during youth interviews.
Homestead Youth and Family Services have both a residential program and a proctor program. Programming between the two programs is fluid and youth
will go between programs depending on the level of services required to meet the current needs of the youth. On a scale from (0-10 where 0 = worst program
in the State and 10 = best program in the State) youth reported Homestead Youth and Family Services overall program to be a: 7, 7, and 8.5. Two of the
youth are currently in foster program and have spent majority time in Residential Program. These youth on the same scale rated the Residential program to
be a 6, and 7.5. These same youth on the same scale rated their foster homes to be a 9 and 9.5.
Two youth reported this is their first program placement, and they are thankful to be placed at Homestead. These youth reported that when talking with other
youth, they feel they are at a good program and are on track to go home. All youth were able to identify skills they are learning: impulse control, positive self-
talk, radical acceptance, how to process emotions, think more logically, think with brain, not catastrophizing, and not rushing through treatment. Youth
reported food at residential center to be: “alright”, “food is good, not terrible but not great”, and the other youth reported food is “really good” and reports
enjoying the “western soup”. Youth reported the following recreational activities at Homestead Youth and Family Services: Basketball at recreation center,
playing softball and kickball at the Roundup Facility, video games, tv, reading, ping pong, and playing cards. One youth reported he enjoyed going to the
Umatilla Reservation and assisting in putting together food boxes for families during Thanksgiving.
2
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 200115)
Observations
During the tour I noted that the shower, that used to have mold concerns, continues to be mold free. Program installed an exhaust ventilation system that has
addressed this previous finding. I witnessed the new plexiglass barrier that is used for on-site visitation for parents, family, and support persons. In addition, I
witnessed the plexiglass barriers for the teachers as they continue to provide on-site education. Youth reported the teachers are great. During my tour I
witnessed youth lunch and class time, and this was organized. During class there were classrooms downstairs being used, and the upstairs was being
utilized to split the groups up into smaller cohort groups. I met and spoke with all staff and teachers during my tour. I witnessed positive interactions between
both staff / teachers and youth at Homestead Youth and Family Services. Ryan Heath, Residential Supervisor, provided the tour. I debriefed with Elisa
Doebler-Irvine and Ryan Heath Residential Supervisor upon the conclusion of the visit.
Corrective Actions and Timeframes:
Please submit the following to verify compliance. Within 45 days of receipt of this report Homestead Youth and Family Services must submit a
letter of verification indicating the agency is in compliance with the specific rules cited above and describing how compliance will be maintained
going forward. Along with the letter of verification, the agency must submit any and all specific documentation requested in the body of this report.
The letter of verification and any additional requested documents can be emailed directly to Ed Wyller edward.wyller@dhsoha.state.or.us or sent
by regular mail to the following address:
Due to Covid-19 pandemic and working remotely the preferred method is to send directly to Ed Wyller at his email address.
Department of Human Services
Children’s Care Licensing Program
Attn: Ed Wyller
201 High St. SE Suite 500
Salem, OR 97301
3-29-21
Licensing Coordinator’s Signature: ________________________ Date: ___________________
Manager Review: ______________________________________ Date: __0_3_-_2_1_-_2_0__2_1_ _____
3
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 200115)

agency_name: Homestead Youth and Family Services (HYFS)

program_name: Residential Program

program_type: (RC) Residential Care Programs

report_type: Unannounced

view_code: RC

licensee: Homestead

executive_director: Elisa Doebler-Irvine

visit_date: March 15th, 2021

licensing_coordinator: Ed Wyller

other_regulatory_agencies: Oregon Youth Authority

purpose:
Per OAR 413-215-0101 (1) (b) Children's Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings: Repeat Comments
Unannounced Site Visit 10/13/2020 Findings
Further Action
Residential Care
Needed
413-215-0021(2)(f) Formally evaluate the Yes[ ] No Joan Howard Board Chair for Homestead Youth and Family Services completed a
exec. Director's performance annually: performance evaluation on

interview_summary:
I interviewed three youth on March 15th, 2021 onsite at Homestead Youth and Family Services. All three-youth reported that they feel safe in the program.
One youth indicated that "not having curtains on windows is scary". This was a finding identified during the tour and confirmed during youth interviews.
Homestead Youth and Family Services have both a residential program and a proctor program. Programming between the two programs is fluid and youth
will go between programs depending on the level of services required to meet the current needs of the youth. On a scale from (0-10 where 0 = worst program
in the State and 10 = best program in the State) youth reported Homestead Youth and Family Services overall program to be a: 7, 7, and 8.5. Two of the
youth are currently in foster program and have spent majority time in Residential Program. These youth on the same scale rated the Residential program to
be a 6, and 7.5. These same youth on the same scale rated their foster homes to be a 9 and 9.5.
Two youth reported this is their first program placement, and they are thankful to be placed at Homestead. These youth reported that when talking with other
youth, they feel they are at a good program and are on track to go home. All youth were able to identify skills they are learning: impulse control, positive self-
talk, radical acceptance, how to process emotions, think more logically, think with brain, not catastrophizing, and not rushing through treatment. Youth
reported food at residential center to be: "alright", "food is good, not terrible but not great", and the other youth reported food is "really good" and reports
enjoying the "western soup". Youth reported the following recreational activities at Homestead Youth and Family Services: Basketball at recreation center,
playing softball and kickball at the Roundup Facility, video games, tv, reading, ping pong, and playing cards. One youth reported he enjoyed going to the
Umatilla Reservation and assisting in putting together food boxes for families during Thanksgiving.
2

previous_findings:
Repeat Comments
Unannounced Site Visit 10/13/2020 Findings
Further Action
Residential Care
Needed
413-215-0021(2)(f) Formally evaluate the Yes[ ] No Joan Howard Board Chair for Homestead Youth and Family Services completed a
exec. Director's performance annually: performance evaluation on Executive Director Elisa Doebler-Irvine. DHS CCLP received
Executive Director Elisa Doebler-Irvine has the evaluation regarding Elisa Doebler-Irvine on 12/15/2020. This is no longer a finding.
informed the Board that this is a requirement.
At time of unannounced visit, the Board has
yet to provide a formal evaluation of Elisa
Doebler-Irvine's performance.
Missing completed Tax Compliance Yes[ ] No Homestead Youth and Family Services provided a completed tax compliance certificate
Certification: Homestead Youth and Family dated 1/21/21. This is no longer a finding.
Services has not provided DHS CCLP with a
completed tax compliance certificate.
1

New Findings from Site Visit Comments
413-215-0516 - One bedroom was missing bedroom window covering. Other bedroom coverings had holes. It
Residential Care Agencies: Room and appears youth may have made these holes to look out. During youth interviews one youth indicated
Space Requirements that it was scary having a room without curtains. 413-215-0516 (3) (h) states each bedroom should
have a window covering on each window to ensure privacy.
A residential care agency must meet all the
following room and space requirements:
(3) Bedrooms. Bedrooms for children in care
may not be exposed to drafts, odors, or
noises that interfere with the health or safety
of the occupants. Each bedroom must
comply with all of the following
requirements:(h) Have a window covering on
each window to ensure privacy.


summary: Unannounced - 16 findings

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Licensee: Homestead Youth & Family Services, Inc.
Executive Director: Elisa Doebler-Irvine
Board Chairperson: Joan Howard
Date of Unannounced: 10.26.2022
Licensing Coordinator: Jorge Pelinski & Todd Cooley
Other Regulatory or Accrediting Agencies: Oregon Youth Authority (OYA)
Purpose: Per OAR 413-215-0101 (1) (b) Children’s Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Comments
Findings
Further Action
Needed
Executive Director or Program Director Yes☐ No Program provided current BCU approved background checks as required. No further action
413-215-0021 needed.
(3)(g) Approval from BCU
The agency shall submit the current
background check once received.
Supplemental Information Provided by Yes☐ No Program submitted Tax Compliance Certificate. No further action needed.
CCA
Documents as indicated on form titled
“Required Financial Documents and
Information”
The agency shall submit the Tax Compliance
Certificate once received.
1
(rev. 200115)
Yes☐ No Program submitted policies meeting all requirements. No further action needed.
Supplemental Information Provided by
CCA
All required policies and procedures as
identified in the “Umbrella Rules”
1)The agency shall update the following
policies and procedures pursuant to each
OAR:
 Grievance Procedures in OAR 413-
215-0046(2)
 Mandatory Abuse Reporting in OAR
413-215-0056(2)
 The child in care’s right to privacy and
uncensored communication,
specifically regarding phone calls.
2)The agency shall submit a written policy
regarding personnel that meets the
requirements of OAR 413-215-0061.
Supplemental Information Provided by Yes☐ No Program submitted policy and procedure for medications. No further action needed.
CCA
All required policies and procedures as
identified in “Residential Care”
The agency shall update the policy and
procedure for Medications pursuant to OAR
413-215-0551.
Supplemental Information Provided by Yes☐ No Program updated SB 710 requirements. No further action needed.
CCA
SB710 Requirements: Policy and Procedures;
notifications to guardian and children in care.
OAR 413-215-0077(8)(e), (11)(e) and
OAR 413-215-0078(1)
The agency shall review their policy and
procedure, including notifications required to
clients and guardians, and update to
specifically including how to access the
quarterly reports.
(rev. 07/21/2022)
The agency shall ensure clients and
guardians receive the notification at intake
and twice yearly thereafter, and document
having provided it.
The corrective action response shall include
the agencies plan detailing how ongoing
compliance will occur.
Physical Plant Yes☐ No The bathroom stall partition was repaired, and the program provided pictures of the repair.
413-215-0511(2)(a) &(c) Buildings are smoke Program has plans to repaint bathroom.
free, clean and in good repair
The bathroom stall partition had a hole
towards the bottom near the floor. Options for
repair were discussed. The agency shall
submit photos of the repaired area.
Safety 413-215-0541 Yes☐ No Discussed with Executive Director to note all staff participating in fire drills. Only one
months of drills to review. Executive Director stated that October fire drill is set for October
(3)(a) Evacuation drill occurs monthly under 26th. No further action needed.
varying conditions, is retained 2 yrs and
contains:
(A) identify of person conducting drill
(B) date & time
(C) notification method
(D) staff participating
(E) # of children & staff evacuated
(F) special conditions simulated
(G) problems encountered
(H) time to complete
Documented drills prior to January 2022 were
unable to be located due to employee
changes and inability to locate documents.
Monthly drills between January – July 2022
were completed and properly documented.
 The agency shall ensure monthly
drills occur, are appropriately
documented and safely stored.
(rev. 07/21/2022)
Medication 413-215-0551 Yes☐ No The agency has updated the policy and procedures pursuant to OAR 413-215-0551. The
agency has updated medication MAR to meet requirements. No further action needed.
(8) Medications are disposed in accordance
with state and federal law
(9) Written record of the disposal of
medications is maintained and includes:
(a) description and amount
(b) name
(c) reason
(d) method
(e) staff & witness signature
(10) Written record of the 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
(h) possible adverse reactions
(i) medication taken outside facility
Items (8), (9) and (10) are unmet due to
various factors disclosed by the program.
•The agency shall ensure the policy and
procedures are updated pursuant to OAR
413-215-0551.
•The agency shall ensure staff who administer
medications are trained in the updated policy
and procedures.
•The agency shall ensure the written record of
the disposal of medications contains all
required elements (items a-e).
•The agency shall ensure the written record of
the administration of medication contains all
required elements (items a-i).
•The agency shall ensure staff are completing
the documentation for all required elements
(rev. 07/21/2022)
on the written disposal record and medication
administration record.
Minimum Staffing Requirements 413-215- Yes☐ No Awake overnight staffing exception on file. No further action required at this time.
0561
(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:
Ages 6 and older: 1:7
Overnight (staff awake) 1:10
Licensing coordinators and program
management discussed overnight awake
staffing ratios, including meeting their
contracted OYA staff requirements.
•Awake overnight staffing exception on file.
Children’s Records Yes☐ No Program has an updated process for obtaining medical history. Medical history is obtained
upon intake. No further action needed.
(2) Medical history obtained within 30 days
(significant findings, current immunizations,
history of surgical procedures-health issues-
injuries, allergies, dental, vision, hearing,
behavioral health, and physician orders)
The medical history section was lacking. The
agency shall ensure a more complete medical
history is obtained and appropriately
documented in each youth file.
Children’s Records Yes☐ No The program has created a curriculum for appropriate instruction – pregnancy prevention,
nutrition, prevention of HIV & AIDS, and prevention and treatment of sexually transmitted
2)(e) Documentation of age-appropriate disease, and the information is being incorporated into weekly groups with the youth. No
instruction – pregnancy prevention, nutrition, further action needed.
prevention of HIV & AIDS, and prevention and
treatment of sexually transmitted disease
(rev. 07/21/2022)
(2)(e) is unmet. The agency shall ensure age-
appropriate instruction is provided and
appropriately documented in each youth file.
Consents 413-215-0576(1) Yes☐ No Program updated language to meet requirements. No further action needed.
(e) Allow access as defined in 413-215-0091
& 0101
(e) The agency shall update language to meet
the requirements.
Information about Children in Care Yes☐ No Program updated summary sheets to meet requirements. No further action needed.
413-215-0581(1) Summary sheet contains the
following:
(a)The name, gender, date of birth, religious
preference, and previous address
Religious preference was not consistently
documented on the summary sheet. The
agency shall ensure an entry is noted for
religious preference.
Case Management 413-215-0581(3) Yes☐ No The agency is ensuring discharge planning and instructions are individualized for each
child in care and documented accordingly. No further action needed.
(b)-(d) discharge planning and instructions
The agency shall ensure discharge planning
and instructions are individualized for each
child in care and documented accordingly.
New Findings from Site Visit Comments
Physical Plant The program shall repair the hole in a way that is less susceptible to being re-damaged.
413-215-0511(2)(a) &(c) Buildings are
smoke free, clean and in good repair
Sometime after the bathroom partition was
repaired (see above), the material used to
patch the partition was removed by youth in
care.
(rev. 07/21/2022)
Interview Summary
Two youth from the program were interviewed at the unannounced site inspection. The following information was obtained from the youth
interviews:
 Both youths stated things were going well at the program.
 When asked what the youth appreciated most about the program the youth stated: “P.E. Community Service, Homestead Staff, movies,
swimming, bowling, and basketball.
 Both youths confirmed they receive enough food to eat, and snacks are provided.
 One youth stated he has family contact and can request more phone calls as requested. The other youth stated he has phone contact
with his family 4 times a week.
 Both youths stated they had someone at the program they could talk to if they felt uncomfortable or needed anything.
 Both youths stated they feel safe at Homestead.
 Both youths feel they have received the necessary skills from the Homestead Program for when they return to the community.
Observations
Staff and youth were observed at the programs during the inspection. The youth that were at the programs appeared to be at ease and
comfortable in their environment. All areas of the programs where youth had access were observed to be well kept, clean and in good repair
with minimal repair needs (see repair needs above in the report). The kitchens were observed to have plenty of food for the youth in the
program. Medication was observed to be in locked medication carts behind locked rooms which was inaccessible to the youth. Homestead
recently updated their phone policy to include four family phone calls per week for all youth.
The Executive Director of Homestead sent an official letter notifying CCLP of their Foster Program closing on 10.25.2022. The Foster Program
closed due to a persistent lack of foster parent applicants, despite the program’s ongoing recruitment efforts.
Corrective Actions and Timeframes:
Please submit the following to verify compliance.
Within 45 days of receipt of this report Agency Name must submit a letter of verification indicating the agency is in compliance with the specific
rules cited above and describing how compliance will be maintained going forward. Along with the letter of verification, the agency must submit any
(rev. 07/21/2022)
and all specific documentation requested in the body of this report. The letter of verification and any additional requested documents can be emailed
directly to Licensing Coordinator email address.
Licensing Coordinator’s Signature: ________________________ Date: ___________________
Manager Review: ______________________________________ Date: _1_1_-_8_-2__0_2_2_________
(rev. 07/21/2022)

licensee: Homestead Youth & Family Services, Inc.

board_chairperson: Joan Howard

licensing_coordinator: Jorge Pelinski & Todd Cooley

other_regulatory_agencies: Oregon Youth Authority (OYA)

purpose:
Per OAR 413-215-0101 (1) (b) Children's Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Comments
Findings
Further Action
Needed

interview_summary:
Two youth from the program were interviewed at the unannounced site inspection. The following information was obtained from the youth
interviews:
- Both youths stated things were going well at the program.
- When asked what the youth appreciated most about the program the youth stated: "P.E. Community Service, Homestead Staff, movies,
swimming, bowling, and basketball.
- Both youths confirmed they receive enough food to eat, and snacks are provided.
- One youth stated he has family contact and can request more phone calls as requested. The other youth stated he has phone contact
with his family 4 times a week.
- Both youths stated they had someone at the program they could talk to if they felt uncomfortable or needed anything.
- Both youths stated they feel safe at Homestead.
- Both youths feel they have received the necessary skills from the Homestead Program for when they return to the community.

observations:
Staff and youth were observed at the programs during the inspection. The youth that were at the programs appeared to be at ease and
comfortable in their environment. All areas of the programs where youth had access were observed to be well kept, clean and in good repair
with minimal repair needs (see repair needs above in the report). The kitchens were observed to have plenty of food for the youth in the
program. Medication was observed to be in locked medication carts behind locked rooms which was inaccessible to the youth. Homestead
recently updated their phone policy to include four family phone calls per week for all youth.
The Executive Director of Homestead sent an official letter notifying CCLP of their Foster Program closing on 10.25.2022. The Foster Program
closed due to a persistent lack of foster parent applicants, despite the program's ongoing recruitment efforts.

previous_findings:
Repeat Comments
Findings
Further Action
Needed
Executive Director or Program Director Yes[ ] No Program provided current BCU approved background checks as required. No further action
413-215-0021 needed.
(3)(g) Approval from BCU
The agency shall submit the current
background check once received.
Supplemental Information Provided by Yes[ ] No Program submitted Tax Compliance Certificate. No further action needed.
CCA
Documents as indicated on form titled
"Required Financial Documents and
Information"
The agency shall submit the Tax Compliance
Certificate once received.
1

Yes[ ] No Program submitted policies meeting all requirements. No further action needed.
Supplemental Information Provided by
CCA
All required policies and procedures as
identified in the "Umbrella Rules"
1)The agency shall update the following
policies and procedures pursuant to each
OAR:
- Grievance Procedures in OAR 413-
215-0046(2)
- Mandatory Abuse Reporting in OAR
413-215-0056(2)
- The child in care's right to privacy and
uncensored communication,
specifically regarding phone calls.
2)The agency shall submit a written policy
regarding personnel that meets the
requirements of OAR 413-215-0061.
Supplemental Information Provided by Yes[ ] No Program submitted policy and procedure for medications. No further action needed.
CCA
All required policies and procedures as
identified in "Residential Care"
The agency shall update the policy and
procedure for Medications pursuant to OAR
413-215-0551.
Supplemental Information Provided by Yes[ ] No Program updated SB 710 requirements. No further action needed.
CCA
SB710 Requirements: Policy and Procedures;
notifications to guardian and children in care.
OAR 413-215-0077(8)(e), (11)(e) and
OAR 413-215-0078(1)
The agency shall review their policy and
procedure, including notifications required to
clients and guardians, and update to
specifically including how to access the
quarterly reports.

The agency shall ensure clients and
guardians receive the notification at intake
and twice yearly thereafter, and document
having provided it.
The corrective action response shall include
the agencies plan detailing how ongoing
compliance will occur.
Physical Plant Yes[ ] No The bathroom stall partition was repaired, and the program provided pictures of the repair.
413-215-0511(2)(a) &(c) Buildings are smoke Program has plans to repaint bathroom.
free, clean and in good repair
The bathroom stall partition had a hole
towards the bottom near the floor. Options for
repair were discussed. The agency shall
submit photos of the repaired area.
Safety 413-215-0541 Yes[ ] No Discussed with Executive Director to note all staff participating in fire drills. Only one
months of drills to review. Executive Director stated that October fire drill is set for October
(3)(a) Evacuation drill occurs monthly under 26th. No further action needed.
varying conditions, is retained 2 yrs and
contains:
(A) identify of person conducting drill
(B) date & time
(C) notification method
(D) staff participating
(E) # of children & staff evacuated
(F) special conditions simulated
(G) problems encountered
(H) time to complete
Documented drills prior to January 2022 were
unable to be located due to employee
changes and inability to locate documents.
Monthly drills between January - July 2022
were completed and properly documented.
- The agency shall ensure monthly
drills occur, are appropriately
documented and safely stored.

Medication 413-215-0551 Yes[ ] No The agency has updated the policy and procedures pursuant to OAR 413-215-0551. The
agency has updated medication MAR to meet requirements. No further action needed.
(8) Medications are disposed in accordance
with state and federal law
(9) Written record of the disposal of
medications is maintained and includes:
(a) description and amount
(b) name
(c) reason
(d) method
(e) staff & witness signature
(10) Written record of the 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
(h) possible adverse reactions
(i) medication taken outside facility
Items (8), (9) and (10) are unmet due to
various factors disclosed by the program.
- The agency shall ensure the policy and
procedures are updated pursuant to OAR
413-215-0551.
- The agency shall ensure staff who administer
medications are trained in the updated policy
and procedures.
- The agency shall ensure the written record of
the disposal of medications contains all
required elements (items a-e).
- The agency shall ensure the written record of
the administration of medication contains all
required elements (items a-i).
- The agency shall ensure staff are completing
the documentation for all required elements

on the written disposal record and medication
administration record.
Minimum Staffing Requirements 413-215- Yes[ ] No Awake overnight staffing exception on file. No further action required at this time.
0561
(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:
Ages 6 and older: 1:7
Overnight (staff awake) 1:10
Licensing coordinators and program
management discussed overnight awake
staffing ratios, including meeting their
contracted OYA staff requirements.
- Awake overnight staffing exception on file.
Children's Records Yes[ ] No Program has an updated process for obtaining medical history. Medical history is obtained
upon intake. No further action needed.
(2) Medical history obtained within 30 days
(significant findings, current immunizations,
history of surgical procedures-health issues-
injuries, allergies, dental, vision, hearing,
behavioral health, and physician orders)
The medical history section was lacking. The
agency shall ensure a more complete medical
history is obtained and appropriately
documented in each youth file.
Children's Records Yes[ ] No The program has created a curriculum for appropriate instruction - pregnancy prevention,
nutrition, prevention of HIV & AIDS, and prevention and treatment of sexually transmitted
2)(e) Documentation of age-appropriate disease, and the information is being incorporated into weekly groups with the youth. No
instruction - pregnancy prevention, nutrition, further action needed.
prevention of HIV & AIDS, and prevention and
treatment of sexually transmitted disease

(2)(e) is unmet. The agency shall ensure age-
appropriate instruction is provided and
appropriately documented in each youth file.
Consents 413-215-0576(1) Yes[ ] No Program updated language to meet requirements. No further action needed.
(e) Allow access as defined in 413-215-0091
& 0101
(e) The agency shall update language to meet
the requirements.
Information about Children in Care Yes[ ] No Program updated summary sheets to meet requirements. No further action needed.
413-215-0581(1) Summary sheet contains the
following:
(a)The name, gender, date of birth, religious
preference, and previous address
Religious preference was not consistently
documented on the summary sheet. The
agency shall ensure an entry is noted for
religious preference.
Case Management 413-215-0581(3) Yes[ ] No The agency is ensuring discharge planning and instructions are individualized for each
child in care and documented accordingly. No further action needed.
(b)-(d) discharge planning and instructions
The agency shall ensure discharge planning
and instructions are individualized for each
child in care and documented accordingly.
New Findings from Site Visit Comments
Physical Plant The program shall repair the hole in a way that is less susceptible to being re-damaged.
413-215-0511(2)(a) &(c) Buildings are
smoke free, clean and in good repair
Sometime after the bathroom partition was
repaired (see above), the material used to
patch the partition was removed by youth in
care.

excerpt:
413-215-0511(2)(a) &(c) Buildings are
smoke free, clean and in good repair
Sometime after the bathroom partition was
repaired (see above), the material used to
patch the partition was removed by youth in
care.
Physical Plant The program shall repair the hole in a way that is less susceptible to being re-damaged.


summary: Unannounced - 1 finding

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Residential Care
Licensee: Homestead Youth & Family Services, Inc.
Executive Director: Elisa Doebler-Irvine
Board Chairperson: Joan Howard
Date of Unannounced: 6.29.2023
Licensing Coordinator: Jorge Pelinski
Other Regulatory or Accrediting Agencies: Oregon Youth Authority (OYA)
Purpose: Per OAR 419-400-0240 (1)(b) Children’s Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Comments
Unannounced Site Visit 10/26/2023 Findings
Further Action
Needed
Physical Plant Yes☐ No Agency used an epoxy finish, versus silicone caulking, for a more permanent fix.
413-215-0511(2)(a) &(c) Buildings are
smoke free, clean and in good repair
Sometime after the bathroom partition
was repaired (see above), the material
used to patch the partition was removed
by youth in care.
The program shall repair the hole in a
way that is less susceptible to being re-
damaged.
1 |P ag e
Form Rev. 01/23/2023
New Findings from Site Visit Comments
No new findings and previous finding have been addressed.
Interview Summary
During the unannounced review I met with two youth and interviewed Executive Director, Elisa Doebler-Irvine.
 Both youths interviewed stated things were going well at the program.
 Both youths enjoy going on outings. Both youths enjoy playing sports and going on community outings. Both youths confirmed that they receive
enough food to eat, and snacks are provided regularly.
 Both youths make daily phone calls.
 Both youths feel respected in the program.
 Both youths feel safe in the program and feel comfortable talking with staff.
Executive Director reported that several youths were acting overly aggressive while “horse playing”. All youth received consequences for their actions. No
injuries reported. Overall, the Executive Director shared that things are going well in the program. This writer followed up with Executive Director regarding
some concerns youth raised during interviews which were:
 Shower in B Hall – water pressure is low. I was informed from one of the Program Managers that the Plumber is coming next month to fix it.
 One youth asked about wanting to go to church. Executive Director has been working on a plan, so youth can attend church regularly and is planning
on talking with the team about virtual visit options.
 Youth talked about wanting more snacks in between meals. I followed up with one of the program managers, and he stated that they get snacks at
8:30pm every night and during groups. It should be noted that youth get seconds on meals as well. I also spoke with the Executive Director
regarding the feedback I got from the youth.
 A youth shared that the food trap in the kitchen has not been cleaned for a while, which causes a foul odor when washing dishes. I followed up with
the Executive Director and one of the Program Managers regarding this youth’s feedback. The Program Manager stated that the food trap does get
cleaned. The Executive Director is following up with team regarding feedback received by licensing coordinator from the youth interviewed.
Observations
Staff and youth were observed at the programs during the unannounced review. The youth that were at the programs, appeared to be at ease
and comfortable in the environment. All areas of the program (inside and outside) where youth had access were observed to be well kept, clean
and in good repair. Medication was observed to be in locked medication carts behind locked rooms which was inaccessible to the youth.
2 |P ag e
Form Rev. 01/23/2023
Corrective Actions and Timeframes:
Please submit the following to verify compliance.
Within 45 days of receipt of this report Homestead 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 Jorge Pelinski @ jorge.l.pelinski@odhsoha.oregon.gov .
Licensing Coordinator’s Signature: ________________________ Date: ___________________
Manager Review: ______________________________________ Date: _7_-1_7_-_2_0_2_3_ _________
3 | P a g e
Form Rev. 01/23/2023

facility_type: Residential Care

licensing_coordinator: Jorge Pelinski

purpose:
Per OAR 419-400-0240 (1)(b) Children's Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Comments
Unannounced Site Visit 10/26/2023 Findings
Further Action
Needed
Physical Plant Yes[ ] No Agency used an epoxy finish, versus silicone caulking, for a more permanent fix.
413-215-0511(2)(a) &(c) Buildings are
smoke free, clean and in good repair
Sometime after the bathroom partition
was repaired (see above), the material
used to patch the partition was removed
by youth in care.
The program shall repair the hole in a
way that is less susceptible to being re-
damaged.

New Findings from Site Visit Comments
No new findings and previous finding have been addressed.
Interview Summary
During the unannounced review I met with two youth and interviewed

interview_summary:
During the unannounced review I met with two youth and interviewed Executive Director, Elisa Doebler-Irvine.
- Both youths interviewed stated things were going well at the program.
- Both youths enjoy going on outings. Both youths enjoy playing sports and going on community outings. Both youths confirmed that they receive
enough food to eat, and snacks are provided regularly.
- Both youths make daily phone calls.
- Both youths feel respected in the program.
- Both youths feel safe in the program and feel comfortable talking with staff.
Executive Director reported that several youths were acting overly aggressive while "horse playing". All youth received consequences for their actions. No
injuries reported. Overall, the Executive Director shared that things are going well in the program. This writer followed up with Executive Director regarding
some concerns youth raised during interviews which were:
- Shower in B Hall - water pressure is low. I was informed from one of the Program Managers that the Plumber is coming next month to fix it.
- One youth asked about wanting to go to church. Executive Director has been working on a plan, so youth can attend church regularly and is planning
on talking with the team about virtual visit options.
- Youth talked about wanting more snacks in between meals. I followed up with one of the program managers, and he stated that they get snacks at
8:30pm every night and during groups. It should be noted that youth get seconds on meals as well. I also spoke with the Executive Director
regarding the feedback I got from the youth.
- A youth shared that the food trap in the kitchen has not been cleaned for a while, which causes a foul odor when washing dishes. I followed up with
the Executive Director and one of the Program Managers regarding this youth's feedback. The Program Manager stated that the food trap does get
cleaned. The Executive Director is following up with team regarding feedback received by licensing coordinator from the youth interviewed.

excerpt:
413-215-0511(2)(a) &(c) Buildings are
smoke free, clean and in good repair
Sometime after the bathroom partition
was repaired (see above), the material
used to patch the partition was removed
by youth in care.
The program shall repair the hole in a
way that is less susceptible to being re-
damaged.
New Findings from Site Visit Comments
No new findings and previous finding have been addressed.
No new findings and previous finding have been addressed.


summary: Unannounced - 03/07/2024

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Residential Care
Licensee: Homestead Youth & Family Services, Inc
Executive Director: Elisa Doebler-Irvine
Program Director(s): Joan Howard
Date of Unannounced: 3.07.2024
Licensing Coordinator: Jorge Pelinski & Todd Cooley
Other Regulatory or Accrediting Agencies: Oregon Youth Authority (OYA)
Purpose: Per OAR 419-400-0240 (1)(b) Children’s Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Comments
Unannounced Site Visit 06/29/2023 Findings
-No Findings Further Action
Needed
Yes☐ No✓
New Findings from Site Visit Comments
None
Form Rev. 11/14/2023 P age 1 | 3
Interview Summary
Two youths were interviewed during the site visit to the Launch Pad Program:
• The two youths interviewed are 17 and 19 years old. One youth has been there for 15 months, and the other youth has been to the program twice for
a total amount of time greater than two years.
• These youth appreciate always having someone to talk with, the rewards for doing well, and one youth felt that the rules are fair. Another youth felt
supported at the program. This youth also expressed that he benefits from the treatment groups offered at the program.
• For fun these youth like to play basketball, flag football, card games, Monopoly, and Spades.
• Youths reported that they are allowed two outgoing and two incoming calls per week. Calls between a youth and their parole & probation officer or
their attorney are not counted toward the two outgoing and incoming calls per week.
• Youths reported that they receive three meals a day with plenty of snacks.
• Youths reported that they are provided with soap, shampoo, and toothpaste as needed.
• Youth expressed that he feels comfortable talking to staff about any needs or concerns that may arise for him.
• Another youth expressed that he gets to have time in the community and wishes he could get more.
• Both youths expressed that they feel safe in the program.
Observations
Staff and youth were observed at the programs during the unannounced review. The youth that were at the programs appeared to be at ease
and comfortable in the environment. All areas of the program (inside and outside) where youth had access were observed to be well kept, clean
and mostly in good repair. Water fountain next to youth dining area is currently not working. Agency has taken steps to address the repair and
has ordered a new water fountain from Amazon. Medication was observed to be in locked medication carts in locked rooms, which are
inaccessible to the youth.
Form Rev. 11/14/2023 P age 2 | 3
Corrective Actions and Timeframes:
Please submit the following to verify compliance.
Within 45 days of receipt of this report Homestead Youth & Family Services, Inc. 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 Jorge Pelinski at Jorge.l.pelinski@odhsoha.oregon.gov.
Licensing Coordinator’s Signature: ________________________ Date: ____0_3_/1__9_/2_0_2_4_______
Manager Review: ______________________________________ Date: _3_-1_4_-_2_0_2_4__________
Form Rev. 11/14/2023 P age 3 | 3

licensee: Homestead Youth & Family Services, Inc

program_director: Joan Howard

purpose:
Per OAR 419-400-0240 (1)(b) Children's Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Comments
Unannounced Site Visit 06/29/2023 Findings
-No Findings Further Action
Needed
Yes[ ] No✓
New Findings from Site Visit Comments
None

Interview Summary
Two youths were interviewed during the site visit to the Launch Pad Program:
- The two youths interviewed are 17 and 19 years old. One youth has been there for 15 months, and the other youth has been to the program twice for
a total amount of time greater than two years.
- These youth appreciate always having someone to talk with, the rewards for doing well, and one youth felt that the rules are fair. Another youth felt
supported at the program. This youth also expressed that he benefits from the treatment groups offered at the program.
- For fun these youth like to play basketball, flag football, card games, Monopoly, and Spades.
- Youths reported that they are allowed two outgoing and two incoming calls per week. Calls between a youth and their parole & probation officer or
their attorney are not counted toward the two outgoing and incoming calls per week.
- Youths reported that they receive three meals a day with plenty of snacks.
- Youths reported that they are provided with soap, shampoo, and toothpaste as needed.
- Youth expressed that he feels comfortable talking to staff about any needs or concerns that may arise for him.
- Another youth expressed that he gets to have time in the community and wishes he could get more.
- Both youths expressed that they feel safe in the program.
Observations
Staff and youth were observed at the programs during the unannounced review. The youth that were at the programs appeared to be at ease
and comfortable in the environment. All areas of the program (inside and outside) where youth had access were observed to be well kept, clean
and mostly in good repair. Water fountain next to youth dining area is currently not working. Agency has taken steps to address the repair and
has ordered a new water fountain from Amazon. Medication was observed to be in locked medication carts in locked rooms, which are
inaccessible to the youth.