summary: Unannounced - 4 findings

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Licensee: West Linn Clementine
Executive Director: Melissa Peterson
Program Director(s): Miranda Acharya
Date of Unannounced: October 3, 2023
Licensing Coordinator: Holly Ivey
Other Regulatory or Accrediting Agencies: Oregon Health Authority
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
Findings
Further Action
Needed
Governance of the Agency419-400- Yes☐ No✓ The agency submitted a Letter of Correction, to the Licensing Coordinator addressing all
0040(2)(g) Approves annual budget. areas of non-compliance from the January 2023 report. The agency sent verification of the
of Board approval of the budget. Nothing further is required to be sent to the Licensing
• The board minutes submitted to Coordinator regarding this finding.
Licensing verified the budget was
reviewed by the board. However,
there was no documentation verifying
the board approved the budget. The
program must provide the Licensing
Coordinator with written
documentation, such as additional
board minutes, e-mails or a signed
letter, indicting the board’s approval of
the program’s budget.
Executive Director or Program Director Yes☐ No✓ The agency submitted a Letter of Correction to the Licensing Coordinator addressing all
419-400-0040(3)(g) Approval from BCU areas of non-compliance from the January 2023 report. The agency sent an approved
• A copy of documentation from the background check for the staff mentioned. Nothing further is required to be sent to the
ODHS Background Check Unit’s Licensing Coordinator regarding this finding.
1| P age
Form Rev. 01/23/2023
(BCU) approval of the Executive
Director must be submitted to the
Licensing Coordinator. At the review
the agency was awaiting a fitness
determination from the BCU.
Supplemental Information Provided by Yes☐ No✓ The agency submitted a Letter of Correction to the Licensing Coordinator addressing all
CCA Documents as indicated on the form areas of non-compliance from the January 2023 report. The agency sent approved
titled “Renewal Licensing Required background checks for the staff mentioned. Nothing further is required to be sent to the
Documents.” Licensing Coordinator regarding this finding.
• The program must provide the
Licensing Coordinator with
documentation of updated approvals
for Miranda Acharya and Staci
Fajardo from the ODHS Background
Check Unit (BCU).
Supplemental Information Provided by Yes☐ No✓ The agency submitted a Letter of Correction to the Licensing Coordinator, addressing all
CCA areas of non-compliance from the January 2023 report. The required policies were revised
All required policies and procedures as to meet the Licensing Rule requirements. Nothing further is required to be sent to the
identified in the “Umbrella Rules.” Licensing Coordinator regarding this finding.
Residential Care Safety 419-470-0080(3)(a) Yes☐ No✓ On October 3, 2023, Holly Ivey, Licensing Coordinator, conducted an unannounced
Evacuation drill occurs monthly under varying inspection, in which she observed the recent evacuation drills meet the rule requirement.
conditions, is retained 2 years and contains: The agency was found to be in compliance regarding the rule requirement.
(F) special conditions simulated.
• The documentation of some of the
evacuation drills was missing the
above required information.
Disclosures419-470-0160(2) Parent/guardian Yes☐ No✓ On October 3, 2023, Holly Ivey, Licensing Coordinator, conducted an unannounced
has acknowledged in writing: (c) Any policies inspection, in which she observed a few files of current youth. She observed that the
and procedures upon request. required disclosure was in the files reviewed. The agency was found to be in compliance
• The above required information was regarding the rule requirement.
missing on the consent document.
Records Relating to Restraint & Yes☐ No✓ On October 3, 2023, Holly Ivey, Licensing Coordinator conducted an unannounced
Involuntary Seclusion 419-400-0180(13)(e) inspection, in which she observed a few current files of youth. She observed that the
Each child caring agency shall provide notice required notice was in the files reviewed. The agency was found to be in compliance
regarding how to access the quarterly reports regarding the rule requirement.
to the parents or guardians of children in care
in the program. The child caring agency shall
provide the notice upon the child in care’s
admission and at least two times each year
thereafter.
2| P age
Form Rev. 01/23/2023
• Youth files reviewed didn’t contain
documentation to verify that the
above requirement had been met.
Records Relating to Restraint & Yes☐ No✓ On October 3, 2023, Holly Ivey, Licensing Coordinator conducted an unannounced
Involuntary Seclusion 419-400-0190(1) inspection, in which she observed a few current files of youth. She observed that the
Information provided to children in care required notice was in the files reviewed. The agency was found to be in compliance
relating to Restraint & Involuntary Seclusion regarding the rule requirement.
• Youth files reviewed didn’t contain
documentation to verify that the
above requirement had been met.
New Findings from Site Visit Comments
N/A
Interview Summary
Two leadership staff were informally interviewed by the Licensing Coordinator at the review. The two staff were Miranda Acharya, Program
Director, Staci Fajardo, Program Supervisor
Two youth were privately interviewed by the Licensing Coordinator at the review. The youth interviews consisted of the following
information obtained:
• When asked how things were going for them at the program the youth stated: “It’s going well,” It’s going really good.”
• When the youth were asked what they appreciated most about the program, the following was stated by the youth: “The program
has a good approach to the treatment process, and the therapists have been helpful to me.”, “I Feel safe going to the staff, and
being able to talk to them.”
• When the youth were asked what they enjoy doing for fun at the program, the following was stated by the youth: “I enjoy drawing
and listening to music.”, “I watch tv on the weekends, sometimes play games, take naps, puzzles, enjoy free time.”
• Both youth confirmed that they have daily contact with their approved contacts outside of the program and that their phone calls
are private.
• Both youth stated that they receive three meals a day and are provided three snacks a day. The youth stated: “I have enough to
eat, the food is ok.” “In the time I have been here we haven’t had a chef. Somedays the food is good, sometimes its frozen food
or it is served a little cold, it’s a little bit discouraging. I am always able to get enough food.”
Follow Up: After the youth interviews, Holly Ivey, Licensing Coordinator, spoke with Miranda Acharya, Program Director, about
the youths stated concern. Miranda confirmed that the chef no longer worked at the program, and they had recently rehired a
chef who started that week. She reported that line staff had been preparing the food and that they were doing their best to make
the meals. The food could get cold if the girls did not eat it when it was served hot, if they allowed it to sit on their plate, it would
get cold.
3| P age
Form Rev. 01/23/2023
• When asked if the program provides hygiene products if needed the youth stated, “Yes, they would provide it if needed.”, “I don’t
know, I ran out of toothpaste, and asked a friend who had an extra tube.”
Follow Up: On 10/4/23, Holly Ivey, Licensing Coordinator, sent an email to Miranda Acharya, Program Director asking if hygiene
products are provided to youth who are in need. She stated, “Yes, clients are provided personal hygiene products if they are in
need of them. We always have these items in stock if necessary. I can remind them of this in our weekly Community Meeting.”
Holly Ivey, responded, “Please remind the youth at the weekly meeting and at intake that they are available to them if they have a
need.”
• When asked if the youth felt respected by staff at the program. The youth stated the following: “yes, I feel respected by staff.”,
“Sometimes it depends on the staff. Some staff have been very unprofessional by talking about their own problems with the
clients. There have been some body comments occasionally made.” When asked by the Licensing Coordinator, to tell her more
about that she stated a staff communicated about the softness of her stomach. She said, “it feels soft.”
Follow Up: After the youth interviews, Holly Ivey, Licensing Coordinator, spoke with Miranda Acharya, Program Director, about
the youths stated concern. Miranda reported the staff was assessing the youth for constipation, the youth took the soft to mean
“fat” the staff was letting the youth know she was not constipated. It was in the staff’s job duties to check stomachs for
constipation. Miranda was aware of the youth’s concern and had looked into the matter previously.)
The youth stated, “A select few staff (she was not willing to provide names of staff) who I feel uncomfortable around due to body
comments, and it has been brought up a few times with staff. We have been told things are going on in the background to
address it with staff, but we don’t know more about it.” The youth stated, “I haven’t specifically heard anything else about body
comments other than a youth stating she had a lot of food on her plate and a staff saying, “Ya that is a lot of food.” The girl was
already stressed about the amount of food on her plate. The staff is no longer working here.”
Follow Up: After the youth interviews, Holly Ivey, Licensing Coordinator, spoke with Miranda Acharya, Program Director, about
the youths stated concern. Miranda stated, “When private professional issues arise, I can’t tell the girls things are being followed
up on with staff when I hear things, I address it with staff and can not disclose what is being said to the girls.” Miranda stated, “I
followed up with the staff regarding the statement made about the amount of food on the plate.”
• When the youth were asked what they would change about the program, the following was stated by the youth: “For the clients
be more respectful to the staff.” “I would change the way staff are trained. The staff run everything, set food out, get everything
scheduled. It’s good to have consistency. When staff don’t do that well, its distressing. When done well, it is helpful.” When
Holly Ivey, the Licensing Coordinator, asked, “What does “not done well” look like?” The youth stated, “Late to meals, snacks
going to bed, late getting up, it just messes things up.”
Follow Up: After the youth interviews, Holly Ivey, Licensing Coordinator spoke with Miranda Acharya, Program Director about
the youths stated concern. Miranda stated, “I work with the staff on being consistent. It is always an area of growth to be
consistent, the staff have trainings around nighttime routines. There are times when youth are not aware of certain
circumstances, for instance if clients wet their bed, we utilize a 1:1 staff while other staff run morning routines, which can slow the
routine down at times. Consistency is always an area of growth. Sixty percent of the staff has recently been out sick, which with
on call staff can affect the routine as well.”
• Both youth reported feeling safe at the program. One youth stated, “I’ve felt a level of discomfort, but safety I always have felt. I
have felt discomfort from inconsistency from a Recovery Coach that isn’t well trained, and it can be uncomfortable. I still feel safe
in the house. The program has been understaffed recently only one or two Recovery Coaches at night, it depends if the night will
go smoothly, and people go to bed. There’s been rough nights with people not able to help with emotional supportive people
4| P age
Form Rev. 01/23/2023
getting the right food snack or food portioning.” When Holly Ivey, the Licensing Coordinator, asked the youth to tell her more
about staff not providing emotional support, the youth stated, “There was a girl who was having a panic attack or something.
The Recovery Coach wasn’t able to help and called the client sensitive. This held everyone up from going to bed. It created an
uncomfortable environment; it held us from our bedtime routine by an extra half an hour. “
Follow Up: After the youth interviews, Holly Ivey, Licensing Coordinator, spoke with Miranda Acharya, Program Director, about
the youths stated concern. Miranda stated, “I am aware of the situation. The staff no longer works here. In my follow up with the
staff it was reported that she had told the girls” Its ok, she is just a sensitive person.” After the comment the girls swore at the
staff and another staff switched her out during the situation. The staff received 1:1 feedback with the lead therapist about the
situation.” The Licensing Coordinator, following up with Miranda the program has been staffed at 2:12 at overnight hours, and
1:7 in daytime hours. This meets the Licensing Staffing Rule Requirements.
Observations
A walk through of the site was conducted by the Licensing Coordinator. The youth at the programs were observed 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. The program has a commercial cleaning company that cleans the facility three times a week. The cleaning
company also washes and changes the youth’s linens and towels. Food was observed to be in the refrigerator and in the pantry. The
program has a chef who is responsible for the meals, which are prepared fresh onsite. The program has a dietitian that ensures the
residents receive proper nutrition. Medication was observed to be locked up and inaccessible to the youth.
Corrective Actions and Timeframes:
Please submit the following to verify compliance.
Within 45 days of receipt of this report West Linn Clementine, 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 Holly.r.ivey@odhaoha.oregon.gov.
Licensing Coordinator’s Signature: ________________________ Date: _1_1_-_1_-2__0_2_3_ _________
Manager Review: ______________________________________ Date: _1_1_-_1_-2__0_2_3_ ________
5| P age
Form Rev. 01/23/2023

report_type: Unannounced

licensee: West Linn Clementine

executive_director: Melissa Peterson

program_director: Miranda Acharya

visit_date: October 3, 2023

other_regulatory_agencies: Oregon Health Authority

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
Findings
Further Action
Needed
Governance of the Agency419-400- Yes[ ] No✓ The agency submitted a Letter of Correction, to the Licensing Coordinator addressing all
0040(2)(g) Approves annual budget. areas of non-compliance from the January 2023 report. The agency sent verification of the
of Board approval of the budget. Nothing further is required to be sent to the Licensing
- The board minutes submitted to Coordinator regarding this finding.
Licensing verified the budget was
reviewed by the board. However,
there was no documentation verifying
the board approved the budget. The
program must provide the Licensing
Coordinator with written
documentation, such as additional
board minutes, e-mails or a signed
letter, indicting the board's approval of
the program's budget.

interview_summary:
Two leadership staff were informally interviewed by the Licensing Coordinator at the review. The two staff were Miranda Acharya, Program
Director, Staci Fajardo, Program Supervisor
Two youth were privately interviewed by the Licensing Coordinator at the review. The youth interviews consisted of the following
information obtained:
- When asked how things were going for them at the program the youth stated: "It's going well," It's going really good."
- When the youth were asked what they appreciated most about the program, the following was stated by the youth: "The program
has a good approach to the treatment process, and the therapists have been helpful to me.", "I Feel safe going to the staff, and
being able to talk to them."
- When the youth were asked what they enjoy doing for fun at the program, the following was stated by the youth: "I enjoy drawing
and listening to music.", "I watch tv on the weekends, sometimes play games, take naps, puzzles, enjoy free time."
- Both youth confirmed that they have daily contact with their approved contacts outside of the program and that their phone calls
are private.
- Both youth stated that they receive three meals a day and are provided three snacks a day. The youth stated: "I have enough to
eat, the food is ok." "In the time I have been here we haven't had a chef. Somedays the food is good, sometimes its frozen food
or it is served a little cold, it's a little bit discouraging. I am always able to get enough food."
Follow Up: After the youth interviews, Holly Ivey, Licensing Coordinator, spoke with Miranda Acharya, Program Director, about
the youths stated concern. Miranda confirmed that the chef no longer worked at the program, and they had recently rehired a
chef who started that week. She reported that line staff had been preparing the food and that they were doing their best to make
the meals. The food could get cold if the girls did not eat it when it was served hot, if they allowed it to sit on their plate, it would
get cold.

- When asked if the program provides hygiene products if needed the youth stated, "Yes, they would provide it if needed.", "I don't
know, I ran out of toothpaste, and asked a friend who had an extra tube."
Follow Up: On 10/4/23, Holly Ivey, Licensing Coordinator, sent an email to Miranda Acharya, Program Director asking if hygiene
products are provided to youth who are in need. She stated, "Yes, clients are provided personal hygiene products if they are in
need of them. We always have these items in stock if necessary. I can remind them of this in our weekly Community Meeting."
Holly Ivey, responded, "Please remind the youth at the weekly meeting and at intake that they are available to them if they have a
need."
- When asked if the youth felt respected by staff at the program. The youth stated the following: "yes, I feel respected by staff.",
"Sometimes it depends on the staff. Some staff have been very unprofessional by talking about their own problems with the
clients. There have been some body comments occasionally made." When asked by the Licensing Coordinator, to tell her more
about that she stated a staff communicated about the softness of her stomach. She said, "it feels soft."
Follow Up: After the youth interviews, Holly Ivey, Licensing Coordinator, spoke with Miranda Acharya, Program Director, about
the youths stated concern. Miranda reported the staff was assessing the youth for constipation, the youth took the soft to mean
"fat" the staff was letting the youth know she was not constipated. It was in the staff's job duties to check stomachs for
constipation. Miranda was aware of the youth's concern and had looked into the matter previously.)
The youth stated, "A select few staff (she was not willing to provide names of staff) who I feel uncomfortable around due to body
comments, and it has been brought up a few times with staff. We have been told things are going on in the background to
address it with staff, but we don't know more about it." The youth stated, "I haven't specifically heard anything else about body
comments other than a youth stating she had a lot of food on her plate and a staff saying, "Ya that is a lot of food." The girl was
already stressed about the amount of food on her plate. The staff is no longer working here."
Follow Up: After the youth interviews, Holly Ivey, Licensing Coordinator, spoke with Miranda Acharya, Program Director, about
the youths stated concern. Miranda stated, "When private professional issues arise, I can't tell the girls things are being followed
up on with staff when I hear things, I address it with staff and can not disclose what is being said to the girls." Miranda stated, "I
followed up with the staff regarding the statement made about the amount of food on the plate."
- When the youth were asked what they would change about the program, the following was stated by the youth: "For the clients
be more respectful to the staff." "I would change the way staff are trained. The staff run everything, set food out, get everything
scheduled. It's good to have consistency. When staff don't do that well, its distressing. When done well, it is helpful." When
Holly Ivey, the Licensing Coordinator, asked, "What does "not done well" look like?" The youth stated, "Late to meals, snacks
going to bed, late getting up, it just messes things up."
Follow Up: After the youth interviews, Holly Ivey, Licensing Coordinator spoke with Miranda Acharya, Program Director about
the youths stated concern. Miranda stated, "I work with the staff on being consistent. It is always an area of growth to be
consistent, the staff have trainings around nighttime routines. There are times when youth are not aware of certain
circumstances, for instance if clients wet their bed, we utilize a 1:1 staff while other staff run morning routines, which can slow the
routine down at times. Consistency is always an area of growth. Sixty percent of the staff has recently been out sick, which with
on call staff can affect the routine as well."
- Both youth reported feeling safe at the program. One youth stated, "I've felt a level of discomfort, but safety I always have felt. I
have felt discomfort from inconsistency from a Recovery Coach that isn't well trained, and it can be uncomfortable. I still feel safe
in the house. The program has been understaffed recently only one or two Recovery Coaches at night, it depends if the night will
go smoothly, and people go to bed. There's been rough nights with people not able to help with emotional supportive people

getting the right food snack or food portioning." When Holly Ivey, the Licensing Coordinator, asked the youth to tell her more
about staff not providing emotional support, the youth stated, "There was a girl who was having a panic attack or something.
The Recovery Coach wasn't able to help and called the client sensitive. This held everyone up from going to bed. It created an
uncomfortable environment; it held us from our bedtime routine by an extra half an hour. "
Follow Up: After the youth interviews, Holly Ivey, Licensing Coordinator, spoke with Miranda Acharya, Program Director, about
the youths stated concern. Miranda stated, "I am aware of the situation. The staff no longer works here. In my follow up with the
staff it was reported that she had told the girls" Its ok, she is just a sensitive person." After the comment the girls swore at the
staff and another staff switched her out during the situation. The staff received 1:1 feedback with the lead therapist about the
situation." The Licensing Coordinator, following up with Miranda the program has been staffed at 2:12 at overnight hours, and
1:7 in daytime hours. This meets the Licensing Staffing Rule Requirements.

observations:
A walk through of the site was conducted by the Licensing Coordinator. The youth at the programs were observed 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. The program has a commercial cleaning company that cleans the facility three times a week. The cleaning
company also washes and changes the youth's linens and towels. Food was observed to be in the refrigerator and in the pantry. The
program has a chef who is responsible for the meals, which are prepared fresh onsite. The program has a dietitian that ensures the
residents receive proper nutrition. Medication was observed to be locked up and inaccessible to the youth.

previous_findings:
Repeat Comments
Findings
Further Action
Needed
Governance of the Agency419-400- Yes[ ] No✓ The agency submitted a Letter of Correction, to the Licensing Coordinator addressing all
0040(2)(g) Approves annual budget. areas of non-compliance from the January 2023 report. The agency sent verification of the
of Board approval of the budget. Nothing further is required to be sent to the Licensing
- The board minutes submitted to Coordinator regarding this finding.
Licensing verified the budget was
reviewed by the board. However,
there was no documentation verifying
the board approved the budget. The
program must provide the Licensing
Coordinator with written
documentation, such as additional
board minutes, e-mails or a signed
letter, indicting the board's approval of
the program's budget.
Executive Director or Program Director Yes[ ] No✓ The agency submitted a Letter of Correction to the Licensing Coordinator addressing all
419-400-0040(3)(g) Approval from BCU areas of non-compliance from the January 2023 report. The agency sent an approved
- A copy of documentation from the background check for the staff mentioned. Nothing further is required to be sent to the
ODHS Background Check Unit's Licensing Coordinator regarding this finding.

(BCU) approval of the Executive
Director must be submitted to the
Licensing Coordinator. At the review
the agency was awaiting a fitness
determination from the BCU.
Supplemental Information Provided by Yes[ ] No✓ The agency submitted a Letter of Correction to the Licensing Coordinator addressing all
CCA Documents as indicated on the form areas of non-compliance from the January 2023 report. The agency sent approved
titled "Renewal Licensing Required background checks for the staff mentioned. Nothing further is required to be sent to the
Documents." Licensing Coordinator regarding this finding.
- The program must provide the
Licensing Coordinator with
documentation of updated approvals
for Miranda Acharya and Staci
Fajardo from the ODHS Background
Check Unit (BCU).
Supplemental Information Provided by Yes[ ] No✓ The agency submitted a Letter of Correction to the Licensing Coordinator, addressing all
CCA areas of non-compliance from the January 2023 report. The required policies were revised
All required policies and procedures as to meet the Licensing Rule requirements. Nothing further is required to be sent to the
identified in the "Umbrella Rules." Licensing Coordinator regarding this finding.
Residential Care Safety 419-470-0080(3)(a) Yes[ ] No✓ On October 3, 2023, Holly Ivey, Licensing Coordinator, conducted an unannounced
Evacuation drill occurs monthly under varying inspection, in which she observed the recent evacuation drills meet the rule requirement.
conditions, is retained 2 years and contains: The agency was found to be in compliance regarding the rule requirement.
(F) special conditions simulated.
- The documentation of some of the
evacuation drills was missing the
above required information.
Disclosures419-470-0160(2) Parent/guardian Yes[ ] No✓ On October 3, 2023, Holly Ivey, Licensing Coordinator, conducted an unannounced
has acknowledged in writing: (c) Any policies inspection, in which she observed a few files of current youth. She observed that the
and procedures upon request. required disclosure was in the files reviewed. The agency was found to be in compliance
- The above required information was regarding the rule requirement.
missing on the consent document.
Records Relating to Restraint & Yes[ ] No✓ On October 3, 2023, Holly Ivey, Licensing Coordinator conducted an unannounced
Involuntary Seclusion 419-400-0180(13)(e) inspection, in which she observed a few current files of youth. She observed that the
Each child caring agency shall provide notice required notice was in the files reviewed. The agency was found to be in compliance
regarding how to access the quarterly reports regarding the rule requirement.
to the parents or guardians of children in care
in the program. The child caring agency shall
provide the notice upon the child in care's
admission and at least two times each year
thereafter.

- Youth files reviewed didn't contain
documentation to verify that the
above requirement had been met.
Records Relating to Restraint & Yes[ ] No✓ On October 3, 2023, Holly Ivey, Licensing Coordinator conducted an unannounced
Involuntary Seclusion 419-400-0190(1) inspection, in which she observed a few current files of youth. She observed that the
Information provided to children in care required notice was in the files reviewed. The agency was found to be in compliance
relating to Restraint & Involuntary Seclusion regarding the rule requirement.
- Youth files reviewed didn't contain
documentation to verify that the
above requirement had been met.
New Findings from Site Visit Comments
N/A

excerpt:
419-400-0190(1) inspection, in which she observed a few current files of youth. She observed that the
Information provided to children in care required notice was in the files reviewed. The agency was found to be in compliance
relating to Restraint & Involuntary Seclusion regarding the rule requirement.
- Youth files reviewed didn't contain
documentation to verify that the
above requirement had been met.
New Findings from Site Visit Comments
N/A
N/A


state: OR

facility_name: West Linn Clementine

summary: Unannounced - 12/09/2024

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Residential Care
Licensee: West Linn Clementine
Executive Director: Melissa Peterson
Program Director(s): Alicia Johnson
Date of Unannounced: December 9, 2024
Licensing Coordinator: Holly Ivey
Other Regulatory or Accrediting Agencies: Oregon Health Authority
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 10/03/2023 Findings
Further Action
Needed
There are no findings found from Yes☐ No✓
unannounced site visit 10/03/2023
New Findings from Site Visit Comments
N/A
Form Rev. 11/14/2023 P age 1 | 3
Interview Summary
Alicia Johnson, Program Director, was informally interviewed by the Licensing Coordinator at the review as she assisted with the walk through
of the program. Two youth were privately interviewed by the Licensing Coordinator at the review. The youth interviews consisted of the
following information obtained:
• When asked how things were going at the program the youth stated: “It’s alright”, “It’s going pretty good.”
• When asked what they appreciated most about the program, the following was stated by the youth: “The support, and care.” “I
really like the staff, most of them are really friendly. They are here to take care of us, they are really casual.”
• When asked what they enjoy doing for fun at the program, the following was stated by the youth: “Arts and crafts.” “Free time,
movie night, and going out on outings on Saturday.”
• Both youth confirmed that they have daily contact with their approved contacts outside of the program and that their phone calls
are private.
• Both youth stated that they receive three meals a day and are provided three snacks a day. The youth stated: “The food is
delicious; we have a personal chef.” “It’s ok, the food is not the type of cultural food I am used to.”
• Both youth stated they felt respected by staff and could ask staff if they had a need for something.
• When asked if the program provides hygiene products if needed the youth stated, “Yes, I brought mine from home.” “You can ask
staff if you need some, I brought mine from home.”
• When the youth were asked what they would change about the program, the following was stated by the youth: “The way they
have the program set up is pretty good, I wouldn’t change anything.” “More opportunities to connect with family. More efficient
cleaning of the bathroom downstairs, there was throw up on the toilet one day and I asked two different staff to clean it up and
they did not.” (Follow Up: After the youth interviews, Holly Ivey, Licensing Coordinator spoke with Alicia Johnson, Program
Director about the youths stated concern. Alicia, stated, she was unaware of the situation but would follow up with staff about the
concern. Holly Ivey, Licensing Coordinator, asked that if this happens in the future that staff address this in a timely manner.
Holly Ivey, Licensing Coordinator observed all bathrooms, and they were all clean the day of the unannounced.) The same youth
also stated, “Better quality food, a client’s chicken was unforkable.” (unable to stab the meat), “This has happened a few times.”
(Follow Up: After the youth interviews, Holly Ivey, Licensing Coordinator spoke with Alicia Johnson about the youths stated
concern. Alicia stated, she was unaware of the situation but would follow up with staff about the concern and send Holly Ivey a
follow up email.) The same youth also stated, “There was a girl in the program who had had some expired tasting cheese, she
told staff, and they got her some new cheese.” (Follow Up: Holly Ivey, Licensing Coordinator, notified Alicia Johnson about this
and asked that she follow up about the situation)
• Both youth reported feeling safe at the program. One youth stated, “Yes,I feel safe, I feel uncomfortable with a youth at the table.
I have told staff about it, but because of other residents’ needs, staff need to sit next to them, and I need to sit by the resident.”
(Follow Up: After the youth interviews, Holly Ivey, Licensing Coordinator spoke with Alicia Johnson about the youths stated
concern. Alicia stated she would follow up with staff about the concern and send Holly Ivey a follow up email.)
Form Rev. 11/14/2023 P age 2 | 3
Observations
A walk through of the site was conducted by the Licensing Coordinator. The youth at the programs were observed 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. The program has a commercial cleaning company that cleans the facility three times a week. The cleaning company also
washes and changes the youth’s linens and towels. Food was observed to be in the refrigerator and in the pantry. The program has a chef who
is responsible for the meals, which are prepared fresh onsite. The program has a dietitian that ensures the residents receive proper nutrition.
Medication was observed to be locked up and inaccessible to the youth.
Corrective Actions and Timeframes:
Please submit the following to verify compliance.
Within 45 days of receipt of this report West Linn Clementine 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 Holly Ivey at Holly.R.Ivey@odhsoha.oregon.gov.
Licensing Coordinator’s Signature: ________________________ Date: ____1_2_-_2_3_-_2_0_2_4______
Manager Review: ______________________________________ Date: ___1_2_-2__3_-2_0__2_4______
Form Rev. 11/14/2023 P age 3 | 3

agency_name: West Linn Clementine (WLC)

program_name: West Linn Clementine

program_type: (RC) Residential Care Programs

view_code: RC

facility_type: Residential Care

program_director: Alicia Johnson

visit_date: December 9, 2024

licensing_coordinator: Holly Ivey

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 10/03/2023 Findings
Further Action
Needed
There are no findings found from Yes[ ] No✓
unannounced site visit 10/03/2023
New Findings from Site Visit Comments
N/A

Interview Summary
Alicia Johnson, Program Director, was informally interviewed by the Licensing Coordinator at the review as she assisted with the walk through
of the program. Two youth were privately interviewed by the Licensing Coordinator at the review. The youth interviews consisted of the
following information obtained:
- When asked how things were going at the program the youth stated: "It's alright", "It's going pretty good."
- When asked what they appreciated most about the program, the following was stated by the youth: "The support, and care." "I
really like the staff, most of them are really friendly. They are here to take care of us, they are really casual."
- When asked what they enjoy doing for fun at the program, the following was stated by the youth: "Arts and crafts." "Free time,
movie night, and going out on outings on Saturday."
- Both youth confirmed that they have daily contact with their approved contacts outside of the program and that their phone calls
are private.
- Both youth stated that they receive three meals a day and are provided three snacks a day. The youth stated: "The food is
delicious; we have a personal chef." "It's ok, the food is not the type of cultural food I am used to."
- Both youth stated they felt respected by staff and could ask staff if they had a need for something.
- When asked if the program provides hygiene products if needed the youth stated, "Yes, I brought mine from home." "You can ask
staff if you need some, I brought mine from home."
- When the youth were asked what they would change about the program, the following was stated by the youth: "The way they
have the program set up is pretty good, I wouldn't change anything." "More opportunities to connect with family. More efficient
cleaning of the bathroom downstairs, there was throw up on the toilet one day and I asked two different staff to clean it up and
they did not." (Follow Up: After the youth interviews, Holly Ivey, Licensing Coordinator spoke with Alicia Johnson, Program
Director about the youths stated concern. Alicia, stated, she was unaware of the situation but would follow up with staff about the
concern. Holly Ivey, Licensing Coordinator, asked that if this happens in the future that staff address this in a timely manner.
Holly Ivey, Licensing Coordinator observed all bathrooms, and they were all clean the day of the unannounced.) The same youth
also stated, "Better quality food, a client's chicken was unforkable." (unable to stab the meat), "This has happened a few times."
(Follow Up: After the youth interviews, Holly Ivey, Licensing Coordinator spoke with Alicia Johnson about the youths stated
concern. Alicia stated, she was unaware of the situation but would follow up with staff about the concern and send Holly Ivey a
follow up email.) The same youth also stated, "There was a girl in the program who had had some expired tasting cheese, she
told staff, and they got her some new cheese." (Follow Up: Holly Ivey, Licensing Coordinator, notified Alicia Johnson about this
and asked that she follow up about the situation)
- Both youth reported feeling safe at the program. One youth stated, "Yes,I feel safe, I feel uncomfortable with a youth at the table.
I have told staff about it, but because of other residents' needs, staff need to sit next to them, and I need to sit by the resident."
(Follow Up: After the youth interviews, Holly Ivey, Licensing Coordinator spoke with Alicia Johnson about the youths stated
concern. Alicia stated she would follow up with staff about the concern and send Holly Ivey a follow up email.)

Observations
A walk through of the site was conducted by the Licensing Coordinator. The youth at the programs were observed 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. The program has a commercial cleaning company that cleans the facility three times a week. The cleaning company also
washes and changes the youth's linens and towels. Food was observed to be in the refrigerator and in the pantry. The program has a chef who
is responsible for the meals, which are prepared fresh onsite. The program has a dietitian that ensures the residents receive proper nutrition.
Medication was observed to be locked up and inaccessible to the youth.


summary: License Renewals - 7 findings

raw_content:
Licensed Child Caring Agency Site Visit Report
Residential Care
Licensee: West Linn Clementine Date of site visit: January 13, 2025
Executive Director: Amanda Soden Licensing Coordinator: Holly Ivey, with Jorge Pelinski
Other Regulatory or Accrediting Agencies: The Oregon Health Authority
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): West Linn Clementine is a residential facility exclusively for adolescent girls seeking treatment for multiple eating
disorders or exercise addiction. They offer medical and psychiatric care integrated with personalized clinical and nutritional care as well as
academic and family support. The program offers 24 hour on-site medical oversight and nursing care, weekly medical monitoring, 24-hour access
to psychiatrists, medication management, family involvement, individual and group counselling sessions and weekly nutrition and cooking groups.
The program serves females, ages 11-17 with a capacity of 12.
Program type and services: Residential Services that specialize in eating disorders treatment.
Capacity and Age Range: 12 youth, ages 11-17 years old.
Funding sources: Medicaid, private insurance, Oregon Health Plan and private pay.
Contracts and sources for referrals: Contracts with insurance companies.
Average length of stay: The average length of stay is 55 days.
Average daily population served: The average daily population is 11 youth.
Number of children served annually: Approximately 139 youth served.
Use of seclusion or restraint: N/A
P age 1 | 18
Form Rev. 1/2/2024
Interviews, Observations:
Staff Interviews:
The following staff were informally interviewed at the review: Amanda Soden, Regional Director, Alicia Johnson, Clinical Director, and Bronwyn
Hassall, Program Manager.
Youth Interviews:
Two youth were privately interviewed by Jorge Pelinski, Licensing Coordinator, at the review. The youth interviews consisted of the following
information obtained:
• Both youth stated things were going fine at the program.
• When the youth were asked what they appreciated most about the program, the following was stated by the youth:
o “It feels like a home like situation, and I like the set schedules of the daily activities.”
o “I appreciates all the help from staff, I feel accepted, and it feels like a safe place.”
• When the youth were asked what they enjoy doing for fun at the program, the following was stated:
o “Watch movies and TV, crocheting, drawing iconic scenes from Disney Movies,“
o “Making bracelets, coloring, journaling, movie nights, outings, car rides, going to Target.”
• Both youth confirmed that they have daily private phone calls with their approved contacts.
• Both youth stated that they receive three meals a day, and are provided three snacks a day.
• Both youth confirmed they receive hygiene products from the program if needed.
• Both youth stated they felt respected by staff at the program.
• When asked if there was anything they thought the Licensing Coordinator should know that wasn’t previously asked one youth
stated, “It was my decision to come to treatment.”
• When the youth were asked what they would change about the program, the following was stated:
o “I wish I could have my personal cell phone.”
o “The ability to have a treatment group that deals with the outside world.”
• Both youth stated they felt safe at the program.
Observations:
A walk through of the site was conducted by Jorge Pelinski, Licensing Coordinator. The youth at the programs were observed 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. The program has a commercial cleaning company that cleans the facility three times a week. The cleaning company also washes and
changes the youth’s linens and towels. The agency vehicles that the youth ride in were observed and met all the requirements per Licensing Rules.
Food was observed to be in the refrigerator and in the pantry. The program has a chef who is responsible for the meals, which are prepared fresh
onsite. The program has a dietitian that ensures the residents receive proper nutrition. Medications were observed to be locked up and inaccessible
to the youth.
P age 2 | 18
Form Rev. 1/2/2024
Program Strengths: The following strengths were identified by leadership at the review:
“Positive outcomes data, positive client satisfaction, strong management and high quality of care.”
Program Challenges: The following challenges were identified by leadership at the review:
“The program has not experienced significant challenges.”
Changes that have occurred in the last 2 years: The following changes were stated by leadership at the time of the review:
“The program has some changes in staffing since last visit. No other significant changes have occurred.”
Lawsuits: None identified at the time of the review.
Grievances and complaints filed in the last two years: None identified at the time of the review.
Corrective Actions and Timeframes: Please submit the following to verify compliance.
Within 45 days of receipt of this report West Linn Clementine, 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 Holly Ivey at Holly.r.ivey@odhsoha.oregon.gov
.
Exceptions: N/A
Changes in License: N/A
Summary of Review
Program and Services
Yes No N/A Corrective Actions/Comments
419-400-0020 (2)
Program and services are in scope of license X
Governance of the Agency
Yes No N/A Corrective Actions/Comments
419-400-0040
(1)(a) Minimum of 5 board members X
(2)(f) Formally evaluate the exec. Director’s
X
performance annually
P age 3 | 18
Form Rev. 1/2/2024
(2)(g) Approves annual budget X
(2)(h) Obtain and review an annual
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
Yes No N/A Corrective Actions/Comments
419-400-0040
(3)(a) knowledge of requirements for
providing care and treatment appropriate to X
programs
(3)(g) Approval from BCU Executive Director or Program Director 419-400-0040(3)(g)
Approval from BCU
• The agency must submit updated background checks for the Regional
Director, Clinical Director, and Program Manager, as they were all recently
X
promoted into their positions. It was reported by the agency the
background checks were in process with the Background Check Unit when
the site report was completed.
Installation and Use of Video Equipment
Used to Monitor or Record Children in
Yes No N/A Corrective Actions/Comments
Care
419-400-0145
(1) If a child-caring agency installs video Installation and Use of Video Equipment Used to Monitor or Record Children in
equipment to monitor or record a child in Care 419-400-0145(1) If a child-caring agency installs video equipment to monitor or
care, all employees, volunteers, parents or record a child in care, all employees, volunteers, parents or guardians, and children in
guardians, and children in care must be X care must be informed about the intended use and locations of the equipment.
informed about the intended use and • The program utilizes outdoor video equipment and must meet the above
locations of the equipment. rule requirement.
Discipline, Behavior Management, and
Suicide Prevention Yes No N/A Corrective Actions/Comments
419-400-0150
(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
P age 4 | 18
Form Rev. 1/2/2024
(3)(e) Agency uses seclusion
X
appropriately/consistent with policy
(4) Agency has adequate plan in place to
X
respond to suicidal behavior/warning signs
Contractors (if applicable)
Yes No N/A Corrective Actions/Comments
419-400-0120(6)
(a) Agency ensures the contractor meets the
requirements of this rule and Chapter 413 X
division 215
(b)(B) Contract includes the following:
(i) Services provided
(ii) Contractor fees
(iii) Disclosure of information from contractor
to agency
(iv) Lines of authority X
(v) Adherence to rules, including background
check
(vi) Any liability of the agency for acts of the
contractor, rights of indemnity and limitations
on liability
Restraints and Involuntary Seclusion
Yes No N/A Corrective Actions/Comments
419-400-0180
(13)(d) Each child caring agency that
submits a report under this section shall
make its quarterly report available to the
X
public upon request at the Child Caring
Agency’s main office and on the child caring
agency’s website if applicable.
Supplemental Information Provided by
Yes No N/A Corrective Actions/Comments
CCA
Documents as indicated on the form titled
X
“Renewal Licensing Required Documents”
Documents as indicated on form titled Supplemental Information Provided by CCA Documents as indicated on form titled
“Required Financial Documents and “Required Financial Documents and Information”
X
Information” • The agency must submit an approved Tax Compliance Certificate.
All required policies and procedures as
X
identified in the “Umbrella Rules”
All required policies and procedures as
X
identified in “Agency Type Specific Rules”
Physical Plant
Yes No N/A Corrective Actions/Comments
419-400-0090(3)(a) Foster Rights Posted (if
X
children in DHS custody)
419-400-0100(1) Sufficient safe space,
X
equipment, and office equipment
P age 5 | 18
Form Rev. 1/2/2024
419-400-0230(12) License is posted in
X
common area at each facility
419-470-0020(2)(a) &(c) Buildings are
X
smoke free, clean and in good repair
419-470-0020 (2)(d) Rooms are free of
X
harmful drafts, odors, and excessive noise
419-470-0020 (2)(e) Rooms are adequate in
X
size and arrangement
419-470-0020 (2)(f) System provides a
continuous supply of hot and cold water to X
taps located throughout the facility
419-470-0020 (2)(h) Building is well
ventilated and room temperature is within a X
normal comfort range
419-470-0030 (1) All parts of the facility
X
ensure the safety of children
Room and Space Requirements
Yes No N/A Corrective Actions/Comments
419-470-0030
(2) There is a separate living room or lounge X
area – 15 SF minimum per child
(5) There is a separate dining room with X
capacity for ½ of children in care and 15 SF
per child in care
(7) Laundry is separate from living, kitchen, X
and dining areas
(8) Separate storage areas are provided for X
food, kitchen supplies, utensils, clean linens,
soiled linens and clothing, cleaning supplies
and equip, poisons, chemicals, outdoor
recreational and maintenance equipment.
(Hazardous materials are properly labeled, in
original container and locked)
(9) Outdoor activity area is protected from X
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 time X The program doesn’t employ time-out as an intervention.
out or quiet time must have adequate space,
heat, light and ventilation and must not be
capable of locking.
Room and Space Requirements
Bedrooms Yes No N/A Corrective Actions/Comments
419-470-0030(3)
(a) Adequate furnishings and personal items X
(b) Separate from rooms used for dining,
X
living, laundry, kitchen, and storage
P age 6 | 18
Form Rev. 1/2/2024
(c) Meet Oregon Fire Code Requirements X
(d) Be an outside room, with a window that
operates as designed. If the window is
modified from its original design, the fire
X
marshal must approve the modification and
indicate this room still meets applicable
Oregon Fire Code.
(d) Ceiling at least 90 inches X
(e) Minimum 60 SF per occupant X
(f) No more than 25 if dorm style X
(g) Permanently wired fixtures X
(h) Window covering X
Room and Space Requirements
Bathrooms Yes No N/A Corrective Actions/Comments
419-470-0030(4)
(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 be in good condition
and free of mold
Room and Space Requirements
Kitchen Yes No N/A Corrective Actions/Comments
419-470-0030(6)
(a) Used exclusively for storage, food
preparation, dishwashing, and activities
X
related to eating and food preparation
activities
(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
Furnishings and Personal Items
Yes No N/A Corrective Actions/Comments
419-470-0040
(1) There is a bed with frame, X
(1)(b) clean mattress in good condition,
X
with a minimum thickness of five inches
(1)(c) a pillow in good condition X
P age 7 | 18
Form Rev. 1/2/2024
(1)(d) a private dresser, closet, or similar
storage area for personal belongings that X
is readily accessible
(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
Yes No N/A Corrective Actions/Comments
419-470-0070
(1)(a) Meals are arranged daily, consistent
with normal mealtimes that occur during the
X
hours of operation and provide snacks
between mealtimes
(1)(b) Menus are prepared in advance in
accordance with USDA guidelines, provide a
X
variety of foods and are adjusted for
seasonal changes including snacks
(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.
Residential Care Safety
Yes No N/A Corrective Actions/Comments
419-470-0080
(2) Written emergency plan that includes X
(a) Identifying the types of emergencies most
likely to happen where the residential care X
agency is located
(b) Identifying a place to meet for each type
X
of emergency identified
(c) Identifying an alternate shelter if
X
necessary
(d) Ensuring access to necessary
X
medications or medical equipment
(e) How to help each child in care recover
X
after a disaster
P age 8 | 18
Form Rev. 1/2/2024
(3) Telephone numbers for local police, fire
department, poison control, after hours
medical advice and other appropriate X
emergency numbers must be posted near all
telephones.
(4) Operative flashlights sufficient in number
X
are readily available to staff
(5)(a) Evacuation drill occurs monthly under
varying conditions, is retained 2 years 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
Umbrella Safety
Yes No N/A Corrective Actions/Comments
419-400-0200
(5)(b) Vehicle has insurance policy, is smoke X
free, safe operating condition, and has first
aid kit and fire extinguisher 2-A:10-BC
(1)(b)(A) Each vehicle used to transport a X
child in care must be: properly registered,
covered by an insurance policy in full force
and effect, maintained in safe operating
condition, and smoke-free.
(3) If a child-caring agency has a swimming X The onsite swimming pool is no longer utilized, the gate is locked to the pool.
pool on the premises that is accessible to
children in care or if a child-caring agency
plans to have children in care engage in
swimming, 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 from X
potentially harmful items and materials.
(4)(b) Direct supervision of children who do X
not have the ability to adjust and control
water temperature
(4)(c) Light fixtures have protective covers X
unless designed to be used without one
Medication Yes No N/A Corrective Actions/Comments
P age 9 | 18
Form Rev. 1/2/2024
419-470-0100
(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
written order signed by a physician or
qualified medical professional. A written X
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
children and stored behind at least two
X
locking mechanisms. This does not apply to
Naloxone.
(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:
(a) name
(b) description
(c) dates and times
(d) missed doses X
(e) medication disposed
(f) method of administration
(g) ID of person administering
(h) possible adverse reactions
(i) medication taken outside facility
Extracurricular, Enrichment, Cultural &
Social Activities Yes No N/A Corrective Actions/Comments
419-470-0110
(2) Children have ongoing opportunities to X
participate in at least one age-appropriate or
developmentally appropriate activity
Minimum Staffing Requirements
Yes No N/A Corrective Actions/Comments
419-470-0130
P age 10 | 18
Form Rev. 1/2/2024
(1)&(2) Supervision is adequate for the type X
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 X There is always more than one staff on duty
additional staff immediately available with
max response time of 30 minutes
(5) There is at least one on-site employee X
authorized to apply the reasonable and
prudent parent standard
Sleeping Arrangements
Yes No N/A Corrective Actions/Comments
419-470-0140
(1) Children are in separate bedrooms than X
adults, unless parent and child, or there is
written approval from guardian/parent and
licensing coordinator
(2) There is adequate supervision of children X
when sleeping
(3) When assigning bedrooms a residential X
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
Personnel Files
Yes No N/A Corrective Actions/Comments
419-400-0120
Staff Name/Position X
P age 11 | 18
Form Rev. 1/2/2024
(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
X
and documented
(3)(d) Annual performance evaluations X
There were no formal personnel actions involving the employees who’s files were
(3)(f) Record of personnel actions X
reviewed.
(3)(g) Termination date, reason for The employee files reviewed didn’t include any employees who had been
X
termination terminated.
(3)(h) Current job description (1)(c)
Employee meets minimum qualifications X
stated in current job description
New Employee Orientation – Umbrella
Requirements (30 days) Yes No N/A Corrective Actions/Comments
419-400-0120(4)
(a) Agency policies and procedures X
(b) Ethical and professional guidelines X
(c) Suicide prevention and intervention X
(d) Attributes of population served X
(e) & (5)(a) to (c) Mandatory reporting that
includes:
(a) legal definition of child abuse in ORS
418.257 and 419B.005 X
(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 (Prior to working alone and
Yes No N/A Corrective Actions/Comments
within 30 days)
419-470-0120(1)
(a) Discipline and behavior management
including de-escalation, crisis prevention,
positive behavior management, and X
disciplinary techniques that are non-punitive
in nature
(b) CPR and First Aid sufficient to retain a
X
current certification
(c) Universal precautions and hygiene X
P age 12 | 18
Form Rev. 1/2/2024
(d) Application of the reasonable and
X
prudent parent standard
(e) Training on the agency’s policy on
suicide prevention and suicide risk X
assessment tool
Crisis Intervention Training Standards
and Certification Yes No N/A Corrective Actions/Comments
419-400-0160(4) (as applicable)
(a)Complete a minimum of 12 hours of initial
training in person from a certified instructor,
including but not limited to a minimum of six
hours of training focused on positive
X The program doesn’t utilize physical restraint.
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:
(A) The dates during which the certification
is current
(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 X The program doesn’t utilize physical restraint.
(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:
(A) Must be personal to the individual
certified by the training provider X The program doesn’t utilize physical restraint.
(B) May be valid for no more than two years
with recertification
Ongoing Training Yes No N/A Corrective Actions/Comments
419-470-0070(2)(b) Employees who handle
food served to children have a valid food X
handler’s card
419-400-0200 (1) 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)
P age 13 | 18
Form Rev. 1/2/2024
419-470-0120 (2)(a) Environmental
X
emergencies
419-470-0120 (2)(b) Universal Precautions X
419-470-0120 (2)(c) Discipline and Behavior
X
Management
419-470-0120 (2)(d) Agency’s policy on
X
suicide prevention and risk assessment tool
419-470-0120 (3) Staff providing direct care
must maintain current CPR/First Aid X
certification
419-470-0120 (4) Designated staff
authorized to apply reasonable and prudent
X
parent standard are trained in application of
the standard
419-400-0120(5) Mandatory reporting
(annually) that includes:
(a) legal definition of child abuse in ORS
418.257 and 419B.005 X
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to
the employee
419-400-0160(4)(b) Receive continuing
education (as applicable on crisis
X
intervention training) from a certified
instructor on an annual basis
Comments:
Children’s Records Yes No N/A Corrective Actions/Comments
Health Services
419-470-0090
(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)
(4)(a) to (f) Medical exams (3 in first year of
life, 2,4,6,9,14) X
P age 14 | 18
Form Rev. 1/2/2024
(g) Have a physical examination within the
first 60 days after admission of a child in
care. Documentation of a physical X
examination having occurred within the
calendar year will meet this requirement.
Consents
Yes No N/A Corrective Actions/Comments
419-470-0160(1)
(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
(e) Allow access as defined in 419-400-0230
X
& 0240
(f) Impose a dress code X
Consents 419-470-0160(1) (g) Apply the reasonable and prudent parent standard.
(g) Apply the reasonable and prudent parent
X • The required consent was missing in the youth files reviewed.
standard
Disclosures
419-470-0160(2) Yes No N/A Corrective Actions/Comments
Parent/guardian has 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 request X
Authorizations
Yes No N/A Corrective Actions/Comments
419-470-0160(3)
(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.
P age 15 | 18
Form Rev. 1/2/2024
Information about Children in Care
419-400-0190(1) Yes No N/A Corrective Actions/Comments
Summary sheet contains the following:
Information about Children in Care 419-400-0190(1) Summary sheet contains the
following: (a) religious preference.
(a)The name, gender, date of birth, religious
X • The program includes religious information in an initial assessment;
preference, and previous address
however, religious preference must be stated on the summary sheet.
(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
different than the parents, and a copy of
X
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)
Service Planning
Yes No N/A Corrective Actions/Comments
419-470-0170(2)
(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 Service Planning 419-470-0170(2) (e) (A)&(B) Service plan within 60 days (parent,
(parent, guardian and child actively involved). guardian and child actively involved). Describes how child’s issues will be addressed,
Describes how child’s issues will be X anticipated outcomes, and reviewed by child and guardian/parent.
addressed, anticipated outcomes, and • Service plans were not consistently signed by parents to verify their
reviewed by child and guardian/parent. participation/involvement in the treatment plans.
(e)(C)&(D) Service plan is reviewed quarterly
and revised when information indicates other X
services should be provided
Case Management
Yes No N/A Corrective Actions/Comments
419-470-0170(3)
(a) Services are documented, progress
X
toward achieving goals is tracked
(c) Discharge summary must include: X
P age 16 | 18
Form Rev. 1/2/2024
(A)Current medications
(B)Name of the physician or qualified medical
professional who prescribed each medication
(C)Any outstanding medical or other
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 X
(f) Incident Reports X
Records Relating to Restraint &
Yes No N/A Corrective Actions/Comments
Involuntary Seclusion
419-400-0180 (12) Records X
419-400-0180(13)(e) Each child caring
agency shall provide notice regarding how to
access the quarterly reports to the parents or
guardians of children in care in the program. X
The 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 to
children in care relating to Restraint & X
Involuntary Seclusion
Financial Records
Yes No N/A Corrective Actions/Comments
419-470-0170(4)
Records contain date, amount, source, Financial Records 419-470-0170(4) signatures
X
purpose, signatures • The financial records did not have youth signatures.
Personal Possessions Records
Yes No N/A Corrective Actions/Comments
419-470-0170 (5)
Individual written inventory of all personal
possessions is maintained and updated as X
needed
Records and Documentation
Yes No N/A Corrective Actions/Comments
419-400-0140
(1) Stored safely X
(2) Permanent, legible, dated, and signed X
(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
X
includes:
P age 17 | 18
Form Rev. 1/2/2024
Name
Gender
Birth date
Names, addresses of parents or guardians
Dates of admission
Placement upon discharge
Comments:
Licensing Coordinator’s Signature: ________________________ Date: _____2_-2_4_-_2_0_2_5_ ______
Manager Review: ______________________________________ Date: ___
2
_
-
_
2
_
4
_
-
_
2
_
0
_
2
_
5
_______
P age 18 | 18
Form Rev. 1/2/2024

report_type: License Renewals

visit_date: January 13, 2025

licensing_coordinator: Holly Ivey, with Jorge Pelinski

other_regulatory_agencies: The Oregon Health Authority

capacity_age_range: 12 youth, ages 11-17 years old.

contracts_and_referrals: Contracts with insurance companies.

average_length_of_stay: The average length of stay is 55 days.

number_of_children_served_annually: Approximately 139 youth served.

use_of_seclusion_or_restraint: N/A P age 1 | 18

interviews_observations:
Staff Interviews:
The following staff were informally interviewed at the review: Amanda Soden, Regional Director, Alicia Johnson, Clinical Director, and Bronwyn
Hassall, Program Manager.
Youth Interviews:
Two youth were privately interviewed by Jorge Pelinski, Licensing Coordinator, at the review. The youth interviews consisted of the following
information obtained:
- Both youth stated things were going fine at the program.
- When the youth were asked what they appreciated most about the program, the following was stated by the youth:
o "It feels like a home like situation, and I like the set schedules of the daily activities."
o "I appreciates all the help from staff, I feel accepted, and it feels like a safe place."
- When the youth were asked what they enjoy doing for fun at the program, the following was stated:
o "Watch movies and TV, crocheting, drawing iconic scenes from Disney Movies,"
o "Making bracelets, coloring, journaling, movie nights, outings, car rides, going to Target."
- Both youth confirmed that they have daily private phone calls with their approved contacts.
- Both youth stated that they receive three meals a day, and are provided three snacks a day.
- Both youth confirmed they receive hygiene products from the program if needed.
- Both youth stated they felt respected by staff at the program.
- When asked if there was anything they thought the Licensing Coordinator should know that wasn't previously asked one youth
stated, "It was my decision to come to treatment."
- When the youth were asked what they would change about the program, the following was stated:
o "I wish I could have my personal cell phone."
o "The ability to have a treatment group that deals with the outside world."
- Both youth stated they felt safe at the program.
Observations:
A walk through of the site was conducted by Jorge Pelinski, Licensing Coordinator. The youth at the programs were observed 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. The program has a commercial cleaning company that cleans the facility three times a week. The cleaning company also washes and
changes the youth's linens and towels. The agency vehicles that the youth ride in were observed and met all the requirements per Licensing Rules.
Food was observed to be in the refrigerator and in the pantry. The program has a chef who is responsible for the meals, which are prepared fresh
onsite. The program has a dietitian that ensures the residents receive proper nutrition. Medications were observed to be locked up and inaccessible
to the youth.
P age 2 | 18

program_strengths:
The following strengths were identified by leadership at the review:
"Positive outcomes data, positive client satisfaction, strong management and high quality of care."

program_challenges:
The following challenges were identified by leadership at the review:
"The program has not experienced significant challenges."

changes_in_last_two_years:
The following changes were stated by leadership at the time of the review:
"The program has some changes in staffing since last visit. No other significant changes have occurred."

excerpt:
(3)(g) Approval from BCU Executive Director or Program Director 419-400-0040(3)(g)
Approval from BCU
• The agency must submit updated background checks for the Regional
Director, Clinical Director, and Program Manager, as they were all recently
promoted into their positions. It was reported by the agency the
background checks were in process with the Background Check Unit when
the site report was completed.

excerpt:
(1) If a child-caring agency installs 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. Installation and Use of Video Equipment Used to Monitor or Record Children in
Care 419-400-0145(1) If a child-caring agency installs 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.
• The program utilizes outdoor video equipment and must meet the above
rule requirement.

excerpt:
Documents as indicated on form titled
“Required Financial Documents and
Information” Supplemental Information Provided by CCA Documents as indicated on form titled
“Required Financial Documents and Information”
• The agency must submit an approved Tax Compliance Certificate.

excerpt:
(g) Apply the reasonable and prudent parent
standard Consents 419-470-0160(1) (g) Apply the reasonable and prudent parent standard.
• The required consent was missing in the youth files reviewed.

excerpt:
(a)The name, gender, date of birth, religious
preference, and previous address Information about Children in Care 419-400-0190(1) Summary sheet contains the
following: (a) religious preference.
• The program includes religious information in an initial assessment;
however, religious preference must be stated on the summary sheet.

excerpt:
(e) (A)&(B) Service plan within 60 days
(parent, guardian and child actively involved).
Describes how child’s issues will be
addressed, anticipated outcomes, and
reviewed by child and guardian/parent. Service Planning 419-470-0170(2) (e) (A)&(B) Service plan within 60 days (parent,
guardian and child actively involved). Describes how child’s issues will be addressed,
anticipated outcomes, and reviewed by child and guardian/parent.
• Service plans were not consistently signed by parents to verify their
participation/involvement in the treatment plans.

excerpt:
Records contain date, amount, source,
purpose, signatures Financial Records 419-470-0170(4) signatures
• The financial records did not have youth signatures.


facility_name: The Academy at Sisters

summary: Unannounced - 10/26/2021

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Therapeutic Boarding School
Licensee: J Bar J Youth Services – The Academy at Sisters
Executive Director: Stephanie Alvstad
Program Director(s): Mindy Elliott / Sandy Vaughn
Board Chairperson: Jeannette McKenzie
Date of Unannounced: October 26th, 2021
Licensing Coordinator: Ed Wyller
Other Regulatory or Accrediting Agencies: Cognia Accreditation / National Association of Therapeutic Schools Programs, Inc (NATSAP) /
Council of Accreditation (COA)
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 12-16-2020 Findings
No Findings Further Action
Needed
New Findings from Site Visit Comments
No new findings N/A
1
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 200115)
Interview Summary
I interviewed four of the current fifteen students who were on-site during my unannounced site visit. I met individually with each student in a private space to
ensue privacy for the interview. Students reported liking the school. One student reported “really loves the school”. Students liked the teachers and the
support. Another student reported this is the best they have ever done in school. Another student who had graduated spoke about the opportunities of online
Central Oregon Community College. Students reported learning the following skills: coping skills, communication skills, setting and holding healthy
boundaries, and good vs. bad relationships in their treatment groups and individual counseling. One student spoke about their joy in working with a horse and
enjoys the equine therapy and caring for the horse. Students reported feeling safe. Two reported that when other students scream and yell, they don’t feel
safe at that moment but know they are not in danger. Students reported they feel they could talk with staff or therapists if feeling unsafe. Three of the four
students reported the food to be good. One student reported the chef is absent and food has become repetitive.
On a scale from 0-10 (0=worst program 10=best program) two students reported program to be a 5 and the other two reported program to an 8. Both of the 5
students and 8 student thought the program should have more phone calls early on and more incentives at the beginning of the program. One student
reported, “Really like it” referring to the program. Staff were reported to be nice and respectful by one student. Other students reported the night staff are
“crankier but respectful”. Other student’s reported felt that the night staff are not as caring and nice. Reported when asking questions that these staff are
“snippy and moody”. For fun students reported going hiking, shopping mall, walks, movies, wellness center, read, play cards, watch tv, and going to the pool.
Observations
When I arrived I observed students getting ready for lunch. All students and employees were wearing masks during my unannounced site visit. Interactions
observed between students and Academy staff were respectful. During the unannounced site visit I noted the following new additions at Sister’s Academy:
New mattresses, new bunk beds, new smart board in classroom, new science lab in school classroom, 8 new paddleboards / life vests, and new exercise
equipment in the wellness center. Another improvement is replacing carpet throughout the Academy. Carpet was in the process of being removed while I
was on-site and is going to be replaced with a new durable carpet.
At the conclusion of the unannounced site visit I debriefed with the Sisters Academy Administrative team. I discussed feedback from the four youth interviews.
The concern that was articulated was only one phone call per week during orientation phase. The frequency of phone calls will need to be increased, and the
team agreed. This led to a discussion regarding revamping the level system regarding incentives that correspond to each level.
Corrective Actions and Timeframes:
Please submit the following to verify compliance.
Within 45 days of receipt of this report J Bar J Youth Services must submit a letter of verification indicating the agency is in compliance with the
specific rules cited above and describing how compliance will be maintained going forward. Along with the letter of verification, the agency must
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:
2
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 200115)
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
Licensing Coordinator’s Signature: ________________________ Date: _____1_1__-1__7_-_2_0_2_1_ ___
11-17-2021
Manager Review: ______________________________________ Date: __________________
3
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 200115)

agency_name: J Bar J Youth Services (JBJYS)

program_name: The Academy at Sisters

program_type: (TBS) Therapeutic Boarding Schools

view_code: TBS

facility_type: Therapeutic Boarding School

licensee: J Bar J Youth Services - The Academy at Sisters

executive_director: Stephanie Alvstad

program_director: Mindy Elliott / Sandy Vaughn

board_chairperson: Jeannette McKenzie

visit_date: October 26th, 2021

licensing_coordinator: Ed Wyller

purpose:
Per OAR 413-215-0101 (1) (b) Children's Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings: Repeat Comments
Unannounced Site Visit 12-16-2020 Findings
No Findings Further Action
Needed
New Findings from Site Visit Comments
No new findings N/A
1

Interview Summary
I interviewed four of the current fifteen students who were on-site during my unannounced site visit. I met individually with each student in a private space to
ensue privacy for the interview. Students reported liking the school. One student reported "really loves the school". Students liked the teachers and the
support. Another student reported this is the best they have ever done in school. Another student who had graduated spoke about the opportunities of online
Central Oregon Community College. Students reported learning the following skills: coping skills, communication skills, setting and holding healthy
boundaries, and good vs. bad relationships in their treatment groups and individual counseling. One student spoke about their joy in working with a horse and
enjoys the equine therapy and caring for the horse. Students reported feeling safe. Two reported that when other students scream and yell, they don't feel
safe at that moment but know they are not in danger. Students reported they feel they could talk with staff or therapists if feeling unsafe. Three of the four
students reported the food to be good. One student reported the chef is absent and food has become repetitive.
On a scale from 0-10 (0=worst program 10=best program) two students reported program to be a 5 and the other two reported program to an 8. Both of the 5
students and 8 student thought the program should have more phone calls early on and more incentives at the beginning of the program. One student
reported, "Really like it" referring to the program. Staff were reported to be nice and respectful by one student. Other students reported the night staff are
"crankier but respectful". Other student's reported felt that the night staff are not as caring and nice. Reported when asking questions that these staff are
"snippy and moody". For fun students reported going hiking, shopping mall, walks, movies, wellness center, read, play cards, watch tv, and going to the pool.
Observations
When I arrived I observed students getting ready for lunch. All students and employees were wearing masks during my unannounced site visit. Interactions
observed between students and Academy staff were respectful. During the unannounced site visit I noted the following new additions at Sister's Academy:
New mattresses, new bunk beds, new smart board in classroom, new science lab in school classroom, 8 new paddleboards / life vests, and new exercise
equipment in the wellness center. Another improvement is replacing carpet throughout the Academy. Carpet was in the process of being removed while I
was on-site and is going to be replaced with a new durable carpet.
At the conclusion of the unannounced site visit I debriefed with the Sisters Academy Administrative team. I discussed feedback from the four youth interviews.
The concern that was articulated was only one phone call per week during orientation phase. The frequency of phone calls will need to be increased, and the
team agreed. This led to a discussion regarding revamping the level system regarding incentives that correspond to each level.

new_findings:
No new findings N/A
1