summary: License Renewals - 2 findings

raw_content:
Licensed Child Caring Agency Site Visit Report
Residential Care
Licensee: Looking Glass Community Services (LGCS) Date of site visit: June 13-14, 2023
Executive Director: Craig Opperman Licensing Coordinator: Todd Cooley
Board Chairperson: Daniel Lacoste
Other Regulatory or Accrediting Agencies: ODHS TxSvcs, OHA
Program Compliance: The program was found to be compliant or will be compliant with OAR 419-400-0005 to 419-400-0310, Licensing Umbrella
Rules, and OAR 419-470-0010 to 419-470-0180, Licensing Residential Care Agencies Rules. Personnel records were reviewed and compliance
with required background checks was documented for employees in all programs.
Program Description(s) as provided by Looking Glass:
Regional Crisis Center (RCC): Provides residential, subacute mental health treatment services for youth of all genders, ages 12 to 18. The length
of stay for youth can vary based on clinical need and treatment progress. Upon successful completion of the program youth will discharge to a
community-based setting.
Adjudicated Youth Services (AYS) aka Pathways Girls Program (PGP):
BRS Intensive Residential program (formerly level 5) that provides behavioral, mental health, and substance use treatment to youth age 12-20, on
parole or probation under the jurisdiction of the Oregon Youth Authority. AYS serves youth either assigned female at birth or those that identify as
female or non-binary. AYS operates under a Restorative Justice and Acceptance and Commitment Therapy (ACT) framework that emphasizes
repairing harm and living by core values.
The program includes individual, family, and group counseling as well as individual and group skills training. Most youth stay an average of 6 to 9
months before graduating from the program and moving to a lower level of care, often in the community. Referrals come solely from the Oregon
Youth Authority, and on rare occasions, child welfare.
Program type and services:
Regional Crisis Center (RCC):
Residential Treatment
The Regional Crisis Center provides 24-hour supervised group living combined with clinical treatment in a therapeutic setting. Youth learn new skills
and behaviors, and as they increase their responsibility, they are rewarded with privileges appropriate to the recovery process. Youth and families
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work with counselors to create individualized service and support plans to determine their goals and the activities to achieve them. These plans
address areas such as mood and behavior regulation, social skills, and family centered relational therapy.
Mental Health Treatment
The program will utilize evidence-based practices (EBP’s) to support youth within a structured and therapeutic environment. Under the guidance of
the Clinical Director and the Medical Director, the program provides a treatment model conducive to stabilization and progress specific to Individual
Service and Support Plans. All team members will be trained in the use of Collaborative Problem Solving and have access to additional EBP’s
based on individual client needs. Team members will also be trained in the use of the crisis intervention model Pro-ACT
Substance Use Disorders Treatment
Regional Crisis Center partners with trained staff from other Looking Glass programs to provide treatment for substance abuse and dependence
issues, if needed. Treatment may include individual and group work.
Academic Instruction/Education
The state-certified on-site school provides lessons in language arts, math, health education, living skills, speech/communications, and physical
education. Some youth prepare for GED tests while others earn credit toward high school diplomas.
Family Counseling
A youth’s family and/or caregivers are integral to successful treatment. Clinicians meet regularly with youth and their identified caregivers to assist
with communication and conflict resolution within the family dynamic. Youth and families will be building on already existing positive interactions and
supports. Parents and families are strongly encouraged to spend time observing and visiting the program. Home visits can be scheduled so that
families can make use of skills introduced in the program either at home or with the family.
Recreation
Youth participate in a variety of recreation experiences such as swimming, bowling, hiking and field trips. These activities allow youth to improve
trust, teamwork, and problem-solving skills. The activities are designed to demonstrate healthy and safe ways to have fun and release energy.
Adjudicated Youth Services (AYS)
Residential Treatment—Youth work with their case manager to create an individualized services plan which is reviewed every 45 days with their
entire treatment team. Youth follow a daily schedule that includes groups, school, recreation, and meals.
Mental health therapy—Youth complete a mental health assessment upon intake to the program through a credentialed mental health therapist that
informs their service plan and interventions in program. Youth then participate in weekly therapy to address mental health needs that impact
activities of daily living. Family therapy is also available and often recommended if the youth is returning to their family following successful
completion of program. The mental health therapist hosts one group per week where youth can process thoughts and emotions while gaining
support and camaraderie from their peers.
Substance Use treatment—Youth complete a substance use assessment upon intake by a CADC-I counselor which informs their service plan.
Youth then meet with their substance use counselor weekly (if recommended by assessment) to address recovery. Youth will create a relapse
prevention plan within this context.
Education—Youth attend school on site and work with a licensed teacher towards their high school diploma or GED through credit recovery, one on
one tutoring, and some group classes or activities.
Recreation—Youth participate in a variety of recreational activities including trips to the YMCA, local parks, walks, and community outings.
Capacity and Age Range:
Regional Crisis Center (RCC): 30 clients ages 12-18
Adjudicated Youth Services (AYS): 24 clients ages 12-20
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Funding sources:
Regional Crisis Center (RCC): Oregon Dept. of Human Service (ODHS)
Adjudicated Youth Services (AYS): Oregon Youth Authority (OYA)
Contracts and sources for referrals:
Regional Crisis Center (RCC): ODHS
Adjudicated Youth Services (AYS): OYA
Average length of stay:
Regional Crisis Center (RCC): 79 days
Adjudicated Youth Services (AYS): 136 days
Average daily population served:
Regional Crisis Center (RCC): 9
Adjudicated Youth Services (AYS): 5
Number of children served annually:
Regional Crisis Center (RCC): 73
Adjudicated Youth Services (AYS): 29
Use of seclusion or restraint:
Regional Crisis Center (RCC): Both. All staff are trained to Crisis Prevention Institute (CPI) standards.
Adjudicated Youth Services (AYS): No
Interviews, Observations:
Regional Crisis Center (RCC):
Interviews: The week prior to the review, licensing was on site at RCC and participated in a client interview conducted by Treatment Services Katie
Wyland. Two additional client interviews were conducted at the time of the review. The Treatment Services interview followed a template and was
intended to collect specific information for use by Treatment Services. The form and notes are on file with the report.
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The first client interviewed during the review had been at the program approximately two months. Client stated they did not feel very involved in
their service planning, but this was due to the client feeling like they were only there for substance abuse issues and not anything else the staff were
attempting to include in the overall service plan. Client also said they feel like nothing has been done to help them reach their goals. They stated
things have gotten worse and they have started self-harming due to a peer passing them a sharp. Staff were aware of this situation and took
necessary steps to resolve it. Client had access to medical/dental and had recently been seen by the dentist. Client did state they had been
involved in a restraint which had caused them some pain in their ribs. Client stated they did not see a doctor but were assessed by nursing staff.
Client felt school needed to be more structured and they mostly did art and did not have any core classes or actual assignments. Client is not in
high school so is unable to earn credits toward graduation. Management provided additional information on this and stated youth are able to let the
teacher’s know what areas they would like to study so there was opportunity for client to study core classes and request “homework” or
assignments. Client said they get large muscle exercise at least twice a day. Client stated sometimes their peers would make them feel unsafe due
to escalations, but staff are present and engaged. Client said there are a lot of personal items that get lost, but they had not had any of their own
personal items go missing. Client stated there wasn’t follow-up on several grievances they had filed (licensing following up with management on
resolutions from the grievances).
Second client interviewed has been at RCC for about three and a half months. They stated they feel involved in their service planning and have
learned to better cope with stress since being in the program. Client said they have recently been to both the doctor and dentist. Client stated
school was mostly good and they are working on math, science and reading. They felt the learning would be better on the computer instead of
paper. Client recently completed state testing at the program and feels there is plenty of adult help when needed for schoolwork. They trust staff,
especially Caitlin (“the big, big boss”) and felt mostly safe in the program. Client stated they feel respected by some staff and have several
favorites. They also said there are other staff who are not respectful and punish youth for no reason. Client was unable to provide any specific
examples. Client stated they wished there were more opportunities to be outside, but said they get enough exercise and physical activity.
Adjudicated Youth Services (AYS): Two clients were interviewed at AYS (Pathways Girls Program). The first client has been at the program over
nine months total, but is on their second stay. Client stated they feel safe in the program, but also had concerns with some staff. Client said some
staff are not professional and when discussing phone calls and phone use, put out to the group that client had a caseworker which client did not
want others to know about. Client also stated staff do not monitor conversations closely enough and there is a lot of inappropriate conversations
and body shaming that occurs and staff are not aware of it. Client isn’t currently in school due to graduating early and is excited about a potential
opportunity to volunteer at another Looking Glass program. Client said the food is decent and they get plenty to eat. Client relayed the groups are
not always relevant to their situation and sometimes finds difficulty participating. Client also said grads only have a life skills group which is very
repetitive. Client feels like any concerns they have can be taken to their case manager or the program manager and they help resolve or provide a
reason why things are the way they are. Client stated some staff don’t listen and make them feel disregarded. They said they are provided good
support within the treatment team.
Second client has been in the program approximately six weeks and said it is great so far. Client said staff are all really good and do their jobs.
Staff keep everyone safe and they really care about the clients. Client stated they have weekly chores and are expected to keep their rooms clean.
Client said school is great and they work a good pace for them. Client said sometimes there is not enough staff to facilitate phone calls. Client
stated staff monitor the calls and watch their body language but still feel like they have privacy within their conversation. Client wanted to have a
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little more outside time and also wished for a little more phone time. Client stated the food was delicious and depending on staff the portion sizes
were sometimes more generous. Client felt staff do a really great job of keeping everyone safe.
Program Strengths (per program):
Regional Crisis Center (RCC):
 Strong leadership team and highly trained staff.
 Ongoing crisis de-escalation and restraint/seclusion training well above and beyond CPI and licensing requirements.
 RCC strives for continuous education and accountability with cultural competency for staff and youth.
 Provides culturally equitable treatment and milieu.
 Strong and thorough documentation.
 A contract that covers the cost of care.
Adjudicated Youth Services (AYS):
 Passionate leadership and staff.
 Ongoing dedication to creating activities, off sites, and opportunities to have fun.
 AYS places an emphasis on education and accountability surrounding cultural competency.
 AYS prioritizes ensuring culturally equitable treatment.
Program Challenges (per program):
Regional Crisis Center (RCC):
• Recruitment and retention due to injury or trauma inducing events.
• Staff injuries/significant increase in insurance coverage.
• Youth being discharged who would have previously been able to be maintained safely in program due to Senate Bill 710/15
youth to the Emergency Department.
• Restraints are less secure causing an increased possibility of injury for clients and staff.
• OHA oversight of renovation contract which includes entering services/training requirements in contract that don’t align with OHA
licensing requirements.
• Securing increased reimbursement rates with statewide CCO’s.
Adjudicated Youth Services (AYS):
• Recruitment and retention due to rates of pay.
• Youth being discharged from program who would have previously been able to be maintained safely in program due to Senate
Bill 710. Program no longer uses restraint due to SB 710.
• Poor reimbursement rates.
• Low referrals.
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Changes that have occurred in the last 2 years (per program):
Regional Crisis Center (RCC):
• Program construction was completed to expand program and double capacity.
• Program switched from utilizing Pro-Act Training to CPI/NCI Training.
• Senate Bill 710 has caused an increase in emergency discharges and staff injuries.
Adjudicated Youth Services (AYS):
• Due to Senate Bill 710, all AYS programs are not trained in and do not perform restraints or hands on interventions of any kind.
Staff continue to be trained in Crisis Intervention, Evasion, and Holding Attacks.
• Leadership change.
Lawsuits:
Regional Crisis Center (RCC): None
Adjudicated Youth Services (AYS): None
Grievances and complaints filed in the last two years:
Regional Crisis Center (RCC): No major grievances. All grievances are on file and available for review.
Adjudicated Youth Services (AYS): No major grievances. All grievances are on file and available for review.
Corrective Actions and Timeframes: Please submit the following to verify compliance.
Within 45 days of receipt of this report (insert name of agency) must submit a letter of verification indicating the agency is in compliance with the
specific rules cited above and describing how compliance will be maintained going forward. Along with the letter of verification, the agency must
submit any and all specific documentation requested in the body of this report. The letter of verification and any additional requested documents can
be emailed directly to (Licensing Coordinator and email address).
Exceptions: All exceptions on file with licensing.
Changes in License: Increased capacity of RCC from 16 to 30
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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
(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 X
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
(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
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(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
(11)(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
“Required Financial Documents and X
Information”
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
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
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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
capacity for ½ of children in care and 15 SF X
per child in care
(7) Laundry is separate from living, kitchen,
X
and dining areas
(8) Separate storage areas are provided for
food, kitchen supplies, utensils, clean linens,
soiled linens and clothing, cleaning supplies
and equip, poisons, chemicals, outdoor X
recreational and maintenance equipment.
(Hazardous materials are properly labeled, in
original container and locked)
(9) Outdoor activity area is protected from
vehicles and other hazards and of a size and
X
availability appropriate to the age and needs
of children in care
(11) Time-out rooms: Rooms used for time
out or quiet time must have adequate space,
X
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
(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 - Exception on file with licensing
marshal must approve the modification and
indicate this room still meets applicable
Oregon Fire Code.
(d) Ceiling at least 90 inches X
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(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
(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
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(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
(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
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(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
free, safe operating condition, and has first X
aid kit and fire extinguisher 2-A:10-BC
(1)(b)(A) Each vehicle used to transport a
child in care must be: properly registered,
covered by an insurance policy in full force X
and effect, maintained in safe operating
condition, and smoke-free.
(3) If a child-caring agency has a swimming
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
X
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
not have the ability to adjust and control X
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
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 X
therapy, physical aides or limitations have a
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written order signed by a physician or
qualified medical professional. A written
order, signed by a physician or qualified
medical professional, is also required before
a restriction on diet or physical activity is
imposed.
(7)(c) Medications are inaccessible to
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
participate in at least one age-appropriate or X
developmentally appropriate activity
Minimum Staffing Requirements
Yes No N/A Corrective Actions/Comments
419-470-0130
(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. X
Minimum ratios are maintained:
Under 30 months of age: 1:4
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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
additional staff immediately available with X
max response time of 30 minutes
(5) There is at least one on-site employee
authorized to apply the reasonable and X
prudent parent standard
Sleeping Arrangements
Yes No N/A Corrective Actions/Comments
419-470-0140
(1) Children are in separate bedrooms than
adults, unless parent and child, or there is
X
written approval from guardian/parent and
licensing coordinator
(2) There is adequate supervision of children
X
when sleeping
(3) When assigning bedrooms a residential
care agency must consider all of the
following:
(a) Chronological age
(b) Developmental age
X
(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
(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
(3)(f) Record of personnel actions X
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(3)(g) Termination date, reason for
X
termination
(3)(h) Current job description (1)(c)
Employee meets minimum qualifications X
stated in current job description
New Employee Orientation – Umbrella
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
(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,
X
including but not limited to a minimum of six
hours of training focused on positive
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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
(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
(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)
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
P a g e 16 | 20
Form Rev. 04/18/2023
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
(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
P a g e 17 | 20
Form Rev. 04/18/2023
(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
(g) Apply the reasonable and prudent parent
X
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.
Information about Children in Care
419-400-0190(1) Yes No N/A Corrective Actions/Comments
Summary sheet contains the following:
RCC did not have religious preference information documented on the summary/face
sheet.
Corrective Action: Add space to document the religious preference, or absence of,
(a)The name, gender, date of birth, religious
X for each client on their summary sheet.
preference, and previous address
*The summary sheet was updated while licensing was still onsite to reflect
religious preference. The summary sheet will be observed at next unannounced
review to ensure the new form is being utilized.
(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: X
(A) The child in care's parents.
P a g e 18 | 20
Form Rev. 04/18/2023
(B) The child in care's legal guardian, if
different than the parents, and a copy of
the document that provides for his or her
authority over the child in care.
(C) Other persons significant to child
(D) Other professionals to be involved in
service planning (if applicable)
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
(parent, guardian and child actively involved).
Describes how child’s issues will be X
addressed, anticipated outcomes, and
reviewed by child and guardian/parent.
(e)(C)&(D) Service plan is reviewed quarterly
and revised when information indicates other X
services should be provided
Case Management
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:
(A)Current medications
(B)Name of the physician or qualified medical
professional who prescribed each medication
(C)Any outstanding medical or other
appointments X
(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
P a g e 19 | 20
Form Rev. 04/18/2023
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 Notice was not documented in client files.
guardians of children in care in the program. X
The child caring agency shall provide the Corrective Action - Document parent/guardian notifications
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,
X
purpose, 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
includes:
Name
Gender
X
Birth date
Names, addresses of parents or guardians
Dates of admission
Placement upon discharge
Comments:
Licensing Coordinator’s Signature: ________________________ Date: ___________________
Manager Review: ______________________________________ Date: _7_-2_6_-_2_0_2_3_ _________
P a g e 20 | 20
Form Rev. 04/18/2023

report_type: License Renewals

board_chairperson: Daniel Lacoste

other_regulatory_agencies: ODHS TxSvcs, OHA

program_services:
Regional Crisis Center (RCC):
Residential Treatment
The Regional Crisis Center provides 24-hour supervised group living combined with clinical treatment in a therapeutic setting. Youth learn new skills
and behaviors, and as they increase their responsibility, they are rewarded with privileges appropriate to the recovery process. Youth and families
P a g e 1 | 20

work with counselors to create individualized service and support plans to determine their goals and the activities to achieve them. These plans
address areas such as mood and behavior regulation, social skills, and family centered relational therapy.
Mental Health Treatment
The program will utilize evidence-based practices (EBP's) to support youth within a structured and therapeutic environment. Under the guidance of
the Clinical Director and the Medical Director, the program provides a treatment model conducive to stabilization and progress specific to Individual
Service and Support Plans. All team members will be trained in the use of Collaborative Problem Solving and have access to additional EBP's
based on individual client needs. Team members will also be trained in the use of the crisis intervention model Pro-ACT
Substance Use Disorders Treatment
Regional Crisis Center partners with trained staff from other Looking Glass programs to provide treatment for substance abuse and dependence
issues, if needed. Treatment may include individual and group work.
Academic Instruction/Education
The state-certified on-site school provides lessons in language arts, math, health education, living skills, speech/communications, and physical
education. Some youth prepare for GED tests while others earn credit toward high school diplomas.
Family Counseling
A youth's family and/or caregivers are integral to successful treatment. Clinicians meet regularly with youth and their identified caregivers to assist
with communication and conflict resolution within the family dynamic. Youth and families will be building on already existing positive interactions and
supports. Parents and families are strongly encouraged to spend time observing and visiting the program. Home visits can be scheduled so that
families can make use of skills introduced in the program either at home or with the family.
Recreation
Youth participate in a variety of recreation experiences such as swimming, bowling, hiking and field trips. These activities allow youth to improve
trust, teamwork, and problem-solving skills. The activities are designed to demonstrate healthy and safe ways to have fun and release energy.
Adjudicated Youth Services (AYS)
Residential Treatment-Youth work with their case manager to create an individualized services plan which is reviewed every 45 days with their
entire treatment team. Youth follow a daily schedule that includes groups, school, recreation, and meals.
Mental health therapy-Youth complete a mental health assessment upon intake to the program through a credentialed mental health therapist that
informs their service plan and interventions in program. Youth then participate in weekly therapy to address mental health needs that impact
activities of daily living. Family therapy is also available and often recommended if the youth is returning to their family following successful
completion of program. The mental health therapist hosts one group per week where youth can process thoughts and emotions while gaining
support and camaraderie from their peers.
Substance Use treatment-Youth complete a substance use assessment upon intake by a CADC-I counselor which informs their service plan.
Youth then meet with their substance use counselor weekly (if recommended by assessment) to address recovery. Youth will create a relapse
prevention plan within this context.
Education-Youth attend school on site and work with a licensed teacher towards their high school diploma or GED through credit recovery, one on
one tutoring, and some group classes or activities.
Recreation-Youth participate in a variety of recreational activities including trips to the YMCA, local parks, walks, and community outings.

interviews_observations:
Regional Crisis Center (RCC):
Interviews: The week prior to the review, licensing was on site at RCC and participated in a client interview conducted by Treatment Services Katie
Wyland. Two additional client interviews were conducted at the time of the review. The Treatment Services interview followed a template and was
intended to collect specific information for use by Treatment Services. The form and notes are on file with the report.
P a g e 3 | 20

The first client interviewed during the review had been at the program approximately two months. Client stated they did not feel very involved in
their service planning, but this was due to the client feeling like they were only there for substance abuse issues and not anything else the staff were
attempting to include in the overall service plan. Client also said they feel like nothing has been done to help them reach their goals. They stated
things have gotten worse and they have started self-harming due to a peer passing them a sharp. Staff were aware of this situation and took
necessary steps to resolve it. Client had access to medical/dental and had recently been seen by the dentist. Client did state they had been
involved in a restraint which had caused them some pain in their ribs. Client stated they did not see a doctor but were assessed by nursing staff.
Client felt school needed to be more structured and they mostly did art and did not have any core classes or actual assignments. Client is not in
high school so is unable to earn credits toward graduation. Management provided additional information on this and stated youth are able to let the
teacher's know what areas they would like to study so there was opportunity for client to study core classes and request "homework" or
assignments. Client said they get large muscle exercise at least twice a day. Client stated sometimes their peers would make them feel unsafe due
to escalations, but staff are present and engaged. Client said there are a lot of personal items that get lost, but they had not had any of their own
personal items go missing. Client stated there wasn't follow-up on several grievances they had filed (licensing following up with management on
resolutions from the grievances).
Second client interviewed has been at RCC for about three and a half months. They stated they feel involved in their service planning and have
learned to better cope with stress since being in the program. Client said they have recently been to both the doctor and dentist. Client stated
school was mostly good and they are working on math, science and reading. They felt the learning would be better on the computer instead of
paper. Client recently completed state testing at the program and feels there is plenty of adult help when needed for schoolwork. They trust staff,
especially Caitlin ("the big, big boss") and felt mostly safe in the program. Client stated they feel respected by some staff and have several
favorites. They also said there are other staff who are not respectful and punish youth for no reason. Client was unable to provide any specific
examples. Client stated they wished there were more opportunities to be outside, but said they get enough exercise and physical activity.
Adjudicated Youth Services (AYS): Two clients were interviewed at AYS (Pathways Girls Program). The first client has been at the program over
nine months total, but is on their second stay. Client stated they feel safe in the program, but also had concerns with some staff. Client said some
staff are not professional and when discussing phone calls and phone use, put out to the group that client had a caseworker which client did not
want others to know about. Client also stated staff do not monitor conversations closely enough and there is a lot of inappropriate conversations
and body shaming that occurs and staff are not aware of it. Client isn't currently in school due to graduating early and is excited about a potential
opportunity to volunteer at another Looking Glass program. Client said the food is decent and they get plenty to eat. Client relayed the groups are
not always relevant to their situation and sometimes finds difficulty participating. Client also said grads only have a life skills group which is very
repetitive. Client feels like any concerns they have can be taken to their case manager or the program manager and they help resolve or provide a
reason why things are the way they are. Client stated some staff don't listen and make them feel disregarded. They said they are provided good
support within the treatment team.
Second client has been in the program approximately six weeks and said it is great so far. Client said staff are all really good and do their jobs.
Staff keep everyone safe and they really care about the clients. Client stated they have weekly chores and are expected to keep their rooms clean.
Client said school is great and they work a good pace for them. Client said sometimes there is not enough staff to facilitate phone calls. Client
stated staff monitor the calls and watch their body language but still feel like they have privacy within their conversation. Client wanted to have a
P a g e 4 | 20

little more outside time and also wished for a little more phone time. Client stated the food was delicious and depending on staff the portion sizes
were sometimes more generous. Client felt staff do a really great job of keeping everyone safe.

exceptions: All exceptions on file with licensing.

excerpt:
(a)The name, gender, date of birth, religious
preference, and previous address RCC did not have religious preference information documented on the summary/face
sheet.
Corrective Action: Add space to document the religious preference, or absence of,
for each client on their summary sheet.
*The summary sheet was updated while licensing was still onsite to reflect
religious preference. The summary sheet will be observed at next unannounced
review to ensure the new form is being utilized.

excerpt:
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.
The child caring agency shall provide the
notice upon the child in care’s admission and
at least two times each year thereafter. Notice was not documented in client files.
Corrective Action - Document parent/guardian notifications


state: OR

facility_name: Looking Glass Community Services - RCC

summary: Unannounced - 2 findings

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Residential Care
Licensee: Looking Glass Community Services – RCC & Adjudicated Youth Services (Pathways Boys, Program, Pathways Girls Program, Parole
Revocation and Diversion Program and Stepping Stone Program)
Executive Director: Craig Opperman
Program Director(s): Maleigha Myers
Date of Unannounced: 10-04-2023
Licensing Coordinator: Todd Cooley
Other Regulatory or Accrediting Agencies: Child Welfare and OHA
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 10/11/2022 & Findings
10/13/2022 Further Action
Needed
Information about Children in Care Yes☐ No☐
419-400-0190(1) During the license renewal review in June the summary sheet template was updated to
Summary sheet contains the following: include a field to document religious preference. It wasn’t confirmed at the time of the
recent unannounced visit whether the new form is in use and if the religious preference of
(a)The name, gender, date of birth, religious youth is being captured currently. This will be checked at the time of the next site visit.
preference, and previous address
The Regional Crisis Center site did not
have religious preference information
documented on the summary/face sheet.
1| P age
Form Rev. 01/23/2023
Records Relating to Restraint & Yes☐ No☐
Involuntary Seclusion It wasn’t confirmed during the unannounced visit if the provision of the required information
419-400-0180(13)(e) Each child caring about how to access quarterly reports is being documented. This will be checked at the
agency shall provide notice regarding how to time of the next site visit.
access the quarterly reports 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.
Notice was not documented in client files.
New Findings from Site Visit Comments
No new findings
Interview Summary
During the unannounced visit licensing interviewed two clients at RCC and all three clients from AYS. The RCC clients had two very different perspectives on
their experiences at the program while all three clients at AYS had very similar things to say about AYS.
At RCC the first client interviewed had been in program about 30 days. They had been to multiple other placements over the past few years. Client felt RCC
wasn’t the best fit because they felt they needed drug/alcohol treatment and not stabilization. Client said both their peers and staff are all very nice. They
stated they were concerned when staff just left the pod without explaining anything. (There was additional follow-up with management around this concern.
Staff provided history of the client being very strong and aggressive, having previously injured staff. Due to the recognition that restraints could not be safely
conducted, the client’s team would instead give the client space and monitor from the office. The client is left to calm in the common area of the pod and
constantly supervised as they de-escalate.) Client followed this by saying they had only been placed in one restraint because they are very strong but had
witnessed peers in restraints and felt staff were always very appropriate. Client also stated they feel comfortable with the staff and can talk to them about
concerns. Client talked about having issues with the teacher and stated they did not like to be put on the spot and this led them to not want to attend school in
the classroom. (Management stated the teacher had asked the client and peer to stop talking and that is when they felt singled out.) They are currently
working on a GED in the pod and the client feels that arrangement works well. Client felt the food was very good and only found themselves hungry when
they woke up really early in the morning. They said snacks were available and always plenty to eat. Client said staff are very accommodating around phone
calls, and they have worked with the client, who happened to have an approved contact with an unusual schedule. Client felt staff were really good at finding
underlying issues to help solve problems and individualizing the treatment to each client. The client could not think of anything they would change about the
program.
The second RCC client was upset about milk stains on the floor and how bad they smelled. This licensor noticed some light staining on the carpet from
normal daily use and possibly a spill, but there was no discernible odor. They said staff are not consistent and always provide conflicting directions. When
asked for an example, none was provided. Client said there was food on the windows of the cafeteria, and it was just plain dirty. This licensor had just
2| P age
Form Rev. 01/23/2023
minutes before walked through the cafeteria, and while they did not specifically check the upper windows for food, the space was sanitary and clean. Client
said staff panic when youth flip out, then provided an example of staff utilizing a room clear to ensure a level of safety for peers not involved the restraint that
was occurring at the time and to ensure safety for the peer and staff engaged in the restraint. Client said the food was good but needs salt. They felt they got
plenty to eat, and snacks were available between meals. Client stated school was amazing. Client said skills groups are a joke and not treatment. Client
stated therapy was off and on, saying it was supposed to be once a week but didn’t always happen. (Management provided history that weekly therapy is
happening, but this particular client wanted to meet with the therapist daily or even more often and has been very vocal about it.) Client stated staff aren’t
supportive and just tell them to, “get over it”. Client had issues with attorney phone calls not going through. They would leave a message, and the attorney
would call back from a different number. Management has been working with the attorney to provide the number they are calling from so they can get the
approved contact list updated with the caseworker, but the attorney refuses to provide the number as they don’t want the client to have it. At this time the
attorney has been unwillingly to compromise in order to update the contact list. Client said they aren’t involved one bit in their own service plan. The client
ended the interview by stating, “chef be cooking it up” when asked about things the program does well.
At AYS all three clients requested to be interviewed together, and since lunch had just started, the interview was conducted in the dining hall. All three have
been at the program for 4-5 months. Clients were asked about various topics from food to phone calls to recreation. All of them said the food is good and
they get plenty to eat. Only one of the three were in school and they said it was going really well and they are currently ahead in credits. They all stated
phone calls were fine but went on to say they wish the calls could be 15 minutes instead of 10, especially since there are only three of them in program right
now. They all said they would like more outings. It was said outings to the park, movies, Wildlife Safari and other places were more common during the
summer but are not occurring regularly since school started even though only one of them is in school. They also did not like that there was not an incentive
system in place and if they were placed on consequence for their actions, it lasted three shifts and they couldn’t interact with their peers so they felt isolated.
They felt staff don’t really listen and could be more conscious of feelings. When asked of things they would change about the program, they referred back to
outings and phone calls. When asked what they thought AYS did really well, one of them quipped, “They are really good at losing staff.”
Observations
Overall the RCC building was clean and in good repair. A milk stain was pointed out by a client in one of the pods and follow-up was conducted with
management. There is scheduled carpet cleaning that typically occurs each quarter. They stated it should be scheduled soon, but is not conducted as
frequently due to both sides of the building being occupied and the time those spaces are off limits to allow them to properly dry. The client concerns were
addressed with management, and context was provided to each situation that was presented which did not raise any cause for concern. The program
appeared to be in a good place with a solid milieu and adequate number of staff for the acuity of clients being served.
AYS was also in good condition with all spaces being presentable and clean. All three clients seem to get along well and were just finishing up crocheting
prior to getting lunch. This seemed to be an activity they all enjoyed given their responses when asked questions about what they were making. The
programs numbers are low at three, but they were expecting an intake later in the afternoon. The numbers are appropriate given the current staffing levels. It
was noted staffing AYS has been a struggle due to other Looking Glass programs offering the opportunity for similar work with better pay. Given the current
number of clients and the opening of Looking Glass’ new PEER Shelter, the clients are being moved to the other side of their current building. This will allow
for some more privacy and spaces that will minimize any potential contact between clients at AYS and the shelter.
Corrective Actions and Timeframes:
Please submit the following to verify compliance.
3| P age
Form Rev. 01/23/2023
Within 45 days of receipt of this report Looking Glass Community 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 Todd Cooley, todd.cooley@odhsoha.oregon.gov
Licensing Coordinator’s Signature: ________________________ Date: _1_0_-_2_4_-_2_0_2_3_ ________
Manager Review: ______________________________________ Date: _1_0_-2_3_-_2_0_2_3_ ________
4| P age
Form Rev. 01/23/2023

agency_name: Looking Glass Community Services (LGCS)

program_name: AYS

program_type: (RC) Residential Care Programs

report_type: Unannounced

view_code: RC

facility_type: Residential Care

licensee: Looking Glass Community Services - RCC & Adjudicated Youth Services (Pathways Boys, Program, Pathways Girls Program, Parole Revocation and Diversion Program and Stepping Stone Program)

executive_director: Craig Opperman

program_director: Maleigha Myers

licensing_coordinator: Todd Cooley

other_regulatory_agencies: Child Welfare and OHA

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 10/11/2022 & Findings
10/13/2022 Further Action
Needed
Information about Children in Care Yes[ ] No[ ]
419-400-0190(1) During the license renewal review in June the summary sheet template was updated to
Summary sheet contains the following: include a field to document religious preference. It wasn't confirmed at the time of the
recent unannounced visit whether the new form is in use and if the religious preference of
(a)The name, gender, date of birth, religious youth is being captured currently. This will be checked at the time of the next site visit.
preference, and previous address
The Regional Crisis Center site did not
have religious preference information
documented on the summary/face sheet.

Records Relating to Restraint & Yes[ ] No[ ]
Involuntary Seclusion It wasn't confirmed during the unannounced visit if the provision of the required information
419-400-0180(13)(e) Each child caring about how to access quarterly reports is being documented. This will be checked at the
agency shall provide notice regarding how to time of the next site visit.
access the quarterly reports 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.
Notice was not documented in client files.
New Findings from Site Visit Comments
No new findings
Interview Summary
During the unannounced visit licensing interviewed two clients at RCC and all three clients from AYS. The RCC clients had two very different perspectives on
their experiences at the program while all three clients at AYS had very similar things to say about AYS.
At RCC the first client interviewed had been in program about 30 days. They had been to multiple other placements over the past few years. Client felt RCC
wasn't the best fit because they felt they needed drug/alcohol treatment and not stabilization. Client said both their peers and staff are all very nice. They
stated they were concerned when staff just left the pod without explaining anything. (There was additional follow-up with management around this concern.
Staff provided history of the client being very strong and aggressive, having previously injured staff. Due to the recognition that restraints could not be safely
conducted, the client's team would instead give the client space and monitor from the office. The client is left to calm in the common area of the pod and
constantly supervised as they de-escalate.) Client followed this by saying they had only been placed in one restraint because they are very strong but had
witnessed peers in restraints and felt staff were always very appropriate. Client also stated they feel comfortable with the staff and can talk to them about
concerns. Client talked about having issues with the teacher and stated they did not like to be put on the spot and this led them to not want to attend school in
the classroom. (Management stated the teacher had asked the client and peer to stop talking and that is when they felt singled out.) They are currently
working on a GED in the pod and the client feels that arrangement works well. Client felt the food was very good and only found themselves hungry when
they woke up really early in the morning. They said snacks were available and always plenty to eat. Client said staff are very accommodating around phone
calls, and they have worked with the client, who happened to have an approved contact with an unusual schedule. Client felt staff were really good at finding
underlying issues to help solve problems and individualizing the treatment to each client. The client could not think of anything they would change about the
program.
The second RCC client was upset about milk stains on the floor and how bad they smelled. This licensor noticed some light staining on the carpet from
normal daily use and possibly a spill, but there was no discernible odor. They said staff are not consistent and always provide conflicting directions. When
asked for an example, none was provided. Client said there was food on the windows of the cafeteria, and it was just plain dirty. This licensor had just

minutes before walked through the cafeteria, and while they did not specifically check the upper windows for food, the space was sanitary and clean. Client
said staff panic when youth flip out, then provided an example of staff utilizing a room clear to ensure a level of safety for peers not involved the restraint that
was occurring at the time and to ensure safety for the peer and staff engaged in the restraint. Client said the food was good but needs salt. They felt they got
plenty to eat, and snacks were available between meals. Client stated school was amazing. Client said skills groups are a joke and not treatment. Client
stated therapy was off and on, saying it was supposed to be once a week but didn't always happen. (Management provided history that weekly therapy is
happening, but this particular client wanted to meet with the therapist daily or even more often and has been very vocal about it.) Client stated staff aren't
supportive and just tell them to, "get over it". Client had issues with attorney phone calls not going through. They would leave a message, and the attorney
would call back from a different number. Management has been working with the attorney to provide the number they are calling from so they can get the
approved contact list updated with the caseworker, but the attorney refuses to provide the number as they don't want the client to have it. At this time the
attorney has been unwillingly to compromise in order to update the contact list. Client said they aren't involved one bit in their own service plan. The client
ended the interview by stating, "chef be cooking it up" when asked about things the program does well.
At AYS all three clients requested to be interviewed together, and since lunch had just started, the interview was conducted in the dining hall. All three have
been at the program for 4-5 months. Clients were asked about various topics from food to phone calls to recreation. All of them said the food is good and
they get plenty to eat. Only one of the three were in school and they said it was going really well and they are currently ahead in credits. They all stated
phone calls were fine but went on to say they wish the calls could be 15 minutes instead of 10, especially since there are only three of them in program right
now. They all said they would like more outings. It was said outings to the park, movies, Wildlife Safari and other places were more common during the
summer but are not occurring regularly since school started even though only one of them is in school. They also did not like that there was not an incentive
system in place and if they were placed on consequence for their actions, it lasted three shifts and they couldn't interact with their peers so they felt isolated.
They felt staff don't really listen and could be more conscious of feelings. When asked of things they would change about the program, they referred back to
outings and phone calls. When asked what they thought AYS did really well, one of them quipped, "They are really good at losing staff."
Observations
Overall the RCC building was clean and in good repair. A milk stain was pointed out by a client in one of the pods and follow-up was conducted with
management. There is scheduled carpet cleaning that typically occurs each quarter. They stated it should be scheduled soon, but is not conducted as
frequently due to both sides of the building being occupied and the time those spaces are off limits to allow them to properly dry. The client concerns were
addressed with management, and context was provided to each situation that was presented which did not raise any cause for concern. The program
appeared to be in a good place with a solid milieu and adequate number of staff for the acuity of clients being served.
AYS was also in good condition with all spaces being presentable and clean. All three clients seem to get along well and were just finishing up crocheting
prior to getting lunch. This seemed to be an activity they all enjoyed given their responses when asked questions about what they were making. The
programs numbers are low at three, but they were expecting an intake later in the afternoon. The numbers are appropriate given the current staffing levels. It
was noted staffing AYS has been a struggle due to other Looking Glass programs offering the opportunity for similar work with better pay. Given the current
number of clients and the opening of Looking Glass' new PEER Shelter, the clients are being moved to the other side of their current building. This will allow
for some more privacy and spaces that will minimize any potential contact between clients at AYS and the shelter.

new_findings: No new findings

excerpt:
419-400-0180(13)(e) Each child caring about how to access quarterly reports is being documented. This will be checked at the
agency shall provide notice regarding how to time of the next site visit.
access the quarterly reports 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.
Notice was not documented in client files.
New Findings from Site Visit Comments
No new findings
No new findings


summary: Unannounced - 2 findings

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Residential Care
Licensee: Looking Glass Community Services - RCC
Executive Director: Chad Westphal
Program Director(s): Adriel Vasquez
Date of Unannounced: November 20, 2024
Licensing Coordinator: Todd Cooley
Other Regulatory or Accrediting Agencies: Child Welfare and OHA
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 10/04/2023 Findings
Further Action
Needed
Information about Children in Care Yes☐ No✓
419-400-0190(1) Religious preference was shown to be documented in client files (Carelogic) at the time of
Summary sheet contains the following: the unannounced visit.
(a)The name, gender, date of birth, religious
preference, and previous address
The Regional Crisis Center site did not have
religious preference information documented
on the summary/face sheet.
• During the license renewal review in
June the summary sheet template
was updated to include a field to
document religious preference. It
wasn’t confirmed at the time of the
recent unannounced visit whether the
new form is in use and if the religious
preference of youth is being captured
Form Rev. 11/14/2023 P age 1 | 4
currently. This will be checked at the time
of the next site visit.
Records Relating to Restraint & Yes☐ No✓
Involuntary Seclusion Quarterly report information is on the main Looking Glass Community Services website.
419-400-0180(13)(e) Each child caring Notification on where to find the report is signed for by the guardian at intake and each
agency shall provide notice regarding how to month where it is documented in the service plan review the guardian participates in or is
access the quarterly reports to the parents or mailed a copy of.
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.
Notice was not documented in client files.
• It wasn’t confirmed during the
unannounced visit if the provision of
the required information about how to
access quarterly reports is being
documented. This will be checked at
the time of the next site visit.
New Findings from Site Visit Comments
No new findings
Form Rev. 11/14/2023 P age 2 | 4
Interview Summary
During the unannounced review I spoke with two clients and had discussions with the Adriel, Director of RCC, and Robin, the Director of the RCC expansion
opening soon.
The first client interviewed had been at the program for just over a month. This particular client was very unhappy with their placement and didn’t feel like their
needs were at the same level as the other clients. They stated this was by far the worst placement they had been in. Client said they were blind in one eye,
didn’t currently have any glasses, and the previous three doctor’s appointments had been canceled. They were concerned about their teeth as braces had
recently been removed and they felt their teeth were moving back to where they were. Client stated their caseworker had lost their retainer and they haven’t
received a replacement. They stated they were started on a medication which lowers their blood pressure and now they are always dizzy when standing up.
They didn’t like when on “constant” (meaning constant supervision) they only received a “constant blanket” (blanket designed to not be utilized in self-harm or
suicide) and they weren’t allowed to talk to their peers. Client stated witnessing multiple restraints each day is very traumatizing. They did relay they have not
been placed in any restraints, only their peers. Youth said they were supposed to have at least an hour of therapy each week but had only seen their therapist
four times in six weeks and only for 10-15min. Client also said their peers can make them feel unsafe, and one gave them a side hug without asking first
causing them to be very uncomfortable. They were also upset about their hygiene products which they felt were being wasted by staff. They stated they have
expensive shampoos, and staff just automatically put it in a paper cup even though client does not wash hair every time they shower. When this occurs staff
will just put it in the garbage can instead of trying to put it back in the bottle. Youth likes school and gets straight A’s but struggles at times because none of
their peers take school seriously, and it makes it hard to concentrate. They said the food was better than cat food and detention food, and the snacks were
plenty.
In review with management there were responses which lent perspective to each of the above situations. The eye appointments did not occur due to various
factors such as unsafe behavior and the Child Welfare Case Worker not providing transportation as discussed. The meds lowering the blood pressure were
prescribed by the doctor, and the dizziness symptoms had been discussed with the doctor by the client. The doctor still felt it best to maintain the current
medication. The hygiene products being wasted had some merit. Management is to discuss preserving hygiene items personal to the youth and how
important these items can be versus the program provided hygiene items. The other issues mostly revolved around the atmosphere, which would be typical of
any high acuity milieu.
The second client interviewed had been at the program for about four months. They feel safe in the program and are comfortable discussing any concerns
with multiple staff. Client said the food was better than detention, they got plenty to eat, and the snacks were good. They noted in particular the meat snacks
as a new snack option they really liked. Youth stated in school they would like to work towards their GED. Client said there are plenty of activities throughout
the day and week. Youth participates in their planning and recently had their discharge date pushed back while awaiting a placement. Client noted one
concern around phone calls saying they are never able to get a hold of their brother. Client thought their brother worked evenings to early morning but had
been unable to contact them to verify the schedule. Client said they felt staff do everything really well and do a good job of taking care of everyone. The
phone call situation was discussed with leadership, and they will work to accommodate contact between client and their brother to ensure regular opportunities
to talk on the phone.
Form Rev. 11/14/2023 P age 3 | 4
Observations
The program was clean and in good repair. Bedrooms, bathrooms, laundry rooms and all other shared spaces were observed during a walkthrough of the
program. Staff were very open when asked questions about routines and procedures. There were no items of concern noted during the walkthrough. Time
was spent with leadership talking about paperwork, hotline reports and other administrative items in an effort to increase efficiency and reduce the amount of
time staff spend on paperwork versus caring for clients.
Corrective Actions and Timeframes:
Please submit the following to verify compliance.
Within 45 days of receipt of this report Looking Glass Community Services - RCC must submit a letter of verification indicating the agency is in
compliance with the specific rules cited above and describing how compliance will be maintained going forward. Along with the letter of verification,
the agency must submit any and all specific documentation requested in the body of this report. The letter of verification and any additional
requested documents can be emailed directly to Todd Cooley at Todd.Cooley@odhsoha.oregon.gov.
Licensing Coordinator’s Signature: ________________________ Date: _1_2_-_6_-2__0_2_4__________
Manager Review: ______________________________________ Date: _1_2_-_5_-2__0_2_4_________
Form Rev. 11/14/2023 P age 4 | 4

licensee: Looking Glass Community Services - RCC

executive_director: Chad Westphal

program_director: Adriel Vasquez

visit_date: November 20, 2024

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 10/04/2023 Findings
Further Action
Needed
Information about Children in Care Yes[ ] No✓
419-400-0190(1) Religious preference was shown to be documented in client files (Carelogic) at the time of
Summary sheet contains the following: the unannounced visit.
(a)The name, gender, date of birth, religious
preference, and previous address
The Regional Crisis Center site did not have
religious preference information documented
on the summary/face sheet.
- During the license renewal review in
June the summary sheet template
was updated to include a field to
document religious preference. It
wasn't confirmed at the time of the
recent unannounced visit whether the
new form is in use and if the religious
preference of youth is being captured

currently. This will be checked at the time
of the next site visit.
Records Relating to Restraint & Yes[ ] No✓
Involuntary Seclusion Quarterly report information is on the main Looking Glass Community Services website.
419-400-0180(13)(e) Each child caring Notification on where to find the report is signed for by the guardian at intake and each
agency shall provide notice regarding how to month where it is documented in the service plan review the guardian participates in or is
access the quarterly reports to the parents or mailed a copy of.
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.
Notice was not documented in client files.
- It wasn't confirmed during the
unannounced visit if the provision of
the required information about how to
access quarterly reports is being
documented. This will be checked at
the time of the next site visit.
New Findings from Site Visit Comments
No new findings

Interview Summary
During the unannounced review I spoke with two clients and had discussions with the Adriel, Director of RCC, and Robin, the Director of the RCC expansion
opening soon.
The first client interviewed had been at the program for just over a month. This particular client was very unhappy with their placement and didn't feel like their
needs were at the same level as the other clients. They stated this was by far the worst placement they had been in. Client said they were blind in one eye,
didn't currently have any glasses, and the previous three doctor's appointments had been canceled. They were concerned about their teeth as braces had
recently been removed and they felt their teeth were moving back to where they were. Client stated their caseworker had lost their retainer and they haven't
received a replacement. They stated they were started on a medication which lowers their blood pressure and now they are always dizzy when standing up.
They didn't like when on "constant" (meaning constant supervision) they only received a "constant blanket" (blanket designed to not be utilized in self-harm or
suicide) and they weren't allowed to talk to their peers. Client stated witnessing multiple restraints each day is very traumatizing. They did relay they have not
been placed in any restraints, only their peers. Youth said they were supposed to have at least an hour of therapy each week but had only seen their therapist
four times in six weeks and only for 10-15min. Client also said their peers can make them feel unsafe, and one gave them a side hug without asking first
causing them to be very uncomfortable. They were also upset about their hygiene products which they felt were being wasted by staff. They stated they have
expensive shampoos, and staff just automatically put it in a paper cup even though client does not wash hair every time they shower. When this occurs staff
will just put it in the garbage can instead of trying to put it back in the bottle. Youth likes school and gets straight A's but struggles at times because none of
their peers take school seriously, and it makes it hard to concentrate. They said the food was better than cat food and detention food, and the snacks were
plenty.
In review with management there were responses which lent perspective to each of the above situations. The eye appointments did not occur due to various
factors such as unsafe behavior and the Child Welfare Case Worker not providing transportation as discussed. The meds lowering the blood pressure were
prescribed by the doctor, and the dizziness symptoms had been discussed with the doctor by the client. The doctor still felt it best to maintain the current
medication. The hygiene products being wasted had some merit. Management is to discuss preserving hygiene items personal to the youth and how
important these items can be versus the program provided hygiene items. The other issues mostly revolved around the atmosphere, which would be typical of
any high acuity milieu.
The second client interviewed had been at the program for about four months. They feel safe in the program and are comfortable discussing any concerns
with multiple staff. Client said the food was better than detention, they got plenty to eat, and the snacks were good. They noted in particular the meat snacks
as a new snack option they really liked. Youth stated in school they would like to work towards their GED. Client said there are plenty of activities throughout
the day and week. Youth participates in their planning and recently had their discharge date pushed back while awaiting a placement. Client noted one
concern around phone calls saying they are never able to get a hold of their brother. Client thought their brother worked evenings to early morning but had
been unable to contact them to verify the schedule. Client said they felt staff do everything really well and do a good job of taking care of everyone. The
phone call situation was discussed with leadership, and they will work to accommodate contact between client and their brother to ensure regular opportunities
to talk on the phone.

Observations
The program was clean and in good repair. Bedrooms, bathrooms, laundry rooms and all other shared spaces were observed during a walkthrough of the
program. Staff were very open when asked questions about routines and procedures. There were no items of concern noted during the walkthrough. Time
was spent with leadership talking about paperwork, hotline reports and other administrative items in an effort to increase efficiency and reduce the amount of
time staff spend on paperwork versus caring for clients.

excerpt:
419-400-0180(13)(e) Each child caring Notification on where to find the report is signed for by the guardian at intake and each
agency shall provide notice regarding how to month where it is documented in the service plan review the guardian participates in or is
access the quarterly reports to the parents or mailed a copy of.
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.
Notice was not documented in client files.
- It wasn't confirmed during the
unannounced visit if the provision of
the required information about how to
access quarterly reports is being
documented. This will be checked at
the time of the next site visit.
New Findings from Site Visit Comments
No new findings
No new findings