raw_content:
October 11, 2024

Justice Resource Institute
160 Gould St. Suite 300
Needham, MA 02494

Re: Biannual licensing inspection of Chesterfield Road Group Home in Oakdale, CT, Regulatory Consultants: Penny Woodward and James Funaro.

On 9/29/24, 10/1/24 and 10/2/24, a biannual re-licensing inspection was conducted at the Chesterfield Road Group Home to determine compliance with Regulations for Operation of Child-Caring Agencies and Facilities Sections 17a-145-48 through 17a-145-98, as well as the DCF Guidelines for the Administration of Medication by certified staff.

DCF has determined that the program is in compliance with all applicable regulatory provisions except those itemized below. Please review areas identified and submit a plan of correction to address each area.

The plan must be submitted within 30 days of receipt of this letter and should identify: 1. Steps to be taken to correct the non-compliance. 2. The date correction(s) will be completed.  The areas of non-compliance are as follows:

17a-145-61: Written policies and procedures.
(Evidence) Upon review of agency manual, the program did not follow policies on no tobacco use at the group home or no contraband in the facility. The supervision of students' policy was outdated, and it needs to be amended to reflect current practices.

17a-145-63: Chief administrative officer.
(Evidence) Upon review of case record information and reports, the program failed to ensure the safety of clients by not adhering to the no tobacco use policy.

(Evidence) Upon inspection of the front entrance, a railing pole was missing, and it needs to be addressed. Upon inspection of the physical plant, the patio area contained discoloration in multiple sections and two light fixtures had an excessive amount of rust. The citations need to be addressed. The basement window contained an extensive amount of dirt and debris, and it needs to be addressed.
17a-145-73: Sleeping accommodations.
(Evidence) Upon review of the physical plant, residents' bedrooms were not always neatly organized or therapeutically designed to meet the individual needs of residents.

17a-145-86: Instruction in safety procedures.
(Evidence) Upon review of program documentation, in 2023 a second shift drill was not conducted in the fourth quarter. On multiple occasions fire drill documentation was incomplete and forms were not filled out to show that regulatory requirements had been met.

17a-145-90: Clothing, storage.
(Evidence) Upon review of residents' bedrooms, the program did not always ensure that clients' clothing and personal items were being properly stored.

Once licensing has reviewed and accepted the service development plan and has determined that your agency is in compliance with the regulations, a decision on the issuance of a regular twenty-four-month license for the program will be made. Until DCF makes this decision the current license will remain in effect. Please be advised that failure to submit an acceptable service development plan within the specified time frame may lead to a licensing action up to and including revocation. Should you have any questions or comments regarding the contents of this report please do not hesitate to call me at (959) 255-0615.

Sincerely,

Penny Woodward

Penny Woodward, LCSW
Regulatory Consultant
Department of Children and Families
505 Hudson Street
Hartford, CT. 06016
Cell Phone: 959-255-0615
Fax: 860-550-6665
penny.woodward@ct.gov

Copy: file|


state: CT

facility_name: Justice Resource Institute / Chesterfield /GH #127

summary: Visit conducted on May 21, 2024. Visit covered 8 main areas/topics. No compliance issues identified.

raw_content:
DCF-3034
1/2013 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

 NAME OF FACILITY / PROGRAM: JRI/ Chesterfield Group Home Program

TIME OF VISIT (FROM - TO): 11:45 am to 12:30 pm                     DATE: May 21, 2024

AGENCY PERSONNEL WHO PARTICIPATED:

Job Title
Program Director
Clinical Case Manager
House Manager
House Supervisor

Areas / Topics covered during visit:

•	Census: The group home currently has four youths at the facility and the bed capacity remains at four.
•	Admissions: There was one new admission in the month of April.
•	Discharges: The group home reported that there were no discharges in the last quarter.
•	Staff vacancies: The program has one vacancy and the position is expected to be filled soon.
•	Staff hires: The group home hired two new residential counselors in the last quarter.
•	Medication: The program currently has seven medication certified employees at the facility.
•	Physical plant: A walkthrough of the group home facility was conducted with the program director and several citations were identified that will be addressed before the fall licensing inspection. The program is planning this summer to renovate the second floor and one bedroom will be made into two residents' rooms.
•	Personnel: Employee records and files were not reviewed during the quarterly visit.

Corrections implemented as a result of previous visit:
N/A

Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning)
N/A

Areas of regulatory non-compliance identified during this visit:
N/A

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Penny Woodward, LCSW                                 June 3, 2024
Regulatory Consultant                                              Date

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

facility_name: JRI/ Chesterfield Group Home Program


summary: Visit conducted on March 12, 2024. Visit covered 9 main areas/topics. No compliance issues identified.

raw_content:
DCF-3034
1/2013 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

 NAME OF FACILITY / PROGRAM: JRI/ Chesterfield Group Home Program

 TIME OF VISIT (FROM - TO): 11:00am to 12:05 pm                     DATE: March 12, 2024

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Title
Program Director

 Areas / Topics covered during visit:

•	Census: The group home currently has three residents at the facility and the bed capacity remains at four.
•	Admissions: There was one new admission in the month of February.
•	Discharges: The group home reported that there were no discharges in the last quarter.
•	Staff vacancies: The program has no vacancies and is operating at full capacity.
•	Staff hires: The group home hired two new residential counselors in the last quarter.
•	Medication: The program currently has nine medication certified employees at the facility.
•	Physical plant: A walkthrough of the group home facility was conducted with the program director and no citations were identified.  A review of what physical plant items should be addressed before the fall licensing inspection was done with the program director.

Additional
•	In the last quarter a new stove and dishwasher were purchased and both have been delivered to the facility.
•	All residents' bedrooms were repainted.

Corrections implemented as a result of previous visit:
N/A

Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning)
N/A

Areas of regulatory non-compliance identified during this visit:
N/A

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Penny Woodward, LCSW                              March 22, 2024
Regulatory Consultant                                            Date

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|


summary: Visit conducted on October 12, 2023. No compliance issues identified.

raw_content:
DCF-3034
1/2013 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

 NAME OF FACILITY / PROGRAM: JRI/ Chesterfield Group Home Program

 TIME OF VISIT (FROM - TO): 11:00am to 12:15 pm                     DATE: October 12, 2023

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Title
Program Director

Areas / Topics covered during visit:
The census was three at the time of the quarterly visit and the group home's licensed bed capacity remains at four. The program reported that there was one residential counselor vacancy and the agency expects to fill the position soon.  A walkthrough of the physical plant was conducted with the program director and no citations were identified during the quarterly visit.

Corrections implemented as a result of previous visit:
N/A

Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning)
N/A

Areas of regulatory non-compliance identified during this visit:
N/A

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Penny Woodward, LCSW                                November 9, 2023
Regulatory Consultant                                            Date

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

visit_date: October 12, 2023


summary: Visit conducted on August 8, 2023. Visit covered 1 main areas/topics. No compliance issues identified.

raw_content:
DCF-3034
1/2013 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

 NAME OF FACILITY / PROGRAM: JRI/ Chesterfield Group Home Program

 TIME OF VISIT (FROM - TO): 11:00 am to 12:30pm                     DATE: August 8, 2023

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Title
Program Director

Areas / Topics covered during visit:
The census was three males at the time of the quarterly visit and the group home's licensed bed capacity remains at four. The program reported that the therapist’s position has been filled and there is one full-time residential counselor vacancy. Recreational activities, menu planning, the milieu, medical and nursing services were discussed and reviewed with the program director. A walkthrough of the physical plant was conducted with the group home director and no citations were identified.

Corrections implemented as a result of previous visit:
N/A

Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning)
N/A

Areas of regulatory non-compliance identified during this visit:
N/A

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Penny Woodward, LCSW                                      September 6, 2023
Regulatory Consultant                                                    Date

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

visit_date: August 8, 2023


summary: Visit conducted on May 18, 2023. Found 1 compliance issues.

raw_content:
/2013 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

 NAME OF FACILITY / PROGRAM: JRI/ Chesterfield Group Home Program

 TIME OF VISIT (FROM - TO): 11:30am to 12:30pm                     DATE: May 18, 2023

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Title :  Program Director

Areas / Topics covered during visit:
The census was three at the time of the quarterly visit and the group home's licensed bed capacity remains at four. The program reported that the vacant clinical case manager position has been filled and the new employee will start in the month of July. A walkthrough of the physical plant was conducted with the program director and one citation was identified please see information below.

Corrections implemented as a result of previous visit:
N/A

Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning)
N/A

Areas of regulatory non-compliance identified during this visit:
Section 17a-145-73. Sleeping accommodations: A walkthrough of the physical plant was conducted and bedroom seven's door frame was broken and it needs to be repaired.

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Penny Woodward, LCSW                           ____June 16, 2023___
Regulatory Consultant                                            Date

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

type: general


summary: Visit conducted on March 10, 2023. No compliance issues identified.

raw_content:
DCF-3034
1/2013 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

 NAME OF FACILITY / PROGRAM: JRI/ Chesterfield Group Home Program

 TIME OF VISIT (FROM - TO): 11:30am to 1:00pm                     DATE: March 10, 2023

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Title  Program Director
 Division Director

Areas / Topics covered during visit:
The census was three at the time of the quarterly visit and the group home's licensed bed capacity is four. The program reported that there was a clinician vacancy and a candidate has been selected to fill the vacant position.  A walkthrough of the physical plant was conducted with the program director and no deficiencies were identified.

Corrections implemented as a result of previous visit:
N/A

Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning)
N/A

Areas of regulatory non-compliance identified during this visit:
N/A

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Penny Woodward, LCSW                              April 6, 2023
Regulatory Consultant                                            Date

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|


raw_content:
November 16, 2022

Justice Resource Institute
160 Gould Street. Suite 300
Needham, MA. 02494

On November 1st and 2nd, a biennial re-licensing inspection was conducted at the Chesterfield Group Home to determine compliance with Regulations for Operation of Child Caring Agencies and Facilities Sections 17a-145-48 through 17a-145-98, as well as the DCF Guidelines for the Administration of Medication by certified staff.

DCF has determined that the program is in compliance with all applicable regulatory provisions except those itemized below: Please review areas identified and submit a plan of correction to address each area.

The service development plan must be submitted within 30 days of receipt of this letter and should identify: 1. The steps to be taken to correct the non-compliance. 2. The date the correction(s) will be completed. The areas of non-compliance identified are as follows:

Section 17a-145-61: Written policies and procedures.
Evidence: Upon review of the program manual, the following policies were outdated or did not reflect current group home practices. The telephone policy, waived testing policy and supervision policy. The outdated information must be amended or removed.

Evidence: Upon review of the program manual, there was no written policy on the discharge of a youth from the group home program.
Evidence: Upon review of the program manual, personnel policies did not include information that required a new employee to have criminal checks, TB and physical health exams completed prior to being hired.

Section 17a-145-63: Chief administrative officer.
Evidence: Upon review of staffing information, the program did not always ensure that there was the required amount of staffing on the third shift.

Section 17a-145-74: Lavatory facilities.
Evidence: Upon inspection of the physical plant, the second-floor bathroom ceiling contained repair marks and it needs to be addressed.

Section 17a-145-75: Health and medical treatment.
Evidence: Upon review of the medication administration system the following violations were identified during the inspection visit: The controlled medication box was not double locked or stored in an appropriate location.  The medication key for controlled medications was not being kept on a second ring as required by regulations. The program did not always ensure that non-medication certified staff did not have access to medication keys. Nursing assessments for two residents had not been completed within the required time frame. The program did not always complete monthly reviews of physician orders in 2021.There was no documentation confirming that staff attended mandated quarterly and annual trainings for medication topics in 2022. The program nurse did not always conduct annual observations of medication administration and skills tests in 2022. For additional information please refer to the DCF Nurse’s report and medication administration guidelines.

Section 17a-145-76: Kitchen, equipment.
Evidence: Upon inspection of the physical plant, the oven contained an excessive amount of grease and food stains and it needs to be addressed.

Section 17a-145-77: Dining areas and supervision.
Evidence: Upon inspection of the dining room area, the floor contained an excessive number of scratches and scuffmarks and it needs to be addressed.

Section 17a-145-97: Discharge of child.
Evidence: Upon review of a discharge record, documentation did not identify the person the youth was discharged to as required by regulation.

Once licensing has reviewed and accepted the service development plan and has determined that your agency is in compliance with the regulations a decision on the issuance of a regular twenty-four-month license for the program will be made. Until DCF makes this decision the current license will remain in effect.

Please be advised that failure to submit an acceptable service development plan within the specified time frame may lead to a licensing action up to and including revocation. Should you have any questions or comments regarding the contents of this report please do not hesitate to call me at (959) 255-0615.

Sincerely,

Penny Woodward

Penny Woodward, LCSW
DCF Regulatory Consultant
Copy: File|

report_type: unstructured


summary: Visit conducted on August 9, 2022. Visit covered 1 main areas/topics. No compliance issues identified.

raw_content:
DCF-3034
1/2013 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM: JRI/ Chesterfield Group Home Program

TIME OF VISIT (FROM - TO): 11:30am to 1:00pm                     DATE: August 9, 2022

 AGENCY PERSONNEL WHO PARTICIPATED:

Name	Job Title
N/A	                       Program Director

Areas / Topics covered during visit:
The Department of Children and Families conducted a scheduled quarterly inspection visit at the Chesterfield Group Home Program on August 9, 2022.  Topics covered during the quarterly visit included staffing and training, physical plant inspection, milieu services, medication administration system and the fall bi-annual inspection visit.

Physical plant: A walkthrough of the physical plant was conducted with the group home director to confirm that the facility was in compliance with regulatory standards.

Corrections implemented as a result of previous visit:
N/A

Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning)
N/A

Areas of regulatory non-compliance identified during this visit:
N/A

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Penny Woodward, LCSW                          September 2, 2022
Regulatory Consultant                                   Date

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

visit_date: August 9, 2022

personnel: N/A	                       Program Director


summary: Visit conducted on May 9, 2022. No compliance issues identified.

raw_content:
DCF-3034
1/2013 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM: JRI/ Chesterfield Group Home Program

 TIME OF VISIT (FROM - TO): 11:30am to 1:00pm                     DATE: May 9, 2022

 AGENCY PERSONNEL WHO PARTICIPATED:

Name	Job Title
N/A	                       Program Director

Areas / Topics covered during visit:
The Department of Children and Families conducted a scheduled quarterly inspection visit at the Chesterfield Program
On May 9, 2022.  Topics covered during the quarterly visit included staffing and training, physical plant inspection, milieu services and medication administration system.

Physical plant: A walkthrough of the facility was conducted with the director; areas of improvement were identified and discussed with the program representative. Some of the rooms had missing window screens and they need to be replaced. The outside patio deck surface contained chipping paint and it needs to be addressed.

Corrections implemented as a result of previous visit:
N/A

Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning)
N/A

Areas of regulatory non-compliance identified during this visit:
N/A

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Penny Woodward, LCSW                          June 17, 2022
Regulatory Consultant                                   Date

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|


facility_name: Klingberg Comprehensive Program Services, Inc./ GH

summary: Visit conducted on 7/22/25. Visit covered 6 main areas/topics. No compliance issues identified.

raw_content:
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form
This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM:   Webster House
TIME OF VISIT (FROM - TO):       1230pm-1pm              			   DATE:  7/22/25
AGENCY PERSONNEL WHO PARTICIPATED: 	Director of Group Care, Supervisor
List of Areas / Topics covered during visit:
•	Current Census=5, LBC=6
•	Staffing:  Program is in the process of hiring a pool of staff to cover 1:1 staffing needs
•	Discharge Planning
•	Significant events: (1)
•	Staff/client interactions: Two (2) youth were home interacting with staff and having lunch.  One (1) youth reported that she is really enjoying her stay at the program.  Two (2) youth were attending summer school and one (1) has been in the hospital following a significant event.
•	Corrective Actions implemented as a result of previous visit: Not applicable

Physical Plant: Staff facilitated a tour of the interior/exterior of the physical plant.  All areas appear clean and organized.
Corrective Actions implemented as a result of previous visit: None
Areas of regulatory non-compliance identified during this visit:  None
Please submit a regulation compliance plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.  -

Amita Patel
Regulatory Consultant                                   Date  8/4/25

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM

Program Director
File|

facility_name: Webster House


summary: Visit conducted on 4/30/25. Visit covered 9 main areas/topics. No compliance issues identified.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

  NAME OF FACILITY / PROGRAM:   Webster House

 TIME OF VISIT (FROM - TO):       9:45-11:45am                 DATE:  4/30/25

 AGENCY PERSONNEL WHO PARTICIPATED: 	Director of Group Care, Program Clinician, Supervisor

List of Areas / Topics covered during visit:

•	Current Census=4, LBC=6
•	Staffing:  One (1) full time (day shift)
•	Discharge Planning
•	Program Updates-Door alarms have been installed.  Camera installation is pending.
•	Significant events: (1)
•	Staff/client interactions: No youth were present as all were attending school or work/vocational programming.
•	Kitchen cabinets newly installed
•	Corrective Actions implemented as a result of previous visit: Not applicable

Physical Plant: Staff facilitated a tour of the interior/exterior of the physical plant.  All areas appear clean and organized.

Corrective Actions implemented as a result of previous visit: None

Areas of regulatory non-compliance identified during this visit:  None

Please submit a regulation compliance plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.  -

Amita Patel
Regulatory Consultant                                   Date  5/15/25

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM

Program Director
File|


summary: Visit conducted on 1/28/25. Visit covered 10 main areas/topics. No compliance issues identified.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

  NAME OF FACILITY / PROGRAM:   Webster House

 TIME OF VISIT (FROM - TO):       12:20-130pm                 DATE:  1/28/25

 AGENCY PERSONNEL WHO PARTICIPATED: 	Director of Group Care, Supervisors

List of Areas / Topics covered during visit:

•	Current Census=4, LBC=6
•	Staffing:  One (1) full time (day shift) and one (1) part-time (2nd shift)
•	Discharge Planning
•	Program Updates-The program will be getting cameras and door alarms.
•	Significant events: (0)
•	Staff/client interactions: One (1) youth returned early from work due to being sick. She was observed having lunch while staff supervised her.
•	Measurements were completed and kitchen cabinets have been ordered.
•	Corrective Actions implemented as a result of previous visit: Not applicable

Physical Plant: Staff facilitated a tour of the interior/exterior of the physical plant.  All areas appear clean and organized.

Milieu: One (1) youth returned early from work due to be sick. She was observed having lunch while staff supervised her.

Corrective Actions implemented as a result of previous visit: None

Areas of regulatory non-compliance identified during this visit:  None

Please submit a regulation compliance plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.  -

Amita Patel
Regulatory Consultant                                   Date  2/13/25

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|


summary: Visit conducted on 10/29/24. Visit covered 11 main areas/topics. No compliance issues identified.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

  NAME OF FACILITY / PROGRAM:   Webster House

 TIME OF VISIT (FROM - TO):       9:45-11:30am                 DATE:  10/29/24

 AGENCY PERSONNEL WHO PARTICIPATED: 	Director of Group Care, Supervisors

List of Areas / Topics covered during visit:

•	Current Census=5, LBC=6
•	Staffing:  No vacancies
•	Discharge Planning- One (1) youth has been matched with DDS Group Home.
•	New admission:  KFC team observed youth at school prior to admission to ensure continuity in behavioral planning.
•	Program Updates: Joint Commission Accreditation inspection completed with no citations.
•	Significant events: 0
•	Milieu observation:  No youth present due to attending school.
•	Staff/client interactions: No youth were present due to attending school.
•	Physical Plant: Staff facilitated a tour of the interior and exterior of the physical plant, which was clean. Measurements were completed and kitchen cabinets have been ordered.
•	Corrective Actions implemented as a result of previous visit: Not applicable

Areas of regulatory non-compliance identified during this visit:

•	N/A

Amita Patel
Regulatory Consultant                                   Date  11/26/24

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|


summary: Visit conducted on 8/14/24. Visit covered 11 main areas/topics. No compliance issues identified.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

  NAME OF FACILITY / PROGRAM:   Webster House

 TIME OF VISIT (FROM - TO):       930-11am                 DATE:  8/14/24

 AGENCY PERSONNEL WHO PARTICIPATED: 	Senior Director of Community-Based Services
Director of Group Care Supervisor
					       	Program Clinician

List of Areas / Topics covered during visit:

•	Current Census=6, LBC=6 (1 respite youth)
•	Staffing:  No vacancies
•	Discharge Planning- One (1) voluntary placed youth discharged to SWCE, One (1) youth scheduled to  discharge to Marrakech on 8/20/24 and another youth will require an over age waiver as youth is turning 21.
•	Program Updates: measurements taken for kitchen remodel (scheduled to start in September)
•	Significant events: 1 occurred on 8/14/24 involving a dysregulated youth physically assaulting staff.
•	Milieu observation:
•	Staff/client interactions: 6 youth were present and observed interacting with staff playing games and doing crafts. One (1) youth was packing for a pre-placement visit.

•	Physical Plant: Staff facilitated a tour of the interior and exterior of the physical plant, which was clean.

•	Corrective Actions implemented as a result of previous visit:
            Not applicable

Areas of regulatory non-compliance identified during this visit:

•	N/A

Amita Patel
Regulatory Consultant                                   Date  9/4/24

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|


summary: Visit conducted on 6/24/24. Visit covered 2 main areas/topics. Found 1 compliance issues.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

  NAME OF FACILITY / PROGRAM:   Webster House

 TIME OF VISIT (FROM - TO):       12-2:00pm                 DATE:  6/24/24

 AGENCY PERSONNEL WHO PARTICIPATED: Director of Group Care
					       Supervisor

List of Areas / Topics covered during visit:

Current Census=7, LBC=6 (1 respite youth-Over LBC Waiver approved (5/23/24-7/22/24)
Staffing:  None
Discharge Planning
Program Updates:  Flower and Vegetable Garden
Significant events: n/a
Milieu observation:
•	Staff/client interactions: 7 youth were present and observed interacting with staff playing games and doing crafts. Some youth left with staff for an off grounds activity.

Physical Plant: Staff facilitated a tour of the interior of the physical plant, which was clean.

Corrective Actions implemented as a result of previous visit:
•	Not applicable

Areas of regulatory non-compliance identified during this visit:

•	Section 17a-145-76. Kitchens, equipment, food-handling:
Kitchen cabinets are showing evidence of wear and tear and water damage.

Amita Patel
Regulatory Consultant                                   Date  6/27/24

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|


summary: Visit conducted on 2/5/24. No compliance issues identified.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

  NAME OF FACILITY / PROGRAM:   Webster House

 TIME OF VISIT (FROM - TO):       11:00am-12:30pm                 DATE:  2/5/24

 AGENCY PERSONNEL WHO PARTICIPATED: Director of Group Care
					       Supervisor

List of Areas / Topics covered during visit:

Current Census=6, LBC=6
Staffing:  Vacancy: 1 full-time (1st/2nd shift) Direct Care Staff.  1 F/T Nurse
Discharge Planning
Program Updates:  Installation of carpet and dining room flooring
Significant events
Milieu observation:
•	Staff/client interactions (1 youth home, 5 youth in school)

Corrective Actions implemented as a result of previous visit:

•	Not applicable

Areas of regulatory non-compliance identified during this visit:

•	None at the time of this quarterly visit.

Amita Patel
Regulatory Consultant                                   Date  3/22/24

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|


summary: Visit conducted on 12/13/23. Found 3 compliance issues.

raw_content:
DCF-3034
1/2013 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM: Webster House

 TIME OF VISIT (FROM - TO):     9:30am-11:00am               DATE: 12/13/23

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Title
Director of Group Care
Program Clinician
Supervisor
Assistant Supervisor
Areas / Topics covered during visit:

Current Census=6, LBC=6
Staffing:  Vacancy: 1 full-time (1st/2nd shift) Direct Care Staff.  Shifts covered by KFC per diem staff.
Discharge Planning
Significant events
Milieu observation:
Staff/client interactions (1 youth home, 5 youth in school)

Physical Plant Inspection:
Tile Floor in dining area has several chipped tiles
Deep Freezer in kitchen was missing a thermometer
Carpet needs repair near hygiene cabinets in hallway.  There are also several areas of "worn" appearance to carpet.
One (1) bedroom has clothes strewn throughout the room, large amount of soiled clothes and a "foul" odor.

Corrections implemented as a result of previous visit:
N/A

Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning)
N/A

Areas of regulatory non-compliance identified during this visit:

Section 17a-145-63: Chief Administrative Officer:
There is missing carpet in a section of the hallway near hygiene cabinets.  There are several areas where the carpet is worn throughout the program.

Section 17a-145-73 Sleeping Accommodations:
One (1) bedroom has clothes strewn throughout the room, large amount of soiled clothes and a "foul" odor.

Section 17a-145-76-Kitchens, equipment, food-handling:
Deep Freezer in kitchen was missing a thermometer.

Section 17a-145-77-Dining areas and supervision:
Several flooring tiles are chipped in dining area.

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Amita Patel           				12/18/23
Regulatory Consultant                                   Date

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

description: Section 17a-145-76-

area_type: Kitchens, equipment, food-handling

description: Section 17a-145-77-


summary: Visit conducted on 8-17-23. Found 5 compliance issues.

raw_content:
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

                                                                 Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM:   Klingberg Family Centers, Inc. - WEBSTER HOUSE

TIME OF VISIT (FROM - TO):  10:00am-1:20pm                    	DATE: 8-17-23

AGENCY PERSONNEL WHO PARTICIPATED:
Job Titles:
•	Program Supervisor
•	Asst. Program Supervisor
•	Clinical Director
•	Clients

List of Areas / Topics covered during visit:  This was a scheduled quarterly Licensing visit to obtain an update on the program, tour the physical plant, and conduct a personnel file review.

A meeting was held with the Clinical Director and Program Supervisors. Areas of discussion included:
•	Census = 6 (2 male, 4 female); LBC= 7
•	Staff vacancies: Vacant Program Director position to be shared with another Klingberg home; 1 FT & 1 PT direct care staff positions; use of one temp agency staff 2-3 times per week; Program Director transitioned to program Clinical Director.
•	Sunsetting of PNMI reviews effective this month.
•	Incidents in the past quarter; Fire Dept. responded to sprinkler alarm.
•	Status reports on residents.
•	Client vocational and education placements; summer school.
•	Summer rec and leisure activities.
•	Life skills training activities.
•	Family involvement; discharge planning.
•	No video cameras in program.
•	Donations from building supply store for garden project.
•	Campus swimming pool.

Milieu observation:
•	Staff/client interactions.
•	Lunch; menu discussion.
•	One family visiting a new resident.

Physical Plant tour:
•	Supervisory staff facilitated tour of physical plant.
•	All areas appeared very clean and well organized.
•	Dining area floor is chipped and warped; Stained/ripped carpeting in common area; Replacement of both reportedly on hold.
•	Discussion on use of multipurpose lounge; improving appearance.
•	Worn appearance of kitchen cabinets.
•	Suggested door alarms on exit doors to enhance client safety.
•	Beautiful floor beds and vegetable garden in front of house.
•	Damage observed in several areas of exterior siding.
•	No water at sink in one bathroom. See 'Areas of regulatory Non-compliance' below.

Interviews with four clients.
•	One concern reported that Clinical Director has followed up on earlier this week.

Personnel file review/meeting with HR Admin Assistant. Topics discussed included:
•	DDS registry checks.
•	Securing background safety checks and physical exam information from temp agency for a regularly scheduled temp staff.
•	HR intern.
•	Personnel file review: Two personnel files were reviewed: See 'Areas of Regulatory Noncompliance' below.

Corrective Actions implemented as a result of previous visit: - Not applicable.

Areas of regulatory non-compliance identified during this visit:

17a-101. Protection of children from abuse. Mandated reporters. Educational and training
    programs.
•	The personnel file of one employee (SD) hired in March 2023 does not contain evidence of training on mandatory reporter requirements.

17a-131. Cardiopulmonary resuscitation training required for persons who directly supervise
    children.
•	The personnel file of one employee (CE) hired in May 2023 does not contain evidence of CPR certification.

17a-145-67	Water Supply. Sewage and garbage facilities.
•	The sink in one client bathroom does not have running water.

46a-154. Internal monitoring, training and development of policies and procedures required and
     subject to state agency inspection.
•	The personnel files of two employees (CE, SD) do not contain evidence of restraint/seclusion training.

Please submit a service development plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The service development plan must be submitted to the attention of the undersigned at the address listed above.

Kathleen Forsythe, LCSW                              			Date: 8-18-23
Regulatory Consultant

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM
Cc: 	Sr. Director of Community-Based Programs|


summary: Visit conducted on 5-4-23. No compliance issues identified. Implemented 1 corrective actions.

raw_content:
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

                                                   Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM:   Klingberg Family Centers, Inc. - WEBSTER HOUSE

TIME OF VISIT (FROM - TO):  10:30am-2:30pm                    	DATE: 5-4-23

AGENCY PERSONNEL WHO PARTICIPATED:
                Job Titles:
Program Supervisor
Director of Nursing
Senior Director of Community-Based Programs
Client
Youth Development Specialist
Certified Nurse's Aid

List of Areas / Topics covered during visit:  This was a scheduled quarterly Licensing visit to obtain an update on the program, tour the physical plant, and conduct a sample record review.

A meeting was held with the Program Supervisor and the Senior Director of Community-Based programs. Areas of discussion included:
•	Census: 5 (3 females, 2 males)
•	Staffing:
o	Program Director scheduled to return from leave next week
o	One part-time direct care worker vacancy
o	Nursing positions are full
o	Clinician position remains vacant - clinical duties covered by Sr. Director of Community-based programs and Program Director
o	Periodic use of temp agency staff
•	Recent client referral to program
•	Incidents in the past quarter
•	Video surveillance cameras
o	two exterior camera locations
o	possible installation of interior cameras
•	Update on each client
•	Life skills training for older teen client
•	Staff appreciation activities
•	New wooden garden bed built by school employee

Milieu observation:
•	Staff client interactions
•	Staff supervision station
•	Another DCF rep onsite conducting scheduled PNMI review

Physical Plant tour:
•	All areas were observed to be very clean and well organized.
•	Dining area tile floor appears worn - staff reported that carpet and tile flooring in the home are scheduled for replacement this year when federal funding is released.
•	Doorbell at front door has been repaired
•	Suggested door alarms on exit doors to enhance client safety

Client Interview. Discussion included:
•	life skill training areas
•	vocation interests
•	discharge planning, transitioning to DMHAS in the future
•	food
•	relationships with peers and staff
•	community outings, rec activities with client from another Klingberg group home

Case Record review: One  client case record was reviewed after site visit. No regulatory deficiencies noted.

Corrective Actions implemented as a result of previous visit: - A service development plan was submitted to DCF by Webster House program following a February 2023 Licensing visit that addressed regulatory citations related to the physical plant. The plan was accepted by the Department.

Areas of regulatory non-compliance identified during this visit: None.

Please submit a service development plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The service development plan must be submitted to the attention of the undersigned at the address listed above.  - No service development plan is required for this Licensing visit.

Kathleen Forsythe, LCSW                                      			Date: 5-9-23
Regulatory Consultant

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM

Cc: 	Sr. Director of Community-Based Programs
       Program Director
       Program Supervisor|


summary: Visit conducted on 2-9-23. Found 3 compliance issues.

raw_content:
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

                                                       Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM: Klingberg - WEBSTER HOUSE

TIME OF VISIT (FROM - TO):       1:00pm-3:00pm                                   		DATE: 2-9-23

AGENCY PERSONNEL WHO PARTICIPATED:
Job Titles:
Director of Clinical Services
Program Supervisor
Clients (3)
Assistant Supervisor
Registered Nurse

List of Areas / Topics covered during visit:  This was an unannounced quarterly Licensing visit to the Webster House to tour the physical plant and obtain a program update.

Physical plant tour conducted by a Youth Development Specialist (YDS):
•	Interior areas appeared clean and organized; sections of carpet are dirty (See 'Areas of Regulatory Non-compliance' below)
•	Privacy curtain, shade, etc. missing from window in bedroom #8 (See 'Areas of Regulatory Non-compliance' below)
•	Doorbell at front entrance remains non-functional
•	Storage room contains damaged mattress

Interview with Program Nurse
•	Meals; menus
•	Mask wearing no longer required on unit

Milieu Observation:
•	One resident relaxing in bedroom
•	Three residents returning from school
•	1:1 staff supervision with one resident
•	Staff/resident interactions
•	Director of Medical Services in the milieu

Meeting held with Director of Clinical Services. Topics discussed:
•	Current census = 5 residents (2 males, 3 females)
•	1:4 ratio
•	Newest resident admitted since last Licensing; prone to wandering
•	No cameras or door alarms on the unit
•	One resident diagnosed with COVID last month (mild symptoms)
•	One resident in remission from cancer is doing well
•	Housekeeping cleaning service two hours per day Monday through Friday
•	Off-site recreation activities
•	Life skills training
•	Group therapy
•	Staff vacancies: program therapist remains vacant; two part-time YDS positions vacant; use of two temporary staffing agencies when needed (Delta-T and Visiting Angels); recently hired 3rd shift YDS
•	Two new televisions on unit
•	Conversion of a YDS position to a certified nurse's aide position
•	One resident stopped attending college classes; daily programming for the resident; discharge planning; paid mentorship at 'Huneebee Project' & transportation; undocumented status
•	Dietician/resident monthly meetings; Menus
•	No major incidents in the past quarter requiring emergency services
•	Program security: lack of cameras, non-functioning doorbell
•	Hair care for residents

Interviews with two residents
•	One resident explained removing window covering
•	One resident not attending a school/work program; daily routine

Corrective Actions implemented as a result of previous visit: N/A

Areas of regulatory non-compliance identified during this visit:

                       Section 17a-145-73. Sleeping accommodations.
•	A window in a female resident's bedroom (#8) does not contain curtains, shades, blinds etc. on the lower half of the window to ensure privacy.

                      Section 17a-145-77. Dining areas and supervision.
•	Carpeting near dining area contains large stains.

Please submit a service development plan to address the above referenced area of non-compliance within 30 days of receipt of this report.  The service development plan must be submitted to the attention of the undersigned at the address listed above.

Kathleen Forsythe, LCSW			             Date :   2-10-23
Regulatory Consultant

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM
Cc: Director of Clinical Services|

description: 73. Sleeping accommodations.

facility_name: Klingberg - WEBSTER HOUSE


summary: Visit conducted on 11-21-22. No compliance issues identified. Implemented 2 corrective actions.

raw_content:
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM: Klingberg Comprehensive Services, Inc. - WEBSTER HOUSE

TIME OF VISIT (FROM - TO):       12:00p-2:00pm                                  DATE: 11-21-22

AGENCY PERSONNEL WHO PARTICIPATED:
              Job Titles:
Director of Clinical Services
Program Supervisor
HR Benefits Coordinator

List of Areas / Topics covered during visit:  This was a scheduled quarterly Licensing visit to obtain an update on the program, tour the physical plant, and conduct a semiannual personnel file review.

Meeting held with the Webster House Director of Clinical Services. Topics discussed:
•	Census (4)
•	Client events since last Licensing visit (medical, academic, vocational, recreation, incidents, etc.)
•	Staffing vacancies: 3 direct care workers, 1 overnight Registered Nurse, 1 Therapist
•	Planned Thanksgiving celebration
•	Director of Clinical Services interim coverage of Therapist duties, therapy schedules
•	Bed check frequency
•	Adding video surveillance for enhance client safety
•	Non-functioning doorbell at front door; planned entrance security upgrade
•	Individual client schedules
•	Covid status and mask requirement in group home; infection control procedures
•	Tour of the physical plant; condition of flooring in common area

Personnel File Review:
•	Semiannual personnel file review conducted. Two personnel files were reviewed. No regulatory deficiencies noted.

Corrective Actions implemented as a result of previous visit:
•	A Service Development Plan (SDP) was submitted by the agency on 9-30-22 as a follow up to the August 2022 Relicensing inspection. The SDP was accepted by the Department.

Areas of regulatory non-compliance identified during this visit: None.

Kathleen Forsythe, LCSW	                    		    Date:         11-23-22
Regulatory Consultant

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM
Cc: Director of Clinical Services|


raw_content:
September 1, 2022

Dr. Steven A. Girelli, PhD.
President/CEO
Klingberg Comprehensive Services, Inc.
370 Linwood Street
New Britain, CT   06052

Re: License #: CCF/GH/131 Webster

Dear Dr. Girelli,

On August 16th and September 1st, 2022, a biennial re-licensing inspection was conducted for the Webster House Group Home, located at 60 State Street, New Britain, CT. This inspection was conducted to determine the compliance of this program with the Regulations of the Connecticut Department of Children and Families Operation of Child-Caring Agencies and Facilities Regulations 17a-145-48 through 17a-145-124.

Additionally, an onsite review was conducted by DCF Nurse Consultant Anna Cherian, RN, MSN, FNP-BC on 6-22-22 to determine the program’s compliance with the DCF Medication Administration Guidelines and the DCF Nursing Standards. A copy of the nursing review site visit summary report is included with this report.

Listed below are the areas of DCF regulatory non-compliance which were identified during the re-licensing inspection. Please review the areas identified and complete a service development plan (SDP) to address each area of noncompliance. The plan must be submitted within 30 days of receipt of this letter and should identify: 1. the steps to be taken to correct the non-compliance; and 2. the date the correction(s) will be completed.

The areas of non-compliance identified are as follows:

17a-131	Cardiopulmonary Resuscitation Training Required for Persons Who Directly Supervise Children.
•	Two personnel files reviewed (JS, IS) did not contain evidence of CPR training.

Chapter 814e 	Physical Restraint, Medication and Seclusion of Persons Receiving Care, Education or Supervision in a School, Institution or Facility.
46a-154	Internal monitoring, training and development of Policies and procedures required and subject to state agency Inspection.
•	One personnel file reviewed (JS) did not contain evidence of physical restraint training.

******************************************************************************

Once the Licensing Unit has reviewed and accepted the service development plan and has determined that your agency is in compliance with the regulations, a decision on the issuance of a regular twenty-four
month license for the program will be made.  Until DCF makes this decision the current license will remain in effect.

Should you have any questions or comments regarding the contents of this report please do not hesitate to contact me at (860) 937-7551.

Sincerely,

Kathleen Forsythe
_________________________
Kathleen Forsythe, LCSW
Regulatory Consultant

Cc: Senior Director of Community Based programs
      Director of Clinical Services
      File|


summary: Visit conducted on 6-1-22. Visit covered 16 main areas/topics. Found 5 compliance issues.

raw_content:
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM: Klingberg - WEBSTER HOUSE

TIME OF VISIT (FROM - TO):       10:30am-2:30pm                                  DATE: 6-1-22

AGENCY PERSONNEL WHO PARTICIPATED:
Job Titles:
Director of Clinical Services
Program Supervisor
Assistant Program Supervisor
Assistant Plant Director
Director of Health Services
HR Administrative Assistant

List of Areas / Topics covered during visit:  This was a scheduled quarterly visit for the newly assigned Regulatory Consultant to tour the program and conduct a semi-annual personnel file review. Discussions were held in the following areas:
•	Introduction of group home management team
•	Current renovation of group home to add a bedroom and an ADA compliant bathroom
•	Restraint and seclusion data from past quarter
•	Hospital visits
•	Fire watch status report
•	Staff vacancies and use of a staffing agency
•	New DCF Physical Plant checklist
•	Reasonable Prudent Parent Standard
•	Physical plant tour, tour of area under renovation when clients are not in the building
•	Grocery delivery, food storage, menu development & Dietician approval
•	Storage of client personal belongings in bedrooms
•	Window screens
•	Use of Multiplacement Lounge (MPL)
•	Biannual relicensing inspection scheduled for August 2022; application materials and due dates reviewed
•	Semi-annual personnel file conducted; 9 files reviewed

Corrective Actions implemented as a result of previous visit: N/A

Areas of regulatory non-compliance identified during this visit:

17a-145-64 Personnel Policies and Procedures
•	One personnel file (AF) did not contain evidence of TB testing results.
•	One file (JF) contained TB testing results obtained six months prior to hire rather than immediately prior to hire.
•	Four files (KD, AR, SF, MB) did not contain evidence of CPR certification.
•	Six files (MG, JF, AR, JJ, AF, MB) did not contain evidence of restraint training certification.

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Kathleen Forsythe, LCSW			                                    6-2-22
______________________________            _________________
Regulatory Consultant                                              Date

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM
Cc: Director of Clinical Services|

description: 64 Personnel Policies and Procedures


facility_name: Klingberg Comprehensive Program Services/ Phoenix

summary: Visit conducted on 7/22/25. Found 4 compliance issues.

raw_content:
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form
This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM: Klingberg Family Centers (KFC) / Phoenix House Group Home
TIME OF VISIT (FROM - TO):     9:30am-10:30am                  			DATE:  7/22/25
AGENCY PERSONNEL WHO PARTICIPATED: Program Supervisor, Program Clinician
List of Areas / Topics covered during visit:  This was a scheduled quarterly Licensing Visit to obtain updates on the program and tour the physical plant.
Topics discussed included:
•	Census: 4 females. LBC =4
•	Staffing Vacancies:  two (2) full time day shift and One (1) full time 3rd shift.
•	Medication Administration
•	Discharge Planning
•	Recreation Activities: Hikes, Library, Go-karting, Laser Tag, Beach
•	Clinical Programming: DBT & Life Skills Groups-continue, Sex Education Group (Healthy Sexuality Group) has ended.

Physical Plant: Staff facilitated a tour of the interior/exterior of the physical plant.  All areas appear clean and organized.
Milieu: Two (2) youth were leaving for a hike with staff.  One (1) youth (NS) has been in the hospital for over one (1) month.  KFC staff visit youth 3-4 times per week.  One (1) youth  was attending summer school.
Corrective Actions implemented as a result of previous visit: None
Areas of regulatory non-compliance identified during this visit:
Connecticut General Statutes 370 Section 20-14h – j, & DCF regulation 17a-6(g)-12-16, to provide training for medically-unlicensed persons to safely administer medications to children in DCF operated and licensed childcare facilities and extended day treatment programs.
•	Youth missed medication from 5/1/25 to 6/16/25.  However, staff documented that the medication was administered.  Staff were not following medication administration training requirements.

Please submit a regulation compliance plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.
Amita Patel, LMSW			Date: 8/4/25
Regulatory Consultant

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM

Cc: Program Director
File|

description: 14h – j, & DCF regulation 17a

description: 16, to provide training for medically


summary: Visit conducted on 4/30/25. No compliance issues identified.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM: Klingberg Family Centers (KFC) / Phoenix House Group Home

TIME OF VISIT (FROM - TO):     12:25-2pm                  			DATE:  4/30/25

AGENCY PERSONNEL WHO PARTICIPATED: Director of Group Care, Program Supervisor, Program Clinician

List of Areas / Topics covered during visit:  This was a scheduled quarterly Licensing Visit to obtain updates on the program and tour the physical plant.

Topics discussed included:

•	Census: 4 females. LBC =4
•	Staffing Vacancies:  One (1) full time day shift and One (1) full time 3rd shift.
•	Medication Administration
•	Program updates-Second agency vehicle arrived
•	Discharge Planning
•	Recreation Activities: Lake Compounce Gym, Pool
•	Clinical Programming: DBT & Life Skills Groups, Sex Education Group (Healthy Sexuality Group)

Physical Plant: Staff facilitated a tour of the interior/exterior of the physical plant.  All areas appear clean and organized.

Milieu: One(1)youth was present but was being transported to CT Children's Hospital due to a fall on the stairs in the morning.  Youth attended school and reported she didn’t feel pain.  While at school, youth's ankle started swelling and the school contacted program.  Staff transported for further evaluation.

Corrective Actions implemented as a result of previous visit: None

Areas of regulatory non-compliance identified during this visit:  None

Please submit a regulation compliance plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.  -

Amita Patel, LMSW			Date: 5/15/25
Regulatory Consultant

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM

Cc:
Program Director
File|


summary: Visit conducted on 1/28/25. No compliance issues identified.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM: Klingberg Family Centers (KFC) / Phoenix House Group Home

TIME OF VISIT (FROM - TO):     9:30-10:45am                  			DATE:  1/28/25

AGENCY PERSONNEL WHO PARTICIPATED: Director of Group Care, Supervisor, Program Clinician

List of Areas / Topics covered during visit:  This was a scheduled quarterly Licensing Visit to obtain updates on the program and tour the physical plant.

Topics discussed included:

•	Census 3 females. LBC =4
•	Program updates-Second agency vehicle is scheduled to arrive the following week
•	Discharge Planning (One (1) youth may transfer to Webster House, One (1) youth may transition from a voluntary to DCF involved youth)
•	Recreation Activities
•	Vacancies:  One (1) full time (Day & 3rd shift).  Shifts are being covered by per diem and school staff, Delta T.
•	Clinical Programming: DBT & Life Skills Groups

Physical Plant: Staff facilitated a tour of the interior/exterior of the physical plant.  All areas appear clean and organized.

Milieu: No youth were present and were at school.

Corrective Actions implemented as a result of previous visit: None

Areas of regulatory non-compliance identified during this visit:  None

Please submit a regulation compliance plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.  -

Amita Patel, LMSW			Date: 2/13/25
Regulatory Consultant

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM
Cc: Senior Director of Community Based Services|


summary: Visit conducted on 10/29/24. Found 2 compliance issues.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM: Klingberg Family Centers (KFC) / Phoenix House Group Home

TIME OF VISIT (FROM - TO):     12-12:45 pm                  				DATE:  10/29/24

AGENCY PERSONNEL WHO PARTICIPATED: Director of Group Care, Supervisor, Program Clinician

List of Areas / Topics covered during visit:  This was a scheduled quarterly Licensing Visit to obtain updates on the program and tour the physical plant.

Topics discussed included:

•	Census 2 females. LBC =4
•	Incidents during past quarter=0
•	Program updates: Joint Commission Accreditation inspection completed with no citations.  New furniture ordered for double bedroom. House next door had a significant fire.
•	Discharge Planning:  One (1) youth d/c to godmother's home.  Youth has been reluctant to participate in aftercare contact/visits.
•	Recreation Activities:  Library, movies, self-care activities in house,
•	Vacancies:  Three (3) full time (1st/2nd).  Shifts are being covered by per diem and school staff, Delta T.
•	DBT Groups occur with residents of Webster House.

Physical Plant: Staff facilitated a tour of the interior/exterior of the physical plant.  All areas appear clean and organized.

Milieu: No youth were present and were at school.

Corrective Actions implemented as a result of previous visit: None

Areas of regulatory non-compliance identified during this visit:

Section 17a-145-74. Lavatory facilities. Toilet articles and linens
•	Resident bathroom bathtub has several spots on the floor is chipped and showing signs of wear.

Please submit a regulation compliance plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.  -

Amita Patel, LMSW			Date: 11/26/24
Regulatory Consultant

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM
Cc: Senior Director of Community Based Services|


summary: Visit conducted on 7/18/24. Found 1 compliance issues.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM: Klingberg Family Centers (KFC) / Phoenix House Group Home

TIME OF VISIT (FROM - TO):     11am-12:30pm                 DATE:  7/18/24

AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:
Program Supervisor

List of Areas / Topics covered during visit:  This was a scheduled quarterly Licensing Visit to obtain updates on the program and tour the physical plant.

Meeting was held with: Senior Director, Program Supervisor and Lead YDS.  Topics discussed included:

•	Census 3 females. LBC =4
•	Incidents during past quarter=0
•	Program updates
•	Recreation Activities
•	Vacancies:  Three (3) full time and two (2) part time child care workers on 1st/2nd shift.
•	Program Clinician has been working for about one (1) month.

Physical Plant: Staff facilitated a tour of the interior/exterior of the physical plant.  All areas appear clean and organized.

Milieu: No youth were present and were at school.

Corrective Actions implemented as a result of previous visit: None

Areas of regulatory non-compliance identified during this visit:

Section 17a-145-73:  Sleeping Accommodations:

•	Bedroom # 2 has a hole in the wall behind the door.

Section 17a-145-74. Lavatory facilities. Toilet articles and linens
•	Resident bathroom bathtub has several spots on the floor is chipped and showing signs of wear.

Section 17a-145-76. Kitchens, equipment, food-handling:
•	Kitchen counters show signs of wear.

Please submit a regulation compliance plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.  -

Amita Patel, LMSW			Date: 7/19/24
Regulatory Consultant

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM

Cc: Senior Director of Community Based Services|

description: Section 17a-145-74.


summary: Visit conducted on 5-2-24.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM: Klingberg Family Centers (KFC) / Phoenix House Group Home

TIME OF VISIT (FROM - TO):     12:00pm - 2:30pm                 DATE:  5-2-24

AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:
Senior Director of Community-Based Services
Program Supervisor
Lead Youth Development Specialist

List of Areas / Topics covered during visit:  This was a scheduled quarterly Licensing Visit to obtain updates on the program and tour the physical plant.

Meeting was held with: Senior Director, Program Supervisor and Lead YDS.  Topics discussed included:

•	Census 3 females. LBC =4
•	Incidents during past quarter
•	Program updates
•	Recreation Activities

Physical Plant: Staff facilitated a tour of the interior/exterior of the physical plant.  All areas appear clean and organized.

Milieu: No youth were present and were at school.

Corrective Actions implemented as a result of previous visit: Not applicable

Please submit a service development plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.  -

Amita Patel, LMSW			Date: 6/14/24
Regulatory Consultant

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM
Cc: Senior Director of Community Based Services|


summary: Visit conducted on 1-30-24.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM: Klingberg Family Centers (KFC) / Phoenix House Group Home

TIME OF VISIT (FROM - TO):     10:00am - 12:30pm                 DATE:  1-30-24

AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:
Senior Director of Community-Based Services
Program Supervisor
Lead Youth Development Specialist

List of Areas / Topics covered during visit:  This was a scheduled quarterly Licensing Visit to obtain updates on the program and tour the physical plant.

Meeting was held with: Senior Director, Program Supervisor and Lead YDS.  Topics discussed included:

•	Census 3 females. LBC =4
•	Incidents during past quarter
•	Medication Refrigerator
•	Program updates
•	Recreation Activities
•	Staff Recruitment and Retention Initiatives

•	Staffing Vacancies:  1 Full-time Youth Development Specialists, Program Clinician.

Physical Plant: Staff facilitated a tour of the interior/exterior of the physical plant.  All areas appear clean and organized.  Rear Fence removal to be scheduled.

Milieu: No youth were present and were at school.

Corrective Actions implemented as a result of previous visit: Not applicable

Please submit a service development plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.  -

Amita Patel, LMSW			Date: 2/15/24
Regulatory Consultant

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM
Cc: Senior Director of Community Based Services|


summary: Visit conducted on 8-10-23. No compliance issues identified.

raw_content:
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

                                                                Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM: Klingberg Family Centers (KFC) / Phoenix House Group Home

TIME OF VISIT (FROM - TO):     10:00am - 12:20pm                 DATE:  8-10-23

AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:
Senior Director of Community-Based Services
Program Supervisor
Lead Youth Development Specialist
Client (D)

List of Areas / Topics covered during visit:  This was a scheduled quarterly Licensing Visit to obtain updates on the program and tour the physical plant.

Meeting was held with: Senior Director, Program Supervisor and Lead YDS.  Topics discussed included:

•	Census 3 females. LBC =4
•	Proposed addition of bedroom in lower level
•	Incidents during past quarter
•	Medication Refrigerator
•	Program updates
•	Video cameras in common areas; Quality Assurance Measures
•	Recreation Activities
•	Discharge Planning
•	Program Vehicles
•	Life Skills Training
•	Klingberg selected as recipient of My Life My Choice Training by outside vendor
•	Two (2) Phoenix House participated in Train the Trainer for Love 146 Training
•	Staff Recruitment and Retention Initiatives
•	Nursing Care Plan for one (1) client
•	Fire Extinguisher installed in Cleaning supply Closet

•	Staffing Vacancies:  2.5 Youth Development Specialists, Program Director and Clinician.
Senior Leadership is serving as Program Director and Clinician. Use of one (1) temp agency staff.

Physical Plant: Staff facilitated a tour of the interior/exterior of the physical plant.  All areas appear clean and organized.  Rear Fence removal to be scheduled.

Milieu: Two clients were observed in the home, observed leaving with staff on off-campus recreation activity.

Client Interview: One (1) client interviewed, reported satisfaction with program and no concerns reported.

Corrective Actions implemented as a result of previous visit: Not applicable

Areas of regulatory non-compliance identified during this visit:  Not applicable

Please submit a service development plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.  - No service development plan is required following this Licensing visit.

Amita Patel, LMSW                       			Date: 8/11/23
Regulatory Consultant

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM
Cc: Senior Director of Community Based Services|


summary: Visit conducted on 5-9-23.

raw_content:
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

                                                             Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM:     Klingberg Family Centers, Inc. - Phoenix House

TIME OF VISIT (FROM - TO):    10:45am-1:15pm                  	DATE: 5-9-23

AGENCY PERSONNEL WHO PARTICIPATED:
       Job Titles:
Asst. Program Supervisors (2)

List of Areas / Topics covered during visit:  This was a scheduled quarterly Licensing visit to obtain an update on the program, tour the physical plant and conduct a case record review.

Meeting held with two Assistant Program Supervisors. Topics discussed included:
•	Census: 3 females. Licensed bed capacity = 4
•	Significant events: 1
•	Two admissions during the past quarter
•	Updates on the three residents
•	Children's Rights statute re: telephone use
•	Improvements to house interior: interior paintings, additional décor, new rugs, sensory area in the lower level
•	Menu planning and approval
•	Recreation activities
•	Life skills trainings: current focus includes boundaries, grocery shopping, home cleaning procedures
•	Planned outdoor gardening
•	Condition of wooden fence in rear yard; brush removal

Staffing Update:
•	Program Director position is currently vacant
•	New Clinician assumed job duties in April
•	One full time third shift, one full-time and one part-time direct care worker vacancies for the awake shifts

Physical Plant: Staff facilitated a tour of the physical plant. All areas appeared very clean and well organized.

Milieu: Client were attending school off-site during the visit. Life Skills Coordinator observed in the dining room.

Case Records: One case record was reviewed after the site visit. No regulatory deficiencies were noted

Corrective Actions implemented as a result of previous visit: Not applicable

Please submit a service development plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The service development plan must be submitted to the attention of the undersigned at the address listed above.  - No service development plan is required for this Licensing visit.

Kathleen Forsythe, LCSW                    				Date: 5-11-23
Regulatory Consultant

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM.

Cc:       Sr. Director of Community-Based Programs|


summary: Visit conducted on 2-16-23. No compliance issues identified.

raw_content:
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

                                                      Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM:                       Klingberg - Phoenix House

TIME OF VISIT (FROM - TO):    11:45am-1:15pm                  	DATE:  2-16-23

AGENCY PERSONNEL WHO PARTICIPATED:

       Job Titles:
Clinical Director
Program Supervisor
Youth Development Specialist (2)
List of Areas / Topics covered during visit:  This was an unannounced quarterly Licensing visit to obtain an update on the program and tour the physical plant.

Meeting held with Clinical Director. Topics discussed included:
•	Census: 1 female.
•	Referrals: 2. Anticipated admissions scheduled for March
•	Staffing vacancies: 1 third shift position, covered by perdiem staff. New Therapist hired today and will start next month.
•	Possible conversion of Phoenix House to a STAR home
•	Building plans for a bedroom on lower level
•	Conversion to Quality Residential Treatment program (QRTP) occurred in December 2022
•	Recent purchase of three new beds
•	Aftercare services
•	Discharge planning for current resident
•	Surveillance cameras
•	Program vehicle monitoring
•	Planned improvements to house interior (relocating washer/dryer, painting bedrooms and bathrooms)
•	Neighbor relationships
•	Grocery shopping
•	Life skills trainings
•	Meeting the needs of a diverse female client population

Physical Plant: The Supervisor facilitated a tour of the physical plant. All areas appeared organized and clean, with the exception of the bathroom shower in master bedroom.

Milieu: Direct care staff observed cleaning common areas. Resident was attending school off-site.

Corrective Actions implemented as a result of previous visit: Not applicable

Areas of regulatory non-compliance identified during this visit: None.

Kathleen Forsythe, LCSW                                           				Date: 2-17-23
Regulatory Consultant

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM
Cc: Clinical Director
      Director of Community Based Programs|

facility_name: Klingberg - Phoenix House


summary: Visit conducted on 11-21-22. Visit covered 1 main areas/topics. Found 3 compliance issues.

raw_content:
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

                                                    Field Visit Reporting Form
This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM:       Klingberg Family Centers, Inc. - PHOENIX House Group Home

TIME OF VISIT (FROM - TO):      1:00p-2:00p              DATE:  11-21-22

AGENCY PERSONNEL WHO PARTICIPATED:
Job Titles:
HR Benefits Coordinator

List of Areas / Topics covered during visit:  This was a scheduled Licensing visit to the HR office on the Klingberg campus in New Britain to conduct a semiannual personnel file review of staff hired in the previous six months for the Phoenix House group home.

•	Two personnel files were reviewed.

Corrective Actions implemented as a result of previous visit: N/A

Areas of regulatory non-compliance identified during this visit:
17a-131 CPR Training & 46a-154 Restraint Training
•	One personnel file of a Youth Development Specialist hired in July 2022 did not contain evidence of CPR certification and restraint training.

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Kathleen Forsythe, LCSW                                         			Date:      11-23-22
Regulatory Consultant

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM
Cc:	Clinical Director
            HR Assistant|

description: 131 CPR Training & 46a

description: 154 Restraint Training


summary: Visit conducted on 11-10-22. No compliance issues identified.

raw_content:
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

                                                         Field Visit Reporting Form
This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM:        Klingberg Family Centers - PHOENIX House Group Home

TIME OF VISIT (FROM - TO):      10:50am-2:00pm              DATE:  11-10-22

AGENCY PERSONNEL WHO PARTICIPATED:
Job Titles:
Clinical Director
Therapist
Program Supervisors (2)
Client

List of Areas / Topics covered during visit:  This was a scheduled quarterly Licensing visit to obtain an update on the program and to tour the physical plant.

Meeting held with program management staff, who provided an update on the program since the previous Licensing visit in August 2022:
•	Current census = 2 females. One client was discharged after she went AWOL. Discussed the involved client's history, family involvement, need for PRTF level of care, etc. Staff reported that two referrals for admission are currently under consideration.
•	Semiannual PNMI review conducted by DCF last week
•	Staffing vacancies: Program therapist who is a master's level Clinician will need to be replaced by a licensed clinician, per PNMI standards. Three full-time and one part-time direct care worker positions are open.
•	Police involvement in two incidents last quarter
•	Investigation
•	Recreation and leisure
•	Meals, menu, food shopping, food prep
•	Life skills training for clients; prepping older client to discharge next spring
•	Neighbor relations
•	Limited availability of parking for staff on the property; three cars parked on the street
•	QRTP designation: The group home is now a qualified residential treatment program, as designated by DCF, to comply with the Families First Act. Licensed bed capacity will reduce to four beds; six months of aftercare services will be provided.
•	Only one vehicle is assigned to the program

Physical plant: Management facilitated a tour of the physical plant. All areas appeared clean and organized. Program installed video cameras this fall. Discussed bed frames, mattresses, bedroom furniture, enhancing privacy on bedroom windows, bathroom privacy, condition of backyard fence. Garbage cans stored in front of house. Planned renovation to create a single bedroom is on hold until early 2023.

Milieu observation: Three direct care staff on duty. One client in the house. Client spoke briefly about the certification program she attends at a local technical institute.

Corrective Actions implemented as a result of previous visit: N/A

Areas of regulatory non-compliance identified during this visit: None

Kathleen Forsythe, LCSW                                             			Date:      11-10-22
Regulatory Consultant

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM
Cc:	Dir. Of Community Based Programs
Clinical Director|


summary: Visit conducted on 8-10-22. Visit covered 16 main areas/topics. No compliance issues identified.

raw_content:
Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

 NAME OF FACILITY / PROGRAM: _          Klingberg - PHOENIX HOUSE GROUP HOME   ¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬

 TIME OF VISIT (FROM - TO):       10:30am-12:45pm              DATE:  8-10-22

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:
Senior Director of Community Based Programs
Clinical Director
Therapist
Program Supervisor
Client

List of Areas / Topics covered during visit:  This was a scheduled quarterly visit to introduce the newly assigned Regulatory Consultant, obtain an update on the program, and to tour the physical plant. Topics discussed:
•	Census (3)
•	Client cases
•	Neighbor relations
•	Physical plant security
•	New QRTP contract requirements
•	Life skills education for clients
•	Summer activities, summer school
•	Education/vocational plans for new school year
•	Menus, food storage
•	Staffing vacancies (1)
•	DMST training and future staff trainings
•	Agency vehicle
•	Physical plant inspection
•	Milieu observation
•	BBQ grill placement
•	Future renovation plan

Corrective Actions implemented as a result of previous visit: None.

Areas of regulatory non-compliance identified during this visit: None.

Kathleen Forsythe, LCSW           			Date: 8-12-22
Regulatory Consultant

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM.
Cc: Clinical Director
      Senior Director of Community Based Programs|


raw_content:
Steve Girelli, President 	     		                          4/27/2022
Klingberg Family Centers
370 Linwood Street
New Britain, CT  06052

Re: Licensing Inspection for Phoenix House
Regulatory Consultants: Tom Cuchara and Penny Woodward

Dear Dr. Girelli,
On 4/26/22 & 4/27/22, a biennial re-licensing inspection was conducted at Phoenix House GH.  This inspection was conducted to determine the compliance of this agency with the Regulations for Operation of Child-Caring Agencies and Facilities 17a-145-48 to 17a-145-98. Below are listed the areas of regulatory non-compliance which were identified during the re-licensing inspection. Please review the areas identified and submit a service development plan to address each area.  The plan must be submitted within 30 days of receipt of this letter and should identify: 1. the steps to be taken to correct the non-compliance; and 2. the date the correction(s) will be completed.  Also included in the report are recommendations.  Recommendations are meant to highlight areas that are not currently areas of non-compliance, but may become non-compliant if actions are not taken.  Recommendations are also made in order to enhance program functioning.  Recommendations do not require the submission of a service development plan.

The areas of non-compliance identified are as follows:

Section 17a-145-64. Personnel policies and procedures.
Evidence:  Two personnel files were reviewed.
    CPR: One file did not have evidence of CPR certification.

Section 17a-145-86. Instructions in safety procedures.
Evidence:
2020: 1st quarter First shift fire drill missing.
          2nd quarter Second & third shift fire drills missing.
          3rd quarter First shift fire drill missing.
2021: 4th quarter Second & third shift fired drills missing. No time or shift is                   documented on the form.
2022: 1st quarter 1st, 2nd and 3rd fire drills were recorded on the fire drill form used, but there is no documentation of the time and shift of when the drills took place.

Once licensing has reviewed and accepted the service development plan and has determined that your agency is in compliance with the regulations a decision on the issuance of a regular twenty-four month license for the program will be made.  Until DCF makes this decision the current license will remain in effect.  Please be advised that failure to submit an acceptable service development plan within the specified time frame may lead to licensing action up to and including revocation.  Please forward a copy of your service development plan to your

assigned DCF Program Development and Oversight Coordinator (PDOC) if applicable.  Should you have any questions or comments regarding the contents of this report please do not hesitate to call me at (860) 550-6310 or 203-675-6975.

Sincerely,
_____Thomas S. Cuchara__________________________________
Thomas S. Cuchara, Regulatory Consultant

Copy: Executive Director
           Licensing File|


facility_name: NAFI Connecticut, Inc. / Tress Rd / GH #42

summary: Visit conducted on 12/15/25. Found 3 compliance issues. Implemented 2 corrective actions.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM: NAFI / Tress Road Home

TIME OF VISIT (FROM - TO):       ____First shift_              DATE: 12/15/25

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:
Administrative Staff

List of Areas / Topics covered during visit:
Reviewed the status of the home and the physical plant. There were 3 youth residing at the home and they were all at school.

There was a clinician and administrative staff on duty at the home. There was one staffing position available at the home. It's a 30 hour position on Thursday and Friday from 2pm to 10 pm and Saturday from 8 am to 10pm.

Corrective Actions implemented as a result of previous visit:
Section 17a-145-76. Kitchens, equipment, food-handling was responded to satisfactorily.

Areas of regulatory non-compliance identified during this visit:
Section 17a-145-71. Living room, lounge
Cottage-type and congregate-type institutions shall provide a living room or lounge in each unit sufficient in size and equipment for the informal use of the children. Each living room or lounge shall be comfortably and attractively furnished, well heated, lighted, ventilated and screened, clean and cheerful, with substantial furnishings suitable for use by children.
•	The repair to the foyer ceiling is less than standard and unsightly.

Section 17a-145-76. Kitchens, equipment, food-handling
All kitchens shall be clean, well lighted, properly ventilated and screened, and provided with essential and proper equipment for the preparation and serving of food. Storage, refrigeration and freezer facilities shall be adequate for the number of persons to be served. All perishable foods shall be refrigerated at a temperature at or below 45° Fahrenheit. Freezers and frozen food compartments shall be maintained at minus 10° to 0° Fahrenheit. Cooking utensils, dishes and tableware shall be in good condition and proper cleaning facilities for this equipment shall be provided. dishes shall be stored in a clean, dry place protected from flies, dust or other contamination. Food preparation and serving areas shall comply with Section 19-13-B42 of the public health code. Proper food handling techniques and sanitation to minimize the possibility of the spread of food-borne diseases shall be maintained.
•	The handle was missing from the refrigerator door.

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Keith Bryan                                                 12/15//25
Regulatory Consultant                                   Date

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

facility_name: NAFI / Tress Road Home