summary: License Renewals - 3 findings

raw_content:
Licensed Child Caring Agency Site Visit Report
Residential Care
Licensee: Josephine County Juvenile Department – Turning Point Date of site visit: February 7th / 8th, 2022
Executive Director: James Goodwin (Juvenile Department Director) Licensing Coordinator: Ed Wyller
Other Regulatory or Accrediting Agencies: Oregon Youth Authority (OYA), Oregon Department of Human Services (ODHS) Treatment Services
Program Compliance: The program was found to be compliant or will be compliant with OAR 413-215-0001 to 413-215-0131, Licensing Umbrella
Rules, and OAR 413-215-0501 to 413-215-0586, Licensing Residential Care Agencies Rules. Personnel records were reviewed and compliance
with required background checks was documented for employees in all programs.
Program Description(s): “Turning Point provides ODHS, OYA, and County Probation youth with individualized treatment service plans which
include cognitive behavioral groups, individual counseling, and skill building services. Youth in the program work on treatment goals while also
attending on-site school, as well as community, vocational, and recreational opportunities. On-site nursing and mental health services are available,
as well as community partners for primary care, mental health, and Alcohol and Drug treatment services.”
Program type and services: Residential Care – BRS Basic Residential
Capacity and Age Range: Capacity 12 / 13–17-year-old age range
Funding sources: ODHS, OYA, and Josephine County Juvenile Probation
Contracts and sources for referrals: ODHS, OYA, and Josephine County Juvenile Probation
Average length of stay: 6-9 months
Average daily population served: 6
Number of children served annually: 20
(rev. 03/25/2021)
Use of seclusion or restraint: Turning Point reports that they do not use either seclusion and or restraints.
Interviews, Observations: I interviewed an OYA youth and a county youth. Both reported feeling safe at Turning Point. Both reported that staff
treat you with respect and it’s a good place. Youth reported the following activities, going to YMCA, playing basketball at park, playing basketball
on-site, doing artwork, bowling, and ice skating. Youth reported looking forward to going to Portland on Saturday to see the Portland Trailblazers
play. It is a day game allowing program to travel from Grants Pass at reasonable hours for the youth. On a scale from 0-10 (0=worst program and
10=best program) youth reported Turning Point to be a 7.5, and an 8. Youth reported food to be really good. Youth reported cook makes Mexican,
Chinese dishes and bakes often. One youth reported learning the skills of patience and listening. The other youth has been in multiple programs
and reported being in groups and needing to apply what he has learned. When asked how the program could be improved, one youth reported
they missed staff that had left. (Turnover of staff). The other youth reported when going out to get a shake at Inn and Out Burger she would like to
order food.
During the site inspection reviewer noted new additions to the program:
 New walk-in fridge/freezer
 New gas kitchen stove
 New dishwasher
 New refrigerated water bottle fountain for youth in living area
 New milk refrigerator
 New outdoor bench in recreation area
 New outdoor shed for storage
 New communications board in staff office for relaying information about youth
 New extra long bed for tall youth (recent youth was 6 foot 7inches)
 An Automated External Defibrillator (AED) is on-site in staff office
During Kitchen tour I noted an allergy board in kitchen regarding what youth maybe allergic to. Cook has dedicated cutting boards for youth with
food allergies to limit any possible cross contamination for those youth during meal prep.
Program Strengths: Turning Point reports:
“1) Food service specialist providing fresh homemade meals cooked in our full-service kitchen
2) Development of community partnerships that provide consistent outings for youth in the program for recreation and vocational opportunities
(horse ranch, YMCA, Vocational Tech program)
3) Contract services with Options for Southern Oregon which provides on-site mental health services with the ability for the Qualified Mental Health
Professional (QMHP) to develop relationships with youth in the program setting and then also allow for additional counseling services off-site at
Options as needed.
4) Purchase and implementation of BestNotes program for electronic documentation and tracking of all BRS services.”
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Program Challenges: Turning Point reports:
“1) Physical location of program is across the street from the Gospel Rescue Mission and next to the railroad tracks.
2) Limited outdoor area on-site for recreation purposes for youth to utilize.
3) The inability to hire and maintain staffing for the program. (Lack of applications for open positions and current staff moving away or taking jobs in
other fields.”
Changes that have occurred in the last 2 years: Turning Point reports, “As mentioned, we have had a lot of staffing changes over that last two
years. This creates difficulty in constantly needing to train new people, creating shifts with no experience, and requiring a lot of assistance from
management and on-call managers regularly. Our Social Services Facilitator has been out for the past 7 months on medical leave. We have been
using three qualified Juvenile Probation Officers to cover the position until her return. We are meeting all BRS requirements, but this obviously has
been a difficult obstacle for the program. Our Juvenile Justice Manager stepped down from his position (this person is supervisor over Group Life
Counselors) and a new manager took over. Our weekend / Asst Manager moved, thus requiring us to hire a new person externally.
Positive changes include new community partners that have been added: 715 Youth Ministries, which provides opportunities for interested youth to
engage in a weekly VoTech program (auto repair, welding, construction, etc.) and additionally Project Youth+ which provides vocational training on-
site including: food handler’s cards, resume writing, career aptitude, interviewing, etc. We applied for and were awarded $3,000 from the Carpenter
Foundation Grant to purchase new recreation equipment and arts/craft supplies for the program.
After a long process and lots of hard work, in November 2020, the Council on Accreditation (COA), informed us that Turning Point Youth Residential
Program, Josephine County Juvenile Justice had been accredited. We are now a Qualified Residential Treatment Program! We were able to
purchase new “behavioral health” furniture for our dayroom area, a new industrial stove, and a new dishwasher / sanitizer for our kitchen with
money we received from our grant for becoming an accredited QRTP.
Lawsuits: Turning Points reports, “No”.
Grievances and complaints filed in the last two years: Turning Points reports, “No”.
Corrective Actions and Timeframes: Please submit the following to verify compliance.
Within 45 days of receipt of this report Josephine County – Turning Point must submit a letter of verification indicating the agency is in compliance
with the specific rules cited above and describing how compliance will be maintained going forward. Along with the letter of verification, the agency
must submit any and all specific documentation requested in the body of this report. The letter of verification and any additional requested
documents can be emailed directly to Ed Wyller at Edward.Wyller@dhsoha.state.or.us or sent by regular mail to the following address:
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Due to Covid-19 pandemic and working remotely the preferred method is to send directly to Ed Wyller at his email address.
Department of Human Services, Children’s Care Licensing Unit
Attn: Ed Wyller
500 Summer St NE (E-94)
Salem, OR 97301
Changes in License: Turning Point has requested to change their age range on their license from 11-17 to 13-17.
Summary of Review
Program and Services Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0011(2) Completed
Program and services are in scope of license x
Governance of the Agency Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0021 Completed
(1)(a) Minimum of 5 board members x  3 Douglas County Board of Commissioners
(2)(f) Formally evaluate the exec. Director’s x
performance annually
(2)(g) Approves annual budget x
(2)(h) Obtain and review an annual x
independent financial review or audit of
financial records.
(2)(k) Written quality improvement program x
(2)(l) Meeting minutes x
Executive Director or Program Director Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0021 Completed
(3)(a) knowledge of requirements for x
providing care and treatment appropriate to
programs
(3)(g) Approval from BCU x
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Discipline, Behavior Management, and Corrective Action
Yes No N/A Corrective Actions/Comments
Suicide Prevention 413-215-0076 Completed
(3) Agency uses appropriate and positive
methods of behavior management and
x
nationally recognized non-violent crisis
intervention
(3)(b)(C) Agency does not use chemical and
mechanical restraint (excluding medically x
necessary devices/prescriptions)
(3)(c) Agency uses appropriate time-out
rooms (adequate space, heat, light and
ventilation and is not capable of locking) and x
documents use in child’s record when
applicable
(3)(e) Agency uses seclusion
x
appropriately/consistent with policy
(4) Agency has adequate plan in place to
x
respond to suicidal behavior/warning signs
Contractors (if applicable) Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0061(6) Completed
(a) Agency ensures the contractor meets the
requirements of this rule and Chapter 413 x
division 215
(b)(B) Contract includes the following:
(i) Services provided
(ii) Contractor fees
(iii) Disclosure of information from contractor
to agency
(iv) Lines of authority x
(v) Adherence to rules, including background
check
(vi) Any liability of the agency for acts of the
contractor, rights of indemnity and limitations
on liability
Supplemental Information Provided by Corrective Action
Yes No N/A Corrective Actions/Comments
CCA Completed
Documents as indicated on the form titled  Fire Marshall reinspection needed to review finding
“Renewal Licensing Required Documents” regarding oven hood. Program has provided the
x
maintenance has been completed, however are
waiting for reinspection.
Documents as indicated on form titled
“Required Financial Documents and x
Information”
All required policies and procedures as
x
identified in the “Umbrella Rules”
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All required policies and procedures as
x
identified in “Agency Type Specific Rules”
Physical Plant Corrective Action
Yes No N/A Corrective Actions/Comments
Completed
413-215-0046(3)(a) Foster Rights Posted (if x 413-215-0511 (2) (a) and (c)
children in DHS custody)  Vents throughout the facility had accumulation of
413-215-0051(1) Sufficient safe space, x dust, grime, and lint. (Laundry room, kitchen,
equipment, and office equipment bathrooms)
413-215-0091(12) License is posted in x  Kitchen floors have a built-in grime. Program reports
common area at each facility they are cleaned but will need to be buffed out and
413-215-0001(5)(d), 0516(4(a)(I) & 0521(1) x redone.
Adequate furnishings and personal items  Carpet in bedrooms and main room dirty. (Needs
413-215-0511(2)(a) &(c) Buildings are x cleaning).
smoke free, clean and in good repair  Carpet runner coming up by living room to dining
413-215-0511(2)(d) Rooms are free of x area (tripping hazard)
harmful drafts, odors, and excessive noise  Spit wads on ceiling in boy’s bathroom need to be
413-215-0511(2)(e) Rooms are adequate in x removed.
size and arrangement
413-215-0511(2)(f) System provides a x
continuous supply of hot and cold water to
taps located throughout the facility
413-215-0511(2)(h) Building is well x
ventilated and room temperature is within a
normal comfort range
413-215-0516(1) All parts of the facility x
ensure the safety of children
Room and Space Requirements Corrective Action
Yes No N/A Corrective Actions/Comments
Bedrooms 413-215-0516(3) Completed
(a) Adequate furnishings and personal items x
(b) Separate from rooms used for dining, x
living, laundry, kitchen, and storage
(c) Outside room with window allowing x
egress from building
(d) Ceiling at least 90 inches x
(e) Minimum 60 SF per bed x
(f) No more than 25 if dorm style x
(g) Permanently wired fixtures x
(h) Window covering x
(i) Beds are 3 feet apart and maintained to x
ensure safety
Room and Space Requirements Corrective Action
Yes No N/A Corrective Actions/Comments
Bathrooms 413-215-0516(4) Completed
(a)(A)&(B) 1:8 ratio for toilets and sinks x
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(a)(D) Hot and cold running water, soap, and x
approved hand drying options
(a)(E) 1:10 ratio for shower or bathtub x
(a)(E) Individual privacy x
(a)(F) Window covering x
(a)(G) Permanently wired fixtures x
(a)(H) Adequate ventilation x
(b)&(c) Wooden racks on floors are x
prohibited and impervious shower mats are
disinfected & dried daily
Room and Space Requirements Corrective Action
Yes No N/A Corrective Actions/Comments
Kitchen 413-215-0516(6) Completed
(a) Used exclusively for storage, food x
preparation, dish washing and activities
related to eating
(b) Walls, floors are easily cleanable x
(c) Equipment and utensils are easily x
cleanable, durable, nontoxic, and kept clean
(e) Equipment is easy to clean beneath, x
between and behind
Room and Space Requirements Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0516 Completed
(2) There is a separate living room or lounge x
area – 15 SF minimum per child
(5) There is a separate dining room with x
capacity for ½ of children in care and 15 SF
per child in care
(7) Laundry is separate from living areas, x
kitchen and dining
(8) Separate storage areas are provided for x
food, kitchen supplies, utensils, clean linens,
soiled linens and clothing, cleaning supplies
and equip, poisons, chemicals, outdoor
recreational and maintenance equipment
(9) Outdoor activity area is protected from x
vehicles and other hazards and of a size and
availability appropriate to the age and needs
of children in care
(11) & 413-215-0076(3)(c)(C)Time out rooms x
have adequate space, heat, light and
ventilation and is not capable of locking
Furnishings and Personal Items Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0521 Completed
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(1) There is a bed with frame, clean mattress x
and pillow and personal storage (dresser,
closet)
(2) Linens are in good repair. There is a x
waterproof mattress cover or mattress.
Linens are appropriate and towels and
washcloths are provided
(3) Bedding is changed weekly or when x
soiled
(4)&(5) Personal hygiene supplies and x
appropriate clothing are provided
Food Services Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0536(1)&(2) Completed
(1)(a) Meals are arranged daily, consistent x
with normal mealtimes that occur during the
hours of operation
(1)(b) Menus are prepared in advance in x
accordance with USDA guidelines, provide a
variety of foods and are adjusted for
seasonal changes.
(1)(b) Menus are kept for at least 6 months x
(1)(c) Drinking water is freely available x
(2)(a) Food is stored, prepared & served in a x
sanitary manner
(2)(c) & (d) Food products are obtained from x
commercial suppliers (exception of fruits &
vegetables), unpasteurized juice is
prohibited, and only Grade A pasteurized
and fortified milk in appropriate container.
Safety Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0541 Completed
(2)(a) Written emergency plan x
(2)(b) Telephone numbers for local police x
and fire are posted near all telephones
(2)(c) Operative flashlights sufficient in x
number are readily available to staff
(3)(a) Evacuation drill occurs monthly under x
varying conditions, is retained 2 yrs and
contains;
(A) identify of person conducting drill
(B) date & time
(C) notification method
(D) staff participating
(E) # of children & staff evacuated
(F) special conditions simulated
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(G) problems encountered
(H) time to complete
Safety – Transportation Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0541 Completed
(5)(b) Vehicle has insurance policy, is smoke x  Turning Point Program Van was missing current
free, safe operating condition, and has first proof of insurance for vehicle.
aid kit and fire extinguisher 2-A:10-BC
Medication Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0551 Completed
(3)&(7)(e) Medications have a prescription x
and are stored in the original container with
prescription label
(4)&(5) Herbal supplements and remedies, x
medical treatments, special diets, physical
therapy, physical aides or limitations have a
written order signed by a physician or
qualified medical professional.
(7)(c) Medications are inaccessible to x
children
(8) Medications are disposed in accordance
with state and federal law
(9) Written record of the disposal of x
medications is maintained and includes:
(a) description and amount
(b) name
(c) reason
(d) method
(e) staff & witness signature
(10) Written record of the administration of x
medication includes:
(a) name
(b) description
(c) dates and times
(d) missed doses
(e) medication disposed
(f) method of administration
(g) ID of person administering
(h) possible adverse reactions
(i) medication taken outside facility
Extracurricular, Enrichment, Cultural &
Corrective Action
Social Activities Yes No N/A Corrective Actions/Comments
Completed
413-215-0554
(2) Children have ongoing opportunities to x
participate in at least one age-appropriate or
developmentally appropriate activity
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Minimum Staffing Requirements Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0561 Completed
(1)&(2) Supervision is adequate for the type x
of program, location, age and type of
children, ability of supervisor to respond,
electronic back-up systems.
Minimum ratios are maintained:
Under 30 months of age: 1:4
30 months to ˃ 6 yrs or non-ambulatory: 1:6
Ages 6 and older: 1:7
Overnight (staff awake)
1:10
(4)(a) When one staff on duty, there is x
additional staff immediately available with
max response time of 30 minutes
(5) There is at least one on-site employee x
authorized to apply the reasonable and
prudent parent standard
Separation of Residents Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0566 Completed
(1) Children are in separate bedrooms than x
adults, unless parent and child, or there is
written approval from guardian/parent and
licensing coordinator
(2) There is adequate supervision of children x
if both males and females are served by the
program
Personnel Files Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0061 Completed
Staff Name/Position
(3)(g) Date of Hire x
(3)(a) record of education, training and
x
previous employment
(1)(b) & (3)(b) reference checks completed
x
and documented
(1)(a) & (3)(c) Background check completed
x
and documented
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(3)(d) Annual performance evaluations x
(3)(f) Record of personnel actions x
(3)(g) Termination date, reason for
x
termination
(3)(h) Current job description (1)(c)
Employee meets minimum qualifications x
stated in current job description
New Employee Orientation – Umbrella
Corrective Action
Requirements (30 days) Yes No N/A Corrective Actions/Comments
Completed
413-215-0061(4)
(a) Agency policies and procedures x
(b) Ethical and professional guidelines x
(c) Organizational lines of authority x
(d) Attributes of population served x
(e) & (5)(a) to (c) Mandatory reporting that
includes:
(a) legal definition of child abuse ORS
419B.005, Oregon Laws 2016, chapter 106,
x
section 36
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to
the employee
(f) Privacy laws x
(g) Emergency procedures x
New Employee Orientation – Residential
Corrective Action
(30 days) Yes No N/A Corrective Actions/Comments
Completed
413-215-0556
(1)(a) Discipline and behavior management
including de-escalation, crisis prevention,
positive behavior management, and x
disciplinary techniques that are non-punitive
in nature
(1)(b) Restraint and seclusion (if applicable) x
Ongoing Training Corrective Action
Yes No N/A Corrective Actions/Comments
Completed
413-215-0536(2)(b) Employees who handle x
food served to children have a valid food
handler’s card
413-215-0541(5)(a) Employees transporting
children have: current driver’s license, x
insurance, trained in emergency procedures
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and behavior management, and training for
15+ passenger vans if applicable)
413-215-0556(2)(a) Environmental
x
emergencies
413-215-0556(2)(b) Universal Precautions x
413-215-0556(2)(c) Discipline and Behavior
x
Management
413-215-0556(3) Staff providing direct care
must maintain current CPR/First Aid x
certification
413-215-0556(4) Designated staff authorized
to apply reasonable and prudent parent
x
standard are trained in application of the
standard
413-215-0061(5) Mandatory reporting
(annually) that includes:
(a) legal definition of child abuse ORS
419B.005, Oregon Laws 2016, chapter 106,
x
section 36
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to
the employee
Comments:
Children’s Records Corrective Action
Yes No N/A Corrective Actions/Comments
Completed
Health Services
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413-215-0546
(2) Medical history obtained within 30 days
(significant findings, current immunizations,
history of surgical procedures-health issues- x
injuries, allergies, dental, vision, hearing,
behavioral health, and physician orders)
(2)(e) Documentation of age appropriate
instruction – pregnancy prevention, nutrition,
prevention of HIV & AIDS, and prevention x
and treatment of sexually transmitted
disease
(4)(a) to (f) Medical exams (3 in first year of
life, 2,4,6,9,14) x
Consents Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0576(1) Completed
(a) Provide routine and emergency medical
x
care
(b) Use the discipline and behavior
x
management system
(c) Use restraint or seclusion (if applicable).
Must specify the reasons for the intervention x
and how staff are trained and supervised
(d) Restrict contact with persons outside of
x
the agency
(e) Allow access as defined in 413-215-0091
x
& 0101
(f) Impose a dress code x
(g) Apply the reasonable and prudent parent
x
standard
Disclosures
Corrective Action
413-215-0576(2) Parent/guardian has Yes No N/A Corrective Actions/Comments
Completed
acknowledged in writing:
(a) Information regarding personal or room
searches and protocols for confiscation of x
contraband
(b) Statement of Rights of Children and
x
Parents/Guardians
(c) Any policies and procedures upon
x
request
Authorizations Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0576(3) Completed
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(a) Disclose or exchange information with
x
others
(b) Child specific visitors x
(c) Visitation resources are pre-approved x
(d) Activity specific authorizations are pre-
approved to allow children to participate in
potentially hazardous activities, including but x
not limited to using motorized yard
equipment, swimming, and horseback riding.
Information about Children in Care
Corrective Action
413-215-0581(1) Summary sheet contains Yes No N/A Corrective Actions/Comments
Completed
the following:
(a)The name, gender, date of birth, religious
x
preference, and previous address
(b) Name and location of previous and
x
current school
(c) Date of admission x
(d) Legal custody x
(e) The name, address, and telephone
number of:
(A) The child in care's parents.
(B) The child in care's legal guardian, if
different than the parents, and a copy of
x
the document that provides for his or her
authority over the child in care.
(C) Other persons significant to child
(D) Other professionals to be involved in
service planning (if applicable)
Service Planning Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0581(2) Completed
(b) Intake document is completed the date
child accepted into care (emergency x
placement 48 hours)
(d) Assessment is completed within 30 days
and contains relevant historical info., current
behavioral observations, identified need for x
services, and how agency will provide
services
(e) (A)&(B) Service plan within 60 days
(parent, guardian and child actively x
involved). Describes how child’s issues will
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be addressed, anticipated outcomes and
reviewed by child and guardian/parent.
(e)(C)&(D) Service plan is reviewed quarterly
and revised when information indicates other x
services should be provided
Case Management Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0581(3) Completed
(a) Services are documented, progress
x
toward achieving goals is tracked
(b)-(d) discharge planning and instructions x
(f) Incident Reports x
Financial Records Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0581(4) Completed
Records contain date, amount, source,
purpose, signatures
Personal Possessions Records Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0581(5) Completed
Individual written inventory of all personal
possessions is maintained and updated as x
needed
Records and Documentation Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0071 Completed
(1) Stored safely x
(2) Permanent, legible, dated, and signed x
(3)&(4) Uniform in organization, readily
identifiable and accessible, current, and
x
complete, containing all required info. No
eraser tape or white out.
(7) Permanent registry for each child
includes:
Name
Gender
x
Birth date
Names, addresses of parents or guardians
Dates of admission
Placement upon discharge
Comments:
Additional Finding Related to SB 710:
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 413-215-077 (11) (e) – Each child caring agency shall provide notice regarding how to access the quarterly reports to the parents or guardians of
children in care in the program. The child caring agency shall provide the notice upon the child in care’s admission and at least two time each year
thereafter.
The program must ensure compliance with this new requirement and provide evidence of compliance to the ODHS Licensing Coordinator.
Licensing Coordinator’s Signature: ________________________ Date: _____2_-_1_4_-_2_0_2_2_ _____
Manager Review: ______________________________________ Date: _ _ _2_-_1_4_-_2_0_2_2_ ______
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report_type: License Renewals

licensee: Josephine County Juvenile Department - Turning Point Date of site visit: February 7th / 8th, 2022

visit_date: February 7th / 8th, 2022

licensing_coordinator: Ed Wyller

program_description:
"Turning Point provides ODHS, OYA, and County Probation youth with individualized treatment service plans which
include cognitive behavioral groups, individual counseling, and skill building services. Youth in the program work on treatment goals while also
attending on-site school, as well as community, vocational, and recreational opportunities. On-site nursing and mental health services are available,
as well as community partners for primary care, mental health, and Alcohol and Drug treatment services."

program_services: Residential Care - BRS Basic Residential

capacity_age_range: Capacity 12 / 13-17-year-old age range

average_length_of_stay: 6-9 months

interviews_observations:
I interviewed an OYA youth and a county youth. Both reported feeling safe at Turning Point. Both reported that staff
treat you with respect and it's a good place. Youth reported the following activities, going to YMCA, playing basketball at park, playing basketball
on-site, doing artwork, bowling, and ice skating. Youth reported looking forward to going to Portland on Saturday to see the Portland Trailblazers
play. It is a day game allowing program to travel from Grants Pass at reasonable hours for the youth. On a scale from 0-10 (0=worst program and
10=best program) youth reported Turning Point to be a 7.5, and an 8. Youth reported food to be really good. Youth reported cook makes Mexican,
Chinese dishes and bakes often. One youth reported learning the skills of patience and listening. The other youth has been in multiple programs
and reported being in groups and needing to apply what he has learned. When asked how the program could be improved, one youth reported
they missed staff that had left. (Turnover of staff). The other youth reported when going out to get a shake at Inn and Out Burger she would like to
order food.
During the site inspection reviewer noted new additions to the program:
- New walk-in fridge/freezer
- New gas kitchen stove
- New dishwasher
- New refrigerated water bottle fountain for youth in living area
- New milk refrigerator
- New outdoor bench in recreation area
- New outdoor shed for storage
- New communications board in staff office for relaying information about youth
- New extra long bed for tall youth (recent youth was 6 foot 7inches)
- An Automated External Defibrillator (AED) is on-site in staff office
During Kitchen tour I noted an allergy board in kitchen regarding what youth maybe allergic to. Cook has dedicated cutting boards for youth with
food allergies to limit any possible cross contamination for those youth during meal prep.

program_strengths:
Turning Point reports:
"1) Food service specialist providing fresh homemade meals cooked in our full-service kitchen
2) Development of community partnerships that provide consistent outings for youth in the program for recreation and vocational opportunities
(horse ranch, YMCA, Vocational Tech program)
3) Contract services with Options for Southern Oregon which provides on-site mental health services with the ability for the Qualified Mental Health
Professional (QMHP) to develop relationships with youth in the program setting and then also allow for additional counseling services off-site at
Options as needed.
4) Purchase and implementation of BestNotes program for electronic documentation and tracking of all BRS services."
2

program_challenges:
Turning Point reports:
"1) Physical location of program is across the street from the Gospel Rescue Mission and next to the railroad tracks.
2) Limited outdoor area on-site for recreation purposes for youth to utilize.
3) The inability to hire and maintain staffing for the program. (Lack of applications for open positions and current staff moving away or taking jobs in
other fields."

changes_in_last_two_years:
Turning Point reports, "As mentioned, we have had a lot of staffing changes over that last two
years. This creates difficulty in constantly needing to train new people, creating shifts with no experience, and requiring a lot of assistance from
management and on-call managers regularly. Our Social Services Facilitator has been out for the past 7 months on medical leave. We have been
using three qualified Juvenile Probation Officers to cover the position until her return. We are meeting all BRS requirements, but this obviously has
been a difficult obstacle for the program. Our Juvenile Justice Manager stepped down from his position (this person is supervisor over Group Life
Counselors) and a new manager took over. Our weekend / Asst Manager moved, thus requiring us to hire a new person externally.
Positive changes include new community partners that have been added: 715 Youth Ministries, which provides opportunities for interested youth to
engage in a weekly VoTech program (auto repair, welding, construction, etc.) and additionally Project Youth+ which provides vocational training on-
site including: food handler's cards, resume writing, career aptitude, interviewing, etc. We applied for and were awarded $3,000 from the Carpenter
Foundation Grant to purchase new recreation equipment and arts/craft supplies for the program.
After a long process and lots of hard work, in November 2020, the Council on Accreditation (COA), informed us that Turning Point Youth Residential
Program, Josephine County Juvenile Justice had been accredited. We are now a Qualified Residential Treatment Program! We were able to
purchase new "behavioral health" furniture for our dayroom area, a new industrial stove, and a new dishwasher / sanitizer for our kitchen with
money we received from our grant for becoming an accredited QRTP.

lawsuits: Turning Points reports, "No".

grievances_and_complaints: Turning Points reports, "No".

excerpt:
Documents as indicated on the form titled
“Renewal Licensing Required Documents”  Fire Marshall reinspection needed to review finding
regarding oven hood. Program has provided the
maintenance has been completed, however are
waiting for reinspection.

excerpt:
&(c) Buildings are
smoke free, clean and in good repair

excerpt:
(5)(b) Vehicle has insurance policy, is smoke
free, safe operating condition, and has first
aid kit and fire extinguisher 2-A:10-BC  Turning Point Program Van was missing current
proof of insurance for vehicle.


state: OR

facility_name: Turning Point

summary: Unannounced - 4 findings

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Licensee: Josephine County Juvenile Department – Turning Point
Executive Director: James Goodwin (Juvenile Department Director)
Program Director(s): Jennifer Horst
Date of Unannounced: September 21st, 2022
Licensing Coordinator: Jorge Pelinski
Other Regulatory or Accrediting Agencies: Oregon Youth Authority (OYA), Oregon Department of Human Services (ODHS) Treatment Services
Purpose: Per OAR 413-215-0101 (1) (b) Children’s Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Comments
Findings
Further Action
Needed
Supplemental Information Provided by Yes☐ No
CCA Documents as indicated on the form
titled “Renewal Licensing Required
Documents”
Fire Marshall reinspection needed to review
finding regarding oven hood. Program has
provided the maintenance has been
completed, however are waiting for
reinspection.
Physical Plant Yes☐ No
413-215-0511(2)(a) &(c) Buildings are smoke
free, clean and in good repair
413-215-0511 (2) (a) and (c)
Vents throughout the facility had accumulation
of dust, grime, and lint. (Laundry room,
kitchen, bathrooms)
1
(rev. 200115)
Kitchen floors have a built-in grime. Program
reports they are cleaned but will need to be
buffed out and redone.
Carpet in bedrooms and main room dirty.
(Needs cleaning).
Carpet runner coming up by living room to
dining area (tripping hazard)
Spit wads on ceiling in boy’s bathroom need to
be removed.
Room and Space Requirements Bedrooms Yes☐ No
413-215-0516(3)
(f) No more than 25 if dorm style
Safety – Transportation 413-215-0541 Yes☐ No
(5)(b) Vehicle has insurance policy, is smoke
free, safe operating condition, and has first aid
kit and fire extinguisher 2-A:10-BC
Turning Point Program Van was missing
current proof of insurance for vehicle.
Additional Finding Related to SB 710: Yes☐ No
413-215-077 (11) (e) – Each child caring
agency shall provide notice regarding how to
access the quarterly reports to the parents or
guardians of children in care in the program.
The child caring agency shall provide the
notice upon the child in care’s admission and
at least two time each year thereafter.
New Findings from Site Visit Comments
N/A Good work!
(rev. 07/21/2022)
Interview Summary
Licensing Coordinators interviewed two youth from the program at the unannounced site inspection. Both youths stated things were going well
for them at the program. When asked what the youth appreciated most about the program, both youths expressed that they enjoyed the outings
and playing sports. Both youths feel safe at the program and feel comfortable talking to staff when they need something. Both youths receive
private phone calls and can talk to anyone on their approved contact list. Youth receive three meals a day: including snacks as necessary. One
youth expressed that if he could change one thing about the program it would be to have more outings than they already go on. This youth did
express that he does enjoy the outings he currently goes on. This youth is a part of one of the high school football team and gets to travel to
different schools to play.
Observations
Licensing Coordinators did a walkthrough of the program. Staff and youth were observed at the program during the inspection. The youth that
were at the program appeared to be at ease and comfortable in their respected environment. All areas of the programs (inside and outside)
where youth had access were observed to be well kept, clean and in good repair. The agency vehicles that the youth ride in were observed and
met the requirements per Licensing Rules. The kitchens were observed to have plenty of food, recently upgraded floors and a floor runner for
safety. Medication was observed to be in locked medication carts in a locked room which was inaccessible to the youth. The program recently
purchased six new chairs for the youth. Licensing Coordinator observed new bulletin boards and privacy screens for staff computers at the
program.
Corrective Actions and Timeframes:
Good work no new findings and all previous findings have been addressed.
Licensing Coordinator’s Signature: ________________________ Date: _9_/3_0_/_2_0_2_2_ __________
Manager Review: ______________________________________ Date: _ 0_9__-3_0_-_2_0_2_2_ _______
(rev. 07/21/2022)

agency_name: Josephine County Juvenile Dept (JOSEPHINECJD)

program_name: Turning Point

program_type: (RC) Residential Care Programs

report_type: Unannounced

view_code: RC

licensee: Josephine County Juvenile Department - Turning Point

program_director: Jennifer Horst

visit_date: September 21st, 2022

licensing_coordinator: Jorge Pelinski

purpose:
Per OAR 413-215-0101 (1) (b) Children's Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Comments
Findings
Further Action
Needed
Supplemental Information Provided by Yes[ ] No
CCA Documents as indicated on the form
titled "Renewal Licensing Required
Documents"
Fire Marshall reinspection needed to review
finding regarding oven hood. Program has
provided the maintenance has been
completed, however are waiting for
reinspection.
Physical Plant Yes[ ] No
413-215-0511(2)(a) &(c) Buildings are smoke
free, clean and in good repair
413-215-0511 (2) (a) and (c)
Vents throughout the facility had accumulation
of dust, grime, and lint. (Laundry room,
kitchen, bathrooms)
1

Kitchen floors have a built-in grime. Program
reports they are cleaned but will need to be
buffed out and redone.
Carpet in bedrooms and main room dirty.
(Needs cleaning).
Carpet runner coming up by living room to
dining area (tripping hazard)
Spit wads on ceiling in boy's bathroom need to
be removed.
Room and Space Requirements Bedrooms Yes[ ] No
413-215-0516(3)
(f) No more than 25 if dorm style
Safety - Transportation 413-215-0541 Yes[ ] No
(5)(b) Vehicle has insurance policy, is smoke
free, safe operating condition, and has first aid
kit and fire extinguisher 2-A:10-BC
Turning Point Program Van was missing
current proof of insurance for vehicle.
Additional Finding Related to SB 710: Yes[ ] No
413-215-077 (11) (e) - Each child caring
agency shall provide notice regarding how to
access the quarterly reports to the parents or
guardians of children in care in the program.
The child caring agency shall provide the
notice upon the child in care's admission and
at least two time each year thereafter.
New Findings from Site Visit Comments
N/A Good work!

Interview Summary

new_findings: N/A Good work!

excerpt:
413-215-0541 Yes[ ] No
(5)(b) Vehicle has insurance policy, is smoke
free, safe operating condition, and has first aid
kit and fire extinguisher 2-A:10-BC
Turning Point Program Van was missing
current proof of insurance for vehicle.
Additional Finding Related to SB 710: Yes[ ] No
413-215-077 (11) (e) - Each child caring
agency shall provide notice regarding how to
access the quarterly reports to the parents or
guardians of children in care in the program.
The child caring agency shall provide the
notice upon the child in care's admission and
at least two time each year thereafter.
New Findings from Site Visit Comments
N/A Good work!
N/A Good work!


summary: License Renewals - 01/09/2024

raw_content:
Licensed Child Caring Agency Site Visit Report
Residential Care
Licensee: Josephine County Juvenile Department – Turning Point Board Chairperson: John West
Executive Director: James Goodwin Date of site visit: 1.9.2024 & 1.10.2024
Program Director: Jennifer Horst Licensing Coordinator: Jorge Pelinski
Other Regulatory or Accrediting Agencies: Oregon Youth Authority (OYA), Oregon Department of Human Services (ODHS) Treatment
Services
Program Compliance: The program was found to be compliant or will be compliant with OAR 419-400-0005 to 419-400-0310, Licensing
Umbrella Rules, and OAR 419-470-0010 to 419-470-0180, Licensing Residential Care Agencies Rules. Personnel records were
reviewed and compliance with required background checks was documented for employees in all programs.
Program Description(s): Turning Point provides ODHS, OYA and County Probation youth with individualized treatment service plans,
which include cognitive behavioral groups, individual counseling, and skill building services. Youth in the program work on treatment
goals while also attending on-site school and participating in community, vocational and recreational opportunities. On-site nursing and
mental health services are available, as well as community partners for primary care, mental health, and Alcohol &Drug treatment
services.
Program type and services: Residential Care – Behavior Rehabilitation Services (BRS) Basic Residential
Capacity and Age Range: Capacity: 12 Age Range: 13-17
Funding sources: OYA, OHA, Josephine Co Juvenile Probation, Crook County Probation
Contracts and sources for referrals: OYA, OHA, Josephine Co Juvenile Probation, Crook County Probation
Average length of stay: 6 - 9 months
Average daily population served: 6 youth.
P a g e 1 | 18
Form Rev. 11/14/2023
Number of children served annually: 26 youth served per year.
Use of seclusion or restraint: Turning Point reports that they do not use either seclusion or restraints.
Interviews:
Opening interview was held with the Program Director, Jennifer Horst. An update regarding the program staffing and status on the program were
discussed. The Agency has built a lot of connections with programs around the Grants Pass area that have donated things for youth in the program
at Christmas time. Youth are receiving gifts from Salvation Army, such as new jackets, etc.. The Director mentioned it is always challenging hiring
new people.
Two youths from the program were interviewed. Both youths are 15 years of age. Both youths have been at the program for 3.5 to 4 months.
When asked what they appreciated most about living in the program, the youth stated: Outings, such as going to the park, YMCA, drives with staff,
swimming, and playing basketball. One youth stated that he enjoys the anger management groups as it helps him communicate better with staff
when he gets frustrated. Both youths stated that they get along well with staff in general. Both youths feel like they can communicate with staff when
needed. Both youths like the food that the program serves. Both youths shared that they get plenty of phone calls to family. Both youths expressed
that they feel safe in the program.
Observations:
Staff and youth were observed at the program during the inspection. The youth that were at the program appeared to be at ease and comfortable in
the environments. All areas of the program (inside and outside) where youth had access were observed to be well kept, clean and mostly in good
repair. One of the agency vehicles that the youth ride in was observed and met the requirements per Licensing Rules. The kitchen was observed to
be well maintained and had an adequate amount of food. Medication was observed to be in locked medication carts in locked rooms which were
inaccessible to the youth.
Program Strengths identified by Turning Point :
1) Addition of a large fenced-in garden area with raised beds and a greenhouse. This has been incorporated into school programming,
allowing youth to help grow food and have a peaceful green space.
2) Development of community partnerships that provide consistent outings for youth in the program for recreation & vocational
opportunities (YMCA, Vocational Tech program, Spartan Boxing, Oregon Futbol Academy [OFA].)
3) Contracted services with two mental health private practices, which provides on-site mental health services with the ability for the
Qualified Mental Health Professional (QMHP) to develop relationships with youth in the program setting and then also allow for
additional counseling services off-site as needed. Adding two providers allows for greater access to mental health services when
needed and creating a back-up provider in times of absences.
4) Implementation of Best Notes system for electronic record keeping has created simplified ways to chart and track BRS services, run
reports and provide up-to-date information for multipurpose needs related to Performance and Quality Improvements.
5) Josephine County built and implemented a new website. This included, for the first time, an area dedicated to Turning Point Youth
Residential under the Juvenile Justice webpages.
P a g e 2 | 18
Form Rev. 11/14/2023
Program Challenges identified by Turning Point:
1) Physical location of program is across the street from the Gospel Rescue Mission and next to the railroad tracks and a small park,
often with a transient population.
2) Limited outdoor area on-site for recreation purposes for youth to utilize.
3) The inability to hire and maintain staffing for the program. (Lack of applications for open positions and lack of retention of hired
employees.) This also contributes to the constant need to provide training and re-training, as we start from scratch each time.
Changes that have occurred in the last 2 years as identified by Turning Point:
As with our last audit, we have had a lot of staffing changes over the last two years. This creates difficulty in constantly needing to train
new people, creating shifts with no extensive experience, and requiring a lot of assistance from management and on-call managers
regularly. In the last 2 years, we have hired 15 new employees.
Our Social Services Facilitator has been on extended medical leave this year. A qualified Juvenile Probation Officer has taken on this role in the
interim until a long-term decision is made. We are meeting all BRS requirements, and the interim is doing well, but this obviously has been a difficult
situation.
In addition to the many new or changing direct care staff (Group Life Counselors), we have also had new employees take over other roles in the last
two years. This includes additions of a new weekend supervisor (Juvenile Justice Supervisor), Food Service Specialist, Education Coordinator, and
the interim Social Services Facilitator.
Positive work with continued community partners such as 715 Youth Ministries, which provides opportunities for interested youth to
engage in a weekly Vo-Tech program (auto repair, welding, construction, etc.), as well as other 715 led outings (mountain bike riding).
Additionally, a newer partner, Spartan Boxing, now provides circuit training and exercise for youth in our program on a regular basis.
We applied for and were awarded approx. $10,000 from an OYA Grant to purchase additional behavioral health furniture for our
dayroom area and replenish curriculum workbooks for group and individual skill building purposes.
We also received grant funding from DHS for Workforce Stability purposes. We were able to use the $148,662 towards longevity
bonuses (at 6 months and 2-year markers), overtime bonuses, training costs, employee sweatshirts, Employee of the Month awards
and other ways to provide staff recognition and encourage employee satisfaction.
Lawsuits: None
Grievances and complaints filed in the last two years: None
Corrective Actions and Timeframes: Please submit the following to verify compliance.
P a g e 3 | 18
Form Rev. 11/14/2023
Within 45 days of receipt of this report (insert name of agency) must submit a letter of verification indicating the agency is in compliance with the
specific rules cited above and describing how compliance will be maintained going forward. Along with the letter of verification, the agency must
submit any and all specific documentation requested in the body of this report. The letter of verification and any additional requested documents can
be emailed directly to (Licensing Coordinator and email address).
Recommendations: None
Exceptions: None
Changes in License: None
Summary of Review
Program and Services
Yes No N/A Corrective Actions/Comments
419-400-0020 (2)
Program and services are in scope of license x
Governance of the Agency
Yes No N/A Corrective Actions/Comments
419-400-0040
(1)(a) Minimum of 5 board members x
(2)(f) Formally evaluate the exec. Director’s
x
performance annually
(2)(g) Approves annual budget x
(2)(h) Obtain and review an annual
independent financial review or audit of x
financial records.
(2)(k) Written quality improvement program x
(2)(l) Meeting minutes x
Executive Director or Program Director
Yes No N/A Corrective Actions/Comments
419-400-0040
(3)(a) knowledge of requirements for
providing care and treatment appropriate to x
programs
(3)(g) Approval from BCU x
Discipline, Behavior Management, and
Suicide Prevention Yes No N/A Corrective Actions/Comments
419-400-0150
(3) Agency uses appropriate and positive
methods of behavior management and
x
nationally recognized non-violent crisis
intervention
P a g e 4 | 18
Form Rev. 11/14/2023
(3)(b)(C) Agency does not use chemical and
mechanical restraint (excluding medically x
necessary devices/prescriptions)
(3)(c) Agency uses appropriate time-out
rooms (adequate space, heat, light and
ventilation and is not capable of locking) and x
documents use in child’s record when
applicable
(3)(e) Agency uses seclusion
x
appropriately/consistent with policy
(4) Agency has adequate plan in place to
x
respond to suicidal behavior/warning signs
Contractors (if applicable)
Yes No N/A Corrective Actions/Comments
419-400-0120(6)
(a) Agency ensures the contractor meets the
requirements of this rule and Chapter 413 x
division 215
(b)(B) Contract includes the following:
(i) Services provided
(ii) Contractor fees
(iii) Disclosure of information from contractor
to agency
(iv) Lines of authority x
(v) Adherence to rules, including background
check
(vi) Any liability of the agency for acts of the
contractor, rights of indemnity and limitations
on liability
Restraints and Involuntary Seclusion
Yes No N/A Corrective Actions/Comments
419-400-0180
(13)(d) Each child caring agency that
submits a report under this section shall
make its quarterly report available to the
x
public upon request at the Child Caring
Agency’s main office and on the child caring
agency’s website if applicable.
Supplemental Information Provided by
Yes No N/A Corrective Actions/Comments
CCA
Documents as indicated on the form titled
x
“Renewal Licensing Required Documents”
Documents as indicated on form titled
“Required Financial Documents and x
Information”
All required policies and procedures as
x
identified in the “Umbrella Rules”
P a g e 5 | 18
Form Rev. 11/14/2023
All required policies and procedures as
x
identified in “Agency Type Specific Rules”
Physical Plant
Yes No N/A Corrective Actions/Comments
419-400-0090(3)(a) Foster Rights Posted (if
x
children in DHS custody)
419-400-0100(1) Sufficient safe space,
x
equipment, and office equipment
419-400-0230(12) License is posted in
x
common area at each facility
419-470-0020(2)(a) &(c) Buildings are
x *See comments section below*
smoke free, clean and in good repair
419-470-0020 (2)(d) Rooms are free of
x
harmful drafts, odors, and excessive noise
419-470-0020 (2)(e) Rooms are adequate in
x
size and arrangement
419-470-0020 (2)(f) System provides a
continuous supply of hot and cold water to x
taps located throughout the facility
419-470-0020 (2)(h) Building is well
ventilated and room temperature is within a x
normal comfort range
419-470-0030 (1) All parts of the facility
x
ensure the safety of children
Room and Space Requirements
Yes No N/A Corrective Actions/Comments
419-470-0030
(2) There is a separate living room or lounge x
area – 15 SF minimum per child
(5) There is a separate dining room with x
capacity for ½ of children in care and 15 SF
per child in care
(7) Laundry is separate from living, kitchen, x
and dining areas
(8) Separate storage areas are provided for x
food, kitchen supplies, utensils, clean linens,
soiled linens and clothing, cleaning supplies
and equip, poisons, chemicals, outdoor
recreational and maintenance equipment.
(Hazardous materials are properly labeled, in
original container and locked)
(9) Outdoor activity area is protected from x
vehicles and other hazards and of a size and
availability appropriate to the age and needs
of children in care
P a g e 6 | 18
Form Rev. 11/14/2023
(11) Time-out rooms: Rooms used for time x
out or quiet time must have adequate space,
heat, light and ventilation and must not be
capable of locking.
Room and Space Requirements
Bedrooms Yes No N/A Corrective Actions/Comments
419-470-0030(3)
(a) Adequate furnishings and personal items x
(b) Separate from rooms used for dining,
x
living, laundry, kitchen, and storage
(c) Meet Oregon Fire Code Requirements x
(d) Be an outside room, with a window that
operates as designed. If the window is
modified from its original design, the fire
x
marshal must approve the modification and
indicate this room still meets applicable
Oregon Fire Code.
(d) Ceiling at least 90 inches x
(e) Minimum 60 SF per occupant x
(f) No more than 25 if dorm style x
(g) Permanently wired fixtures x
(h) Window covering x
Room and Space Requirements
Bathrooms Yes No N/A Corrective Actions/Comments
419-470-0030(4)
(a)(A)&(B) 1:8 ratio for toilets and sinks x
(a)(D) Hot and cold running water, soap, and
x
approved hand drying options
(a)(E) 1:10 ratio for shower or bathtub x
(a)(E) Individual privacy x
(a)(F) Window covering x
(a)(G) Permanently wired fixtures x
(a)(H) Adequate ventilation x
(b)&(c) Wooden racks on floors are
prohibited and impervious shower mats are
x
disinfected & dried daily be in good condition
and free of mold
Room and Space Requirements
Kitchen Yes No N/A Corrective Actions/Comments
419-470-0030(6)
(a) Used exclusively for storage, food
preparation, dishwashing, and activities
x
related to eating and food preparation
activities
(b) Walls, floors are easily cleanable x
P a g e 7 | 18
Form Rev. 11/14/2023
(c) Equipment and utensils are easily
x
cleanable, durable, nontoxic, and kept clean
(e) Equipment is easy to clean beneath,
x
between and behind
Furnishings and Personal Items
Yes No N/A Corrective Actions/Comments
419-470-0040
(1) There is a bed with frame, x
(1)(b) clean mattress in good condition,
x
with a minimum thickness of five inches
(1)(c) a pillow in good condition x Agency ordered twenty new pillows for youth in the program.
(1)(d) a private dresser, closet, or similar
storage area for personal belongings that x
is readily accessible
(2) Linens are in good repair. There is a
waterproof mattress cover or mattress.
x
Linens are appropriate and towels and
washcloths are provided
(3) Bedding is changed weekly or when
x
soiled
(4)&(5) Personal hygiene supplies and
x
appropriate clothing are provided
Food Services
Yes No N/A Corrective Actions/Comments
419-470-0070
(1)(a) Meals are arranged daily, consistent
with normal mealtimes that occur during the
x
hours of operation and provide snacks
between mealtimes
(1)(b) Menus are prepared in advance in
accordance with USDA guidelines, provide a
x
variety of foods and are adjusted for
seasonal changes including snacks
(1)(b) Menus are kept for at least 6 months x
(1)(c) Drinking water is freely available x
(2)(a) Food is stored, prepared & served in a
x
sanitary manner
(2)(c) & (d) Food products are obtained from
commercial suppliers (exception of fruits &
vegetables), unpasteurized juice is x
prohibited, and only Grade A pasteurized
and fortified milk in appropriate container.
Residential Care Safety
Yes No N/A Corrective Actions/Comments
419-470-0080
(2) Written emergency plan that includes x
P a g e 8 | 18
Form Rev. 11/14/2023
(a) Identifying the types of emergencies most
likely to happen where the residential care x
agency is located
(b) Identifying a place to meet for each type
x
of emergency identified
(c) Identifying an alternate shelter if
x
necessary
(d) Ensuring access to necessary
x
medications or medical equipment
(e) How to help each child in care recover
x
after a disaster
(3) Telephone numbers for local police, fire
department, poison control, after hours
medical advice and other appropriate x
emergency numbers must be posted near all
telephones.
(4) Operative flashlights sufficient in number
x
are readily available to staff
(5)(a) Evacuation drill occurs monthly under
varying conditions, is retained 2 years and
contains:
(A) identify of person conducting drill
(B) date & time
(C) notification method x
(D) staff participating
(E) # of children & staff evacuated
(F) special conditions simulated
(G) problems encountered
(H) time to complete
Umbrella Safety
Yes No N/A Corrective Actions/Comments
419-400-0200
(5)(b) Vehicle has insurance policy, is smoke x
free, safe operating condition, and has first
aid kit and fire extinguisher 2-A:10-BC
(1)(b)(A) Each vehicle used to transport a x
child in care must be: properly registered,
covered by an insurance policy in full force
and effect, maintained in safe operating
condition, and smoke-free.
(3) If a child-caring agency has a swimming x
pool on the premises that is accessible to
children in care or if a child-caring agency
plans to have children in care engage in
swimming, the child-caring agency must
have and adhere to policies and procedures
that address, at a minimum, providing
P a g e 9 | 18
Form Rev. 11/14/2023
disclosures and obtaining consents,
assessing swimming ability of children in
care, and ensuring the safety of pool access.
(4)(a) The program protects children from x
potentially harmful items and materials.
(4)(b) Direct supervision of children who do x
not have the ability to adjust and control
water temperature
(4)(c) Light fixtures have protective covers x
unless designed to be used without one
Medication
Yes No N/A Corrective Actions/Comments
419-470-0100
(3)&(7)(e) Medications have a prescription
and are stored in the original container with x
prescription label
(4)&(5) Herbal supplements and remedies,
medical treatments, special diets, physical
therapy, physical aides or limitations have a
written order signed by a physician or
qualified medical professional. A written x
order, signed by a physician or qualified
medical professional, is also required before
a restriction on diet or physical activity is
imposed.
(7)(c) Medications are inaccessible to
children and stored behind at least two
x
locking mechanisms. This does not apply to
Naloxone.
(8) Medications are disposed in accordance
x
with state and federal law
(9) Written record of the disposal of
medications is maintained and includes:
(a) description and amount
(b) name x
(c) reason
(d) method
(e) staff & witness signature
(10) Written record of the administration of
medication includes:
(a) name
(b) description
(c) dates and times x
(d) missed doses
(e) medication disposed
(f) method of administration
(g) ID of person administering
P a g e 10 | 18
Form Rev. 11/14/2023
(h) possible adverse reactions
(i) medication taken outside facility
Extracurricular, Enrichment, Cultural &
Social Activities Yes No N/A Corrective Actions/Comments
419-470-0110
(2) Children have ongoing opportunities to x
participate in at least one age-appropriate or
developmentally appropriate activity
Minimum Staffing Requirements
Yes No N/A Corrective Actions/Comments
419-470-0130
(1)&(2) Supervision is adequate for the type x
of program, location, age and type of
children, ability of supervisor to respond,
electronic back-up systems.
Minimum ratios are maintained:
Under 30 months of age: 1:4
30 months to ˃ 6 years or non-ambulatory:
1:6
Ages 6 and older: 1:7
Overnight (staff awake)
1:10
(4)(a) When one staff on duty, there is x
additional staff immediately available with
max response time of 30 minutes
(5) There is at least one on-site employee x
authorized to apply the reasonable and
prudent parent standard
Sleeping Arrangements
Yes No N/A Corrective Actions/Comments
419-470-0140
(1) Children are in separate bedrooms than x
adults, unless parent and child, or there is
written approval from guardian/parent and
licensing coordinator
(2) There is adequate supervision of children x
when sleeping
(3) When assigning bedrooms a residential x
care agency must consider all of the
following:
(a) Chronological age
(b) Developmental age
(c) Gender identity
(d) Personal history, including medical,
mental health, behavioral health, and past
P a g e 11 | 18
Form Rev. 11/14/2023
adverse experiences including any physical
or sexual abuse
Personnel Files
Yes No N/A Corrective Actions/Comments
419-400-0120
Staff Name/Position x
(3)(g) Date of Hire x
(3)(a) record of education, training, and
x
previous employment
(1)(b) & (3)(b) reference checks completed
x
and documented
(1)(a) & (3)(c) Background check completed
x
and documented
(3)(d) Annual performance evaluations x
(3)(f) Record of personnel actions x
(3)(g) Termination date, reason for
x
termination
(3)(h) Current job description (1)(c)
Employee meets minimum qualifications x
stated in current job description
New Employee Orientation – Umbrella
Requirements (30 days) Yes No N/A Corrective Actions/Comments
419-400-0120(4)
(a) Agency policies and procedures x
(b) Ethical and professional guidelines x
(c) Suicide prevention and intervention x
(d) Attributes of population served x
(e) & (5)(a) to (c) Mandatory reporting that
includes:
(a) legal definition of child abuse in ORS
418.257 and 419B.005 x
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to
the employee
(f) Privacy laws x
(g) Emergency procedures x
New Employee Orientation
Residential (Prior to working alone and
Yes No N/A Corrective Actions/Comments
within 30 days)
419-470-0120(1)
(a) Discipline and behavior management
including de-escalation, crisis prevention, x
positive behavior management, and
P a g e 12 | 18
Form Rev. 11/14/2023
disciplinary techniques that are non-punitive
in nature
(b) CPR and First Aid sufficient to retain a
x
current certification
(c) Universal precautions and hygiene x
(d) Application of the reasonable and
x
prudent parent standard
(e) Training on the agency’s policy on
suicide prevention and suicide risk x
assessment tool
Crisis Intervention Training Standards
and Certification Yes No N/A Corrective Actions/Comments
419-400-0160(4) (as applicable)
(a)Complete a minimum of 12 hours of initial
training in person from a certified instructor,
including but not limited to a minimum of six
hours of training focused on positive
x
behavior support, nonviolent crisis
intervention and other methods of
nonphysical intervention to support children
in care during a crisis
(d) Receive a certificate that states:
(A) The dates during which the certification
is current
(B) The type of restraint which the individual
is certified to perform if applicable
(C) The type of training the individual is
certified to conduct if applicable x
(D) Any special endorsements earned by the
individual
(E) The level of training
(F) The name of the certified instructor who
conducted the training and administered the
assessment of proficiency.
(e) A certification issued:
(A) Must be personal to the individual
certified by the training provider x
(B) May be valid for no more than two years
with recertification
Ongoing Training Yes No N/A Corrective Actions/Comments
419-470-0070(2)(b) Employees who handle
food served to children have a valid food x
handler’s card
P a g e 13 | 18
Form Rev. 11/14/2023
419-400-0200 (1) Employees transporting
children have: current driver’s license,
insurance, trained in emergency procedures x
and behavior management, and training for
15+ passenger vans if applicable)
419-470-0120 (2)(a) Environmental
x
emergencies
419-470-0120 (2)(b) Universal Precautions x
419-470-0120 (2)(c) Discipline and Behavior
x
Management
419-470-0120 (2)(d) Agency’s policy on
x
suicide prevention and risk assessment tool
419-470-0120 (3) Staff providing direct care
must maintain current CPR/First Aid x
certification
419-470-0120 (4) Designated staff
authorized to apply reasonable and prudent
x
parent standard are trained in application of
the standard
419-400-0120(5) Mandatory reporting
(annually) that includes:
(a) legal definition of child abuse in ORS
418.257 and 419B.005 x
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to
the employee
419-400-0160(4)(b) Receive continuing
education (as applicable on crisis
x
intervention training) from a certified
instructor on an annual basis
Comments:
Children’s Records Yes No N/A Corrective Actions/Comments
Health Services
419-470-0090
P a g e 14 | 18
Form Rev. 11/14/2023
(2) Medical history obtained within 30 days
(significant findings, current immunizations,
history of surgical procedures-health issues- x
injuries, allergies, dental, vision, hearing,
behavioral health, and physician orders)
(4)(a) to (f) Medical exams (3 in first year of
life, 2,4,6,9,14) x
(g) Have a physical examination within the
first 60 days after admission of a child in
care. Documentation of a physical x
examination having occurred within the
calendar year will meet this requirement.
Consents
Yes No N/A Corrective Actions/Comments
419-470-0160(1)
(a) Provide routine and emergency medical
x
care
(b) Use the discipline and behavior
x
management system
(c) Use restraint or seclusion (if applicable).
Must specify the reasons for the intervention x
and how staff are trained and supervised
(d) Restrict contact with persons outside of
x
the agency
(e) Allow access as defined in 419-400-0230
x
& 0240
(f) Impose a dress code x
(g) Apply the reasonable and prudent parent
x
standard
Disclosures
419-470-0160(2) Yes No N/A Corrective Actions/Comments
Parent/guardian has acknowledged in writing:
(a) Information regarding personal or room
searches and protocols for confiscation of x
contraband
(b) Statement of Rights of Children and
x
Parents/Guardians
(c) Any policies and procedures upon request x
Authorizations
Yes No N/A Corrective Actions/Comments
419-470-0160(3)
(a) Disclose or exchange information with
x
others
(b) Child specific visitors x
(c) Visitation resources are pre-approved x
P a g e 15 | 18
Form Rev. 11/14/2023
(d) Activity specific authorizations are pre-
approved to allow children to participate in
potentially hazardous activities, including but x
not limited to using motorized yard
equipment, swimming, and horseback riding.
Information about Children in Care
419-400-0190(1) Yes No N/A Corrective Actions/Comments
Summary sheet contains the following:
(a)The name, gender, date of birth, religious
x
preference, and previous address
(b) Name and location of previous and
x
current school
(c) Date of admission x
(d) Legal custody x
(e) The name, address, and telephone
number of:
(A) The child in care's parents.
(B) The child in care's legal guardian, if
different than the parents, and a copy of
x
the document that provides for his or her
authority over the child in care.
(C) Other persons significant to child
(D) Other professionals to be involved in
service planning (if applicable)
Service Planning
Yes No N/A Corrective Actions/Comments
419-470-0170(2)
(b) Intake document is completed the date
child accepted into care (emergency x
placement 48 hours)
(d) Assessment is completed within 30 days
and contains relevant historical info., current
behavioral observations, identified need for x
services, and how agency will provide
services
(e) (A)&(B) Service plan within 60 days
(parent, guardian and child actively involved).
Describes how child’s issues will be x
addressed, anticipated outcomes, and
reviewed by child and guardian/parent.
(e)(C)&(D) Service plan is reviewed quarterly
and revised when information indicates other x
services should be provided
Case Management
Yes No N/A Corrective Actions/Comments
419-470-0170(3)
P a g e 16 | 18
Form Rev. 11/14/2023
(a) Services are documented, progress
x
toward achieving goals is tracked
(c) Discharge summary must include:
(A)Current medications
(B)Name of the physician or qualified medical
professional who prescribed each medication
(C)Any outstanding medical or other
appointments x
(D)Summary of the child’s participation in the
program and progress achieved
(E)Results of evaluations
(F)Recommendations regarding services
(G)Discharge destination
(e) Follow up services x
(f) Incident Reports x
Records Relating to Restraint &
Yes No N/A Corrective Actions/Comments
Involuntary Seclusion
419-400-0180 (12) Records x
419-400-0180(13)(e) Each child caring
agency shall provide notice regarding how to
access the quarterly reports to the parents or
guardians of children in care in the program. x
The child caring agency shall provide the
notice upon the child in care’s admission and
at least two times each year thereafter.
419-400-0190(1) Information provided to
children in care relating to Restraint & x
Involuntary Seclusion
Financial Records
Yes No N/A Corrective Actions/Comments
419-470-0170(4)
Records contain date, amount, source,
x
purpose, signatures
Personal Possessions Records
Yes No N/A Corrective Actions/Comments
419-470-0170 (5)
Individual written inventory of all personal
possessions is maintained and updated as x
needed
Records and Documentation
Yes No N/A Corrective Actions/Comments
419-400-0140
(1) Stored safely x
(2) Permanent, legible, dated, and signed x
(3)&(4) Uniform in organization, readily
x
identifiable and accessible, current, and
P a g e 17 | 18
Form Rev. 11/14/2023
complete, containing all required info. No
eraser tape or white out.
(7) Permanent registry for each child
includes:
Name
Gender
x
Birth date
Names, addresses of parents or guardians
Dates of admission
Placement upon discharge
Comments:
419-470-0020(2)(a) &(c) Buildings are smoke free, clean and in good repair
Agency day room vents, and all youth bedroom vents need cleaning.
Corrective Action:
• Agency will clean vents in day room and youth bedrooms, and then send pictures to licensing coordinator as part of their Corrective Action
Plan.
419-470-0020(2)(a) &(c) Buildings are smoke free, clean and in good repair
Agency school classroom needs repainting.
Corrective Action:
• The Agency will repaint the classroom and send pictures to licensing coordinator when completed as part of their corrective action plan.
419-470-0020(2)(a) &(c) Buildings are smoke free, clean and in good repair
Agency day room carpet has visible spots that needs cleaning.
Corrective Action:
• Agency will clean the day room carpet and send pictures to licensing coordinator as part of their corrective action plan.
Licensing Coordinator’s Signature: ________________________ Date: ___0_1_-1_8_-_2_0_2_4________
Manager Review: ______________________________________ Date: _1_-1_8_-_2_0_2_4_ _________
P a g e 18 | 18
Form Rev. 11/14/2023

facility_type: Residential Care

licensee: Josephine County Juvenile Department - Turning Point Board Chairperson: John West

board_chairperson: John West

program_services: Residential Care - Behavior Rehabilitation Services (BRS) Basic Residential

capacity_age_range: Capacity: 12 Age Range: 13-17

average_length_of_stay: 6 - 9 months

average_daily_population_served: 6 youth. P a g e 1 | 18

number_of_children_served_annually: 26 youth served per year.


summary: Unannounced - 4 findings

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Residential Care
Licensee: Josephine County Juvenile Dept – Turning Point
Executive Director: James Goodwin
Program Director(s): Jennifer Horst
Date of Unannounced: 7.9.2026
Licensing Coordinator: Jorge Pelinski & Ed Wyller
Other Regulatory or Accrediting Agencies: Oregon Youth Authority (OYA), Oregon Department of Human Services (ODHS) Treatment Services
Purpose: Per OAR 419-400-0240 (1)(b) Children’s Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Comments
License Renewal Site Visit 01/9-10/2024 Findings
Further Action
Needed
Physical Plant Yes☐ No✓
419-470-0020(2)(a) &(c) Buildings are smoke
free, clean and in good repair Agency cleaned vents in day room and youth bedrooms. Agency also repainted the
classroom and cleaned the room carpet. No further action needed.
• Agency day room vents, and all youth
bedroom vents need cleaning.
Corrective Action: Agency will clean vents in
day room and youth bedrooms, and then send
pictures to licensing coordinator as part of
their Corrective Action Plan.
• Agency school classroom needs
repainting.
Corrective Action: The Agency will repaint
the classroom and send pictures to licensing
coordinator when completed as part of their
corrective action plan.
Form Rev. 11/14/2023 P age 1 | 3
• Agency day room carpet has visible
spots that needs cleaning.
Corrective Action: Agency will clean the day
room carpet and send pictures to licensing
coordinator as part of their corrective action
plan.
New Findings from Site Visit Comments
Physical Plant Laminate in front of youth’s bathroom counter needs replaced.
419-470-0020(2)(a) &(c) Buildings are
smoke free, clean and in good repair Corrective Action:
• Agency will replace laminate in youth’s bathroom and then send pictures to licensing
coordinator as part of their Corrective Action Plan.
Physical Plant Paper towel dispenser needs to be secured to wall.
419-470-0020(2)(a) &(c) Buildings are
smoke free, clean and in good repair Corrective Action:
• Agency will secure paper towel dispenser and then send pictures to licensing coordinator as
part of their Corrective Action Plan.
Physical Plant Hole in bathroom wall needs a doorstopper.
419-470-0020(2)(a) &(c) Buildings are
smoke free, clean and in good repair Corrective Action:
• Agency will fix hole in wall, put in a doorstopper, and then send pictures to licensing
coordinator as part of their Corrective Action Plan.
Interview Summary
Opening interview was held with the Program Director, Jennifer Horst. An update regarding program status was discussed. Two youths from the
program were interviewed. Both youths are 16 years of age. Both youths have been at the program less than 2.5 months. Both youths really
enjoy being a part of the program. When asked what they appreciated most about living in the program, the youth stated: Outings, such as
going to the park, YMCA, swimming, and playing basketball. Both youths are involved in treatment groups. Both youths stated that they get
along well with staff in general. Both youths feel like they can communicate with staff when needed. Both youths like the food that the program
serves. Both youths shared that they get 2 to 3 phone calls to family a day. Both youths shared that they feel safe in the program.
Form Rev. 11/14/2023 P age 2 | 3
Observations
Staff and youth were observed at the program during the inspection. The youth that were at the program appeared to be at ease and
comfortable in the environment. All areas of the program (inside and outside) where youth had access were observed to be well kept, clean and
mostly in good repair. Kitchen was observed to be well maintained and had an adequate amount of food. Medication was observed to be in
locked medication carts in locked rooms which were inaccessible to the youth.
Corrective Actions and Timeframes:
Please submit the following to verify compliance.
Within 45 days of receipt of this report Josephine County Juvenile Department must submit a letter of verification indicating the agency is in
compliance with the specific rules cited above and describing how compliance will be maintained going forward. Along with the letter of verification,
the agency must submit any and all specific documentation requested in the body of this report. The letter of verification and any additional
requested documents can be emailed directly to Jorge Pelinski at Jorge.l.pelinski@odhsoha.oregon.gov.
Licensing Coordinator’s Signature: ________________________ Date: ____0_7_/_1_5_/2_0_2_4_______
Manager Review: ______________________________________ Date: __7_-_1_5_-_2_0_2_4________
Form Rev. 11/14/2023 P age 3 | 3

licensee: Josephine County Juvenile Dept - Turning Point

executive_director: James Goodwin

licensing_coordinator: Jorge Pelinski & Ed Wyller

purpose:
Per OAR 419-400-0240 (1)(b) Children's Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Comments
License Renewal Site Visit 01/9-10/2024 Findings
Further Action
Needed
Physical Plant Yes[ ] No✓
419-470-0020(2)(a) &(c) Buildings are smoke
free, clean and in good repair Agency cleaned vents in day room and youth bedrooms. Agency also repainted the
classroom and cleaned the room carpet. No further action needed.
- Agency day room vents, and all youth
bedroom vents need cleaning.
Corrective Action: Agency will clean vents in
day room and youth bedrooms, and then send
pictures to licensing coordinator as part of
their Corrective Action Plan.
- Agency school classroom needs
repainting.
Corrective Action: The Agency will repaint
the classroom and send pictures to licensing
coordinator when completed as part of their
corrective action plan.

- Agency day room carpet has visible
spots that needs cleaning.
Corrective Action: Agency will clean the day
room carpet and send pictures to licensing
coordinator as part of their corrective action
plan.
New Findings from Site Visit Comments
Physical Plant Laminate in front of youth's bathroom counter needs replaced.
419-470-0020(2)(a) &(c) Buildings are
smoke free, clean and in good repair Corrective Action:
- Agency will replace laminate in youth's bathroom and then send pictures to licensing
coordinator as part of their Corrective Action Plan.
Physical Plant Paper towel dispenser needs to be secured to wall.
419-470-0020(2)(a) &(c) Buildings are
smoke free, clean and in good repair Corrective Action:
- Agency will secure paper towel dispenser and then send pictures to licensing coordinator as
part of their Corrective Action Plan.
Physical Plant Hole in bathroom wall needs a doorstopper.
419-470-0020(2)(a) &(c) Buildings are
smoke free, clean and in good repair Corrective Action:
- Agency will fix hole in wall, put in a doorstopper, and then send pictures to licensing
coordinator as part of their Corrective Action Plan.
Interview Summary
Opening interview was held with the Program Director, Jennifer Horst. An update regarding program status was discussed. Two youths from the
program were interviewed. Both youths are 16 years of age. Both youths have been at the program less than 2.5 months. Both youths really
enjoy being a part of the program. When asked what they appreciated most about living in the program, the youth stated: Outings, such as
going to the park, YMCA, swimming, and playing basketball. Both youths are involved in treatment groups. Both youths stated that they get
along well with staff in general. Both youths feel like they can communicate with staff when needed. Both youths like the food that the program
serves. Both youths shared that they get 2 to 3 phone calls to family a day. Both youths shared that they feel safe in the program.

Observations
Staff and youth were observed at the program during the inspection. The youth that were at the program appeared to be at ease and
comfortable in the environment. All areas of the program (inside and outside) where youth had access were observed to be well kept, clean and
mostly in good repair. Kitchen was observed to be well maintained and had an adequate amount of food. Medication was observed to be in
locked medication carts in locked rooms which were inaccessible to the youth.

excerpt:
419-470-0020(2)(a) &(c) Buildings are
smoke free, clean and in good repair Corrective Action:
- Agency will fix hole in wall, put in a doorstopper, and then send pictures to licensing
coordinator as part of their Corrective Action Plan.
Physical Plant Laminate in front of youth's bathroom counter needs replaced.


facility_name: Cadenza Y.A.T

summary: Unannounced - 2 findings

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Licensee: Kairos
Executive Director: Craig Norton
Clinical Director: John Trapold
Date of Unannounced: May 13 and 14, 2021
Licensing Coordinator: Robin DuVal
Other Regulatory or Accrediting Agencies: Oregon Department of Human Services (ODHS) Child Welfare division; Oregon Health Authority
(OHA)
Program Compliance: OAR 413-215-0001 to 413-215-0136 Licensing Umbrella Rules; OAR 413-215-0501 to 413-215-0586 Licensing Residential
Care Agencies Rules; and OAR 413-215-0701 to 413-215-0766 Licensing Homeless, Runaway, and Transitional Living Shelters Rules.
Purpose: Per OAR 413-215-0101 (1) (b) Children’s Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings: Unannounced Site Visit 11/4/2020 (All Repeat Findings) Repeat Findings Comments
Further Action
Needed
Residential New Beginnings East
413-215-0541(3)(a) Evacuation drill occurs monthly under varying conditions, Yes☐ No The program was utilizing the updated form
is retained 2 yrs and contains; (C) notification method containing all required elements. No further
(H) time to complete: “The evacuation form is missing item (C), and item (H) is action needed.
not consistently captured during drills. The agency shall update the form and
ensure the revised form is utilized.
Note: The agency retains evacuation drill logs in two places; paper on-site and
scanned online copy managed by safety coordinator. The agency shall streamline
this process to ensure documentation is complete, accurate and available for
future licensing reviews.”
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I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 200115)
 The form had been updated to include item (C), provided to staff and staff
trained; however New Beginnings East was using the old form. The agency
shall ensure the updated form is utilized at the program site(s) going forward.
Transitional Living Shelters
413-215-0746 (4) Written record of administration of medication includes Yes☐ No The agency has changed to an electronic MAR
(name, description, date and time dispensed, dosage, staff who dispensed): system which has built-in quality checks and
“Medication records had several blanks, mostly connected to when a resident is on alerts. No further action needed.
Leave of Absence (LOA). The agency shall ensure the main record of medication
administration is filled out accurately and completely, identifying the reason or
circumstances for any missed medications or other anomalies.”
 Tempo site: Medication administration records (MARs) had several blanks.
The agency shall ensure each individual youth’s medication administration
record is filled out accurately and completely, identifying the reason or
circumstance for any missed medications or other anomalies.
New Findings from Site Visit Comments
None
Interview Summary
New Beginnings East: Resident E. is 15 years old, has been in the program approximately 9 months, and feels this program is helping with coping skills. Trusts
staff, likes it here, and feels safe. Described activities on and off site. Talks to mom on phone and calls aren’t generally limited. Food is good, gets enough and
complimented the cook. No problems with medication. Struggles with school and teachers try to help. Favorite thing here is getting help when needed. Least
favorite is being away from family. The program does well at being there for youth when struggling and brings calm. Staff care and genuinely care about the
youth. Youth B. is 14 years old, has been in the program almost 2 months and feels this program is helping with coping skills and learning triggers. Staff are
trusting, feels safe and likes it here. Has phone contact with people on approved contact list and isn’t restricted. Is a picky eater, but gets enough. No issues
with medications. Has school and gets help but doesn’t like it. The program does well at helping youth when struggling, and staff are genuine, kind and
understanding. Likes the variety of staff personalities.
Momentum: Resident R. is 17 years old, has been in the program for approximately 4 months, and feels the program is generally helping. Feels safe and staff
are trusting. Likes it here but roommates can be annoying. Has input in their treatment plan and feels listened to. No issues with medication. Food is good and
gets enough.
Tempo: Resident T. is 19 years old, has been in the program for approximately 8 months, and feels the program is really helping by assisting with signing up
for college and volunteering. They wouldn’t have done that on their own. Likes it here, feels safe and staff are trusting. The people here feel like family and has
no complaints. No issues with medication. The program does well at helping people, is supportive and has their “backs”.
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I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 200115)
Cadenza: Resident C. is 18 years old, had been in the program for approximately 10 months, and feels the program is helping with teach life lessons. Loves it
here, feels safe, and staff are trusting. The food is good but it’s “fend for your own meals”. Gives input in their treatment plan. Has a lot of freedoms. Wants more
help and guidance on finding own transportation and budgeting. Resident J. is 20 years old, has been in the program for 2.5 years and the program is helping
them to become more independent and comfortable doing things on their own. The program doesn’t hinder trying new things. Staff are trusting and helpful. The
program does well at helping cope with emotions. No issues with medications. States that outings are limited due to program budget. Wants more outings for
“real world” experiences.
Observations
New Beginnings East: The program had good COVID-19 visitor protocols and all staff wore face masks, as mandated statewide due to the COVID-19 pandemic.
The environment was clean, in good repair, several youth rooms had personalized décor on walls. The “med call” room has beautiful and calming painted
artwork, painted by the art teacher.
Momentum, Tempo, and Cadenza locations were clean, welcoming, and home-like, and in good repair. Each location had good COVID-19 visitor protocols and
staff wore face masks, as mandated statewide due to the COVID-19 pandemic, except staff at Cadenza. Follow-up was provided to management.
Questions? Contact Robin DuVal at ROBIN.M.DuVal@dhsoha.state.or.us.
6/14/2021
Licensing Coordinator’s Signature: ________________________ Date: ___________________
Manager Review: ______________________________________ Date: _____0__6_-_1_4_-_2_0_2_1__ _
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I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 200115)

agency_name: Kairos

program_name: Cadenza Y.A.T

licensee: Kairos

executive_director: Craig Norton

licensing_coordinator: Robin DuVal

purpose:
Per OAR 413-215-0101 (1) (b) Children's Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings: Unannounced Site Visit 11/4/2020 (All Repeat Findings) Repeat Findings Comments
Further Action
Needed
Residential New Beginnings East
413-215-0541(3)(a) Evacuation drill occurs monthly under varying conditions, Yes[ ] No The program was utilizing the updated form
is retained 2 yrs and contains; (C) notification method containing all required elements. No further
(H) time to complete: "The evacuation form is missing item (C), and item (H) is action needed.
not consistently captured during drills. The agency shall update the form and
ensure the revised form is utilized.
Note: The agency retains evacuation drill logs in two places; paper on-site and
scanned online copy managed by safety coordinator. The agency shall streamline
this process to ensure documentation is complete, accurate and available for
future licensing reviews."
1

- The form had been updated to include item (C), provided to staff and staff
trained; however New Beginnings East was using the old form. The agency
shall ensure the updated form is utilized at the program site(s) going forward.
Transitional Living Shelters
413-215-0746 (4) Written record of administration of medication includes Yes[ ] No The agency has changed to an electronic MAR
(name, description, date and time dispensed, dosage, staff who dispensed): system which has built-in quality checks and
"Medication records had several blanks, mostly connected to when a resident is on alerts. No further action needed.
Leave of Absence (LOA). The agency shall ensure the main record of medication
administration is filled out accurately and completely, identifying the reason or
circumstances for any missed medications or other anomalies."
- Tempo site: Medication administration records (MARs) had several blanks.
The agency shall ensure each individual youth's medication administration
record is filled out accurately and completely, identifying the reason or
circumstance for any missed medications or other anomalies.
New Findings from Site Visit Comments
None
Interview Summary
New Beginnings East: Resident E. is 15 years old, has been in the program approximately 9 months, and feels this program is helping with coping skills. Trusts
staff, likes it here, and feels safe. Described activities on and off site. Talks to mom on phone and calls aren't generally limited. Food is good, gets enough and
complimented the cook. No problems with medication. Struggles with school and teachers try to help. Favorite thing here is getting help when needed. Least
favorite is being away from family. The program does well at being there for youth when struggling and brings calm. Staff care and genuinely care about the
youth. Youth B. is 14 years old, has been in the program almost 2 months and feels this program is helping with coping skills and learning triggers. Staff are
trusting, feels safe and likes it here. Has phone contact with people on approved contact list and isn't restricted. Is a picky eater, but gets enough. No issues
with medications. Has school and gets help but doesn't like it. The program does well at helping youth when struggling, and staff are genuine, kind and
understanding. Likes the variety of staff personalities.
Momentum: Resident R. is 17 years old, has been in the program for approximately 4 months, and feels the program is generally helping. Feels safe and staff
are trusting. Likes it here but roommates can be annoying. Has input in their treatment plan and feels listened to. No issues with medication. Food is good and
gets enough.
Tempo: Resident T. is 19 years old, has been in the program for approximately 8 months, and feels the program is really helping by assisting with signing up
for college and volunteering. They wouldn't have done that on their own. Likes it here, feels safe and staff are trusting. The people here feel like family and has
no complaints. No issues with medication. The program does well at helping people, is supportive and has their "backs".
2

Cadenza: Resident C. is 18 years old, had been in the program for approximately 10 months, and feels the program is helping with teach life lessons. Loves it
here, feels safe, and staff are trusting. The food is good but it's "fend for your own meals". Gives input in their treatment plan. Has a lot of freedoms. Wants more
help and guidance on finding own transportation and budgeting. Resident J. is 20 years old, has been in the program for 2.5 years and the program is helping
them to become more independent and comfortable doing things on their own. The program doesn't hinder trying new things. Staff are trusting and helpful. The
program does well at helping cope with emotions. No issues with medications. States that outings are limited due to program budget. Wants more outings for
"real world" experiences.
Observations
New Beginnings East: The program had good COVID-19 visitor protocols and all staff wore face masks, as mandated statewide due to the COVID-19 pandemic.
The environment was clean, in good repair, several youth rooms had personalized décor on walls. The "med call" room has beautiful and calming painted
artwork, painted by the art teacher.
Momentum, Tempo, and Cadenza locations were clean, welcoming, and home-like, and in good repair. Each location had good COVID-19 visitor protocols and
staff wore face masks, as mandated statewide due to the COVID-19 pandemic, except staff at Cadenza. Follow-up was provided to management.
Questions? Contact Robin DuVal at ROBIN.M.DuVal@dhsoha.state.or.us.
6/14/2021

excerpt:
413-215-0746 (4) Written record of administration of medication includes Yes[ ] No The agency has changed to an electronic MAR
(name, description, date and time dispensed, dosage, staff who dispensed): system which has built-in quality checks and
"Medication records had several blanks, mostly connected to when a resident is on alerts. No further action needed.
Leave of Absence (LOA). The agency shall ensure the main record of medication
administration is filled out accurately and completely, identifying the reason or
circumstances for any missed medications or other anomalies."
- Tempo site: Medication administration records (MARs) had several blanks.
The agency shall ensure each individual youth's medication administration
record is filled out accurately and completely, identifying the reason or
circumstance for any missed medications or other anomalies.
New Findings from Site Visit Comments
None
None