summary: Unannounced - 2 findings

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Licensee: Madrona Recovery
Executive Director: Charley Downing
Program Director(s): Michael Knapp
Date of Unannounced: 06/07/2021
Licensing Coordinator: Aubrey Kelly
Other Regulatory or Accrediting Agencies: OHA, 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
License Renewal Site Visit 02-10-2021 Findings
Further Action
Needed
413-215-0061(1)(a) & (3)(c) Background Yes☐ No Two background checks of recently promoted staff were reviewed and it was confirmed
check completed and documented: “One of new background checks were completed as required.
the files reviewed included staff who had
received a promotion and a new background
check had not been conducted per rule.”
413-215-0546(2)(e) Documentation of age Yes☐ No The nursing assessment that is completed when a client is admitted to the program was
appropriate instruction – pregnancy reviewed and the assessment contains the required information.
prevention, nutrition, prevention of HIV &
AIDS, and prevention and treatment of
sexually transmitted disease: “There was no
documentation of age appropriate instruction.
Madrona Recovery plans to add this to the
nursing assessment at intake so any concerns
around diet, pregnancy prevention, STDs, etc.
can be discussed with the nursing staff.”
1
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 200115)
New Findings from Site Visit Comments
None
Interview Summary
Client #1: They have been at the program since May 21st. They were previously at another program and likes it
here better because this program teaches more coping skills. They feel safe here and have not had a time when
they felt unsafe. They get along with the other clients and staff. The food is good, they like the hamburger helper
and crepes. They see their therapist one time a week. They have calls with family two times a day and has virtual
visits with family on Saturdays and Sundays. They like the showers here and the beds are comfortable. They are
hoping to be discharged in 11 days.
Client #2: They have been at the program for one week. They previously had been at two different hospitals.
They like it here, it’s much better than the hospital. Staff members here are in touch and knows how to deal with
mental health issues. After discharge, the plan is to go home. They feel safe here and have not had a time when
they felt unsafe. No one has placed their hands on them since admission. They get along well with staff, they like
the staff are younger and they understand diagnosis. The food here is good and the program is very
accommodating. They like all the staff. They have calls with family two times a day. The groups here are helpful.
2
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 200115)
Observations
The program was in good repair. There are 23 cameras throughout campus. The current census is 13. During
sleeping hours, bed checks are completed every 15 minutes and randomly throughout the night. Staff are
required to check for signs of life during bed checks.
06.09.2021
Licensing Coordinator’s Signature: ________________________ Date: ___________________
Manager Review: ______________________________________ Date: ____6_-_8_-_2_0_2__1_ _____
3
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 200115)

report_type: Unannounced

licensee: Madrona Recovery

executive_director: Charley Downing

program_director: Michael Knapp

licensing_coordinator: Aubrey Kelly

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
License Renewal Site Visit 02-10-2021 Findings
Further Action
Needed
413-215-0061(1)(a) & (3)(c) Background Yes[ ] No Two background checks of recently promoted staff were reviewed and it was confirmed
check completed and documented: "One of new background checks were completed as required.
the files reviewed included staff who had
received a promotion and a new background
check had not been conducted per rule."
413-215-0546(2)(e) Documentation of age Yes[ ] No The nursing assessment that is completed when a client is admitted to the program was
appropriate instruction - pregnancy reviewed and the assessment contains the required information.
prevention, nutrition, prevention of HIV &
AIDS, and prevention and treatment of
sexually transmitted disease: "There was no
documentation of age appropriate instruction.
Madrona Recovery plans to add this to the
nursing assessment at intake so any concerns
around diet, pregnancy prevention, STDs, etc.
can be discussed with the nursing staff."
1

New Findings from Site Visit Comments
None
Interview Summary
Client #1: They have been at the program since May 21st. They were previously at another program and likes it
here better because this program teaches more coping skills. They feel safe here and have not had a time when
they felt unsafe. They get along with the other clients and staff. The food is good, they like the hamburger helper
and crepes. They see their therapist one time a week. They have calls with family two times a day and has virtual
visits with family on Saturdays and Sundays. They like the showers here and the beds are comfortable. They are
hoping to be discharged in 11 days.
Client #2: They have been at the program for one week. They previously had been at two different hospitals.
They like it here, it's much better than the hospital. Staff members here are in touch and knows how to deal with
mental health issues. After discharge, the plan is to go home. They feel safe here and have not had a time when
they felt unsafe. No one has placed their hands on them since admission. They get along well with staff, they like
the staff are younger and they understand diagnosis. The food here is good and the program is very
accommodating. They like all the staff. They have calls with family two times a day. The groups here are helpful.
2

Observations
The program was in good repair. There are 23 cameras throughout campus. The current census is 13. During
sleeping hours, bed checks are completed every 15 minutes and randomly throughout the night. Staff are
required to check for signs of life during bed checks.
06.09.2021

excerpt:
413-215-0546(2)(e) Documentation of age Yes[ ] No The nursing assessment that is completed when a client is admitted to the program was
appropriate instruction - pregnancy reviewed and the assessment contains the required information.
prevention, nutrition, prevention of HIV &
AIDS, and prevention and treatment of
sexually transmitted disease: "There was no
documentation of age appropriate instruction.
Madrona Recovery plans to add this to the
nursing assessment at intake so any concerns
around diet, pregnancy prevention, STDs, etc.
can be discussed with the nursing staff."
1
New Findings from Site Visit Comments
None
None


state: OR

facility_name: Madrona Recovery Date of site visit: 04/28/2025

summary: Unannounced - 10/05/2022

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Licensee: Madrona Recovery Inc
Executive Director: John Thornton
Program Director(s):
Date of Unannounced: 10/05/2022
Licensing Coordinator: Jeff Minden and Aubrey Kelly
Other Regulatory or Accrediting Agencies: OHA
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
No outstanding findings from 2021 noted Yes☐ No☐
Yes☐ No☐
New Findings from Site Visit Comments
None
1
(rev. 200115)
Interview Summary
2 youth were interviewed during the site visit. Both youth reported liking Madrona Recovery better then other programs they had been at previously. Both
youth reported feeling safe in the program. One youth described Madrona Recovery as “just ok,” the food being ok, and wishing the beds were more
comfortable and that they had the ability to have community time outside the program. The other youth reported that the food is good, staff are nice and
supportive and that they feel like they are having the most success with their sobriety they have ever experienced. One of the youth reported a recent
negative interaction with 1 specific staff but reported that the rest of the program staff were very supportive and understanding and they felt the situation was
handled well by the program. Both youth were aware of their discharge plans and tentative discharge dates.
Observations
Facility was clean and in good repair. Random employee training files were reviewed, and trainings had been completed in a timely manner. Youth interviews
did not note any concerns.
Corrective Actions and Timeframes:
Please submit the following to verify compliance.
Within 45 days of receipt of this report Agency Name must submit a letter of verification indicating the agency is in compliance with the specific
rules cited above and describing how compliance will be maintained going forward. Along with the letter of verification, the agency must submit any
and all specific documentation requested in the body of this report. The letter of verification and any additional requested documents can be emailed
directly to Licensing Coordinator email address.
Licensing Coordinator’s Signature: ________________________ Date: _____10/05/2022_____
Manager Review: ______________________________________ Date: _1_0_-_2_7_-_2_0_2_2_ _______
(rev. 07/21/2022)

agency_name: Madrona Recovery (MR)

program_type: (RC) Residential Care Programs

view_code: RC

licensee: Madrona Recovery Inc

executive_director: John Thornton

program_director: Date of Unannounced: 10/05/2022

licensing_coordinator: Jeff Minden and Aubrey Kelly

other_regulatory_agencies: OHA

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
No outstanding findings from 2021 noted Yes[ ] No[ ]
Yes[ ] No[ ]
New Findings from Site Visit Comments
None
1

Interview Summary
2 youth were interviewed during the site visit. Both youth reported liking Madrona Recovery better then other programs they had been at previously. Both
youth reported feeling safe in the program. One youth described Madrona Recovery as "just ok," the food being ok, and wishing the beds were more
comfortable and that they had the ability to have community time outside the program. The other youth reported that the food is good, staff are nice and
supportive and that they feel like they are having the most success with their sobriety they have ever experienced. One of the youth reported a recent
negative interaction with 1 specific staff but reported that the rest of the program staff were very supportive and understanding and they felt the situation was
handled well by the program. Both youth were aware of their discharge plans and tentative discharge dates.
Observations
Facility was clean and in good repair. Random employee training files were reviewed, and trainings had been completed in a timely manner. Youth interviews
did not note any concerns.

new_findings:
None
1


summary: Unannounced - 9 findings

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Residential Care
Licensee: Madrona Recover
Executive Director: James Paul Bryant
Program Director(s): John Thornton (CEO)
Date of Unannounced: July 2, 2024
Licensing Coordinator: Jeff Minden, Irvin Minten
Other Regulatory or Accrediting Agencies: Oregon Health Authority
Purpose: Per OAR 419-400-0240 (1)(b) Children’s Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Comments
Unannounced Site Visit 10/23/2023 Findings
Further Action
Needed
419-400-0040(2)(g)– Board Approval of Yes☐ No✓ Board meeting minutes including budget approval were provided.
budget was not available for review
previously.
• This finding will be deferred to the
next reviews as the program has not
had any board meetings since the
licensing review in April. A board
meeting is scheduled for November.
419-400-0040(2)(k)- a written quality Yes☐ No✓ Board meeting minutes including quality improvement were provided.
improvement plan was not available for review
previously.
• This finding will be deferred to the
next reviews as the program has not
had any board meetings since the
licensing review in April. A board
meeting is scheduled for November.
Form Rev. 11/14/2023 P age 1 | 5
419-400-0040(2)(I)- board meeting minutes Yes☐ No✓ Board meeting minutes were provided.
was not available for review previously.
• This finding will be deferred to the
next reviews as the program has not
had any board meetings since the
licensing review in April. A board
meeting is scheduled for November.
419-470-0020(2)(a)(c) – A wall next to the Yes✓ No✓ The dining room wall was repaired, and the source of the buckle in the wall was addressed
dining room had started to buckle due to the as a part of a significant remodel at the program.
weight of a large water tank located in a
space behind the wall.
• This finding will be deferred to the
next review as the program is still in
the middle of a large renovation, and
the water tank fix is included in the
process.
419-400-0120(4)(c)(d)(g) 2 reviewed files did Yes☐ No✓ Reviewed files included all required trainings
not indicate ethics and professional guidelines
training, attributes of population served
training, and emergency procedure training
was received within 30 days of hire
• Reviewed files were missing the
attributes of populations served
training documentation, and 1 file was
missing the list of trainings. The
program did note that their usual HR
point person is on vacation and may
have the documentation in another
location, however it could not be
located today.
(repeat finding)
419-400-0180(12) and (13), 419-400-0190(1) Yes✓ No☐ Client files still lack documentation to verify parents and guardians were informed about
Specific information about reporting wrongful how to access quarterly restraint reports on the Madrona Recovery website.
restraint and seclusion was not being
provided as well as contact information for
entities required by rule. Additionally, the
program did not have a process for ensuring
parents/guardians receive notice of how to
access quarterly reports at intake.
• The program does have quarterly
restraint information available on their
website, however they have not
updated their documentation during
intake to include where to locate the
Form Rev. 11/14/2023 P age 2 | 5
quarterly report or how to report
concerns of wrongful restraint or
seclusion.
(repeat finding)
New Findings from Site Visit Comments
419-400-0200(4)(c): Each light fixture A light above a sink in the program’s art room did not have a protective cover.
must have a protective cover unless
it is designed to be used without one.
419-400-0090 (1) Rights of children The program has worked on allowing clients to make phone calls in private, and does have
in care and families served by the areas that can be utilized privately by clients. However, based on interviews with staff and
child-caring agency. A child-caring clients, it appears staff are still present in the room with clients during phone calls and do
agency must guarantee the rights of have the ability to listen in. The program needs to ensure a practice where clients are able
children in care and the families the to make phone calls without staff present and are aware of the option to do so.
child-caring agency serves. A child-
caring agency must enact and
adhere to a policy ensuring those
rights. A written copy must be
distributed to all children in care and
families served by the child-caring
agency, and afford the following
rights:
------
(b) The child in care's right to privacy.
Form Rev. 11/14/2023 P age 3 | 5
Interview Summary
3 staff were interviewed as a part of the site visit. All 3 staff were selected randomly and had roles including nurse, coordinator, and
case manager. All 3 staff stated they enjoyed working at the program, and although they said it is a hard job which takes a lot out of
you, it is also rewarding and satisfying. Two of the staff stated they enjoyed making a difference in the lives of youth. One of the
staff stated they very much enjoyed the creation of each youth’s individual treatment plan, as each youth’s plan was different and
focused on different strengths and areas needing improvement. All 3 staff also stated they received adequate to good initial and
ongoing training, although much of the job was learned by doing the work and getting regular feedback from other staff. All 3 staff
stated that if they had a question, there was always someone they could contact to get the answer. All 3 staff identified the high
turnover and burnout as the largest problem the program is facing in the past several months, as currently there is a high amount of
call-outs, and the program is also short staffed due to the turnover. One of the staff reported the staff training in the past 6 months
has not been as good as previous training, something they attributed to the fact that the program has lost some of their most
experienced line staff to promotions and turnover, resulting in some of the line staff feeling a lack of support and being
unappreciated. To improve the situation, this staff felt management staff should be more verbal in their acknowledgment of the
good work being done by the line staff, while also regularly communicating with all staff about the efforts being made to improve the
situation. Two of the staff were able to identify some of the management’s efforts to improve the situation. All 3 staff reported the
program had an effective process at the time of shift change, with sufficient time provided to talk about each of the youth’s current
issues and supervision needs. However, 1 of the staff stated the program used to have regular “mini-trainings,” or very brief
“refresher trainings” at the time of shift change focusing on de-escalation techniques, suicide prevention, etc., but over the last few
months, since the program is short staffed, these no longer occur. This staff felt such trainings were valuable and wanted them to
start up again. When asked if the program could improve in one area, 1 staff stated there was a lack of consistency in the way in
which staff on the same shift or staff on different shifts enforced the rules of the program, resulting in an increase in the anxiety of
the youth enrolled in the program, while making the job more difficult. Two of the staff stated the program needed to “have more
staff,” as currently staff are working too many hours, increasing their chance of burnout. All 3 staff stated the relationship between
line staff and management staff was good, and, for the most part, all staff could provide input on how to more effectively do the
work, and they felt listened to by management staff. When asked about whether the youth were able to have private phone calls,
one of the staff stated that youth knew that staff would be listening in on each of their phone calls, as the staff sat in close enough
proximity to the youth during phone calls to clearly hear what the youth was saying, and often staff could even hear what the person
on the other end of the line was saying. Another staff stated that although they could hear what the youth was talking about, they
really didn’t listen in to the calls. Finally, all 3 staff were able to effectively articulate the program’s suicide prevention protocol.
One youth was interviewed as a part of the unannounced visit. Although several youth were asked, only one was willing to be
interviewed. Youth reported being at the program for approximately 3 weeks and hating it. Youth later clarified that they didn’t hate
Madrona Recovery specifically but hated being at programs in general. Youth also noted that they had been to other programs in
Oregon and detention, and Madrona was the best location they had been to. Youth reported that some staff were “cool” and some
were on kids about the rules a lot more and “micro managed.” Youth also reported that they felt safe in the program, had never
been a part of or witness to a restraint, and that staff are consistent in their responses. Youth reported that staff are present during
Form Rev. 11/14/2023 P age 4 | 5
phone calls but they felt that staff weren’t actively trying to listen it. Youth reported knowing their discharge plan, and also wishing
that the program would reduce restrictions on MP3’s and makeup.
Observations
A site tour was conducted as a part of the Madrona Recovery unannounced visit. The program has recently completed an
extensive remodel and begun providing Psychiatric Residential Treatment Facility (PRTF) services. The facility was clean and in
good repair and has been well thought out for the new programs it is offering. There is art throughout the facility which helped with
the overall aesthetic of the facility.
In conversation with CEO John Thornton, he reported that the program is doing well. However, they have had issues with keeping
staff levels up, which is impacting their daily census. Thornton reported that the program has an extensive waiting list and has been
working on interviewing youth prior to admittance to ensure they are a good fit, but that they are working on hiring staff so they can
serve more clients.
Corrective Actions and Timeframes:
Please submit the following to verify compliance.
Within 45 days of receipt of this report Madrona Recovery 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 Jeff Minden at Jeffrey.E.Minden@odhsoha.oregon.gov.
Licensing Coordinator’s Signature: ________________________ Date: ___0_7__-1_6_-_2_0_2_4_______
Manager Review: ______________________________________ Date: _7_-_1_6_-2__0_2_4_________
Form Rev. 11/14/2023 P age 5 | 5

facility_type: Residential Care

licensee: Madrona Recover

executive_director: James Paul Bryant

program_director: John Thornton (CEO)

licensing_coordinator: Jeff Minden, Irvin Minten

other_regulatory_agencies: Oregon Health Authority

purpose:
Per OAR 419-400-0240 (1)(b) Children's Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Comments
Unannounced Site Visit 10/23/2023 Findings
Further Action
Needed
419-400-0040(2)(g)- Board Approval of Yes[ ] No✓ Board meeting minutes including budget approval were provided.
budget was not available for review
previously.
- This finding will be deferred to the
next reviews as the program has not
had any board meetings since the
licensing review in April. A board
meeting is scheduled for November.
419-400-0040(2)(k)- a written quality Yes[ ] No✓ Board meeting minutes including quality improvement were provided.
improvement plan was not available for review
previously.
- This finding will be deferred to the
next reviews as the program has not
had any board meetings since the
licensing review in April. A board
meeting is scheduled for November.

419-400-0040(2)(I)- board meeting minutes Yes[ ] No✓ Board meeting minutes were provided.
was not available for review previously.
- This finding will be deferred to the
next reviews as the program has not
had any board meetings since the
licensing review in April. A board
meeting is scheduled for November.
419-470-0020(2)(a)(c) - A wall next to the Yes✓ No✓ The dining room wall was repaired, and the source of the buckle in the wall was addressed
dining room had started to buckle due to the as a part of a significant remodel at the program.
weight of a large water tank located in a
space behind the wall.
- This finding will be deferred to the
next review as the program is still in
the middle of a large renovation, and
the water tank fix is included in the
process.
419-400-0120(4)(c)(d)(g) 2 reviewed files did Yes[ ] No✓ Reviewed files included all required trainings
not indicate ethics and professional guidelines
training, attributes of population served
training, and emergency procedure training
was received within 30 days of hire
- Reviewed files were missing the
attributes of populations served
training documentation, and 1 file was
missing the list of trainings. The
program did note that their usual HR
point person is on vacation and may
have the documentation in another
location, however it could not be
located today.
(repeat finding)
419-400-0180(12) and (13), 419-400-0190(1) Yes✓ No[ ] Client files still lack documentation to verify parents and guardians were informed about
Specific information about reporting wrongful how to access quarterly restraint reports on the Madrona Recovery website.
restraint and seclusion was not being
provided as well as contact information for
entities required by rule. Additionally, the
program did not have a process for ensuring
parents/guardians receive notice of how to
access quarterly reports at intake.
- The program does have quarterly
restraint information available on their
website, however they have not
updated their documentation during
intake to include where to locate the

quarterly report or how to report
concerns of wrongful restraint or
seclusion.
(repeat finding)
New Findings from Site Visit Comments
419-400-0200(4)(c): Each light fixture A light above a sink in the program's art room did not have a protective cover.
must have a protective cover unless
it is designed to be used without one.
419-400-0090 (1) Rights of children The program has worked on allowing clients to make phone calls in private, and does have
in care and families served by the areas that can be utilized privately by clients. However, based on interviews with staff and
child-caring agency. A child-caring clients, it appears staff are still present in the room with clients during phone calls and do
agency must guarantee the rights of have the ability to listen in. The program needs to ensure a practice where clients are able
children in care and the families the to make phone calls without staff present and are aware of the option to do so.
child-caring agency serves. A child-
caring agency must enact and
adhere to a policy ensuring those
rights. A written copy must be
distributed to all children in care and
families served by the child-caring
agency, and afford the following
rights:
------
(b) The child in care's right to privacy.

Interview Summary
3 staff were interviewed as a part of the site visit. All 3 staff were selected randomly and had roles including nurse, coordinator, and
case manager. All 3 staff stated they enjoyed working at the program, and although they said it is a hard job which takes a lot out of
you, it is also rewarding and satisfying. Two of the staff stated they enjoyed making a difference in the lives of youth. One of the
staff stated they very much enjoyed the creation of each youth's individual treatment plan, as each youth's plan was different and
focused on different strengths and areas needing improvement. All 3 staff also stated they received adequate to good initial and
ongoing training, although much of the job was learned by doing the work and getting regular feedback from other staff. All 3 staff
stated that if they had a question, there was always someone they could contact to get the answer. All 3 staff identified the high
turnover and burnout as the largest problem the program is facing in the past several months, as currently there is a high amount of
call-outs, and the program is also short staffed due to the turnover. One of the staff reported the staff training in the past 6 months
has not been as good as previous training, something they attributed to the fact that the program has lost some of their most
experienced line staff to promotions and turnover, resulting in some of the line staff feeling a lack of support and being
unappreciated. To improve the situation, this staff felt management staff should be more verbal in their acknowledgment of the
good work being done by the line staff, while also regularly communicating with all staff about the efforts being made to improve the
situation. Two of the staff were able to identify some of the management's efforts to improve the situation. All 3 staff reported the
program had an effective process at the time of shift change, with sufficient time provided to talk about each of the youth's current
issues and supervision needs. However, 1 of the staff stated the program used to have regular "mini-trainings," or very brief
"refresher trainings" at the time of shift change focusing on de-escalation techniques, suicide prevention, etc., but over the last few
months, since the program is short staffed, these no longer occur. This staff felt such trainings were valuable and wanted them to
start up again. When asked if the program could improve in one area, 1 staff stated there was a lack of consistency in the way in
which staff on the same shift or staff on different shifts enforced the rules of the program, resulting in an increase in the anxiety of
the youth enrolled in the program, while making the job more difficult. Two of the staff stated the program needed to "have more
staff," as currently staff are working too many hours, increasing their chance of burnout. All 3 staff stated the relationship between
line staff and management staff was good, and, for the most part, all staff could provide input on how to more effectively do the
work, and they felt listened to by management staff. When asked about whether the youth were able to have private phone calls,
one of the staff stated that youth knew that staff would be listening in on each of their phone calls, as the staff sat in close enough
proximity to the youth during phone calls to clearly hear what the youth was saying, and often staff could even hear what the person
on the other end of the line was saying. Another staff stated that although they could hear what the youth was talking about, they
really didn't listen in to the calls. Finally, all 3 staff were able to effectively articulate the program's suicide prevention protocol.
One youth was interviewed as a part of the unannounced visit. Although several youth were asked, only one was willing to be
interviewed. Youth reported being at the program for approximately 3 weeks and hating it. Youth later clarified that they didn't hate
Madrona Recovery specifically but hated being at programs in general. Youth also noted that they had been to other programs in
Oregon and detention, and Madrona was the best location they had been to. Youth reported that some staff were "cool" and some
were on kids about the rules a lot more and "micro managed." Youth also reported that they felt safe in the program, had never
been a part of or witness to a restraint, and that staff are consistent in their responses. Youth reported that staff are present during

phone calls but they felt that staff weren't actively trying to listen it. Youth reported knowing their discharge plan, and also wishing
that the program would reduce restrictions on MP3's and makeup.
Observations
A site tour was conducted as a part of the Madrona Recovery unannounced visit. The program has recently completed an
extensive remodel and begun providing Psychiatric Residential Treatment Facility (PRTF) services. The facility was clean and in
good repair and has been well thought out for the new programs it is offering. There is art throughout the facility which helped with
the overall aesthetic of the facility.
In conversation with CEO John Thornton, he reported that the program is doing well. However, they have had issues with keeping
staff levels up, which is impacting their daily census. Thornton reported that the program has an extensive waiting list and has been
working on interviewing youth prior to admittance to ensure they are a good fit, but that they are working on hiring staff so they can
serve more clients.


summary: Unannounced - 5 findings

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Residential Care
Licensee: Madrona Recovery
Executive Director: James Paul Bryant
Program Director(s): Paul Bryant
Date of Unannounced: 03/04/2025
Licensing Coordinator: Jeff Minden
Other Regulatory or Accrediting Agencies: Oregon Health Authority
Purpose: Per OAR 419-400-0240 (1)(b) Children’s Care Licensing is required to perform at least one unannounced site visit a year
where children in care reside.
Previous Findings Repeat Comments
Unannounced Site Visit – 7/02/2024 Findings
Further Action
Needed
419-400-0180(12) and (13), 419-400-0190(1) Yes☐ No✓ Intake forms have been updated to include information on
Specific information about reporting wrongful how to find quarterly reports.
restraint and seclusion was not being provided as
well as contact information for
entities required by rule. Additionally, the
program did not have a process for ensuring
parents/guardians receive notice of how to
access quarterly reports at intake.
• The program does have quarterly restraint
information available on their website, however
they have not updated their documentation during
intake to include where to locate the quarterly
Form Rev. 11/14/2023 P age 1 | 5
report or how to report concerns of wrongful
restraint or seclusion.
(repeat finding)
• Client files still lack documentation to verify
parents and guardians were informed about
how to access quarterly restraint reports on
the Madrona Recovery website.
419-400-0200(4)(c): Each light fixture must have a Yes☐ No✓ The light fixture has a protective cover now.
protective cover unless it is designed to be used
without one.
• A light above a sink in the program’s art
room did not have a protective cover.
419-400-0090 (1) Rights of children in care and Yes☐ No✓ The program reported that youth are allowed to make phone
families served by the child-caring agency. A calls alone in rooms. Staff will watch via video without
child-caring agency must guarantee the rights of sound for safety. Client interviews confirmed they are
children in care and the families the child-caring allowed to make phone calls without staff present.
agency serves. A child-caring agency must enact
and adhere to a policy ensuring those rights. A
written copy must be distributed to all children in
care and families served by the child-caring
agency, and afford the following rights: ------
(b) The child in care's right to privacy.
• The program has worked on allowing
clients to make phone calls in private and
does have areas that can be utilized
privately by clients. However, based on
interviews with staff and clients, it appears
staff are still present in the room with
clients during phone calls and do have the
ability to listen in. The program needs to
ensure a practice where clients are able to
make phone calls without staff present and
are aware of the option to do so.
Form Rev. 11/14/2023 P age 2 | 5
New Findings from Site Visit Comments
419-400-0230(2) Adhere to and comply with all Concerns were noted that Madrona Recovery was not meeting minimum
policies and procedures of the licensee and staffing requirements that the program has established to comply with OHA
ensures that employees and volunteers comply rule requirements. Multiple staff reported that the program is routinely out of
with policies and procedures compliance with staffing levels.
Interview Summary
3 staff and 3 youth were interviewed as a part of the unannounced site visit. All 3 interviewed youth reported feeling safe in the
program, reported liking staff and feeling like they could approach them for support. 2 of the interviewed youth reported being at
similar programs previously in other states and stated that Madrona Recovery was better than other locations they had been to. 2
of the 3 clients reported that the food was excellent, and 1 wished that there was more variety (and specifically wished for Carne
Asada on the menu). The clients were able to name specific staff they preferred and trusted to reach out to, including Kennedy,
Karli, Brittany, Taylor, Cici, May and Tashe. Clients all reported being aware of the discharge planning for their case and being able
to make phone calls privately. One client reported a concern about an incident that had occurred approximately 2 weeks prior
between a staff and a youth that resulted in a physical altercation. This concern was forwarded to Madrona staff who were able to
find documentation about the report and called the report in for screening and investigation.
3 staff were also interviewed as a part of the review process. Staff were consistent in feeling like their supervisors supported them,
and one staff specifically mention the new Executive Director, Paul, had been a great addition to the program. All 3 staff separately
noted concerns about staffing levels and having to meet required ratios. Reports indicated that ratios were out of compliance at
least twice a week if not more, and one staff reported that they had been supervising 6-7 clients alone from 7am to approximately
830am. Interviewed staff indicated that both nurses and managers are being used to cover floor staff requirements, and that nurses
are then not able to complete their nursing duties. It was additionally reported that managers will just stay in the fishbowl and not
assist with floor duties despite being counted towards ratios.
Interviewed staff also reported clients are not being held accountable for their behaviors, and one staff characterized the clients
being able to do anything they want and the clients are “running the show.” Staff described clients being able to stay in bed all day
if they wished as an example. Multiple staff reported feeling uncomfortable with CPI, restraints, and de-escalation training and
Form Rev. 11/14/2023 P age 3 | 5
knowing what to do. It was noted by one of the interviewed staff that there had been an intent for staff to practice CPI at the end of
shifts, so that those hours could be counted towards certification, however the staff did not know if the CPI trainers would be
conducting the training or if it would just be floor staff practicing together.
Two staff talked about the program utilizing a program called “Focus” for addressing client behaviors; however, neither staff was
able to articulate what “Focus” was or how it was supposed to be implemented. Staff reported that training, both initial and ongoing,
was unclear and unhelpful. One staff specifically reported not feeling like the suicide prevention training gave them the skills to
address suicidal ideation. Another staff indicated that they wished that the program would better cover de-escalation training and
removing glass from clients when its being used for self-harm. One staff indicated that some clients can be very difficult to work
with to the point they are afraid to approach them.
One staff also noted concerns that management may be watching and listening in during the interview with OTIS staff. This licensor
also heard from an OTIS Investigator with an open investigation at Madrona that they had learned from a different staff member that
Madrona management had been observing OTIS investigation interviews through the camera system which allowed for audio and
video observation.
Observations
The program appeared clean and in good repair. Bedrooms, bathrooms, and common areas were not cluttered and well organized.
CCLP followed up with Madrona management about the reported concern that OTIS interviews are being observed through the
video system by management staff. Management noted that the Summit Room is where most interviews occur, and that the camera
had been removed from the room. All OTIS interviews should be conducted in this room.
Recommendation:
It is recommended that Madrona Recovery management review the training process and work with staff to ensure they are informed
and comfortable handling situations that may arise at the program. Additionally, its recommended that management work to ensure
the “Focus” program is clear to staff in its purpose and function. Management staff have noted since the interview that the program
has several trainings scheduled about the “Focus” program and its function and intent.
Corrective Actions and Timeframes:
Form Rev. 11/14/2023 P age 4 | 5
Please submit the following to verify compliance.
Within 45 days of receipt of this report Madrona Recovery 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 Jeff Minden at Jeffrey.E.Minden@odhsoha.oregon.gov.
Licensing Coordinator’s Signature: ________________________ Date: _3_/1_2_/_2_0_2_5___________
Manager Review: ______________________________________ Date: _3_-1_2_-_2_0_2_5__________
Form Rev. 11/14/2023 P age 5 | 5

program_director: Paul Bryant

licensing_coordinator: Jeff Minden

purpose:
Per OAR 419-400-0240 (1)(b) Children's Care Licensing is required to perform at least one unannounced site visit a year
where children in care reside.
Previous Findings Repeat Comments
Unannounced Site Visit - 7/02/2024 Findings
Further Action
Needed
419-400-0180(12) and (13), 419-400-0190(1) Yes[ ] No✓ Intake forms have been updated to include information on
Specific information about reporting wrongful how to find quarterly reports.
restraint and seclusion was not being provided as
well as contact information for
entities required by rule. Additionally, the
program did not have a process for ensuring
parents/guardians receive notice of how to
access quarterly reports at intake.
- The program does have quarterly restraint
information available on their website, however
they have not updated their documentation during
intake to include where to locate the quarterly

report or how to report concerns of wrongful
restraint or seclusion.
(repeat finding)
- Client files still lack documentation to verify
parents and guardians were informed about
how to access quarterly restraint reports on
the Madrona Recovery website.
419-400-0200(4)(c): Each light fixture must have a Yes[ ] No✓ The light fixture has a protective cover now.
protective cover unless it is designed to be used
without one.
- A light above a sink in the program's art
room did not have a protective cover.
419-400-0090 (1) Rights of children in care and Yes[ ] No✓ The program reported that youth are allowed to make phone
families served by the child-caring agency. A calls alone in rooms. Staff will watch via video without
child-caring agency must guarantee the rights of sound for safety. Client interviews confirmed they are
children in care and the families the child-caring allowed to make phone calls without staff present.
agency serves. A child-caring agency must enact
and adhere to a policy ensuring those rights. A
written copy must be distributed to all children in
care and families served by the child-caring
agency, and afford the following rights: ------
(b) The child in care's right to privacy.
- The program has worked on allowing
clients to make phone calls in private and
does have areas that can be utilized
privately by clients. However, based on
interviews with staff and clients, it appears
staff are still present in the room with
clients during phone calls and do have the
ability to listen in. The program needs to
ensure a practice where clients are able to
make phone calls without staff present and
are aware of the option to do so.

New Findings from Site Visit Comments
419-400-0230(2) Adhere to and comply with all Concerns were noted that Madrona Recovery was not meeting minimum
policies and procedures of the licensee and staffing requirements that the program has established to comply with OHA
ensures that employees and volunteers comply rule requirements. Multiple staff reported that the program is routinely out of
with policies and procedures compliance with staffing levels.
Interview Summary
3 staff and 3 youth were interviewed as a part of the unannounced site visit. All 3 interviewed youth reported feeling safe in the
program, reported liking staff and feeling like they could approach them for support. 2 of the interviewed youth reported being at
similar programs previously in other states and stated that Madrona Recovery was better than other locations they had been to. 2
of the 3 clients reported that the food was excellent, and 1 wished that there was more variety (and specifically wished for Carne
Asada on the menu). The clients were able to name specific staff they preferred and trusted to reach out to, including Kennedy,
Karli, Brittany, Taylor, Cici, May and Tashe. Clients all reported being aware of the discharge planning for their case and being able
to make phone calls privately. One client reported a concern about an incident that had occurred approximately 2 weeks prior
between a staff and a youth that resulted in a physical altercation. This concern was forwarded to Madrona staff who were able to
find documentation about the report and called the report in for screening and investigation.
3 staff were also interviewed as a part of the review process. Staff were consistent in feeling like their supervisors supported them,
and one staff specifically mention the new Executive Director, Paul, had been a great addition to the program. All 3 staff separately
noted concerns about staffing levels and having to meet required ratios. Reports indicated that ratios were out of compliance at
least twice a week if not more, and one staff reported that they had been supervising 6-7 clients alone from 7am to approximately
830am. Interviewed staff indicated that both nurses and managers are being used to cover floor staff requirements, and that nurses
are then not able to complete their nursing duties. It was additionally reported that managers will just stay in the fishbowl and not
assist with floor duties despite being counted towards ratios.
Interviewed staff also reported clients are not being held accountable for their behaviors, and one staff characterized the clients
being able to do anything they want and the clients are "running the show." Staff described clients being able to stay in bed all day
if they wished as an example. Multiple staff reported feeling uncomfortable with CPI, restraints, and de-escalation training and

knowing what to do. It was noted by one of the interviewed staff that there had been an intent for staff to practice CPI at the end of
shifts, so that those hours could be counted towards certification, however the staff did not know if the CPI trainers would be
conducting the training or if it would just be floor staff practicing together.
Two staff talked about the program utilizing a program called "Focus" for addressing client behaviors; however, neither staff was
able to articulate what "Focus" was or how it was supposed to be implemented. Staff reported that training, both initial and ongoing,
was unclear and unhelpful. One staff specifically reported not feeling like the suicide prevention training gave them the skills to
address suicidal ideation. Another staff indicated that they wished that the program would better cover de-escalation training and
removing glass from clients when its being used for self-harm. One staff indicated that some clients can be very difficult to work
with to the point they are afraid to approach them.
One staff also noted concerns that management may be watching and listening in during the interview with OTIS staff. This licensor
also heard from an OTIS Investigator with an open investigation at Madrona that they had learned from a different staff member that
Madrona management had been observing OTIS investigation interviews through the camera system which allowed for audio and
video observation.
Observations
The program appeared clean and in good repair. Bedrooms, bathrooms, and common areas were not cluttered and well organized.
CCLP followed up with Madrona management about the reported concern that OTIS interviews are being observed through the
video system by management staff. Management noted that the Summit Room is where most interviews occur, and that the camera
had been removed from the room. All OTIS interviews should be conducted in this room.
Recommendation:
It is recommended that Madrona Recovery management review the training process and work with staff to ensure they are informed
and comfortable handling situations that may arise at the program. Additionally, its recommended that management work to ensure
the "Focus" program is clear to staff in its purpose and function. Management staff have noted since the interview that the program
has several trainings scheduled about the "Focus" program and its function and intent.