state: OR

facility_name: New Leaf Academy

summary: Unannounced - 4 findings

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Licensee: Program Design Concepts, dba New Leaf Academy
Executive Director: Deveney Marshall
Board Chairperson: Craig Christiansen
Date of Unannounced: October 13, 2022
Licensing Coordinator: Robin DuVal
Other Regulatory or Accrediting Agencies: COGNIA accredited, Student Exchange and Visitor Program (SEVS) approved, certified by California
Dept. of Education to provide special education 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 11/18/2021 Repeat Findings Comments
Further Action
Needed
Medication 413-215-0651 (10) Written record of the administration of medication Yes☐ No Medication administration records were
includes: (h) possible adverse reactions observed, and adverse reactions were
included. No further corrective action
Corrective Action: (h) Possible adverse reactions (side effects) for each medication must be needed.
included on or with the youths medication record.
Consents 413-215-0676(1)(e) To allow access as required in ORS418.305, OAR413-215- Yes☐ No Records of two youth records were
0091 & 0101 observed and this consent was met. No
further corrective action needed.
The consent allowing access was added to the consent document during the review and was
provided to this licensor.
Service Planning 413-215-0681(2)(e) (A)&(B) SerPage 1 of 2vice plan. Completed within Yes☐ No Records were reviewed and this
60 days (parent, guardian and child actively involved). Describes how child’s issues requirement was met. No further
will be addressed, anticipated outcomes and reviewed by child and guardian/parent. corrective action needed.
The service plan shall document involvement of the child and parent/guardian in creation of
the service plan as well as documented evidence that the service plan was reviewed by the
child and guardian/parent.
Page 1 of 2
Case Management 413-215-0681(3)(f) Incident Reporting Yes No☐ 1)Incident reports were individualized by
youth when an incident involved more
Incident Reports were filed separately from each youths file. The agency shall ensure Incident than one youth. No further corrective
Reports must be individualized by each youth and retained in each youth file. action needed.
2)Incident reports were filed together,
and not in each youth’s file. The agency
shall provide a systematic procedure to
prevent recurrences. This is a repeat
finding.
New Findings from Site Visit
None
Interview Summary
Two youth, ages 11 and 13, who have been in the program 2 and 7 months respectively, were individually interviewed. Both reported feeling safe and gave
personal examples of how this program is benefiting them. They said food is good and plentiful. They have weekly individual and family therapy and several
phone and Zoom contacts with parents weekly. They indicated they received medications as prescribed and that staff and therapists are trusting and supportive.
They said peer relationships are average, as to be expected with several youth living in the same space. There is a peer-to-peer bullying issue that the staff are
aware of and have implemented safety measures and group discussions to prevent bullying. Both reported liking the program, it teaches personal responsibility.
However, they wish there were more weekend outings*. They report the program does well at helping people, being supportive, and providing a “homey” place
to live. One youth reports the program could improve on staff consistency because it makes it confusing for youth sometimes. *I inquired with the Executive
Director regarding the weekend schedule. The youth are involved in soccer programs and Saturdays are spent at soccer games, leaving Sunday as an outing
day for store shopping.
Observations
The environment was welcoming, in good condition and clean. However, there was some pink build-up in bathtubs and showers, and they could benefit from a
good scrubbing. The kitchen and dining room was clean, and plenty of food was observed in the various refrigerators, freezers, and pantry. Bedrooms and dorm
rooms were clean, and each youth’s bed was neatly made and had individualized décor.
Corrective Actions and Timeframes: Please submit the following to verify compliance.
Within 45 days of receipt of this report New Leaf Academy 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 robin.m.duval@dhsoha.state.or.us.
Licensing Coordinator’s Signature: ________________________ Date: _1_0_/_2_0_/2_0_2__2_ ________
Manager Review: ______________________________________ Date: _1_0_-_1_8_-_2_0_2_2_ _______
Page 2 of 2

agency_name: Calo Programs of Missouri, Inc. dba Embark Behavioral Health (EBH)

program_name: New Leaf Academy

program_type: (RC) Residential Care Programs

report_type: Unannounced

view_code: RC

executive_director: Deveney Marshall

board_chairperson: Craig Christiansen

visit_date: October 13, 2022

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 11/18/2021 Repeat Findings Comments
Further Action
Needed
Medication 413-215-0651 (10) Written record of the administration of medication Yes[ ] No Medication administration records were
includes: (h) possible adverse reactions observed, and adverse reactions were
included. No further corrective action
Corrective Action: (h) Possible adverse reactions (side effects) for each medication must be needed.
included on or with the youths medication record.
Consents 413-215-0676(1)(e) To allow access as required in ORS418.305, OAR413-215- Yes[ ] No Records of two youth records were
0091 & 0101 observed and this consent was met. No
further corrective action needed.
The consent allowing access was added to the consent document during the review and was
provided to this licensor.
Service Planning 413-215-0681(2)(e) (A)&(B) SerPage 1 of 2vice plan. Completed within Yes[ ] No Records were reviewed and this
60 days (parent, guardian and child actively involved). Describes how child's issues requirement was met. No further
will be addressed, anticipated outcomes and reviewed by child and guardian/parent. corrective action needed.
The service plan shall document involvement of the child and parent/guardian in creation of
the service plan as well as documented evidence that the service plan was reviewed by the
child and guardian/parent.
Page 1 of 2
Case Management 413-215-0681(3)(f) Incident Reporting Yes No[ ] 1)Incident reports were individualized by
youth when an incident involved more
Incident Reports were filed separately from each youths file. The agency shall ensure Incident than one youth. No further corrective
Reports must be individualized by each youth and retained in each youth file. action needed.
2)Incident reports were filed together,
and not in each youth's file. The agency
shall provide a systematic procedure to
prevent recurrences. This is a repeat
finding.
New Findings from Site Visit
None
Interview Summary
Two youth, ages 11 and 13, who have been in the program 2 and 7 months respectively, were individually interviewed. Both reported feeling safe and gave
personal examples of how this program is benefiting them. They said food is good and plentiful. They have weekly individual and family therapy and several
phone and Zoom contacts with parents weekly. They indicated they received medications as prescribed and that staff and therapists are trusting and supportive.
They said peer relationships are average, as to be expected with several youth living in the same space. There is a peer-to-peer bullying issue that the staff are
aware of and have implemented safety measures and group discussions to prevent bullying. Both reported liking the program, it teaches personal responsibility.
However, they wish there were more weekend outings*. They report the program does well at helping people, being supportive, and providing a "homey" place
to live. One youth reports the program could improve on staff consistency because it makes it confusing for youth sometimes. *I inquired with the Executive
Director regarding the weekend schedule. The youth are involved in soccer programs and Saturdays are spent at soccer games, leaving Sunday as an outing
day for store shopping.
Observations
The environment was welcoming, in good condition and clean. However, there was some pink build-up in bathtubs and showers, and they could benefit from a
good scrubbing. The kitchen and dining room was clean, and plenty of food was observed in the various refrigerators, freezers, and pantry. Bedrooms and dorm
rooms were clean, and each youth's bed was neatly made and had individualized décor.


summary: Unannounced - 3 findings

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Residential Care
Licensee: Program Design Concepts, dba New Leaf Academy
Executive Director: Deveney Marshall Date of Unannounced: May 22, 2023
Board Chairperson: Craig Christiansen Licensing Coordinator: Robin DuVal
Other Regulatory or Accrediting Agencies: COGNIA accredited, Student Exchange and Visitor Program (SEVS) approved, certified by California
Dept. of Education to provide special education 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 Findings Comments
Unannounced Site Visit 10-13-2022 Further Action
Needed
Case Management 413-215-0681(3)(f) Incident Reporting Yes☐ No The agency recently changed to an electronic system for
Incident Report documentation which allows individual
Incident Reports were filed separately from each youths file. The documentation and tracking per youth.
agency shall ensure Incident Reports must be individualized by each
youth and retained in each youth file.  This licensor will provide technical assistance to ensure
all incident reporting documentation requirements in this
1)Incident reports were individualized by youth when an incident new electronic system are being met.
involved more than one youth. No further corrective action needed.
2)Incident reports were filed together, and not in each youth’s file. The
agency shall provide a systematic procedure to prevent recurrences.
This is a repeat finding.
1 |P ag e
Form Rev. 01/23/2023
New Findings from Site Visit Corrective Action
OAR 419-470-0020(2)(c) All areas of buildings where children in care are present must be Corrective Action: The agency shall ensure these areas are
kept clean and in good repair. corrected and institute a prevention method to reduce future
OAR 419-470-0020(2)(h)(A) Buildings must be ventilated by natural or mechanical means occurrences.
and must be free of excessive heat, condensation, and obnoxious odors.
The following was observed during the walk-thru.
 The concrete near the front door is cracked and raised exposing sharp areas creating
a trip/fall hazard.
 The downstairs bathroom ceiling and wall had black substance, possibly be mold,
which is also a health concern.
 The downstairs bathroom ventilation fan cover has build-up, which could impact the
effectiveness of ventilation from showers.
Interview Summary
Three youth were individually interviewed, ages 14, 15, and 13, ranging from 3-13 months in the program. They described how the program is
helping them. All reported the food is amazing since the new chef started December 2022, they’re well fed, and the chef works closely with the
nutritionist. They reported getting their medications as prescribed, the therapists are great, and there’s staff that are trusting. Family contact is
better with therapy and when it’s mediated, and they have regular contact in therapy sessions, private calls, and in-person. School is reported as
good, and they get help when needed, but one youth reports not liking the change to “online” version of school. With the lower census, it’s been
good to form closer relationships with peers, but it’s also challenging to be with the same group every day. There’s some drama among peers and
can feel toxic at times. Staff try to redirect, but some insert their personal opinions, side with one youth over another, or let it slide. If a youth gets
in trouble, they report there’s different levels of consequences such as therapeutic focus paperwork or restrictions ranging from no TV or movie
time, not going to the store or an outing, or restriction from interacting with another peer (like time out from peer to peer). One youth described
the process when/if a youth is on safety.* On-site activities and outings were described, however a desire was expressed for more or different
outings.**
They report the agency does well at implementing natural consequences, works well with families, personal development, building family
relationship, and having great therapists. The agency could improve on reducing the amount of down time in the evenings, which was referred to
as “My Time”*** and described as sitting in the living room with staff present for “silent” time, not able to speak to other peers while doing quiet
activities. When asked if they could change anything, it was reported the desire to reduce and/or change “My Time”, improve staff’s abilities on
dealing with youth and peer-to-peer behaviors, and to integrate technology for skill-building to prepare for the “real world” and create opportunities
for work or volunteering.
This licensor followed up on the below areas:
*Further information obtained regarding a youth on “safety” to confirm it meets current licensing rule requirements.
**The activity schedule for April, May, and June was provided to this licensor demonstrating regular activities and outing opportunities.
***My Time. The Program Director shared that youth concerns were expressed over a month ago and with youth input, changes were implemented
approximately mid-April and documentation of this was provided.
2 |P ag e
Form Rev. 01/23/2023
Other notable info: In addition to the full-time RN during the week, a new LPN nurse was recently hired for weekend coverage.
Observations
The Executive Director accompanied this licensor for the walk-thru which consisted of the dorm rooms, bedrooms, living rooms, medication
room, dining hall, kitchen, and therapists’ office area. The environment was welcoming, in good condition and clean, except areas noted above.
Food was observed in the various refrigerators, freezers, and pantry. Bedrooms and dorm rooms were relatively clean with beds made and had
individualized décor.
Corrective Actions and Timeframes: Please submit the following to verify compliance.
Within 45 days of receipt of this report, New Leaf Academy 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 robin.m.duval@odhsoha.oregon.gov.
Licensing Coordinator’s Signature: ________________________ Date: _6_/2__/2_0_2_3_ ___________
Manager Review: ______________________________________ Date: _6_-_2_-2_0__2_3_ _________
3 | P a g e
Form Rev. 01/23/2023

facility_type: Residential Care

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 Findings Comments
Unannounced Site Visit 10-13-2022 Further Action
Needed
Case Management 413-215-0681(3)(f) Incident Reporting Yes[ ] No The agency recently changed to an electronic system for
Incident Report documentation which allows individual
Incident Reports were filed separately from each youths file. The documentation and tracking per youth.
agency shall ensure Incident Reports must be individualized by each
youth and retained in each youth file. - This licensor will provide technical assistance to ensure
all incident reporting documentation requirements in this
1)Incident reports were individualized by youth when an incident new electronic system are being met.
involved more than one youth. No further corrective action needed.
2)Incident reports were filed together, and not in each youth's file. The
agency shall provide a systematic procedure to prevent recurrences.
This is a repeat finding.

New Findings from Site Visit Corrective Action
OAR 419-470-0020(2)(c) All areas of buildings where children in care are present must be Corrective Action: The agency shall ensure these areas are
kept clean and in good repair. corrected and institute a prevention method to reduce future
OAR 419-470-0020(2)(h)(A) Buildings must be ventilated by natural or mechanical means occurrences.
and must be free of excessive heat, condensation, and obnoxious odors.
The following was observed during the walk-thru.
- The concrete near the front door is cracked and raised exposing sharp areas creating
a trip/fall hazard.
- The downstairs bathroom ceiling and wall had black substance, possibly be mold,
which is also a health concern.
- The downstairs bathroom ventilation fan cover has build-up, which could impact the
effectiveness of ventilation from showers.
Interview Summary
Three youth were individually interviewed, ages 14, 15, and 13, ranging from 3-13 months in the program. They described how the program is
helping them. All reported the food is amazing since the new chef started December 2022, they're well fed, and the chef works closely with the
nutritionist. They reported getting their medications as prescribed, the therapists are great, and there's staff that are trusting. Family contact is
better with therapy and when it's mediated, and they have regular contact in therapy sessions, private calls, and in-person. School is reported as
good, and they get help when needed, but one youth reports not liking the change to "online" version of school. With the lower census, it's been
good to form closer relationships with peers, but it's also challenging to be with the same group every day. There's some drama among peers and
can feel toxic at times. Staff try to redirect, but some insert their personal opinions, side with one youth over another, or let it slide. If a youth gets
in trouble, they report there's different levels of consequences such as therapeutic focus paperwork or restrictions ranging from no TV or movie
time, not going to the store or an outing, or restriction from interacting with another peer (like time out from peer to peer). One youth described
the process when/if a youth is on safety.* On-site activities and outings were described, however a desire was expressed for more or different
outings.**
They report the agency does well at implementing natural consequences, works well with families, personal development, building family
relationship, and having great therapists. The agency could improve on reducing the amount of down time in the evenings, which was referred to
as "My Time"*** and described as sitting in the living room with staff present for "silent" time, not able to speak to other peers while doing quiet
activities. When asked if they could change anything, it was reported the desire to reduce and/or change "My Time", improve staff's abilities on
dealing with youth and peer-to-peer behaviors, and to integrate technology for skill-building to prepare for the "real world" and create opportunities
for work or volunteering.
This licensor followed up on the below areas:
*Further information obtained regarding a youth on "safety" to confirm it meets current licensing rule requirements.
**The activity schedule for April, May, and June was provided to this licensor demonstrating regular activities and outing opportunities.
***My Time. The

interview_summary:
Three youth were individually interviewed, ages 14, 15, and 13, ranging from 3-13 months in the program. They described how the program is
helping them. All reported the food is amazing since the new chef started December 2022, they're well fed, and the chef works closely with the
nutritionist. They reported getting their medications as prescribed, the therapists are great, and there's staff that are trusting. Family contact is
better with therapy and when it's mediated, and they have regular contact in therapy sessions, private calls, and in-person. School is reported as
good, and they get help when needed, but one youth reports not liking the change to "online" version of school. With the lower census, it's been
good to form closer relationships with peers, but it's also challenging to be with the same group every day. There's some drama among peers and
can feel toxic at times. Staff try to redirect, but some insert their personal opinions, side with one youth over another, or let it slide. If a youth gets
in trouble, they report there's different levels of consequences such as therapeutic focus paperwork or restrictions ranging from no TV or movie
time, not going to the store or an outing, or restriction from interacting with another peer (like time out from peer to peer). One youth described
the process when/if a youth is on safety.* On-site activities and outings were described, however a desire was expressed for more or different
outings.**
They report the agency does well at implementing natural consequences, works well with families, personal development, building family
relationship, and having great therapists. The agency could improve on reducing the amount of down time in the evenings, which was referred to
as "My Time"*** and described as sitting in the living room with staff present for "silent" time, not able to speak to other peers while doing quiet
activities. When asked if they could change anything, it was reported the desire to reduce and/or change "My Time", improve staff's abilities on
dealing with youth and peer-to-peer behaviors, and to integrate technology for skill-building to prepare for the "real world" and create opportunities
for work or volunteering.
This licensor followed up on the below areas:
*Further information obtained regarding a youth on "safety" to confirm it meets current licensing rule requirements.
**The activity schedule for April, May, and June was provided to this licensor demonstrating regular activities and outing opportunities.
***My Time. The Program Director shared that youth concerns were expressed over a month ago and with youth input, changes were implemented
approximately mid-April and documentation of this was provided.

Other notable info: In addition to the full-time RN during the week, a new LPN nurse was recently hired for weekend coverage.

observations:
The Executive Director accompanied this licensor for the walk-thru which consisted of the dorm rooms, bedrooms, living rooms, medication
room, dining hall, kitchen, and therapists' office area. The environment was welcoming, in good condition and clean, except areas noted above.
Food was observed in the various refrigerators, freezers, and pantry. Bedrooms and dorm rooms were relatively clean with beds made and had
individualized décor.


summary: License Renewals - 11/06/2023

raw_content:
Licensed Child Caring Agency Site Visit Report
Residential Care
Licensee: Calo Programs Missouri, Inc., d.b.a. Embark Behavioral Health Date of site visit: November 6-7, 2023
Executive Director: Deveney Marshall Licensing Coordinator: Robin DuVal
Board Chairperson: Russell Petrella
Other Regulatory or Accrediting Agencies: Joint Commission Accreditation.
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, type, and services: 24-hour residential program for adolescents who struggle with mental health challenges and who require
increased levels of support to maximize their individual potential. Through the milieu model that a residential stay can afford, youth are able to receive
assistance through individual evidence-based psychotherapy (e.g., Dialectical Behavioral Therapy (DBT), Trauma-Focused Cognitive Behavioral
Therapy (TF-CBT), Sensory Motor Arousal Regulation Treatment (SMART), Eye Movement Desensitization and Reprocessing (EMDR)) and
specialized psychosocial groups (e.g., health and human sexuality, family relationships, social skills, group therapy). Concurrently, psychiatric and
medication monitoring help ensure that all aspects of the participant’s health are being supported. The program is designed to treat youth with a
variety of mental health struggles and diagnoses, in a safe, structured, and therapeutic environment. The goal is to leverage our therapeutic services
to minimize the risk of hospitalization by giving the participant the stability needed to achieve independence in the general community. Our core
purpose is to create Joy and Heal Generations. This purpose is lived out through our core values of empathy, service, trusting relationships, growth,
and results – the lens by which they approach their therapeutic program.
Capacity and Age Range: 50, ages 10-17
Funding sources: Commercial insurance.
Contracts and sources for referrals: No contracts. Sources for referrals: internet, hospitals, OP therapists, medical providers.
Average length of stay: 65 days
Average daily population served: 5
P a g e 1 | 14
Form Rev. 11/14/2023
Number of children served annually: 12 since new programming took effect February 2023.
Use of seclusion or restraint: No.
Interviews: Two youth were individually interviewed, ages 14 and 13, with stays of 7 weeks and 3 weeks, respectively. Both report feeling safe in
the program and that they feel the program is helping them. They have regular contact with people on their approved contact list, have privacy and
time isn’t restricted. Youth described regular activities on and off-site. The food is good and plentiful. Neither youth report any issues getting
medications as prescribed. School is going well, and they get help when needed. Youth report giving input on their treatment plan and feeling listened
to. They report the program does well at the educational component and their therapists. If there was something they could change about the
program, it would be changing the age-range to group the younger residents and older residents together and allow more freedoms.
Two staff were individually interviewed and have worked in the program for almost 3 years and 6 months, respectively. Both described the types and
frequency of training at time of hire and ongoing. They have regular staff meetings, have regular contact with their immediate supervisor, and
management is responsive to concerns or suggestions made by staff. Staffing is sufficient for the current census. Forms of recreation for the youth,
both on-site and off-site, were described. They described the ways to obtain information when a child enters the program. They report the program
does well at building relationships with the youth, are attuned to their needs, and affirming to youth’s gender fluidity. The program could improve on
having more staff, staff consistency with boundaries within shifts, and improved communication. When asked if there was anything they could change
about the program, they reported having more time in the morning for youth to be outside, more outdoor experiences, and more structure and staff
consistency around areas of laundry and clean-up.
Observations: The walk-through consisted of the youth bedrooms, dorm rooms, bathrooms, living rooms, kitchen, medication room. Areas observed
were clean, odor-free, and in good condition.
Program Strengths: Joint Commission Accredited, outcome driven, 1 to 3 staff to youth ratio, weekly treatment meetings with parental involvement,
therapist caseload of 6 or less, family services programming including weekly parent coaching, monthly family workshops, daily family phone calls,
two therapeutic groups per day, 7 day a week nursing, weekly psychiatric oversight, insurance funded.
Program Challenges: Current leadership challenge is visibility and marketing. There’s a need to do more outreach to let Oregon families know this
program is an option for youth.
Changes that have occurred in the last 2 years: In January of 2023, New Leaf Academy changed ownership to Calo Programs Missouri, Inc. The
program kept the private pay long term program open until June of 2023 and started to take student funding through commercial insurance in February
2023, and have since served 12 youth via insurance funding. The agency received their Joint Commission Accreditation following a site visit in April
2023.
Lawsuits: none
P a g e 2 | 14
Form Rev. 11/14/2023
Grievances and complaints filed in the last two years: none
Corrective Actions and Timeframes: Please submit the following to verify compliance.
Within 45 days of receipt of this report Calo Programs Missouri, Inc. 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 are to be emailed directly to Robin DuVal at robin.m.duval@odhsoha.oregon.gov.
Summary of Review
Program and Services 419-400-0020 (2) Yes No N/A
Program and services are in scope of license X
Governance of the Agency 419-400-0040 Yes No N/A
(1)(a) Minimum of 5 board members X
(2)(f) Formally evaluate the exec. Director’s performance annually X
(2)(g) Approves annual budget X
(2)(h) Obtain and review an annual independent financial review or audit of financial
X
records.
(2)(k) Written quality improvement program X
(2)(l) Meeting minutes X
Executive Director or Program Director 419-400-0040 Yes No N/A
(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 419-400-0150 Yes No N/A Corrective Actions/Comments
(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
X
medically necessary devices/prescriptions)
(3)(c) Agency uses appropriate time-out rooms (adequate space, heat, light and
ventilation and is not capable of locking) and documents use in child’s record when X
applicable
(3)(e) Agency uses seclusion appropriately/consistent with policy X
(4) Agency has adequate plan in place to respond to suicidal behavior/warning
X
signs
P a g e 3 | 14
Form Rev. 11/14/2023
Contractors (if applicable) 419-400-0120(6) Yes No N/A
(a) Agency ensures the contractor meets the requirements of this rule and Chapter
X
413 division 215
(b)(B) Contract includes the following:
(i) Services provided
(ii) Contractor fees
(iii) Disclosure of information from contractor to agency
X
(iv) Lines of authority
(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 419-400-0180 Yes No N/A Corrective Actions/Comments
(13)(d) Each child caring agency that submits a report under this section shall make
its quarterly report available to the public upon request at the Child Caring Agency’s X
main office and on the child caring agency’s website if applicable.
Supplemental Information Provided by CCA Yes No N/A Corrective Actions
Documents as indicated on the form titled “Renewal Licensing Required
X
Documents”
Documents as indicated on form titled “Required Financial Documents and
X
Information”
All required policies and procedures as identified in the “Umbrella Rules” Upon review of the following policies and procedures,
there are minor to moderate edits needed.
Corrective Action: The agency shall update the
following policies and procedures pursuant to each
OAR and submit for review.
• Conflict of interest in OAR 419-400-0070
• Children Rights in OAR 419-400-0090(1)
• Grievance Procedures in OAR 419-400-
0090(2)
X • Mandatory Abuse Reporting in OAR 400-
0110(2)(a)
• Incident reporting in OAR 419-400-0110(2)(b)
• Personnel in OAR 419-400-0120
• Privacy in OAR 419-400-0130
• Suicide Prevention in OAR 419-400-0150(4)
• Discipline and behavior management in OAR
419-400-0150
• Transportation in OAR 419-400-0200(1)
• Searches in OAR 419-400-0200(2)
• Hazards in OAR 419-400-0200(4)
P a g e 4 | 14
Form Rev. 11/14/2023
All required policies and procedures as identified in “Agency Type Specific Rules”
The agency shall update the following policy and
procedure pursuant to the OAR and submit for review.
X
• Medications in OAR 419-470-0110
Physical Plant Yes No N/A Comments
419-400-0090(3)(a) Foster Rights Posted (if children in DHS custody) X
419-400-0100(1) Sufficient safe space, equipment, and office equipment X
419-400-0230(12) License is posted in common area at each facility Comment: This licensor recommended the license
X also be posted in the foyer as it’s a common area at
the program.
419-470-0020(2)(a) &(c) Buildings are smoke free, clean and in good repair X
419-470-0020 (2)(d) Rooms are free of harmful drafts, odors, and excessive noise X
419-470-0020 (2)(e) Rooms are adequate in size and arrangement X
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 ensure the safety of children X
Room and Space Requirements 419-470-0030 Yes No N/A
(2) There is a separate living room or lounge area – 15 SF minimum per child X
(5) There is a separate dining room with capacity for ½ of children in care and 15 X
SF per child in care
(7) Laundry is separate from living, kitchen, and dining areas X
(8) Separate storage areas are provided for food, kitchen supplies, utensils, clean X
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 vehicles and other hazards and of a size X
and availability appropriate to the age and needs of children in care
(11) Time-out rooms: Rooms used for time out or quiet time must have adequate X
space, heat, light and ventilation and must not be capable of locking.
Room and Space Requirements Bedrooms 419-470-0030(3) Yes No N/A
(a) Adequate furnishings and personal items X
(b) Separate from rooms used for dining, living, laundry, kitchen, and storage X
(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 marshal must approve the modification X
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
P a g e 5 | 14
Form Rev. 11/14/2023
Room and Space Requirements Bathrooms 419-470-0030(4) Yes No N/A
(a)(A)&(B) 1:8 ratio for toilets and sinks X
(a)(D) Hot and cold running water, soap, and approved hand drying options X
(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 419-470-0030(6) Yes No N/A
(a) Used exclusively for storage, food preparation, dishwashing, and activities
X
related to eating and food preparation activities
(b) Walls, floors are easily cleanable X
(c) Equipment and utensils are easily cleanable, durable, nontoxic, and kept clean X
(e) Equipment is easy to clean beneath, between and behind X
Furnishings and Personal Items 419-470-0040 Yes No N/A
(1) There is a bed with frame X
(1)(b) clean mattress in good condition, with a minimum thickness of five inches X
(1)(c) a pillow in good condition X
(1)(d) a private dresser, closet, or similar storage area for personal belongings that
X
is readily accessible
(2) Linens are in good repair. There is a waterproof mattress cover or mattress.
X
Linens are appropriate and towels and washcloths are provided
(3) Bedding is changed weekly or when soiled X
(4)&(5) Personal hygiene supplies and appropriate clothing are provided X
Food Services 419-470-0070 Yes No N/A
(1)(a) Meals are arranged daily, consistent with normal mealtimes that occur during
X
the hours of operation and provide snacks between mealtimes
(1)(b) Menus are prepared in advance in accordance with USDA guidelines,
X
provide a 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 sanitary manner X
(2)(c) & (d) Food products are obtained from commercial suppliers (exception of
fruits & vegetables), unpasteurized juice is prohibited, and only Grade A X
pasteurized and fortified milk in appropriate container.
Residential Care Safety 419-470-0080 Yes No N/A Corrective Actions/Comments
(2) Written emergency plan that includes X
(a) Identifying the types of emergencies most likely to happen where the residential
X
care agency is located
(b) Identifying a place to meet for each type of emergency identified X
(c) Identifying an alternate shelter if necessary X
P a g e 6 | 14
Form Rev. 11/14/2023
(d) Ensuring access to necessary medications or medical equipment X
(e) How to help each child in care recover after a disaster X
(3) Telephone numbers for local police, fire department, poison control, after hours
medical advice and other appropriate emergency numbers must be posted near all X
telephones.
(4) Operative flashlights sufficient in number are readily available to staff Comment: This licensor recommended moving the
X box of flashlights to a more readily available space.
(5)(a) Evacuation drill occurs monthly under varying conditions, is retained 2 years Documentation of evacuation drills were inconsistent.
and contains:
(A) identify of person conducting drill Corrective Action:
(B) date & time The agency shall ensure the evacuation drill log form
(C) notification method includes all required elements noted in (A-H); ensure
X
(D) staff participating that evacuation drills occur monthly and are
(E) # of children & staff evacuated appropriately documented.
(F) special conditions simulated
(G) problems encountered
(H) time to complete
Umbrella Safety 419-400-0200 Yes No N/A
(5)(b) Vehicle has insurance policy, is smoke free, safe operating condition, and X
has first aid kit and fire extinguisher 2-A:10-BC
(1)(b)(A) Each vehicle used to transport a child in care must be: properly registered, X
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 pool on the premises that is accessible X
to children in care or if a child-caring agency plans to have children in care engage
in swimming, the child-caring agency must have and adhere to policies and
procedures that address, at a minimum, providing disclosures and obtaining
consents, assessing swimming ability of children in care, and ensuring the safety of
pool access.
(4)(a) The program protects children from potentially harmful items and materials. X
(4)(b) Direct supervision of children who do not have the ability to adjust and control X
water temperature
(4)(c) Light fixtures have protective covers unless designed to be used without one X
Medication 419-470-0100 Yes No N/A Corrective Actions and Comments
(3)&(7)(e) Medications have a prescription and are stored in the original container
X
with 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 order, signed by a physician X
or qualified medical professional, is also required before a restriction on diet or
physical activity is imposed.
(7)(a) Prescription medications that are unused and medications that are expired or Several bubble pack medications were observed to be
recalled may not be maintained with current medication and must be disposed of as X unsealed, however there were still pills tucked back in
described in agency disposal policy. the bubble and/or taped back in. The medication
P a g e 7 | 14
Form Rev. 11/14/2023
record did not provide a reasoning for any anomalies.
Medications that have been popped out of their
bubble packs and subsequently not administered to a
child in care must not be placed back in the original
container.
This concern was brought to the attention of the
Executive Director and the Nurse and immediately
began investigating.
Corrective Action:
• The agency shall ensure staff are retrained
and following procedures to dispose of
medications when a medication is refused,
missed or any other type of medication error
that results in a medication not being
administered as prescribed and to follow the
agency’s disposal policy.
• The agency shall ensure management
oversight occurs regularly to ensure proper
procedures are followed.
(7)(c) Medications are inaccessible to children and stored behind at least two
Comment: Requirements are met within the program
locking mechanisms. This does not apply to Naloxone.
medication room, however the storage of discontinued
medications in the Nurse’s office was not locked behind
two locking mechanisms at the time of my walk-thru.
X Typically, the drawer is locked, and the office is locked.
However, the drawer was unlocked at the time of the
walk-thru. Other staff have keys to unlock the office,
leaving a potential risk of mishandling of those
medications.
(8) Medications are disposed in accordance with state and federal law Comment: It is recommended that the collection of
medications to be disposed are stored in a separate
container in the medication cabinet and clearly marked
X
as “medications to be disposed.” While on-site, the
Nurse provided a labeled container in the cabinet.
(9) Written record of the disposal of medications is maintained and includes: Comment: The Nurse maintains discontinued
(a) description and amount medications in their office in a baggie labeled per each
(b) name child in care. However, there’s no corresponding record
(c) reason identifying the medications contained in that baggie.
X
(d) method Agency policy allows for return of discontinued
(e) staff & witness signature medications to the child’s parent/guardian.
• This licensor recommended that a record be
created and utilized to document each
P a g e 8 | 14
Form Rev. 11/14/2023
medication, the amount, the child’s name, and
the date at a minimum.
(10) Written record of the administration of medication includes: Medications that were not administered, refused,
(a) name missed or any other type of medication error must be
(b) description documented. Refer to (7)(c) above.
(c) dates and times
(d) missed doses Corrective Action:
(e) medication disposed • The agency shall ensure medication errors, or
(f) method of administration anomalies in documentation, are documented
(g) ID of person administering by adding a notation to the medication
X
(h) possible adverse reactions administration record.
(i) medication taken outside facility • The agency shall ensure staff are retrained
and following procedures for proper
documentation.
• The agency shall ensure management
oversight occurs regularly to ensure proper
procedures are followed.
Extracurricular, Enrichment, Cultural & Social Activities 419-470-0110 Yes No N/A
(2) Children have ongoing opportunities to participate in at least one age- X
appropriate or developmentally appropriate activity
Minimum Staffing Requirements 419-470-0130 Yes No N/A
(1)&(2) Supervision is adequate for the type of program, location, age and type of X
children, ability of supervisor to respond, electronic back-up systems.
Minimum ratios are maintained:
Ages 6 and older: 1:7; Overnight (staff awake) 1:10
(4)(a) When one staff on duty, there is additional staff immediately available with X
max response time of 30 minutes
(5) There is at least one on-site employee authorized to apply the reasonable and X
prudent parent standard
Sleeping Arrangements 419-470-0140 Yes No N/A
(1) Children are in separate bedrooms than adults, unless parent and child, or there X
is written approval from guardian/parent and licensing coordinator
(2) There is adequate supervision of children when sleeping X
(3) When assigning bedrooms a residential care agency must consider all of the X
following:
(a) Chronological age
(b) Developmental age
(c) Gender identity
(d) Personal history, including medical, mental health, behavioral health, and past
adverse experiences including any physical or sexual abuse
P a g e 9 | 14
Form Rev. 11/14/2023
Personnel Files 419-400-0120 Yes No N/A Comments
Staff Name/Position X
(3)(g) Date of Hire X
(3)(a) record of education, training, and previous employment X
(1)(b) & (3)(b) reference checks completed and documented X
(1)(a) & (3)(c) Background check completed and documented X A reminder was provided to initiate new background
checks at times of position changes.
(3)(d) Annual performance evaluations X
(3)(f) Record of personnel actions X
(3)(g) Termination date, reason for termination X
(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
419-400-0120(4)
(a) Agency policies and procedures X
(b) Ethical and professional guidelines X
(c) Suicide prevention and intervention X The agency shall ensure that all new employees
(under Calo Programs Missouri Inc.) complete this
training within 30 days of hire, regardless of their prior
employment.
(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 419-470-0120(1)
Yes No N/A Corrective Actions
(Prior to working alone and within 30 days)
(a) Discipline and behavior management including de-escalation, crisis prevention,
positive behavior management, and disciplinary techniques that are non-punitive X
in nature
(b) CPR and First Aid sufficient to retain a current certification X
(c) Universal precautions and hygiene X
(d) Application of the reasonable and prudent parent standard X
(e) Training on the agency’s policy on suicide prevention and suicide risk The agency shall ensure that all new employees
assessment tool (under Calo Programs Missouri Inc.) complete this
X training within 30 days of hire, regardless of their prior
employment.
Crisis Intervention Training Standards and Certification
Yes No N/A Corrective Actions/Comments
419-400-0160(4) (as applicable)
P a g e 10 | 14
Form Rev. 11/14/2023
(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
X
on positive 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
419-470-0070(2)(b) Employees who handle food served to children have a valid
X
food handler’s card
419-400-0200 (1) Employees transporting children have: current driver’s license,
insurance, trained in emergency procedures and behavior management, and X
training for 15+ passenger vans if applicable)
419-470-0120 (2)(a) Environmental emergencies X
419-470-0120 (2)(b) Universal Precautions X
419-470-0120 (2)(c) Discipline and Behavior Management X
419-470-0120 (2)(d) Agency’s policy on suicide prevention and risk assessment tool X
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
Children’s Records Yes No N/A
Health Services 419-470-0090
P a g e 11 | 14
Form Rev. 11/14/2023
(2) Medical history obtained within 30 days (significant findings, current
immunizations, history of surgical procedures-health issues-injuries, allergies, X
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 examination having occurred within the X
calendar year will meet this requirement.
Consents 419-470-0160(1) Yes No N/A Corrective Actions
(a) Provide routine and emergency medical care X
(b) Use the discipline and behavior management system X
(c) Use restraint or seclusion (if applicable). Must specify the reasons for the
X
intervention and how staff are trained and supervised
(d) Restrict contact with persons outside of the agency X
(e) Allow access as defined in 419-400-0230 & 0240 X
(f) Impose a dress code The agency shall ensure consent to impose a dress
X code is obtained from the child in care’s
parent/guardian and properly documented.
(g) Apply the reasonable and prudent parent standard X
Disclosures 419-470-0160(2) Parent/guardian has acknowledged in writing: Yes No N/A Corrective Actions
(a) Information regarding personal or room searches and protocols for confiscation
X
of contraband
(b) Statement of Rights of Children and Parents/Guardians The agency shall ensure this disclosure is provided
X and properly documented indicating that the
parent/guardian has acknowledged.
(c) Any policies and procedures upon request The agency shall ensure this disclosure is provided
X and properly documented indicating that the
parent/guardian has acknowledged.
Authorizations 419-470-0160(3) Yes No N/A
(a) Disclose or exchange information with others X
(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 not limited to using motorized yard X
equipment, swimming, and horseback riding.
Information about Children in Care 419-400-0190(1)
Yes No N/A Corrective Actions
Summary sheet contains the following:
(a)The name, gender, date of birth, religious preference, and previous address The agency shall ensure an entry is noted for
religious preference.
• While on-site, the agency discussed ways to
X
incorporate that into their electronic system in
the demographic page.
(b) Name and location of previous and current school The agency shall ensure this information is obtained
X
and documented.
P a g e 12 | 14
Form Rev. 11/14/2023
• While on-site, the agency discussed ways to
incorporate that into their electronic system in
the demographic page.
(c) Date of admission X
(d) Legal custody The agency shall ensure an entry is noted for legal
custody.
X • While on-site, the agency discussed ways to
incorporate that into their electronic system in
the demographic page.
(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
X
of the document that provides for his or her authority over the child in care.
(C) Other persons significant to child
(D) Other professionals to be involved in service planning (if applicable)
Service Planning 419-470-0170(2) Yes No N/A Comments
(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 services, and how agency will X
provide services
(e) (A)&(B) Service plan within 60 days (parent, guardian and child actively Comment: The agency shall continue efforts to
involved). Describes how child’s issues will be addressed, anticipated outcomes, X ensure documentation is clear when the review with
and reviewed by child and guardian/parent. the child and parent/guardian occurs.
(e)(C)&(D) Service plan is reviewed quarterly and revised when information
X
indicates other services should be provided
Case Management 419-470-0170(3) Yes No N/A Corrective Actions
(a) Services are documented, progress toward achieving goals is tracked X
(c) Discharge planning evaluations and decisions are documented. The agency shall ensure discharge planning
X evaluations, decisions, etc. are captured and
documented.
(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 & Involuntary Seclusion Yes No N/A Corrective Actions
P a g e 13 | 14
Form Rev. 11/14/2023
419-400-0180 (12) Records X
419-400-0180(13)(e) Each child caring agency shall provide notice regarding how
to access the quarterly reports to the parents or guardians of children in care in This requirement is not met in its entirety. The
X
the program. The child caring agency shall provide the notice upon the child in agency shall update the notice and submit for review.
care’s admission and at least two times each year thereafter.
419-400-0190(1) Information provided to children in care relating to Restraint & This requirement is not met in its entirety. The
X
Involuntary Seclusion agency shall update the notice and submit for review.
Financial Records 419-470-0170(4) Yes No N/A Corrective Actions and Comments
Records contain date, amount, source, purpose, signatures A small amount of cash was discovered after a child’s
admission process, and it was placed in a baggie
labeled with the child’s name and stored in the office.
Corrective Action:
• The agency shall create a financial record log
to document any monies belonging to a child
in care. The form must include all elements
notes in this rule. Note: Typically, the
X
program does not allow cash, however a log
is required in the event
Comment: The agency has a process for in-program
earnings for each child in care which translates into
money on a debit card that’s specific to each child to
use on store outings. The agency provided
documentation outlining how the debit card system
works and how it’s tracked.
Personal Possessions Records 419-470-0170 (5) Yes No N/A
Individual written inventory of all personal possessions is maintained and updated
X
as needed
Records and Documentation 419-400-0140 Yes No N/A
(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; Birth date; Names,
addresses of parents or guardians; Dates of admission; Placement upon X
discharge
Licensing Coordinator’s Signature: ________________________ Date: _1_2_/_2_8_/2_0_2__3_________
Manager Review: ______________________________________ Date: _1_2_-2_7_-_2_0_2_3_ ________
P age 14 | 14
Form Rev. 11/14/2023

program_name: Embark

report_type: License Renewals

board_chairperson: Russell Petrella

visit_date: November 6-7, 2023

other_regulatory_agencies: Joint Commission Accreditation.

funding_sources: Commercial insurance.

average_length_of_stay: 65 days

use_of_seclusion_or_restraint: No. Interviews: Two youth were individually interviewed, ages 14 and 13, with stays of 7 weeks and 3 weeks, respectively. Both report feeling safe in the program and that they feel the program is helping them. They have regular contact with people on their approved contact list, have privacy and time isn't restricted. Youth described regular activities on and off-site. The food is good and plentiful. Neither youth report any issues getting medications as prescribed. School is going well, and they get help when needed. Youth report giving input on their treatment plan and feeling listened to. They report the program does well at the educational component and their therapists. If there was something they could change about the program, it would be changing the age-range to group the younger residents and older residents together and allow more freedoms. Two staff were individually interviewed and have worked in the program for almost 3 years and 6 months, respectively. Both described the types and frequency of training at time of hire and ongoing. They have regular staff meetings, have regular contact with their immediate supervisor, and management is responsive to concerns or suggestions made by staff. Staffing is sufficient for the current census. Forms of recreation for the youth, both on-site and off-site, were described. They described the ways to obtain information when a child enters the program. They report the program does well at building relationships with the youth, are attuned to their needs, and affirming to youth's gender fluidity. The program could improve on having more staff, staff consistency with boundaries within shifts, and improved communication. When asked if there was anything they could change about the program, they reported having more time in the morning for youth to be outside, more outdoor experiences, and more structure and staff consistency around areas of laundry and clean-up. Observations: The walk-through consisted of the youth bedrooms, dorm rooms, bathrooms, living rooms, kitchen, medication room. Areas observed were clean, odor-free, and in good condition.

program_challenges:
Current leadership challenge is visibility and marketing. There's a need to do more outreach to let Oregon families know this
program is an option for youth.

lawsuits:
none
P a g e 2 | 14


summary: Unannounced - 27 findings

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Residential Care
Licensee: Calo Programs Missouri, Inc., d.b.a. Embark Behavioral Health Date of Unannounced: May 13, 2024
Executive Director: Deveney Marshall Licensing Coordinator: Robin DuVal
Program Director: Amber Hailey
Other Regulatory or Accrediting Agencies: Joint Commission Accreditation
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 Findings Comments
License Renewal Site Visit 11/06-07/2023 Further Action
Needed
Supplemental Information Provided by CCA Yes☐ No✓ All policies and procedures were updated
All required policies and procedures as identified in the “Umbrella Rules” pursuant to each OAR. There’s no further
corrective action needed at this time.
Upon review of the following policies and procedures, there are minor to moderate
edits needed.
Corrective Action: The agency shall update the following policies and procedures
pursuant to each OAR and submit for review.
• Conflict of interest in OAR 419-400-0070
• Children Rights in OAR 419-400-0090(1)
• Grievance Procedures in OAR 419-400-0090(2)
• Mandatory Abuse Reporting in OAR 400-0110(2)(a)
• Incident reporting in OAR 419-400-0110(2)(b)
• Personnel in OAR 419-400-0120
• Privacy in OAR 419-400-0130
• Suicide Prevention in OAR 419-400-0150(4)
• Discipline and behavior management in OAR 419-400-0150
• Transportation in OAR 419-400-0200(1)
• Searches in OAR 419-400-0200(2)
• Hazards in OAR 419-400-0200(4)
Supplemental Information Provided by CCA Yes☐ No✓ All policies and procedures were updated
All required policies and procedures as identified in “Agency Type Specific Rules” pursuant to this OAR. There’s no further
corrective action needed at this time.
The agency shall update the following policy and procedure pursuant to the OAR and
submit for review.
• Medications in OAR 419-470-0110
Form Rev. 11/14/2023 P age 1 | 6
Residential Care Safety 419-470-0080(5)(a) Evacuation drill occurs monthly under Yes☐ No✓ Records were reviewed, and this requirement
varying conditions, is retained 2 years and contains: was met. There’s no further corrective action
(A) identify of person conducting drill needed at this time.
(B) date & time
(C) notification method
(D) staff participating
(E) # of children & staff evacuated
(F) special conditions simulated
(G) problems encountered
(H) time to complete
Documentation of evacuation drills were inconsistent.
Corrective Action: The agency shall ensure the evacuation drill log form includes all
required elements noted in (A-H); ensure that evacuation drills occur monthly and are
appropriately documented.
Medication 419-470-0100(7)(a) Prescription medications that are unused and Yes☐ No✓ Medications were observed, and this finding
medications that are expired or recalled may not be maintained with current has been corrected. There’s no further
medication and must be disposed of as described in agency disposal policy. corrective action needed at this time.
Several bubble pack medications were observed to be unsealed, however there were
still pills tucked back in the bubble and/or taped back in. The medication record did
not provide a reasoning for any anomalies. Medications that have been popped out of
their bubble packs and subsequently not administered to a child in care must not be
placed back in the original container.
This concern was brought to the attention of the Executive Director and the Nurse and
immediately began investigating.
Corrective Action:
• The agency shall ensure staff are retrained and following procedures to dispose of
medications when a medication is refused, missed or any other type of medication
error that results in a medication not being administered as prescribed and to follow
the agency’s disposal policy.
• The agency shall ensure management oversight occurs regularly to ensure proper
procedures are followed.
Form Rev. 11/14/2023 P age 2 | 6
Medication 419-470-0100(10) Written record of the administration of medication Yes✓ No Blanks were observed on the Medication
includes: Administration Records (MAR) with no
(a) name corresponding notation. During the review,
(b) description this was discussed with the program RN and
(c) dates and times they will increase their weekly audit to 3-4
(d) missed doses times weekly.
(e) medication disposed
(f) method of administration Corrective action: The agency shall ensure
(g) ID of person administering medication errors, or anomalies in
(h) possible adverse reactions documentation, are documented by adding a
(i) medication taken outside facility notation to the MAR.
Medications that were not administered, refused, missed or any other type of This is a repeat violation.
medication error must be documented. Refer to (7)(c) above.
Corrective Action:
• The agency shall ensure medication errors, or anomalies in documentation, are
documented by adding a notation to the medication administration record.
• The agency shall ensure staff are retrained and following procedures for proper
documentation.
• The agency shall ensure management oversight occurs regularly to ensure proper
procedures are followed.
New Employee Orientation – Umbrella Requirements (30 days) 419-400-0120(4) Yes☐ No✓ Records were reviewed, and this requirement
(c) Suicide prevention and intervention was met. There’s no further corrective action
needed at this time.
The agency shall ensure that all new employees (under Calo Programs Missouri Inc.)
complete this training within 30 days of hire, regardless of their prior employment.
New Employee Orientation – Residential 419-470-0120(1)(e) Training on the Yes☐ No✓ Records were reviewed, and this requirement
agency’s policy on suicide prevention and suicide risk assessment tool. (Prior to was met. There’s no further corrective action
working alone and within 30 days) needed at this time.
The agency shall ensure that all new employees (under Calo Programs Missouri Inc.)
complete this training within 30 days of hire, regardless of their prior employment.
Consents 419-470-0160(1)(f) Impose a dress code Yes☐ No✓ Records were reviewed, and this requirement
was met. There’s no further corrective action
The agency shall ensure consent to impose a dress code is obtained from the child in needed at this time.
care’s parent/guardian and properly documented.
Disclosures 419-470-0160(2) Parent/guardian has acknowledged in writing: Yes☐ No✓ Records were reviewed, and this requirement
(b) Statement of Rights of Children and Parents/Guardians was met. There’s no further corrective action
needed at this time.
The agency shall ensure this disclosure is provided and properly documented
indicating that the parent/guardian has acknowledged.
Form Rev. 11/14/2023 P age 3 | 6
Disclosures 419-470-0160(2) Parent/guardian has acknowledged in writing: Yes☐ No✓ Records were reviewed, and this requirement
(c) Any policies and procedures upon request was met. There’s no further corrective action
needed at this time.
The agency shall ensure this disclosure is provided and properly documented
indicating that the parent/guardian has acknowledged.
Information about Children in Care 419-400-0190(1) Summary sheet contains the Yes☐ No✓ Records were reviewed, and this requirement
following: (a)The name, gender, date of birth, religious preference, and previous was met. There’s no further corrective action
address. needed at this time.
The agency shall ensure an entry is noted for religious preference.
While on-site, the agency discussed ways to incorporate that into their electronic
system in the demographic page.
Information about Children in Care 419-400-0190(1) Summary sheet contains the Yes☐ No✓ Records were reviewed, and this requirement
following: (b) Name and location of previous and current school was met. There’s no further corrective action
needed at this time.
• The agency shall ensure this information is obtained and documented.
• While on-site, the agency discussed ways to incorporate that into their
electronic system in the demographic page.
Information about Children in Care 419-400-0190(1) Summary sheet contains the Yes☐ No✓ Records were reviewed, and this requirement
following: (d) Legal custody was met. There’s no further corrective action
needed at this time.
The agency shall ensure an entry is noted for legal custody.
• While on-site, the agency discussed ways to incorporate that into their electronic
system in the demographic page.
Case Management 419-470-0170(3)(c) Discharge planning evaluations and Yes☐ No✓ Records were reviewed, and this requirement
decisions are documented. was met. There’s no further corrective action
needed at this time.
The agency shall ensure discharge planning evaluations, decisions, etc. are captured
and documented.
Records Relating to Restraint & Involuntary Seclusion 419-400-0180(13)(e) Each Yes☐ No✓ Records were reviewed, and this requirement
child caring agency shall provide notice regarding how to access the quarterly reports was met. There’s no further corrective action
to the parents or guardians of children in care in the program. The child caring agency needed at this time.
shall provide the notice upon the child in care’s admission and at least two times each
year thereafter.
This requirement is not met in its entirety. The agency shall update the notice and
submit for review.
Form Rev. 11/14/2023 P age 4 | 6
Records Relating to Restraint & Involuntary Seclusion 419-400-0190(1) Yes☐ No✓ Records were reviewed, and this requirement
Information provided to children in care relating to Restraint & Involuntary Seclusion was met. There’s no further corrective action
needed at this time.
This requirement is not met in its entirety. The agency shall update the notice and
submit for review.
Financial Records 419-470-0170(4) Records contain date, amount, source, purpose, Yes☐ No✓ Records were reviewed, and this requirement
signatures. was met. There’s no further corrective action
needed at this time.
A small amount of cash was discovered after a child’s admission process, and it was
placed in a baggie labeled with the child’s name and stored in the office.
Corrective Action:
• The agency shall create a financial record log to document any monies belonging to
a child in care. The form must include all elements notes in this rule. Note: Typically,
the program does not allow cash, however a log is required in the event
Comment: The agency has a process for in-program earnings for each child in care
which translates into money on a debit card that’s specific to each child to use on
store outings. The agency provided documentation outlining how the debit card
system works and how it’s tracked.
Comments
While on-site, this licensor and the Program Registered Nurse (RN) who oversees all medication policies, procedures, practices, etc. discussed options regarding
their practice of securely storing unused medications that were being held to return to the guardian. It was decided that this practice will stop, and the stored
medications at the time of this review will be destroyed utilizing the disposal procedures, and the guardians will be notified. Going forward, any unused medications
will be timely destroyed in accordance with disposal procedures.
Action: The RN will update policies and procedures and update all other intake paperwork referring to the practice,
New Findings from Site Visit
None
Form Rev. 11/14/2023 P age 5 | 6
Interview Summary
Two youth were individually interviewed, both ages 13, who had been in the program approximately 22 and 83 days. Both reported that staff are trusting, the
food and chef are good, school is going ok, and they get their medications as prescribed. They feel generally safe, Activities in the program and outings were
described. Due to some other youth’s behaviors, it can be challenging day-to-day to tolerate, but the staff make efforts to separate in groups when possible.
They report having regular contact with approved people outside the program, such as family, and have privacy unless it’s in their plan to be monitored for safety
reasons. When asked to describe “monitoring”, they said a staff person sits on the stairs while youth are in the downstairs living room to monitor but not actively
listening. They report the program does well at keeping a routine and schedule and accommodating each youth’s needs. The program could improve on having
more staff, especially during times when 1-2 other youth are dysregulated. This would provide more ability to separate youth from youth who are dysregulated,
so the other youth aren’t triggered.
Observations
This program has a home-like environment in one building consisting of two dorm-like wings with the dining room in between. An adjacent building houses the
therapists’ offices with along with a milieu space. Youth bedrooms, dorm rooms, bathrooms, living rooms, kitchen, dining room, and the medication room were
observed to be clean, odor-free, and in good condition. A variety of food was observed in appropriate food storage areas. Staff were observed interacting with
youth, as well as other administrative staff, and staff were welcoming. The outside grounds are maintained with areas of green grass, pavement, and gravel
areas for outside activities.
Corrective Actions and Timeframes: Please submit the following to verify compliance.
Within 45 days of receipt of this report Calo Programs Missouri, Inc. 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 are to be emailed directly to Robin DuVal at robin.m.duval@odhsoha.oregon.gov.
Licensing Coordinator’s Signature: ________________________ Date: _8_/1_2_/_2_0_2_4___________
8-12-2024
Manager Review: ______________________________________ Date: __________________
Form Rev. 11/14/2023 P age 6 | 6

program_director: Amber Hailey

other_regulatory_agencies: Joint Commission Accreditation

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 Findings Comments
License Renewal Site Visit 11/06-07/2023 Further Action
Needed
Supplemental Information Provided by CCA Yes[ ] No✓ All policies and procedures were updated
All required policies and procedures as identified in the "Umbrella Rules" pursuant to each OAR. There's no further
corrective action needed at this time.
Upon review of the following policies and procedures, there are minor to moderate
edits needed.
Corrective Action: The agency shall update the following policies and procedures
pursuant to each OAR and submit for review.
- Conflict of interest in OAR 419-400-0070
- Children Rights in OAR 419-400-0090(1)
- Grievance Procedures in OAR 419-400-0090(2)
- Mandatory Abuse Reporting in OAR 400-0110(2)(a)
- Incident reporting in OAR 419-400-0110(2)(b)
- Personnel in OAR 419-400-0120
- Privacy in OAR 419-400-0130
- Suicide Prevention in OAR 419-400-0150(4)
- Discipline and behavior management in OAR 419-400-0150
- Transportation in OAR 419-400-0200(1)
- Searches in OAR 419-400-0200(2)
- Hazards in OAR 419-400-0200(4)
Supplemental Information Provided by CCA Yes[ ] No✓ All policies and procedures were updated
All required policies and procedures as identified in "Agency Type Specific Rules" pursuant to this OAR. There's no further
corrective action needed at this time.
The agency shall update the following policy and procedure pursuant to the OAR and
submit for review.
- Medications in OAR 419-470-0110

Residential Care Safety 419-470-0080(5)(a) Evacuation drill occurs monthly under Yes[ ] No✓ Records were reviewed, and this requirement
varying conditions, is retained 2 years and contains: was met. There's no further corrective action
(A) identify of person conducting drill needed at this time.
(B) date & time
(C) notification method
(D) staff participating
(E) # of children & staff evacuated
(F) special conditions simulated
(G) problems encountered
(H) time to complete
Documentation of evacuation drills were inconsistent.
Corrective Action: The agency shall ensure the evacuation drill log form includes all
required elements noted in (A-H); ensure that evacuation drills occur monthly and are
appropriately documented.
Medication 419-470-0100(7)(a) Prescription medications that are unused and Yes[ ] No✓ Medications were observed, and this finding
medications that are expired or recalled may not be maintained with current has been corrected. There's no further
medication and must be disposed of as described in agency disposal policy. corrective action needed at this time.
Several bubble pack medications were observed to be unsealed, however there were
still pills tucked back in the bubble and/or taped back in. The medication record did
not provide a reasoning for any anomalies. Medications that have been popped out of
their bubble packs and subsequently not administered to a child in care must not be
placed back in the original container.
This concern was brought to the attention of the

interview_summary:
Two youth were individually interviewed, both ages 13, who had been in the program approximately 22 and 83 days. Both reported that staff are trusting, the
food and chef are good, school is going ok, and they get their medications as prescribed. They feel generally safe, Activities in the program and outings were
described. Due to some other youth's behaviors, it can be challenging day-to-day to tolerate, but the staff make efforts to separate in groups when possible.
They report having regular contact with approved people outside the program, such as family, and have privacy unless it's in their plan to be monitored for safety
reasons. When asked to describe "monitoring", they said a staff person sits on the stairs while youth are in the downstairs living room to monitor but not actively
listening. They report the program does well at keeping a routine and schedule and accommodating each youth's needs. The program could improve on having
more staff, especially during times when 1-2 other youth are dysregulated. This would provide more ability to separate youth from youth who are dysregulated,
so the other youth aren't triggered.

observations:
This program has a home-like environment in one building consisting of two dorm-like wings with the dining room in between. An adjacent building houses the
therapists' offices with along with a milieu space. Youth bedrooms, dorm rooms, bathrooms, living rooms, kitchen, dining room, and the medication room were
observed to be clean, odor-free, and in good condition. A variety of food was observed in appropriate food storage areas. Staff were observed interacting with
youth, as well as other administrative staff, and staff were welcoming. The outside grounds are maintained with areas of green grass, pavement, and gravel
areas for outside activities.

previous_findings:
Repeat Findings Comments
License Renewal Site Visit 11/06-07/2023 Further Action
Needed
Supplemental Information Provided by CCA Yes[ ] No✓ All policies and procedures were updated
All required policies and procedures as identified in the "Umbrella Rules" pursuant to each OAR. There's no further
corrective action needed at this time.
Upon review of the following policies and procedures, there are minor to moderate
edits needed.
Corrective Action: The agency shall update the following policies and procedures
pursuant to each OAR and submit for review.
- Conflict of interest in OAR 419-400-0070
- Children Rights in OAR 419-400-0090(1)
- Grievance Procedures in OAR 419-400-0090(2)
- Mandatory Abuse Reporting in OAR 400-0110(2)(a)
- Incident reporting in OAR 419-400-0110(2)(b)
- Personnel in OAR 419-400-0120
- Privacy in OAR 419-400-0130
- Suicide Prevention in OAR 419-400-0150(4)
- Discipline and behavior management in OAR 419-400-0150
- Transportation in OAR 419-400-0200(1)
- Searches in OAR 419-400-0200(2)
- Hazards in OAR 419-400-0200(4)
Supplemental Information Provided by CCA Yes[ ] No✓ All policies and procedures were updated
All required policies and procedures as identified in "Agency Type Specific Rules" pursuant to this OAR. There's no further
corrective action needed at this time.
The agency shall update the following policy and procedure pursuant to the OAR and
submit for review.
- Medications in OAR 419-470-0110

Residential Care Safety 419-470-0080(5)(a) Evacuation drill occurs monthly under Yes[ ] No✓ Records were reviewed, and this requirement
varying conditions, is retained 2 years and contains: was met. There's no further corrective action
(A) identify of person conducting drill needed at this time.
(B) date & time
(C) notification method
(D) staff participating
(E) # of children & staff evacuated
(F) special conditions simulated
(G) problems encountered
(H) time to complete
Documentation of evacuation drills were inconsistent.
Corrective Action: The agency shall ensure the evacuation drill log form includes all
required elements noted in (A-H); ensure that evacuation drills occur monthly and are
appropriately documented.
Medication 419-470-0100(7)(a) Prescription medications that are unused and Yes[ ] No✓ Medications were observed, and this finding
medications that are expired or recalled may not be maintained with current has been corrected. There's no further
medication and must be disposed of as described in agency disposal policy. corrective action needed at this time.
Several bubble pack medications were observed to be unsealed, however there were
still pills tucked back in the bubble and/or taped back in. The medication record did
not provide a reasoning for any anomalies. Medications that have been popped out of
their bubble packs and subsequently not administered to a child in care must not be
placed back in the original container.
This concern was brought to the attention of the Executive Director and the Nurse and
immediately began investigating.
Corrective Action:
- The agency shall ensure staff are retrained and following procedures to dispose of
medications when a medication is refused, missed or any other type of medication
error that results in a medication not being administered as prescribed and to follow
the agency's disposal policy.
- The agency shall ensure management oversight occurs regularly to ensure proper
procedures are followed.

Medication 419-470-0100(10) Written record of the administration of medication Yes✓ No Blanks were observed on the Medication
includes: Administration Records (MAR) with no
(a) name corresponding notation. During the review,
(b) description this was discussed with the program RN and
(c) dates and times they will increase their weekly audit to 3-4
(d) missed doses times weekly.
(e) medication disposed
(f) method of administration Corrective action: The agency shall ensure
(g) ID of person administering medication errors, or anomalies in
(h) possible adverse reactions documentation, are documented by adding a
(i) medication taken outside facility notation to the MAR.
Medications that were not administered, refused, missed or any other type of This is a repeat violation.
medication error must be documented. Refer to (7)(c) above.
Corrective Action:
- The agency shall ensure medication errors, or anomalies in documentation, are
documented by adding a notation to the medication administration record.
- The agency shall ensure staff are retrained and following procedures for proper
documentation.
- The agency shall ensure management oversight occurs regularly to ensure proper
procedures are followed.
New Employee Orientation - Umbrella Requirements (30 days) 419-400-0120(4) Yes[ ] No✓ Records were reviewed, and this requirement
(c) Suicide prevention and intervention was met. There's no further corrective action
needed at this time.
The agency shall ensure that all new employees (under Calo Programs Missouri Inc.)
complete this training within 30 days of hire, regardless of their prior employment.
New Employee Orientation - Residential 419-470-0120(1)(e) Training on the Yes[ ] No✓ Records were reviewed, and this requirement
agency's policy on suicide prevention and suicide risk assessment tool. (Prior to was met. There's no further corrective action
working alone and within 30 days) needed at this time.
The agency shall ensure that all new employees (under Calo Programs Missouri Inc.)
complete this training within 30 days of hire, regardless of their prior employment.
Consents 419-470-0160(1)(f) Impose a dress code Yes[ ] No✓ Records were reviewed, and this requirement
was met. There's no further corrective action
The agency shall ensure consent to impose a dress code is obtained from the child in needed at this time.
care's parent/guardian and properly documented.
Disclosures 419-470-0160(2) Parent/guardian has acknowledged in writing: Yes[ ] No✓ Records were reviewed, and this requirement
(b) Statement of Rights of Children and Parents/Guardians was met. There's no further corrective action
needed at this time.
The agency shall ensure this disclosure is provided and properly documented
indicating that the parent/guardian has acknowledged.

Disclosures 419-470-0160(2) Parent/guardian has acknowledged in writing: Yes[ ] No✓ Records were reviewed, and this requirement
(c) Any policies and procedures upon request was met. There's no further corrective action
needed at this time.
The agency shall ensure this disclosure is provided and properly documented
indicating that the parent/guardian has acknowledged.
Information about Children in Care 419-400-0190(1) Summary sheet contains the Yes[ ] No✓ Records were reviewed, and this requirement
following: (a)The name, gender, date of birth, religious preference, and previous was met. There's no further corrective action
address. needed at this time.
The agency shall ensure an entry is noted for religious preference.
While on-site, the agency discussed ways to incorporate that into their electronic
system in the demographic page.
Information about Children in Care 419-400-0190(1) Summary sheet contains the Yes[ ] No✓ Records were reviewed, and this requirement
following: (b) Name and location of previous and current school was met. There's no further corrective action
needed at this time.
- The agency shall ensure this information is obtained and documented.
- While on-site, the agency discussed ways to incorporate that into their
electronic system in the demographic page.
Information about Children in Care 419-400-0190(1) Summary sheet contains the Yes[ ] No✓ Records were reviewed, and this requirement
following: (d) Legal custody was met. There's no further corrective action
needed at this time.
The agency shall ensure an entry is noted for legal custody.
- While on-site, the agency discussed ways to incorporate that into their electronic
system in the demographic page.
Case Management 419-470-0170(3)(c) Discharge planning evaluations and Yes[ ] No✓ Records were reviewed, and this requirement
decisions are documented. was met. There's no further corrective action
needed at this time.
The agency shall ensure discharge planning evaluations, decisions, etc. are captured
and documented.
Records Relating to Restraint & Involuntary Seclusion 419-400-0180(13)(e) Each Yes[ ] No✓ Records were reviewed, and this requirement
child caring agency shall provide notice regarding how to access the quarterly reports was met. There's no further corrective action
to the parents or guardians of children in care in the program. The child caring agency needed at this time.
shall provide the notice upon the child in care's admission and at least two times each
year thereafter.
This requirement is not met in its entirety. The agency shall update the notice and
submit for review.

Records Relating to Restraint & Involuntary Seclusion 419-400-0190(1) Yes[ ] No✓ Records were reviewed, and this requirement
Information provided to children in care relating to Restraint & Involuntary Seclusion was met. There's no further corrective action
needed at this time.
This requirement is not met in its entirety. The agency shall update the notice and
submit for review.
Financial Records 419-470-0170(4) Records contain date, amount, source, purpose, Yes[ ] No✓ Records were reviewed, and this requirement
signatures. was met. There's no further corrective action
needed at this time.
A small amount of cash was discovered after a child's admission process, and it was
placed in a baggie labeled with the child's name and stored in the office.
Corrective Action:
- The agency shall create a financial record log to document any monies belonging to
a child in care. The form must include all elements notes in this rule. Note: Typically,
the program does not allow cash, however a log is required in the event
Comment: The agency has a process for in-program earnings for each child in care
which translates into money on a debit card that's specific to each child to use on
store outings. The agency provided documentation outlining how the debit card
system works and how it's tracked.
Comments
While on-site, this licensor and the Program Registered Nurse (RN) who oversees all medication policies, procedures, practices, etc. discussed options regarding
their practice of securely storing unused medications that were being held to return to the guardian. It was decided that this practice will stop, and the stored
medications at the time of this review will be destroyed utilizing the disposal procedures, and the guardians will be notified. Going forward, any unused medications
will be timely destroyed in accordance with disposal procedures.
Action: The RN will update policies and procedures and update all other intake paperwork referring to the practice,
New Findings from Site Visit
None

excerpt:
419-400-0070
- Children Rights in OAR

excerpt:
419-400-0150
- Transportation in OAR

excerpt:
419-470-0110
Residential Care Safety