summary: License Renewals - 66 findings

raw_content:
Licensed Child Caring Agency Site Visit Report
Residential Care - License Renewal
Licensee: Northwest Youth Discovery, Inc Date of site visit: March 12, 2025
Executive Director: Richard Streeter Licensing Coordinator: Todd Cooley
Board Chairperson: Jennifer Weeks
Other Regulatory or Accrediting Agencies: Oregon Youth Authority (OYA)
Program compliance: The program was found to be compliant or will be compliant with OAR 419-400-0005 to 419-400-0310,
Licensing Umbrella Rules, and OAR 419-470-0010 to 419-470-0180, Licensing Residential Care Agencies Rules. Personnel records
were reviewed and compliance with required background checks was documented for employees in all programs.
Program description(s): The following content provided by NW Youth Discovery: Located in Bend Oregon, Northwest Youth
Discovery (NWYD) serves adolescent females ages 12 to 21 within a therapeutic milieu supported by professionally trained staff. Most
of our clients have experienced some form of trauma in their lives which has contributed to school failure, drug and alcohol abuse,
emotional dysregulation, poor self-esteem, and the development of maladaptive coping strategies. NWYD serves youth who have not
met success within a less restrictive level of care and demonstrate a need for 24-hour supervision.
NWYD provides Behavior Rehabilitation Services (BRS) by utilizing evidence-based approaches to target those psychosocial,
emotional, and behavioral issues that have impeded our clients from achieving their full potential. Our high staff-to-youth ratio enables
us to meet success at providing physical, emotional, and psychological support while remediating our risk factors. NWYD’s services
include but are not limited to case management, treatment planning, goal development, aftercare services, individual and group
counseling, psychoeducation, therapeutic work experience, crisis support, therapeutic recreation, educational support, culinary
experience, cultural/spiritual involvement, milieu therapy, and independent living skills. NWYD employ interventions and strategies from
evidence-based models such as Dialectical Behavior Therapy and Therapeutic Crisis Intervention.
Program type and services: Residential with BRS
Capacity and age range: 10 clients ages 12-20
Form revised 3/12/2025 Page 1 of 26
Funding sources: OYA
Contracts and sources for referrals: OYA
Average length of stay: 180 days
Average daily population served: 8-9
Number of children served annually: 24
Use of seclusion or restraint: No seclusion or restraint.
Interviews/observations: During the onsite license renewal two youth were interviewed and all areas of the residence were observed.
Both youth interviewed had only been at the program for a short while, but one had been there previously. The following information
was obtained during the interviews:
- Program is safe, and youth had several staff they were comfortable bringing any concerns or issues to.
- Residents receive plenty of food and snacks. They have input into the menu, and one day a week they can request a preferred meal.
- Resident have lots of recreation opportunities in residence and out in the community. Provided examples of volleyball, Just Dance
(video game), walks, workouts. Summer provides additional outdoor activity opportunities.
- Stated during winter it is hard to get “outside” time. By the time they finish school and dinner it is already starting to get dark outside.
- Youth felt phone calls were minimally adequate and are provided 10 minutes 3 times a week minimum. The time limit is imposed in
order to give all youth opportunities to use the phone. Between school, recreation, chores, homework, etc., there is a small window in
which 10 clients use the phone. Youth said the calls are enough, but would prefer 15 minutes if given the opportunity. They did state
they can petition for additional calls and additional time on a case-by-case basis.
- Youth attend the local public school and said things were going well.
- Youth participate in both community and BRS groups, which they found repetitive but beneficial.
- Program is very structured, and they have found that helpful in staying on track.
- Youth stated some staff lack sympathy for their situation, and clarified this was only one or two staff (not named).
- Staff are really good at checking-in with youth and helping them achieve their goals.
Form revised 3/12/2025 Page 2 of 26
- Staff are consistent with the rules and keeping to the schedule.
- Staff are good at communicating and very understanding.
A walkthrough of the property and residence was conducted. Overall, the program is in good condition, and the program has00 been
making incremental improvements over time. There was new flooring in the bedrooms and alterations to the stairwell for safety. Youth
had hygiene products, bedding and other essential items. The pantry, fridge and multiple freezers contained adequate food and
snacks. Vehicles show some signs of age but are in safe operating condition.
Program strengths (per program): Northwest administrative staff qualifications far exceed contractual requirements and include an
executive director, clinical director, program director, and director of operations. We provide approximately two additional FTE in direct
care staff to maintain a 3:10 staff to client ratio between the hours of 3pm and 11pm, which is not required per contract. Northwest also
has an outpatient mental health clinic which can provide residential clients with an additional layer of mental health support if
necessary. Northwest continues to provide internship
opportunities for master’s level student seeking degrees in mental health counseling and/or social work. In addition to regular updates
to the physical plant, Northwest has incorporated a horticulture skills learning program which includes a greenhouse, orchard, and a
garden supervised by a bachelor’s level botanist.
Program challenges (per program): Northwest continues to experience some micromanagement from state officially to include being
required to complete tasks that would be more appropriate for state officials rather than program staff. In addition, Northwest has lost
approximately $32,235 in revenue since June 2024 due to a lack of prompt BRS authorization.
Changes that have occurred in the last two years (per program): Staff turnover has decreased after Northwest was able to
increase starting wages due to an increase in daily rates. Northwest has implemented a horticulture skills learning program by adding a
greenhouse, orchard/garden, and hired a botanist.
Lawsuits: None
Grievances and complaints filed in the last two years: None
Form revised 3/12/2025 Page 3 of 26
Corrective actions and timeframes: Please submit the following to verify compliance.
Within 45 days of receipt of this report Northwest Youth Discovery must submit a letter of verification indicating the agency is in
compliance with the specific rules cited above and describing how compliance will be maintained going forward. Along with the letter of
verification, the agency must submit any and all specific documentation requested in the body of this report. The letter of verification
and any additional requested documents can be emailed directly to Todd Cooley at Todd.Cooley@odhsoha.oregon.gov.
Recommendations: N/A
Exceptions: None
Changes in license: None
Summary of review
Program and services Yes/No or Corrective actions/comments
419-400-0020 (2) N/A
Program and services are in scope of license Yes
Governance of the agency Yes/No or Corrective actions/comments
419-400-0040 N/A
(1)(a) Minimum of 5 board members Yes
(2)(f) Formally evaluate the Executive Director’s
Yes
performance annually
(2)(g) Approves annual budget Yes
Form revised 3/12/2025 Page 4 of 26
Governance of the agency Yes/No or Corrective actions/comments
419-400-0040 N/A
(2)(h) Obtain and review an annual independent The financial audit is in progress and will be made available
financial review or audit of financial records. No to licensing upon completion (projected to be completed by
end of April 2025)
(2)(k) Written quality improvement program Yes
(2)(l) Meeting minutes Yes
Executive Director or Program Director Yes/No or Corrective actions/comments
419-400-0040 N/A
(3)(a) knowledge of requirements for providing
Yes
care and treatment appropriate to programs
(3)(g) Approval from BCU Yes
Installation and use of video equipment used Yes/No or Corrective actions/comments
to monitor or record children in care N/A
419-400-0145
(1) If a child-caring agency installs video
equipment to monitor or record a child in care, all
employees, volunteers, parents or guardians and Yes
children in care must be informed about the
intended use and locations of the equipment.
Discipline, behavior management and suicide Yes/No or Corrective actions/comments
prevention N/A
419-400-0150
(3) Agency uses appropriate and positive methods
of behavior management and nationally Yes
recognized non-violent crisis intervention
Form revised 3/12/2025 Page 5 of 26
Discipline, behavior management and suicide Yes/No or Corrective actions/comments
prevention N/A
419-400-0150
(3)(b)(C) Agency does not use chemical and
mechanical restraint (excluding medically Yes
necessary devices/prescriptions)
(3)(c) Agency uses appropriate time-out rooms
(adequate space, heat, light and ventilation and is
N/A Time-out rooms are not utilized at NWYD
not capable of locking) and documents use in
child’s record when applicable
(3)(e) Agency uses seclusion
N/A NWYD does not use restraint or seclusion.
appropriately/consistent with policy
(4) Agency has adequate plan in place to respond
Yes
to suicidal behavior/warning signs
Contractors (if applicable) Yes/No or Corrective actions/comments
419-400-0120(6) N/A
(a) Agency ensures the contractor meets the
requirements of this rule and Chapter 413 division N/A NWYD does not use any contractors.
215
(b)(B) Contract includes the following:
(i) Services provided
(ii) Contractor fees
(iii) Disclosure of information from contractor to
agency
(iv) Lines of authority N/A NWYD does not use any contractors.
(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
Form revised 3/12/2025 Page 6 of 26
Restraints and Involuntary Seclusion Yes/No or Corrective actions/comments
419-400-0180 N/A
(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 Yes
child caring agency’s main office and on the child
caring agency’s website if applicable.
Supplemental information provided by CCA Yes/No or Corrective actions/comments
N/A
Documents as indicated on the form titled
Yes
“Renewal Licensing Required Documents”
Documents as indicated on form titled “Required
No Financial audit in progress.
Financial Documents and Information”
All required policies and procedures as identified
Yes
in the “Umbrella Rules”
All required policies and procedures as identified
Yes
in “Agency Type Specific Rules”
Physical plant Yes/No or Corrective actions/comments
N/A
419-400-0090(3)(a) Foster Rights Posted (if
N/A Only OYA clients.
children in ODHS custody)
419-400-0100(1) Sufficient safe space, equipment
Yes
and office equipment
419-400-0230(12) License is posted in common
Yes
area at each facility
419-470-0020(2)(a) and (c) Buildings are smoke
Yes
free, clean and in good repair
419-470-0020 (2)(d) Rooms are free of harmful
Yes
drafts, odors and excessive noise
Form revised 3/12/2025 Page 7 of 26
Physical plant Yes/No or Corrective actions/comments
N/A
419-470-0020 (2)(e) Rooms are adequate in size
Yes
and arrangement
419-470-0020 (2)(f) System provides a continuous
supply of hot and cold water to taps located Yes
throughout the facility
419-470-0020 (2)(h) Building is well ventilated and
room temperature is within a normal comfort Yes
range
419-470-0030 (1) All parts of the facility ensure
Yes
the safety of children
Room and space requirements Yes/No or Corrective actions/comments
419-470-0030 N/A
(2) There is a separate living room or lounge area
Yes
– 15 SF minimum per child
(5) There is a separate dining room with capacity
for ½ of children in care and 15 SF per child in Yes
care
(7) Laundry is separate from living, kitchen and
Yes
dining areas
(8) Separate storage areas are provided for food,
kitchen supplies, utensils, clean linens, soiled
linens and clothing, cleaning supplies and
equipment, poisons, chemicals, outdoor Yes
recreational and maintenance equipment.
(Hazardous materials are properly labeled, in
original container and locked)
(9) Outdoor activity area is protected from Yes
vehicles and other hazards and of a size and
Form revised 3/12/2025 Page 8 of 26
Room and space requirements Yes/No or Corrective actions/comments
419-470-0030 N/A
availability appropriate to the age and needs of
children in care
(11) Time-out rooms: Rooms used for time out or
quiet time must have adequate space, heat, light
N/A Time-out rooms are not used at NWYD
and ventilation and must not be capable of
locking.
Room and space requirements -bedrooms Yes/No or Corrective actions/comments
419-470-0030(3) N/A
(a) Adequate furnishings and personal items Yes
(b) Separate from rooms used for dining, living,
Yes
laundry, kitchen and storage
(c) Meet Oregon Fire Code Requirements Yes
(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 Yes
approve the modification and indicate this room
still meets applicable Oregon Fire Code.
(d) Ceiling at least 90 inches Yes
(e) Minimum 60 SF per occupant Yes
(f) No more than 25 if dorm style N/A Not dorm style rooms.
(g) Permanently wired fixtures Yes
(h) Window covering Yes
Room and space requirements - bathrooms Yes/No or Corrective actions/comments
419-470-0030(4) N/A
(a)(A) and (B) 1:8 ratio for toilets and sinks Yes
(a)(D) Hot and cold running water, soap and
Yes
approved hand drying options
Form revised 3/12/2025 Page 9 of 26
Room and space requirements - bathrooms Yes/No or Corrective actions/comments
419-470-0030(4) N/A
(a)(E) 1:10 ratio for shower or bathtub Yes
(a)(E) Individual privacy Yes
(a)(F) Window covering Yes
(a)(G) Permanently wired fixtures Yes
(a)(H) Adequate ventilation Yes
(b) and (c) Wooden racks on floors are prohibited
and impervious shower mats are disinfected and N/A Wooden racks are not used in bathrooms.
dried daily be in good condition and free of mold
Room and space requirements - Yes/No or Corrective actions/comments
kitchen N/A
419-470-0030(6)
(a) Used exclusively for storage, food preparation,
dishwashing and activities related to eating and Yes
food preparation activities
(b) Walls, floors are easily cleanable Yes
(c) Equipment and utensils are easily cleanable,
Yes
durable, nontoxic and kept clean
(e) Equipment is easy to clean beneath, between
Yes
and behind
Furnishings and personal items Yes/No or Corrective actions/comments
419-470-0040 N/A
(1) There is a bed with frame Yes
(1)(b) clean mattress in good condition, with a
Yes
minimum thickness of five inches
(1)(c) a pillow in good condition Yes
Form revised 3/12/2025 Page 10 of 26
Furnishings and personal items Yes/No or Corrective actions/comments
419-470-0040 N/A
(1)(d) a private dresser, closet, or similar storage
area for personal belongings that is readily Yes
accessible
(2) Linens are in good repair. There is a
waterproof mattress cover or mattress. Linens are
Yes
appropriate and towels and washcloths are
provided
(3) Bedding is changed weekly or when soiled Yes
(4) and (5) Personal hygiene supplies and
Yes
appropriate clothing are provided
Food services Yes/No or Corrective actions/comments
419-470-0070 N/A
(1)(a) Meals are arranged daily, consistent with
normal mealtimes that occur during the hours of Yes
operation and provide snacks between mealtimes
(1)(b) Menus are prepared in advance in
accordance with USDA guidelines, provide a
Yes
variety of foods and are adjusted for seasonal
changes including snacks
(1)(b) Menus are kept for at least 6 months Yes
(1)(c) Drinking water is freely available Yes
(2)(a) Food is stored, prepared and served in a
Yes
sanitary manner
(2)(c) and (d) Food products are obtained from
commercial suppliers (exception of fruits and
vegetables), unpasteurized juice is prohibited, and Yes
only Grade A pasteurized and fortified milk in
appropriate container.
Form revised 3/12/2025 Page 11 of 26
Residential care safety Yes/No or Corrective actions/comments
419-470-0080 N/A
(2) Written emergency plan that includes Yes
(a) Identifying the types of emergencies most
likely to happen where the residential care agency Yes
is located
(b) Identifying a place to meet for each type of
Yes
emergency identified
(c) Identifying an alternate shelter if necessary Yes
(d) Ensuring access to necessary medications or
Yes
medical equipment
(e) How to help each child in care recover after a
Yes
disaster
(3) Telephone numbers for local police, fire
department, poison control, after hours medical
Yes
advice and other appropriate emergency numbers
must be posted near all telephones.
(4) Operative flashlights sufficient in number are
Yes
readily available to staff
(5)(a) Evacuation drill occurs monthly under
varying conditions, is retained 2 years and
contains:
(A) identify of person conducting drill
(B) date and time
(C) notification method Yes
(D) staff participating
(E) number of children and staff evacuated
(F) special conditions simulated
(G) problems encountered
(H) time to complete
Form revised 3/12/2025 Page 12 of 26
Umbrella safety Yes/No or Corrective actions/comments
419-400-0200 N/A
(5)(b) Vehicle has insurance policy, is smoke free,
safe operating condition, and has first aid kit and Yes
fire extinguisher 2-A:10-BC
(1)(b)(A) Each vehicle used to transport a child in
care must be: properly registered,
covered by an insurance policy in full force and Yes
effect, maintained in safe operating condition and
smoke-free.
(3) If a child-caring agency has a swimming pool
on the premises that is accessible to children in
care or if a child-caring agency plans to have
children in care engage in swimming, the child-
caring agency must have and adhere to policies N/A There is no onsite swimming pool.
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
Yes
potentially harmful items and materials.
(4)(b) Direct supervision of children who do not
have the ability to adjust and control water Yes
temperature
(4)(c) Light fixtures have protective covers unless
Yes
designed to be used without one
Medication Yes/No or Corrective actions/comments
419-470-0100 N/A
(3) and (7)(e) Medications have a prescription and
are stored in the original container with Yes
prescription label
Form revised 3/12/2025 Page 13 of 26
Medication Yes/No or Corrective actions/comments
419-470-0100 N/A
(4) and (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
Yes
medical professional. A written order, signed by a
physician or qualified medical professional, is also
required before a restriction on diet or physical
activity is imposed.
(7)(c) Medications are inaccessible to children and
stored behind at least two locking mechanisms. Yes
This does not apply to Naloxone.
(8) Medications are disposed in accordance with
Yes
state and federal law
(9) Written record of the disposal of medications is
maintained and includes:
(a) description and amount
(b) name No Medication disposal log did not contain a witness signature.
(c) reason
(d) method
(e) staff and witness signature
(10) Written record of the administration of
medication includes:
(a) name
(b) description
(c) dates and times
(d) missed doses Yes
(e) medication disposed
(f) method of administration
(g) ID of person administering
(h) possible adverse reactions
(i) medication taken outside facility
Form revised 3/12/2025 Page 14 of 26
Extracurricular, enrichment, cultural and Yes/No or Corrective actions/comments
social activities N/A
419-470-0110
(2) Children have ongoing opportunities to
Yes
participate in at least one age-appropriate or
developmentally appropriate activity
Minimum staffing requirements Yes/No or Corrective actions/comments
419-470-0130 N/A
(1) and (2) Supervision is adequate for the type of
program, location, age and type of children, ability
of supervisor to respond, electronic back-up
systems.
Minimum ratios are maintained:
Yes
Under 30 months of age: 1:4
30 months to ˃ 6 years or non-ambulatory: 1:6
Ages 6 and older: 1:7
Overnight (staff awake)
1:10
(4)(a) When one staff on duty, there is additional
staff immediately available with max response Yes
time of 30 minutes
(5) There is at least one on-site employee
authorized to apply the reasonable and prudent Yes
parent standard
Sleeping arrangements Yes/No or Corrective actions/comments
419-470-0140 N/A
Form revised 3/12/2025 Page 15 of 26
(1) Children are in separate bedrooms than
adults, unless parent and child, or there is written
Yes
approval from guardian/parent and licensing
coordinator
(2) There is adequate supervision of children
Yes
when sleeping
(3) When assigning bedrooms a residential care
agency must consider all of the following:
(a) Chronological age
(b) Developmental age
(c) Gender identity Yes
(d) Personal history, including medical, mental
health, behavioral health and past adverse
experiences including any physical or sexual
abuse
Personnel files Yes/No or Corrective actions/comments
419-400-0120 N/A
Staff name/position Yes
(3)(g) Date of hire Yes
(3)(a) record of education, training and previous
Yes
employment
(1)(b) and (3)(b) reference checks completed and
Yes
documented
(1)(a) and (3)(c) Background check completed
Yes
and documented
(3)(d) Annual performance evaluations Yes
(3)(f) Record of personnel actions Yes
(3)(g) Termination date, reason for termination Yes
(3)(h) Current job description (1)(c) Employee
meets minimum qualifications stated in current job Yes
description
Form revised 3/12/2025 Page 16 of 26
New employee orientation – Umbrella Yes/No or Corrective actions/comments
Requirements (30 days) N/A
419-400-0120(4)
(a) Agency policies and procedures Yes
(b) Ethical and professional guidelines Yes
(c) Suicide prevention and intervention Yes
(d) Attributes of population served Yes
(e) and (5)(a) to (c) Mandatory reporting that
includes:
(a) legal definition of child abuse in ORS 418.257
and 419B.005 Yes
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to the
employee
(f) Privacy laws Yes
(g) Emergency procedures Yes
New employee orientation Yes/No or Corrective actions/comments
residential (prior to working alone and within N/A
30 days)
419-470-0120(1)
(a) Discipline and behavior management including
de-escalation, crisis prevention, positive behavior
Yes
management and disciplinary techniques that are
non-punitive in nature
(b) CPR and First Aid sufficient to retain a current
Yes
certification
(c) Universal precautions and hygiene Yes
(d) Application of the reasonable and prudent
Yes
parent standard
Form revised 3/12/2025 Page 17 of 26
New employee orientation Yes/No or Corrective actions/comments
residential (prior to working alone and within N/A
30 days)
419-470-0120(1)
(e) Training on the agency’s policy on suicide
Yes
prevention and suicide risk assessment tool
Crisis intervention training standards and Yes/No or Corrective actions/comments
certification N/A
419-400-0160(4) (as applicable)
(a)Complete a minimum of 12 hours of initial
training in person from a certified instructor,
including but not limited to a minimum of six hours
of training focused on positive behavior support, N/A NWYD does not utilize restraint so does not apply
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 N/A NWYD does not utilize restraint so does not apply
(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.
Form revised 3/12/2025 Page 18 of 26
Crisis intervention training standards and Yes/No or Corrective actions/comments
certification N/A
419-400-0160(4) (as applicable)
(e) A certification issued:
(A) Must be personal to the individual certified by
the training provider N/A NWYD does not utilize restraint so does not apply
(B) May be valid for no more than two years with
recertification
Ongoing training Yes/No or Corrective actions/comments
N/A
419-470-0070(2)(b) Employees who handle food
served to children have a valid food handler’s Yes
card
419-400-0200 (1) Employees transporting
children have: current driver’s license, insurance,
trained in emergency procedures and behavior Yes
management and training for 15+ passenger vans
if applicable)
419-470-0120 (2)(a) Environmental emergencies Yes
419-470-0120 (2)(b) Universal precautions Yes
419-470-0120 (2)(c) Discipline and behavior
Yes
management
419-470-0120 (2)(d) Agency’s policy on suicide
Yes
prevention and risk assessment tool
419-470-0120 (3) Staff providing direct care must
Yes
maintain current CPR/First Aid certification
419-470-0120 (4) Designated staff authorized to
apply reasonable and prudent parent standard Yes
are trained in application of the standard
Form revised 3/12/2025 Page 19 of 26
Ongoing training Yes/No or Corrective actions/comments
N/A
419-400-0120(5) Mandatory reporting (annually)
that includes:
(a) legal definition of child abuse in ORS 418.257
and 419B.005 Yes
(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 intervention training) from Yes
a certified instructor on an annual basis
Comments:
Children’s records Yes/No or Corrective actions/comments
health services N/A
419-470-0090
(2) Medical history obtained within 30 days
(significant findings, current immunizations,
history of surgical procedures-health issues- Yes
injuries, allergies, dental, vision, hearing,
behavioral health and physician orders)
(4)(a) to (f) Medical exams (3 in first year of life,
2,4,6,9,14) Yes
(g) Have a physical examination within the first 60
days after admission of a child in care. Yes
Documentation of a physical examination having
Form revised 3/12/2025 Page 20 of 26
Children’s records Yes/No or Corrective actions/comments
health services N/A
419-470-0090
occurred within the calendar year will meet this
requirement.
Consents Yes/No or Corrective actions/comments
419-470-0160(1) N/A
(a) Provide routine and emergency medical care Yes
(b) Use the discipline and behavior management
Yes
system
(c) Use restraint or seclusion (if applicable). Must
specify the reasons for the intervention and how Yes
staff are trained and supervised
(d) Restrict contact with persons outside of the
Yes
agency
(e) Allow access as defined in 419-400-0230 and Not addressed in the program’s consents.
0240
No
Correction Action: Add language to address allowing
access.
(f) Impose a dress code Not addressed in the program’s consents.
No
Correction Action: Add language to address imposing a
dress code.
(g) Apply the reasonable and prudent parent
Yes
standard
Form revised 3/12/2025 Page 21 of 26
Disclosures Yes/No or Corrective actions/comments
419-470-0160(2) N/A
Parent/guardian has acknowledged in writing:
(a) Information regarding personal or room
searches and protocols for confiscation of Yes
contraband
(b) Statement of Rights of Children and
Yes
Parents/Guardians
(c) Any policies and procedures upon request Yes
Authorizations Yes/No or Corrective actions/comments
419-470-0160(3) N/A
(a) Disclose or exchange information with others Yes
(b) Child specific visitors Yes
(c) Visitation resources are pre-approved Yes
(d) Activity specific authorizations are pre-
approved to allow children to participate in
potentially hazardous activities, including but not Yes
limited to using motorized yard equipment,
swimming and horseback riding.
Information about children in care Yes/No or Corrective actions/comments
419-400-0190(1) N/A
Summary sheet contains the following:
(a)The name, gender, date of birth, religious
Yes
preference and previous address
(b) Name and location of previous and current
Yes
school
(c) Date of admission Yes
(d) Legal custody Yes
(e) The name, address and telephone number of: Yes
Form revised 3/12/2025 Page 22 of 26
Information about children in care Yes/No or Corrective actions/comments
419-400-0190(1) N/A
Summary sheet contains the following:
(A) The child in care's parents.
(B) The child in care's legal guardian, if
different than the parents and a copy of the
document that provides for his or her authority
over the child in care.
(C) Other persons significant to child
(D) Other professionals to be involved in service
planning (if applicable)
Service planning Yes/No or Corrective actions/comments
419-470-0170(2) N/A
(b) Intake document is completed the date child
accepted into care (emergency placement 48 Yes
hours)
(d) Assessment is completed within 30 days and
contains relevant historical information, current
Yes
behavioral observations, identified need for
services and how agency will provide services
(e) (A) and (B) Service plan within 60 days
(parent, guardian and child actively involved).
Describes how child’s issues will be addressed, Yes
anticipated outcomes and reviewed by child and
guardian/parent.
(e)(C) and (D) Service plan is reviewed quarterly
and revised when information indicates other Yes
services should be provided
Form revised 3/12/2025 Page 23 of 26
Case management Yes/No or Corrective actions/comments
419-470-0170(3) N/A
(a) Services are documented, progress toward
Yes
achieving goals is tracked
(c) Discharge summary must include:
(A)Current medications
(B)Name of the physician or qualified medical
professional who prescribed each medication
(C)Any outstanding medical or other
appointments Yes
(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 Yes
(f) Incident reports Yes
Records relating to Restraint and Involuntary Yes/No or Corrective actions/comments
Seclusion N/A
419-400-0180 (12) Records N/A NWYD does not utilize restraint or seclusion.
419-400-0180(13)(e) Each child caring agency
shall provide notice regarding how to access the
quarterly reports to the parents or guardians of
children in care in the program. The child caring Yes
agency shall provide the notice upon the child in
care’s admission and at least two times each year
thereafter.
419-400-0190(1) Information provided to children
Serves OYA youth. OYA responsible for providing this
in care relating to Restraint and Involuntary N/A
information.
Seclusion
Form revised 3/12/2025 Page 24 of 26
Financial records Yes/No or Corrective actions/comments
419-470-0170(4) N/A
Records contain date, amount, source, purpose,
Yes
signatures
Personal possessions records Yes/No or Corrective actions/comments
419-470-0170 (5) N/A
Individual written inventory of all personal
possessions is maintained and updated as Yes
needed
Records and documentation Yes/No or Corrective actions/comments
419-400-0140 N/A
(1) Stored safely Yes
(2) Permanent, legible, dated and signed Yes
(3) and (4) Uniform in organization, readily
identifiable and accessible, current and complete,
Yes
containing all required info. No eraser tape or
white out.
(7) Permanent registry for each child includes:
Name
Gender
Birth date Yes
Names, addresses of parents or guardians
Dates of admission
Placement upon discharge
Comments:
Form revised 3/12/2025 Page 25 of 26
Licensing Coordinator’s Signature: ________________________ Date: _4_-1_7_-_2_0_2_5__________
Manager Review: _____________________________________ Date: _4_-1_6_-_2_02_5___________
Form revised 3/12/2025 Page 26 of 26

report_title: Licensed Child Caring Agency Site Visit Report

facility_type: Residential Care - License Renewal

licensee: Northwest Youth Discovery, Inc

program_description:
The following content provided by NW Youth Discovery: Located in Bend Oregon, Northwest Youth
Discovery (NWYD) serves adolescent females ages 12 to 21 within a therapeutic milieu supported by professionally trained staff. Most
of our clients have experienced some form of trauma in their lives which has contributed to school failure, drug and alcohol abuse,
emotional dysregulation, poor self-esteem, and the development of maladaptive coping strategies. NWYD serves youth who have not
met success within a less restrictive level of care and demonstrate a need for 24-hour supervision.
NWYD provides Behavior Rehabilitation Services (BRS) by utilizing evidence-based approaches to target those psychosocial,
emotional, and behavioral issues that have impeded our clients from achieving their full potential. Our high staff-to-youth ratio enables
us to meet success at providing physical, emotional, and psychological support while remediating our risk factors. NWYD's services
include but are not limited to case management, treatment planning, goal development, aftercare services, individual and group
counseling, psychoeducation, therapeutic work experience, crisis support, therapeutic recreation, educational support, culinary
experience, cultural/spiritual involvement, milieu therapy, and independent living skills. NWYD employ interventions and strategies from
evidence-based models such as Dialectical Behavior Therapy and Therapeutic Crisis Intervention.

program_services: Residential with BRS

capacity_age_range: 10 clients ages 12-20 Form revised 3/12/2025 Page 1 of 26

funding_sources: OYA

contracts_and_referrals: OYA

average_length_of_stay: 180 days

use_of_seclusion_or_restraint: No seclusion or restraint. Interviews/observations: During the onsite license renewal two youth were interviewed and all areas of the residence were observed. Both youth interviewed had only been at the program for a short while, but one had been there previously. The following information was obtained during the interviews: - Program is safe, and youth had several staff they were comfortable bringing any concerns or issues to. - Residents receive plenty of food and snacks. They have input into the menu, and one day a week they can request a preferred meal. - Resident have lots of recreation opportunities in residence and out in the community. Provided examples of volleyball, Just Dance (video game), walks, workouts. Summer provides additional outdoor activity opportunities. - Stated during winter it is hard to get "outside" time. By the time they finish school and dinner it is already starting to get dark outside. - Youth felt phone calls were minimally adequate and are provided 10 minutes 3 times a week minimum. The time limit is imposed in order to give all youth opportunities to use the phone. Between school, recreation, chores, homework, etc., there is a small window in which 10 clients use the phone. Youth said the calls are enough, but would prefer 15 minutes if given the opportunity. They did state they can petition for additional calls and additional time on a case-by-case basis. - Youth attend the local public school and said things were going well. - Youth participate in both community and BRS groups, which they found repetitive but beneficial. - Program is very structured, and they have found that helpful in staying on track. - Youth stated some staff lack sympathy for their situation, and clarified this was only one or two staff (not named). - Staff are really good at checking-in with youth and helping them achieve their goals. Form revised 3/12/2025 Page 2 of 26 - Staff are consistent with the rules and keeping to the schedule. - Staff are good at communicating and very understanding. A walkthrough of the property and residence was conducted. Overall, the program is in good condition, and the program has00 been making incremental improvements over time. There was new flooring in the bedrooms and alterations to the stairwell for safety. Youth had hygiene products, bedding and other essential items. The pantry, fridge and multiple freezers contained adequate food and snacks. Vehicles show some signs of age but are in safe operating condition.

grievances_and_complaints:
None
Form revised 3/12/2025 Page 3 of 26

excerpt:
419-400-0040 N/A
(1)(a) Minimum of 5 board members Yes
(2)(f) Formally evaluate the Executive Director's
Yes
performance annually
(2)(g) Approves annual budget Yes
Form revised 3/12/2025 Page 4 of 26
Governance of the agency Yes/No or Corrective actions/comments

excerpt:
419-400-0150
(3)(b)(C) Agency does not use chemical and
mechanical restraint (excluding medically Yes
necessary devices/prescriptions)
(3)(c) Agency uses appropriate time-out rooms
(adequate space, heat, light and ventilation and is
N/A Time-out rooms are not utilized at NWYD
not capable of locking) and documents use in
child's record when applicable
(3)(e) Agency uses seclusion
N/A NWYD does not use restraint or seclusion.
appropriately/consistent with policy
(4) Agency has adequate plan in place to respond
Yes
to suicidal behavior/warning signs
Contractors (if applicable) Yes/No or Corrective actions/comments

excerpt:
419-400-0180 N/A
(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 Yes
child caring agency's main office and on the child
caring agency's website if applicable.
Supplemental information provided by CCA Yes/No or Corrective actions/comments
N/A
Documents as indicated on the form titled
Yes
"Renewal Licensing Required Documents"
Documents as indicated on form titled "Required
No Financial audit in progress.
Financial Documents and Information"
All required policies and procedures as identified
Yes
in the "Umbrella Rules"
All required policies and procedures as identified
Yes
in "Agency Type Specific Rules"
Physical plant Yes/No or Corrective actions/comments
N/A

excerpt:
419-400-0100(1) Sufficient safe space, equipment
Yes
and office equipment

excerpt:
419-400-0230(12) License is posted in common
Yes
area at each facility

excerpt:
419-470-0020 (2)(e) Rooms are adequate in size
Yes
and arrangement

excerpt:
419-470-0030 N/A
(2) There is a separate living room or lounge area
Yes
- 15 SF minimum per child
(5) There is a separate dining room with capacity
for ½ of children in care and 15 SF per child in Yes
care
(7) Laundry is separate from living, kitchen and
Yes
dining areas
(8) Separate storage areas are provided for food,
kitchen supplies, utensils, clean linens, soiled
linens and clothing, cleaning supplies and
equipment, poisons, chemicals, outdoor Yes
recreational and maintenance equipment.
(Hazardous materials are properly labeled, in
original container and locked)
(9) Outdoor activity area is protected from Yes
vehicles and other hazards and of a size and
Form revised 3/12/2025 Page 8 of 26
Room and space requirements Yes/No or Corrective actions/comments

excerpt:
419-400-0120 N/A
Staff name/position Yes
(3)(g) Date of hire Yes
(3)(a) record of education, training and previous
Yes
employment
(1)(b) and (3)(b) reference checks completed and
Yes
documented
(1)(a) and (3)(c) Background check completed
Yes
and documented
(3)(d) Annual performance evaluations Yes
(3)(f) Record of personnel actions Yes
(3)(g) Termination date, reason for termination Yes
(3)(h) Current job description (1)(c) Employee
meets minimum qualifications stated in current job Yes
description
Form revised 3/12/2025 Page 16 of 26
New employee orientation - Umbrella Yes/No or Corrective actions/comments
Requirements (30 days) N/A

excerpt:
419-470-0120(1)
(e) Training on the agency's policy on suicide
Yes
prevention and suicide risk assessment tool
Crisis intervention training standards and Yes/No or Corrective actions/comments
certification N/A

excerpt:
419-470-0070(2)(b) Employees who handle food
served to children have a valid food handler's Yes
card

excerpt:
419-400-0200 (1) Employees transporting
children have: current driver's license, insurance,
trained in emergency procedures and behavior Yes
management and training for 15+ passenger vans
if applicable)

excerpt: 419-470-0120 (2)(a) Environmental emergencies Yes

excerpt: 419-470-0120 (2)(b) Universal precautions Yes

excerpt:
419-470-0120 (2)(c) Discipline and behavior
Yes
management

excerpt:
419-470-0120 (2)(d) Agency's policy on suicide
Yes
prevention and risk assessment tool

excerpt:
419-400-0160(4)(b) Receive continuing education
(as applicable on crisis intervention training) from Yes
a certified instructor on an annual basis
Comments:
Children's records Yes/No or Corrective actions/comments
health services N/A

excerpt:
419-470-0090
(2) Medical history obtained within 30 days
(significant findings, current immunizations,
history of surgical procedures-health issues- Yes
injuries, allergies, dental, vision, hearing,
behavioral health and physician orders)
(4)(a) to (f) Medical exams (3 in first year of life,
2,4,6,9,14) Yes
(g) Have a physical examination within the first 60
days after admission of a child in care. Yes
Documentation of a physical examination having
Form revised 3/12/2025 Page 20 of 26
Children's records Yes/No or Corrective actions/comments
health services N/A

excerpt:
419-400-0230 and Not addressed in the program's consents.
0240
No
Correction Action: Add language to address allowing
access.
(f) Impose a dress code Not addressed in the program's consents.
No
Correction Action: Add language to address imposing a
dress code.
(g) Apply the reasonable and prudent parent
Yes
standard
Form revised 3/12/2025 Page 21 of 26
Disclosures Yes/No or Corrective actions/comments

excerpt:
419-470-0170(2) N/A
(b) Intake document is completed the date child
accepted into care (emergency placement 48 Yes
hours)
(d) Assessment is completed within 30 days and
contains relevant historical information, current
Yes
behavioral observations, identified need for
services and how agency will provide services
(e) (A) and (B) Service plan within 60 days
(parent, guardian and child actively involved).
Describes how child's issues will be addressed, Yes
anticipated outcomes and reviewed by child and
guardian/parent.
(e)(C) and (D) Service plan is reviewed quarterly
and revised when information indicates other Yes
services should be provided
Form revised 3/12/2025 Page 23 of 26
Case management Yes/No or Corrective actions/comments

excerpt:
419-470-0170(3) N/A
(a) Services are documented, progress toward
Yes
achieving goals is tracked
(c) Discharge summary must include:
(A)Current medications
(B)Name of the physician or qualified medical
professional who prescribed each medication
(C)Any outstanding medical or other
appointments Yes
(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 Yes
(f) Incident reports Yes
Records relating to Restraint and Involuntary Yes/No or Corrective actions/comments
Seclusion N/A

excerpt:
419-400-0180(13)(e) Each child caring agency
shall provide notice regarding how to access the
quarterly reports to the parents or guardians of
children in care in the program. The child caring Yes
agency shall provide the notice upon the child in
care's admission and at least two times each year
thereafter.


state: OR

facility_name: New Era House

summary: Unannounced - 2 findings

raw_content:
Licensed Child Caring Agency Site Visit Report
Residential Care
Licensee: Parrott Creek Licensing Coordinator:
Program Director: Leah Lamb Aubrey Kelly
Date of site visit: April 21, 2021
Other Regulatory or Accrediting Agencies: Oregon Youth Authority; Child welfare.
Corrective Actions and Timeframes: Please submit the following to verify compliance.
Within 45 days of receipt of this report Parrott Creek 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 Aubrey.J.Kelly@dhsoha.state.or.us or sent by regular mail to the following address:
Department of Human Services, Children’s Care Licensing Unit
Attn: Aubrey Kelly
500 Summer St NE (E-94)
Salem, OR 97301
Physical Plant Yes No N/A Comments Corrective Action
Completed
413-215-0046(3)(a) Foster Rights Posted (if X
children in DHS custody)
413-215-0051(1) Sufficient safe space, X
equipment, and office equipment
413-215-0091(12) License is posted in X
common area at each facility
413-215-0001(5)(d), 0516(4(a)(I) & 0521(1) X
Adequate furnishings and personal items
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 07/29/2020)
413-215-0511(2)(a) &(c) Buildings are X The overall condition of the program was poor. There
smoke free, clean and in good repair were numerous holes in the wall. There was graffiti type
413-215-0511(2)(d) Rooms are free of X writing and carvings in several areas. The door in the
harmful drafts, odors, and excessive noise lower rec room is damaged and broken. The carpet was
413-215-0511(2)(e) Rooms are adequate in X ripped and coming up in the lower rec room. In several of
size and arrangement the clients’ bedrooms, there were clothes and
413-215-0511(2)(f) System provides a X belongings all over the floor. The furniture in the lower
continuous supply of hot and cold water to rec room was torn and damaged. The program shall
taps located throughout the facility ensure all areas of the program are in good repair to
413-215-0511(2)(h) Building is well X include painting over all writing and carvings, repairing
ventilated and room temperature is within a the holes in the walls, repairing or replacing broken and
normal comfort range damaged furniture, repairing or replacing the door in the
413-215-0516(1) All parts of the facility X lower rec room.
ensure the safety of children
Room and Space Requirements Yes No N/A Comments Corrective Action
Bedrooms 413-215-0516(3) Completed
(a) Adequate furnishings and personal items X
(b) Separate from rooms used for dining, X
living, laundry, kitchen, and storage
(c) Outside room with window allowing X
egress from building
(d) Ceiling at least 90 inches X
(e) Minimum 60 SF per bed X
(f) No more than 25 if dorm style X
(g) Permanently wired fixtures X
(h) Window covering X
(i) Beds are 3 feet apart and maintained to X
ensure safety
Room and Space Requirements Yes No N/A Comments Corrective Action
Bathrooms 413-215-0516(4) Completed
(a)(A)&(B) 1:8 ratio for toilets and sinks X
(a)(D) Hot and cold running water, soap, and X
approved hand drying options
(a)(E) 1:10 ratio for shower or bathtub X
(a)(E) Individual privacy X
(a)(F) Window covering X
(a)(G) Permanently wired fixtures X
(a)(H) Adequate ventilation X
(b)&(c) Wooden racks on floors are X
prohibited and impervious shower mats are
disinfected & dried daily
Room and Space Requirements Yes No N/A Comments Corrective Action
Kitchen 413-215-0516(6) Completed
2
(a) Used exclusively for storage, food X
preparation, dish washing and activities
related to eating
(b) Walls, floors are easily cleanable X
(c) Equipment and utensils are easily X
cleanable, durable, nontoxic, and kept clean
(e) Equipment is easy to clean beneath, X
between and behind
Room and Space Requirements Yes No N/A Comments Corrective Action
413-215-0516 Completed
(2) There is a separate living room or lounge X
area – 15 SF minimum per child
(5) There is a separate dining room with X
capacity for ½ of children in care and 15 SF
per child in care
(7) Laundry is separate from living areas, X
kitchen and dining
(8) Separate storage areas are provided for X
food, kitchen supplies, utensils, clean linens,
soiled linens and clothing, cleaning supplies
and equip, poisons, chemicals, outdoor
recreational and maintenance equipment.
(hazardous materials are properly labeled, in
original container and locked)
(9) Outdoor activity area is protected from X
vehicles and other hazards and of a size and
availability appropriate to the age and needs
of children in care
(11) & 413-215-0076(3)(c)(C)Time out rooms X
have adequate space, heat, light and
ventilation and is not capable of locking
Furnishings and Personal Items Yes No N/A Comments Corrective Action
413-215-0521 Completed
(1) There is a bed with frame, clean mattress X
and pillow and personal storage (dresser,
closet)
(2) Linens are in good repair. There is a X
waterproof mattress cover or mattress.
Linens are appropriate and towels and
washcloths are provided
(3) Bedding is changed weekly or when X
soiled
(4)&(5) Personal hygiene supplies and X
appropriate clothing are provided
3
04.23.2021
Licensing Coordinator’s Signature: ________________________ Date: ___________________
04-23-2021
Manager Review: ______________________________________ Date: __________________
4

agency_name: Parrott Creek Child and Family Services (PCCFS)

program_name: New Era House

program_type: (RC) Residential Care Programs

report_type: Unannounced

view_code: RC

facility_type: Residential Care

licensee: Parrott Creek Licensing Coordinator

program_director: Leah Lamb Aubrey Kelly

other_regulatory_agencies: Oregon Youth Authority; Child welfare.

excerpt:
&(c) Buildings are
smoke free, clean and in good repair The overall condition of the program was poor. There
were numerous holes in the wall. There was graffiti type
writing and carvings in several areas. The door in the
lower rec room is damaged and broken. The carpet was
ripped and coming up in the lower rec room. In several of
the clients’ bedrooms, there were clothes and
belongings all over the floor. The furniture in the lower
rec room was torn and damaged. The program shall
ensure all areas of the program are in good repair to
include painting over all writing and carvings, repairing
the holes in the walls, repairing or replacing broken and
damaged furniture, repairing or replacing the door in the
lower rec room.

excerpt:
All parts of the facility
ensure the safety of children


summary: Unannounced - 2 findings

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Licensee: Parrott Creek Child and Family Services
Executive Director: Leah Lamb
Date of Unannounced: 05/26/2021
Licensing Coordinator: Aubrey Kelley
Other Regulatory or Accrediting Agencies: Oregon Youth Authority; Child welfare.
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
Unannounced Site Visit 04/21/2021 Findings
Further Action
Needed
413-215-0511(2)(a) &(c) Buildings are smoke Yes☐ No
free, clean and in good repair:
“The overall condition of the program was poor.
There were numerous holes in the wall. There
was graffiti type writing and carvings in several
areas. The door in the lower rec room is
damaged and broken. The carpet was ripped and
coming up in the lower rec room. In several of
the clients’ bedrooms, there were clothes and
belongings all over the floor. The furniture in the
lower rec room was torn and damaged. The
program shall ensure all areas of the program
are in good repair to include painting over all
writing and carvings, repairing the holes in the
walls, repairing or replacing broken and
damaged furniture, repairing or replacing the
door in the lower rec room.”
1
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 200115)
413-215-0516(1) All parts of the facility Yes☐ No
ensure the safety of children:
“The overall condition of the program was poor.
There were numerous holes in the wall. There
was graffiti type writing and carvings in several
areas. The door in the lower rec room is
damaged and broken. The carpet was ripped and
coming up in the lower rec room. In several of
the clients’ bedrooms, there were clothes and
belongings all over the floor. The furniture in the
lower rec room was torn and damaged. The
program shall ensure all areas of the program
are in good repair to include painting over all
writing and carvings, repairing the holes in the
walls, repairing or replacing broken and
damaged furniture, repairing or replacing the
door in the lower rec room.”
New Findings from Site Visit Comments
None
Interview Summary
Client #1 – Been at New Era for a few months. They were previously at Fowler House and Robinswood, they really enjoyed Fowler
House because of the freedom there, there is less freedom here. They feel safe here and there has never been a time of feeling
unsafe. At Fowler House they could watch Youtube, they can’t watch it here. They get along with the staff and doesn’t like to
socialize with the other clients. The food is good, Carly is the cook and she cooks really well. At Fowler house, clients could help
make meals, clients here don’t help with food prep. They have frequent contact with family, 15 minute calls every day. They see
their family every other weekend. Teachers sit in the classroom and clients do their schoolwork on the computer. They go on
outings every Saturday.
2
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 200115)
Observations
The physical condition of the program has improved. All but three clients and 90% of the staff at the program have been vaccinated
against Covid-19. The program is raising their starting wage for line staff $2.00 an hour.
Corrective Actions and Timeframes:
Please submit the following to verify compliance.
Within 45 days of receipt of this report Parrott Creek Child and Family Services must submit a letter of verification indicating the agency is in
compliance with the specific rules cited above and describing how compliance will be maintained going forward. Along with the letter of verification,
the agency must submit any and all specific documentation requested in the body of this report. The letter of verification and any additional
requested documents can be emailed directly to Aubrey Kelly, AUBREY.J.KELLY@dhsoha.state.or.us or sent by regular mail to the following
address:
Department of Human Services
Children’s Care Licensing Program
Attn: Aubrey Kelly
201 High St. SE Suite 500
Salem, OR 97301
Licensing Coordinator’s Signature: ________________________ Date: _____0_6_._0_2_._2_0_2_1_____
05-28-2021
Manager Review: ______________________________________ Date: __________________
3
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 200115)

licensee: Parrott Creek Child and Family Services

executive_director: Leah Lamb

licensing_coordinator: Aubrey Kelley

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
Unannounced Site Visit 04/21/2021 Findings
Further Action
Needed
413-215-0511(2)(a) &(c) Buildings are smoke Yes[ ] No
free, clean and in good repair:
"The overall condition of the program was poor.
There were numerous holes in the wall. There
was graffiti type writing and carvings in several
areas. The door in the lower rec room is
damaged and broken. The carpet was ripped and
coming up in the lower rec room. In several of
the clients' bedrooms, there were clothes and
belongings all over the floor. The furniture in the
lower rec room was torn and damaged. The
program shall ensure all areas of the program
are in good repair to include painting over all
writing and carvings, repairing the holes in the
walls, repairing or replacing broken and
damaged furniture, repairing or replacing the
door in the lower rec room."
1

413-215-0516(1) All parts of the facility Yes[ ] No
ensure the safety of children:
"The overall condition of the program was poor.
There were numerous holes in the wall. There
was graffiti type writing and carvings in several
areas. The door in the lower rec room is
damaged and broken. The carpet was ripped and
coming up in the lower rec room. In several of
the clients' bedrooms, there were clothes and
belongings all over the floor. The furniture in the
lower rec room was torn and damaged. The
program shall ensure all areas of the program
are in good repair to include painting over all
writing and carvings, repairing the holes in the
walls, repairing or replacing broken and
damaged furniture, repairing or replacing the
door in the lower rec room."
New Findings from Site Visit Comments
None
Interview Summary
Client #1 - Been at New Era for a few months. They were previously at Fowler House and Robinswood, they really enjoyed Fowler
House because of the freedom there, there is less freedom here. They feel safe here and there has never been a time of feeling
unsafe. At Fowler House they could watch Youtube, they can't watch it here. They get along with the staff and doesn't like to
socialize with the other clients. The food is good, Carly is the cook and she cooks really well. At Fowler house, clients could help
make meals, clients here don't help with food prep. They have frequent contact with family, 15 minute calls every day. They see
their family every other weekend. Teachers sit in the classroom and clients do their schoolwork on the computer. They go on
outings every Saturday.
2

Observations
The physical condition of the program has improved. All but three clients and 90% of the staff at the program have been vaccinated
against Covid-19. The program is raising their starting wage for line staff $2.00 an hour.

excerpt:
413-215-0516(1) All parts of the facility Yes[ ] No
ensure the safety of children:
"The overall condition of the program was poor.
There were numerous holes in the wall. There
was graffiti type writing and carvings in several
areas. The door in the lower rec room is
damaged and broken. The carpet was ripped and
coming up in the lower rec room. In several of
the clients' bedrooms, there were clothes and
belongings all over the floor. The furniture in the
lower rec room was torn and damaged. The
program shall ensure all areas of the program
are in good repair to include painting over all
writing and carvings, repairing the holes in the
walls, repairing or replacing broken and
damaged furniture, repairing or replacing the
door in the lower rec room."
New Findings from Site Visit Comments
None
None


summary: License Renewals - 19 findings

raw_content:
Licensed Child Caring Agency Site Visit Report
Residential Care
Licensee: Parrott Creek Child and Family Services Date of site visit: 09/12/2022
Executive Director: Simon Fulford Licensing Coordinator: Aubrey Kelley and Jeff Minden
Board Chairperson: Glen Wachter
Other Regulatory or Accrediting Agencies: Oregon Youth Authority (OYA), Oregon Department of Human Services (ODHS) Child Welfare
Program Compliance: The program was found to be compliant or will be compliant with OAR 413-215-0001 to 413-215-0131, Licensing Umbrella
Rules, and OAR 413-215-0501 to 413-215-0586, Licensing Residential Care Agencies Rules. Personnel records were reviewed and compliance
with required background checks was documented for employees in all programs.
Program Description(s): Parrott Creek Child and Family Services has partnered with both the Oregon Youth Authority (OYA) and the Oregon
Department of Human Services (ODHS) to provide respective child caring facilities for youth in the custody of the Oregon Youth Authority or ODHS
Child Welfare.
The OYA residential facility provides residential treatment for up to 20 adjudicated male youth between the ages of 13 and 18 years old from
throughout the state of Oregon. New Era House is an intensive residential program for male identified youth ages 13-18 who are in the custody of
Oregon’s Child Welfare and who have sexually harming or sexually reactive behaviors. These youth have also struggled to maintain placement in
traditional foster care or other residential settings.
Program type and services: The program describes New Era as a mindfulness-based program. All staff working in the program are conversant in
Dialectical Behavioral Therapy (DBT) and facilitate treatment groups in mindfulness, emotional regulation, and new skill acquisition for the youth.
New Era uses Collaborative and Proactive Solutions as a behavioral intervention to help youth identify lagging skills and create their own solutions
to internal and external problems. In addition, youth work with a certified sex offender therapist to determine the treatment needed to move forward
living a life free from sexual harm. Family therapy is offered to keep youth connected with their loved ones and increase the likelihood of success if
the youth is returning home at the end of treatment. New Era’s services include intensive individual, family and group counseling, cognitive-
behavioral interventions and skill building, educational and recreational activities. The program provides youth with rehabilitative services to develop
age-appropriate emotional and behavioral competencies in a structured environment,
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 08/13/2020)
The residential program provides family, individual and group counseling that is facilitated by licensed therapists. The program follows a D.B.T.
(Dialectical Behavior Therapy) model. This model is modified to meet the treatment needs of the youth in the program. Youth are also involved in
several skill-building groups as well as individual skill building with youth workers. Drug and alcohol counseling is provided on-site for youth who
are assessed as requiring services.
Education for both facilities is provided for the youth on-site by the Clackamas Education Services District.
Capacity and Age Range: The residential program serves youth, ages 13-18, and has a capacity of 20. New Era serves males ages 13-18 with a
capacity of 4.
Funding sources: Oregon Youth Authority (OYA), Oregon Department of Human Services (ODHS) Child Welfare
Contracts and sources for referrals: The program has contracts with OYA and Oregon Department of Human Services (ODHS) Child Welfare.
Average length of stay: The Average length of stay is 8-12 months
Average daily population served: The Ranch (OYA): 14, New Era (ODHS): 3
Number of children served annually: 50-75 between both programs
Use of seclusion or restraint: Parrott Creek was previously using Right Response restraint training, however, following the new rules adopted to
implement Senate Bill 710, the program has suspended the use of restraints while working to get staff trained on Crisis Prevention Institute (CPI)
restraint methods.
Interviews, Observations: A walkthrough of spaces and common areas used by clients was conducted. Overall, the spaces were clean and
appeared in good repair. Residential Program Manager Leah Lamb conducted the tour and pointed out that they have been dealing with graffiti
issues, and the program will spot paint over the graffiti, and maintenance will routinely color match the walls. At the time of the visit there were 13
youth in The Ranch Program and none at New Era. As a part of the review process, 2 youth and 1 staff were interviewed.
Both youth interviewed reported feeling safe in the program and liking the food, although one reported the food can sometimes be boring. Both
reported receiving adequate food. Both youth reported being able to make phone calls home 3 times a week and being able to participate in home
visits. One of the interviewed youth reported being at several programs previous and liking Parrott Creek better. Parrott Creek was the first
program for the other youth. Both you reported having staff they felt they could reach out to if they needed to and identified favorite staff. Both
youth reported having a few months left, and neither was clear on the transition plan for their exit from the program at this point. When asked, one
youth wished the program had a pool and the other could not think of anything he would want to change.
2
Program Strengths: Program uses a relationship approach combined with Collaborative Problem Solving as their main behavior interventions.
This allows youth and staff to create safe and supportive relationships so that they can work together to process behaviors and build skills.
Program Challenges: Ove the past 2 years Parrott Creek has been impacted by Covid-19 and has struggled to hire and retain staff members
throughout it.
Changes that have occurred in the last 2 years: Parrott Creek has had large staffing turnover during the last two years and has had to
temporarily change policies and adapt to working with our clients during a pandemic. This temporarily changed the way they were able to
incorporate families and home visits into the youth’s treatment.
Lawsuits: None reported by the program
Grievances and complaints filed in the last two years: None reported by the program.
Corrective Actions and Timeframes: Please submit the following to verify compliance.
Within 45 days of receipt of this report (insert name of agency) must submit a letter of verification indicating the agency is in compliance with the
specific rules cited above and describing how compliance will be maintained going forward. Along with the letter of verification, the agency must
submit any and all specific documentation requested in the body of this report. The letter of verification and any additional requested documents can
be emailed directly to Aubrey.J.Kelly@dhsoha.state.or.us or sent by regular mail to the following address:
Department of Human Services, Children’s Care Licensing Program
Attn: Aubrey Kelly
201 High St SE, Suite 500
Salem, OR 97301
Recommendations: Current youth intake files include an authorization for Parrott Creek to provide for all medical care for youth. Recommended
changing language to say routine and emergency medical care to better align with 413-215-0576.
Exceptions: In 2021 Parrott Creek requested a total of 3 Licensing rule exceptions; a request to admit a youth outside the agency’s licensed age
range, fixed windows at the OYA facility and a room share exception for a 17 year old to share a room with two 18 year olds. A new exception
regarding the fixed windows at the OYA facility will need to be submitted for the next licensing period (2022 – 2024).
Changes in License: None
3
Summary of Review
Program and Services Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0011(2) Completed
Program and services are in scope of license x
Governance of the Agency Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0021 Completed
(1)(a) Minimum of 5 board members x
(2)(f) Formally evaluate the exec. Director’s x
performance annually
(2)(g) Approves annual budget x
(2)(h) Obtain and review an annual x
independent financial review or audit of
financial records.
(2)(k) Written quality improvement program x
(2)(l) Meeting minutes x
Executive Director or Program Director Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0021 Completed
(3)(a) knowledge of requirements for x
providing care and treatment appropriate to
programs
(3)(g) Approval from BCU x
Discipline, Behavior Management, and Corrective Action
Yes No N/A Corrective Actions/Comments
Suicide Prevention 413-215-0076 Completed
(3) Agency uses appropriate and positive
methods of behavior management and
x
nationally recognized non-violent crisis
intervention
(3)(b)(C) Agency does not use chemical and
mechanical restraint (excluding medically x
necessary devices/prescriptions)
(3)(c) Agency uses appropriate time-out
rooms (adequate space, heat, light and
ventilation and is not capable of locking) and x
documents use in child’s record when
applicable
(3)(e) Agency uses seclusion
x
appropriately/consistent with policy
(4) Agency has adequate plan in place to
respond to suicidal behavior/warning signs x
Contractors (if applicable) Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0061(6) Completed
4
(a) Agency ensures the contractor meets the
requirements of this rule and Chapter 413 x
division 215
(b)(B) Contract includes the following:
(i) Services provided
(ii) Contractor fees
(iii) Disclosure of information from contractor
to agency
(iv) Lines of authority x
(v) Adherence to rules, including background
check
(vi) Any liability of the agency for acts of the
contractor, rights of indemnity and limitations
on liability
Supplemental Information Provided by Corrective Action
Yes No N/A Corrective Actions/Comments
CCA Completed
Documents as indicated on the form titled A completed fire marshal inspection had not yet been
“Renewal Licensing Required Documents” x completed at the time of the review. The program shall
ensure a fire marshal inspection is completed.
Documents as indicated on form titled
“Required Financial Documents and x
Information”
All required policies and procedures as Written policies for compliance with Interstate Compact on
identified in the “Umbrella Rules” the Placement of Children (ICPC) and compliance with the
x
Indian Child Welfare Act (ICWA) were not submitted. The
program shall ensure these policies are submitted to CCLP.
All required policies and procedures as
identified in “Agency Type Specific Rules” x
Physical Plant Corrective Action
Yes No N/A Corrective Actions/Comments
Completed
413-215-0046(3)(a) Foster Rights Posted (if x
children in DHS custody)
413-215-0051(1) Sufficient safe space, x
equipment, and office equipment
413-215-0091(12) License is posted in x
common area at each facility
413-215-0001(5)(d), 0516(4(a)(I) & 0521(1) x
Adequate furnishings and personal items
413-215-0511(2)(a) &(c) Buildings are x
smoke free, clean and in good repair
413-215-0511(2)(d) Rooms are free of x
harmful drafts, odors, and excessive noise
5
413-215-0511(2)(e) Rooms are adequate in x
size and arrangement
413-215-0511(2)(f) System provides a x
continuous supply of hot and cold water to
taps located throughout the facility
413-215-0511(2)(h) Building is well x
ventilated and room temperature is within a
normal comfort range
413-215-0516(1) All parts of the facility x
ensure the safety of children
Room and Space Requirements Corrective Action
Yes No N/A Corrective Actions/Comments
Bedrooms 413-215-0516(3) Completed
(a) Adequate furnishings and personal items x An exception request was granted for the 2020-2022
(b) Separate from rooms used for dining, x licensing period for the windows to be secure in The Ranch
living, laundry, kitchen, and storage facility.
(c) Outside room with window allowing x
egress from building CORRECTIVE ACTION: Submit new exception request for
(d) Ceiling at least 90 inches x licensing period 2022-2024 for windows to continue to remain
(e) Minimum 60 SF per bed x fixed.
(f) No more than 25 if dorm style x
(g) Permanently wired fixtures x
(h) Window covering x
(i) Beds are 3 feet apart and maintained to x
ensure safety
Room and Space Requirements Corrective Action
Yes No N/A Corrective Actions/Comments
Bathrooms 413-215-0516(4) Completed
(a)(A)&(B) 1:8 ratio for toilets and sinks x
(a)(D) Hot and cold running water, soap, and x
approved hand drying options
(a)(E) 1:10 ratio for shower or bathtub x
(a)(E) Individual privacy x
(a)(F) Window covering x
(a)(G) Permanently wired fixtures x
(a)(H) Adequate ventilation x
(b)&(c) Wooden racks on floors are x
prohibited and impervious shower mats are
disinfected & dried daily
Room and Space Requirements Corrective Action
Yes No N/A Corrective Actions/Comments
Kitchen 413-215-0516(6) Completed
(a) Used exclusively for storage, food x
preparation, dish washing and activities
related to eating
(b) Walls, floors are easily cleanable x
6
(c) Equipment and utensils are easily x
cleanable, durable, nontoxic, and kept clean
(e) Equipment is easy to clean beneath, x
between and behind
Room and Space Requirements Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0516 Completed
(2) There is a separate living room or lounge x
area – 15 SF minimum per child
(5) There is a separate dining room with x
capacity for ½ of children in care and 15 SF
per child in care
(7) Laundry is separate from living areas, x
kitchen and dining
(8) Separate storage areas are provided for x
food, kitchen supplies, utensils, clean linens,
soiled linens and clothing, cleaning supplies
and equip, poisons, chemicals, outdoor
recreational and maintenance equipment
(9) Outdoor activity area is protected from x
vehicles and other hazards and of a size and
availability appropriate to the age and needs
of children in care
(11) & 413-215-0076(3)(c)(C)Time out rooms x
have adequate space, heat, light and
ventilation and is not capable of locking
Furnishings and Personal Items Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0521 Completed
(1) There is a bed with frame, clean mattress x
and pillow and personal storage (dresser,
closet)
(2) Linens are in good repair. There is a x
waterproof mattress cover or mattress.
Linens are appropriate and towels and
washcloths are provided
(3) Bedding is changed weekly or when x
soiled
(4)&(5) Personal hygiene supplies and x
appropriate clothing are provided
Food Services Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0536(1)&(2) Completed
(1)(a) Meals are arranged daily, consistent x
with normal mealtimes that occur during the
hours of operation
(1)(b) Menus are prepared in advance in x
accordance with USDA guidelines, provide a
7
variety of foods and are adjusted for
seasonal changes.
(1)(b) Menus are kept for at least 6 months x
(1)(c) Drinking water is freely available x
(2)(a) Food is stored, prepared & served in a x
sanitary manner
(2)(c) & (d) Food products are obtained from x
commercial suppliers (exception of fruits &
vegetables), unpasteurized juice is
prohibited, and only Grade A pasteurized
and fortified milk in appropriate container.
Safety Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0541 Completed
(2)(a) Written emergency plan x Evacuation and fire drills were not conducted on a monthly
(2)(b) Telephone numbers for local police x basis, and nearly a year’s worth of drills was not logged. The
and fire are posted near all telephones program has been consistent in conducting them for the last
(2)(c) Operative flashlights sufficient in x few months.
number are readily available to staff
(3)(a) Evacuation drill occurs monthly under x CORRECTIVE ACTION: Ensure drills are being conducted
varying conditions, is retained 2 yrs and on a monthly basis and documented accurately.
contains;
(A) identify of person conducting drill
(B) date & time
(C) notification method
(D) staff participating
(E) # of children & staff evacuated
(F) special conditions simulated
(G) problems encountered
(H) time to complete
Safety – Transportation Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0541 Completed
(5)(b) Vehicle has insurance policy, is smoke x
free, safe operating condition, and has first
aid kit and fire extinguisher 2-A:10-BC
Medication Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0551 Completed
(3)&(7)(e) Medications have a prescription x
and are stored in the original container with
prescription label
(4)&(5) Herbal supplements and remedies, x
medical treatments, special diets, physical
therapy, physical aides or limitations have a
written order signed by a physician or
qualified medical professional.
8
(7)(c) Medications are inaccessible to x
children
(8) Medications are disposed in accordance x
with state and federal law
(9) Written record of the disposal of x
medications is maintained and includes:
(a) description and amount
(b) name
(c) reason
(d) method
(e) staff & witness signature
(10) Written record of the administration of x
medication includes:
(a) name
(b) description
(c) dates and times
(d) missed doses
(e) medication disposed
(f) method of administration
(g) ID of person administering
(h) possible adverse reactions
(i) medication taken outside facility
Extracurricular, Enrichment, Cultural &
Corrective Action
Social Activities Yes No N/A Corrective Actions/Comments
Completed
413-215-0554
(2) Children have ongoing opportunities to x
participate in at least one age-appropriate or
developmentally appropriate activity
Minimum Staffing Requirements Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0561 Completed
(1)&(2) Supervision is adequate for the type x
of program, location, age and type of
children, ability of supervisor to respond,
electronic back-up systems.
Minimum ratios are maintained:
Under 30 months of age: 1:4
30 months to ˃ 6 yrs or non-ambulatory: 1:6
Ages 6 and older: 1:7
Overnight (staff awake)
1:10
(4)(a) When one staff on duty, there is x
additional staff immediately available with
max response time of 30 minutes
9
(5) There is at least one on-site employee x
authorized to apply the reasonable and
prudent parent standard
Separation of Residents Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0566 Completed
(1) Children are in separate bedrooms than x
adults, unless parent and child, or there is
written approval from guardian/parent and
licensing coordinator
(2) There is adequate supervision of children x
if both males and females are served by the
program
Personnel Files Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0061 Completed
Staff Name/Position x
(3)(g) Date of Hire x
(3)(a) record of education, training and
x
previous employment
(1)(b) & (3)(b) reference checks completed
x
and documented
(1)(a) & (3)(c) Background check completed
x
and documented
(3)(d) Annual performance evaluations x
(3)(f) Record of personnel actions x
(3)(g) Termination date, reason for
x
termination
(3)(h) Current job description (1)(c)
Employee meets minimum qualifications x
stated in current job description
New Employee Orientation – Umbrella
Corrective Action
Requirements (30 days) Yes No N/A Corrective Actions/Comments
Completed
413-215-0061(4)
(a) Agency policies and procedures x
New employee trainings are being completed, and all topics
(b) Ethical and professional guidelines x
are being covered. However, documentation in 4 out of 5
(c) Organizational lines of authority x
files reviewed did not indicate the trainings were being
(d) Attributes of population served x
completed within 30 days of hire.
(e) & (5)(a) to (c) Mandatory reporting that
x
includes:
10
(a) legal definition of child abuse ORS CORRECTIVE ACTION: Ensure that all employees are
419B.005, Oregon Laws 2016, chapter 106, receiving the New Employee Orientation trainings within 30
section 36 days of hire and trainings are documented as occurring in
(b) legal responsibility to immediately report that time frame.
(c) legal responsibility to report is personal to
the employee
(f) Privacy laws x
(g) Emergency procedures x
New Employee Orientation – Residential
Corrective Action
(30 days) Yes No N/A Corrective Actions/Comments
Completed
413-215-0556
(1)(a) Discipline and behavior management New employee trainings are being completed, and all topics
including de-escalation, crisis prevention, are being covered. However, documentation in 4 out of 5
positive behavior management, and x files reviewed did not indicate the trainings were being
disciplinary techniques that are non-punitive completed within 30 days of hire.
in nature
CORRECTIVE ACTION: Ensure that all employees are
receiving the New Employee Orientation trainings within 30
days of hire and are documented as occurring in that time
frame.
(1)(b) Restraint and seclusion (if applicable) x
The program is not currently training staff for restraints or
utilizing restraints in the program.
Ongoing Training Corrective Action
Yes No N/A Corrective Actions/Comments
Completed
413-215-0536(2)(b) Employees who handle x
food served to children have a valid food
handler’s card
413-215-0541(5)(a) Employees transporting
children have: current driver’s license,
insurance, trained in emergency procedures x
and behavior management, and training for
15+ passenger vans if applicable)
413-215-0556(2)(a) Environmental
x
emergencies
413-215-0556(2)(b) Universal Precautions x
413-215-0556(2)(c) Discipline and Behavior
x
Management
413-215-0556(3) Staff providing direct care
must maintain current CPR/First Aid x
certification
11
413-215-0556(4) Designated staff authorized
to apply reasonable and prudent parent
x
standard are trained in application of the
standard
413-215-0061(5) Mandatory reporting
(annually) that includes:
(a) legal definition of child abuse ORS
419B.005, Oregon Laws 2016, chapter 106,
x
section 36
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to
the employee
Children’s Records Corrective Action
Yes No N/A Corrective Actions/Comments
Completed
Health Services
413-215-0546
(2) Medical history obtained within 30 days
(significant findings, current immunizations,
history of surgical procedures-health issues- x
injuries, allergies, dental, vision, hearing,
behavioral health, and physician orders)
(2)(e) Documentation of age appropriate
instruction – pregnancy prevention, nutrition,
prevention of HIV & AIDS, and prevention x
and treatment of sexually transmitted
disease
(4)(a) to (f) Medical exams (3 in first year of
life, 2,4,6,9,14) x
Consents Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0576(1) Completed
(a) Provide routine and emergency medical
x
care
Only 1 of the 5 files reviewed included a consent for the
(b) Use the discipline and behavior reasonable and prudent parent standard.
x
management system
(c) Use restraint or seclusion (if applicable). CORRECTIVE ACTION: Ensure that all required consents
Must specify the reasons for the intervention x are in each resident’s file moving forward.
and how staff are trained and supervised
12
(d) Restrict contact with persons outside of
x
the agency
(e) Allow access as defined in 413-215-0091
x
& 0101
(f) Impose a dress code x
(g) Apply the reasonable and prudent parent
x
standard
Disclosures
Corrective Action
413-215-0576(2) Parent/guardian has Yes No N/A Corrective Actions/Comments
Completed
acknowledged in writing:
(a) Information regarding personal or room
searches and protocols for confiscation of x
contraband
(b) Statement of Rights of Children and
x
Parents/Guardians
(c) Any policies and procedures upon
x
request
Authorizations Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0576(3) Completed
(a) Disclose or exchange information with
x
others
(b) Child specific visitors x
(c) Visitation resources are pre-approved x
(d) Activity specific authorizations are pre-
approved to allow children to participate in
potentially hazardous activities, including but x
not limited to using motorized yard
equipment, swimming, and horseback riding.
Information about Children in Care
Corrective Action
413-215-0581(1) Summary sheet contains Yes No N/A Corrective Actions/Comments
Completed
the following:
(a)The name, gender, date of birth, religious
x The Summary Sheet did not contain information regarding
preference, and previous address
religious preference.
(b) Name and location of previous and
x
current school
CORRECTIVE ACTION: The program will ensure that
(c) Date of admission x
summary sheet documentation includes religious preference.
(d) Legal custody x
13
(e) The name, address, and telephone
number of:
(A) The child in care's parents.
(B) The child in care's legal guardian, if
different than the parents, and a copy of
x
the document that provides for his or her
authority over the child in care.
(C) Other persons significant to child
(D) Other professionals to be involved in
service planning (if applicable)
Service Planning Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0581(2) Completed
(b) Intake document is completed the date
child accepted into care (emergency x
placement 48 hours)
(d) Assessment is completed within 45 days
and contains relevant historical info., current
behavioral observations, identified need for x
services, and how agency will provide
One of the files reviewed indicated the Assessment was
services
completed on day 52.
(e) (A)&(B) Service plan within 60 days CORRECTIVE ACTION: The program will ensure that all
(parent, guardian and child actively Assessments are completed within the 45 day timeline.
involved). Describes how child’s issues will x
be addressed, anticipated outcomes and
reviewed by child and guardian/parent.
(e)(C)&(D) Service plan is reviewed quarterly
and revised when information indicates other x
services should be provided
Case Management Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0581(3) Completed
(a) Services are documented, progress
x
toward achieving goals is tracked
(b)-(d) discharge planning and instructions x
(f) Incident Reports x
14
Financial Records Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0581(4) Completed
Records contain date, amount, source,
x
purpose, signatures
Personal Possessions Records Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0581(5) Completed
Individual written inventory of all personal
possessions is maintained and updated as x
needed
Records and Documentation Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0071 Completed
(1) Stored safely x
(2) Permanent, legible, dated, and signed x
(3)&(4) Uniform in organization, readily
identifiable and accessible, current, and
x
complete, containing all required info. No
eraser tape or white out.
(7) Permanent registry for each child
includes:
Name
Gender
x
Birth date
Names, addresses of parents or guardians
Dates of admission
Placement upon discharge
Licensing Coordinator’s Signature: ________________________ Date: _1_0_-1_2_-_2_0_2_2_ _________
Manager Review: ______________________________________ Date: _1_0_-1_2_-_2_0_2_2_ ________
15

report_type: License Renewals

board_chairperson: Glen Wachter

licensing_coordinator: Aubrey Kelley and Jeff Minden

program_description:
Parrott Creek Child and Family Services has partnered with both the Oregon Youth Authority (OYA) and the Oregon
Department of Human Services (ODHS) to provide respective child caring facilities for youth in the custody of the Oregon Youth Authority or ODHS
Child Welfare.
The OYA residential facility provides residential treatment for up to 20 adjudicated male youth between the ages of 13 and 18 years old from
throughout the state of Oregon. New Era House is an intensive residential program for male identified youth ages 13-18 who are in the custody of
Oregon's Child Welfare and who have sexually harming or sexually reactive behaviors. These youth have also struggled to maintain placement in
traditional foster care or other residential settings.

program_services:
The program describes New Era as a mindfulness-based program. All staff working in the program are conversant in
Dialectical Behavioral Therapy (DBT) and facilitate treatment groups in mindfulness, emotional regulation, and new skill acquisition for the youth.
New Era uses Collaborative and Proactive Solutions as a behavioral intervention to help youth identify lagging skills and create their own solutions
to internal and external problems. In addition, youth work with a certified sex offender therapist to determine the treatment needed to move forward
living a life free from sexual harm. Family therapy is offered to keep youth connected with their loved ones and increase the likelihood of success if
the youth is returning home at the end of treatment. New Era's services include intensive individual, family and group counseling, cognitive-
behavioral interventions and skill building, educational and recreational activities. The program provides youth with rehabilitative services to develop
age-appropriate emotional and behavioral competencies in a structured environment,

The residential program provides family, individual and group counseling that is facilitated by licensed therapists. The program follows a D.B.T.
(Dialectical Behavior Therapy) model. This model is modified to meet the treatment needs of the youth in the program. Youth are also involved in
several skill-building groups as well as individual skill building with youth workers. Drug and alcohol counseling is provided on-site for youth who
are assessed as requiring services.
Education for both facilities is provided for the youth on-site by the Clackamas Education Services District.

average_daily_population_served: The Ranch (OYA): 14, New Era (ODHS): 3

number_of_children_served_annually: 50-75 between both programs

changes_in_last_two_years:
Parrott Creek has had large staffing turnover during the last two years and has had to
temporarily change policies and adapt to working with our clients during a pandemic. This temporarily changed the way they were able to
incorporate families and home visits into the youth's treatment.

lawsuits: None reported by the program

grievances_and_complaints: None reported by the program.

exceptions:
In 2021 Parrott Creek requested a total of 3 Licensing rule exceptions; a request to admit a youth outside the agency's licensed age
range, fixed windows at the OYA facility and a room share exception for a 17 year old to share a room with two 18 year olds. A new exception
regarding the fixed windows at the OYA facility will need to be submitted for the next licensing period (2022 - 2024).

changes_in_license:
None
3

excerpt:
Documents as indicated on the form titled
“Renewal Licensing Required Documents”

excerpt:
All required policies and procedures as
identified in the “Umbrella Rules”

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(a) Adequate furnishings and personal items An exception request was granted for the 2020-2022
licensing period for the windows to be secure in The Ranch
facility.
CORRECTIVE ACTION: Submit new exception request for
licensing period 2022-2024 for windows to continue to remain
fixed.

excerpt:
(c) Outside room with window allowing
egress from building

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(2)(a) Written emergency plan Evacuation and fire drills were not conducted on a monthly
basis, and nearly a year’s worth of drills was not logged. The
program has been consistent in conducting them for the last
few months.
CORRECTIVE ACTION: Ensure drills are being conducted
on a monthly basis and documented accurately.

excerpt:
(3)(a) Evacuation drill occurs monthly under
varying conditions, is retained 2 yrs and
contains;
(A) identify of person conducting drill
(B) date & time
(C) notification method
(D) staff participating
(E) # of children & staff evacuated
(F) special conditions simulated
(G) problems encountered
(H) time to complete

excerpt:
(a) Agency policies and procedures New employee trainings are being completed, and all topics
are being covered. However, documentation in 4 out of 5
files reviewed did not indicate the trainings were being
completed within 30 days of hire.

excerpt: (b) Ethical and professional guidelines

excerpt: (c) Organizational lines of authority

excerpt: (d) Attributes of population served

excerpt:
(e) & (5)(a) to (c) Mandatory reporting that
includes:

excerpt:
(a) legal definition of child abuse ORS
419B.005, Oregon Laws 2016, chapter 106,
section 36
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to
the employee CORRECTIVE ACTION: Ensure that all employees are
receiving the New Employee Orientation trainings within 30
days of hire and trainings are documented as occurring in
that time frame.

excerpt: (f) Privacy laws

excerpt: (g) Emergency procedures

excerpt:
(1)(a) Discipline and behavior management
including de-escalation, crisis prevention,
positive behavior management, and
disciplinary techniques that are non-punitive
in nature New employee trainings are being completed, and all topics
are being covered. However, documentation in 4 out of 5
files reviewed did not indicate the trainings were being
completed within 30 days of hire.
CORRECTIVE ACTION: Ensure that all employees are
receiving the New Employee Orientation trainings within 30
days of hire and are documented as occurring in that time
frame.
The program is not currently training staff for restraints or
utilizing restraints in the program. Only 1 of the 5 files reviewed included a consent for the
reasonable and prudent parent standard.
CORRECTIVE ACTION: Ensure that all required consents
are in each resident’s file moving forward.

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(g) Apply the reasonable and prudent parent
standard

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(a)The name, gender, date of birth, religious
preference, and previous address

excerpt:
(b) Intake document is completed the date
child accepted into care (emergency
placement 48 hours) One of the files reviewed indicated the Assessment was
completed on day 52.
CORRECTIVE ACTION: The program will ensure that all
Assessments are completed within the 45 day timeline.

excerpt:
(d) Assessment is completed within 45 days
and contains relevant historical info., current
behavioral observations, identified need for
services, and how agency will provide
services