facility_name: Harkins House

summary: Unannounced - 3 findings

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Licensee: Washington County Juvenile Harkins House
Executive Director: Lynne Schroeder
Program Director(s): LaRoy LaBonte
Date of Unannounced: August 5, 2021
Licensing Coordinator: Todd Cooley
Other Regulatory or Accrediting Agencies: n/a
Purpose: Per OAR 413-215-0101 (1) (b) Children’s Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Comments
Findings
Further Action
Needed
413-215-0046(3)(a) Foster Rights Posted (if Yes☐ No  Foster Rights not posted in the program.
children in DHS custody) - Foster Rights were posted in multiple easy to access locations throughout the
program
New Employee Orientation – Umbrella Yes☐ No  Organizational lines of authority was not documented in the New Employee Orientation.
Requirements (30 days) - Organizational lines of authority is displayed in the employee handbook which is
413-215-0061(4) (c) Organizational lines of provided to all new employees during orientation. Harkins House is adding a
authority separate box to the training checklist to easily identify this requirement and
acknowledge the handbook was received by the employee.
413-215-0061(5) Mandatory reporting Yes☐ No  There was inconsistent documentation of mandatory
(annually) that includes: reporter training on an annual basis.
(a) legal definition of child abuse ORS - Annual training has not been conducted for mandatory reporting this year. Will
419B.005, Oregon Laws 2016, chapter 106, verify at next review or unannounced visit.
section 36
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to
the employee
1
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 200115)
Yes☐ No☐
New Findings from Site Visit Comments
No new findings
Interview Summary
Two youth were on-site and able to be interviewed at the time of the unannounced visit. Both youths had been at the program for about a
month and neither had been at any other residential programs.
The first youth interviewed stated they thought the program was really great. They were working on graduating a year early and are hoping to
remain in the program to focus on finishing school without the distractions they have at home. This youth is exploring military options along with
other higher education opportunities after graduation. The client stated they feel safe in the program and are very comfortable with all of the
staff. They said the food is “so good” and that they probably eat too much because it is good. Their favorites are the tortellini and French toast.
Snacks are always available and they are never hungry.
Youth stated they go on outings about twice a week and do activities like fishing and swap meets. They said they enjoyed the fishing because
at home they like to fly fish. They have daily recreation and all the youth like to play volleyball, so that is what they do most often. Youth said
they have lots of community (church) and family support and can make daily phone calls to stay in touch.
Youth had nothing negative to say about the program and said all the staff are great. They also said the groups are very helpful as they help
them understand what they can be doing better. They stated they participate in two groups a day. The first is a goals group and the second
rotates and could be on a variety of topics.
The second youth also stated they like Harkins House very much. They love helping in the kitchen and the food is amazing. Pizza, Fish and
Fried Rice are at the top of their list of favorites. There is always lots of food and snacks available.
This youth stated school was good, but there are times they have a hard time processing things. Stated they participate in recreation at least
three times a day and play lots of volleyball and ping pong tournaments. On outings they have enjoyed hiking and bird watching. This youth
also spoke of the Summer Works program farm and said the work is hard, but they like going out there. They typically do things around the
farm like clean out pig pens.
Client stated they have plenty of time to talk with family, 10-minute phone calls three times a day. Also stated they appreciate getting a 2-
minute warning, so they have time to say goodbyes before needing to get off the phone. Youth said staff all do a really good job of helping out
and reminding them to stay on track. This client also spoke of the daily groups and thought they were really good.
2
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 200115)
Observations
A walkthrough of all shared spaces, kitchen, bathrooms/showers, bedrooms, classrooms, and outdoor spaces was conducted during this
unannounced. The living spaces are always well kept and clean during unannounced visits and reviews. This was no exception. Youth have
daily chores and staff do a great job of ensuring these chores are followed through on. You get the sense both youth and staff take pride in
their space.
Having a full time cook in the program continues to be a positive for Harkins House. The kitchen is also in the process of getting site certified by
Summer Works. Harkins House currently partners with Summer Works and Central Cultural which allows their youth to gain job skills, earn
education credits, and even a stipend. This is mainly done on a local farm at the moment, but once the kitchen is certified youth will be afforded
the same opportunities in program. The program appears to be very popular with those who have participated.
Corrective Actions and Timeframes:
Please submit the following to verify compliance.
Within 45 days of receipt of this report Washington County Juvenile Harkins House 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, todd.cooley@dhsoha.state.or.us or sent by regular mail to the following address:
Department of Human Services
Children’s Care Licensing Program
Attn: Todd Cooley
201 High St. SE Suite 500
Salem, OR 97301
8-19-2021
Licensing Coordinator’s Signature: ________________________ Date: ___________________
8-18-2021
Manager Review: ______________________________________ Date: __________________
3
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 200115)

agency_name: Washington Cty. Juvenille Dept. (WCJD)

program_name: Harkins House

executive_director: Lynne Schroeder

program_director: LaRoy LaBonte

visit_date: August 5, 2021

licensing_coordinator: Todd Cooley

purpose:
Per OAR 413-215-0101 (1) (b) Children's Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Comments
Findings
Further Action
Needed
413-215-0046(3)(a) Foster Rights Posted (if Yes[ ] No - Foster Rights not posted in the program.
children in DHS custody) - Foster Rights were posted in multiple easy to access locations throughout the
program
New Employee Orientation - Umbrella Yes[ ] No - Organizational lines of authority was not documented in the New Employee Orientation.
Requirements (30 days) - Organizational lines of authority is displayed in the employee handbook which is
413-215-0061(4) (c) Organizational lines of provided to all new employees during orientation. Harkins House is adding a
authority separate box to the training checklist to easily identify this requirement and
acknowledge the handbook was received by the employee.
413-215-0061(5) Mandatory reporting Yes[ ] No - There was inconsistent documentation of mandatory
(annually) that includes: reporter training on an annual basis.
(a) legal definition of child abuse ORS - Annual training has not been conducted for mandatory reporting this year. Will
419B.005, Oregon Laws 2016, chapter 106, verify at next review or unannounced visit.
section 36
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to
the employee
1

Yes[ ] No[ ]
New Findings from Site Visit Comments
No new findings
Interview Summary
Two youth were on-site and able to be interviewed at the time of the unannounced visit. Both youths had been at the program for about a
month and neither had been at any other residential programs.
The first youth interviewed stated they thought the program was really great. They were working on graduating a year early and are hoping to
remain in the program to focus on finishing school without the distractions they have at home. This youth is exploring military options along with
other higher education opportunities after graduation. The client stated they feel safe in the program and are very comfortable with all of the
staff. They said the food is "so good" and that they probably eat too much because it is good. Their favorites are the tortellini and French toast.
Snacks are always available and they are never hungry.
Youth stated they go on outings about twice a week and do activities like fishing and swap meets. They said they enjoyed the fishing because
at home they like to fly fish. They have daily recreation and all the youth like to play volleyball, so that is what they do most often. Youth said
they have lots of community (church) and family support and can make daily phone calls to stay in touch.
Youth had nothing negative to say about the program and said all the staff are great. They also said the groups are very helpful as they help
them understand what they can be doing better. They stated they participate in two groups a day. The first is a goals group and the second
rotates and could be on a variety of topics.
The second youth also stated they like Harkins House very much. They love helping in the kitchen and the food is amazing. Pizza, Fish and
Fried Rice are at the top of their list of favorites. There is always lots of food and snacks available.
This youth stated school was good, but there are times they have a hard time processing things. Stated they participate in recreation at least
three times a day and play lots of volleyball and ping pong tournaments. On outings they have enjoyed hiking and bird watching. This youth
also spoke of the Summer Works program farm and said the work is hard, but they like going out there. They typically do things around the
farm like clean out pig pens.
Client stated they have plenty of time to talk with family, 10-minute phone calls three times a day. Also stated they appreciate getting a 2-
minute warning, so they have time to say goodbyes before needing to get off the phone. Youth said staff all do a really good job of helping out
and reminding them to stay on track. This client also spoke of the daily groups and thought they were really good.
2

Observations
A walkthrough of all shared spaces, kitchen, bathrooms/showers, bedrooms, classrooms, and outdoor spaces was conducted during this
unannounced. The living spaces are always well kept and clean during unannounced visits and reviews. This was no exception. Youth have
daily chores and staff do a great job of ensuring these chores are followed through on. You get the sense both youth and staff take pride in
their space.
Having a full time cook in the program continues to be a positive for Harkins House. The kitchen is also in the process of getting site certified by
Summer Works. Harkins House currently partners with Summer Works and Central Cultural which allows their youth to gain job skills, earn
education credits, and even a stipend. This is mainly done on a local farm at the moment, but once the kitchen is certified youth will be afforded
the same opportunities in program. The program appears to be very popular with those who have participated.

new_findings: No new findings

excerpt:
413-215-0061(5) Mandatory reporting Yes[ ] No - There was inconsistent documentation of mandatory
(annually) that includes: reporter training on an annual basis.
(a) legal definition of child abuse ORS - Annual training has not been conducted for mandatory reporting this year. Will
419B.005, Oregon Laws 2016, chapter 106, verify at next review or unannounced visit.
section 36
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to
the employee
1
Yes[ ] No[ ]
New Findings from Site Visit Comments
No new findings
No new findings


state: OR

summary: License Renewals - 24 findings

raw_content:
Licensed Child Caring Agency Site Visit Report
Residential Care
Licensee: Washington County Juvenile Department Board Chairperson: Kathryn Harrington
Shelter Manager: LaRoy LaBonte Date of site visit: 06/02/22
Juvenile Services Supervisor: Carol Anderson Licensing Coordinator: Mary Torres
Other Regulatory or Accrediting Agencies: Oregon Department of Education (ODE), Oregon Health Authority (OHA), Oregon Department of
Human Services (ODHS)
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: As written on the program’s website, the Washington County Juvenile Shelter (Harkins House) is a short term temporary
residential shelter care and evaluation program. The program provides evaluation and individual care for delinquent youth pending alleged
violations of the law who volunteer to participate in lieu of detention. The program has capacity for eighteen youth, both boys and girls between the
ages of twelve and seventeen years old. Professional staff work 24/7 assisting in the daily care and supervision of each youth while documenting
and reporting their observation and recommendations in a final report to the Juvenile Court. The program performs a comprehensive evaluation of
each youth assessing the youth’s response to a well-defined set of rules and expectations, opportunities for positive recreational, artistic, and
cultural activities, school, and individual and family counseling. Both personal responsibility and maintaining respectful behavior are strongly
emphasized. The program partners with Hillsboro School District for the operation of an on-site year-round public school. Family counseling
services are provided to all youth and their family through Youth Contact.
Program type and services: Harkins House Basic Residential provides youth with individual and group skill building, individual counseling, parent
training, recreational activities, and opportunities for community outings.
Capacity and Age Range: 18 youth, ages 12 – 17 years old
Funding, Contracts, and referral sources: Washington County general fund, Oregon Department of Education (ODE), Oregon Health Authority
(OHA), Oregon Department of Human Services (ODHS)
(rev. 03/25/2021)
Average length of stay: 57 days
Average daily population served: 7 youth
Number of children served annually: 45 youth
Use of seclusion or restraint: The program does not utilize the use of seclusion and/or restraint. Staff are trained in Crisis Prevention Institute
(CPI) – Nonviolent Crisis Prevention
Interviews, Observations: The tour of the facility was led by the Juvenile Services Supervisor. Conversations were held with various staff
members and three youth were interviewed. Managers identify COVID as a major struggle this last licensing period. This translated to limited
employee training, transitional visits for residents and staffing shortages. Despite challenges, the program remains forward thinking, looking at
creating a youth advisory council and revising the program’s curriculum. There are currently 14 youth in program. The program works closely with a
nearby farm where youth are allowed to work and harvest seasonal fruit and vegetables. Youth will also prepare meals for peers with this produce.
All youth report having positive experiences in the program. Youth report feeling safe and are comfortable approaching any staff member with
concerns and/or questions. Staff are reportedly well trained and are readily available to youth. Identified strengths of the program include outings,
group sessions, the amount of family contact and being able to wear their own clothing. Areas of improvement include being able to double up
mattresses as a single mattress does not provide enough support and the length of “down time” youth are expected to take alone in their bedrooms,
another youth encouraged staff to provide “more supervision” when youth circle up and talk among themselves. This youth stressed the importance
of staff knowing what youth are talking about for safety reasons. Management was advised of this very specific request. It was acknowledged that
this particular youth is triggered when there is a sense that their safety could be compromised. Staff understand this particular youth’s needs and
are prepared to intervene if needed. Youth report daily contact with family members. Given the program’s current milieu size, phone calls are
limited to ten minutes, allowing all youth to have some family contact daily. When census is low, youth are given more phone time.
Program Strengths: Strengths summarized by the program are as follows: The core of the leadership and residential staff has remained consistent
for the last 5 years. Staff that work in the facility have a passion to serve the high-risk youth that come into our facility. All staff are trained in
trauma informed care and discussions routinely occur in regard to issues of equity for the youth we serve. We consider our program a hands-off
facility – the only times staff have needed to assist in intervening physically has been when the Juvenile Department Custody Services Unit is taking
our youth into custody for violating conditions of release/probation. We are continuing to improve at giving youth and families more of a voice in
their planning and setting goals. We strive to create as much of a home-like environment as possible where the youth participate in daily chores to
help keep the facility clean. While the pandemic has been difficult on all of us, the staff have been resilient. In the summer of 2020, we changed
from a BRS Shelter Evaluation Facility to a Basic Residential Facility and now offer additional services to the youth in our care.
Program Challenges: The program reports that the COVID-19 pandemic has been a struggle for staff and youth in our facility. We have limited
visitation and home visits in an effort to ensure the safety of youth and staff. We have experienced a large amount of staff turnover starting in
2
September 2021 and we are still not fully staffed. We have three vacant positions as I fill out this form. For over two years we capped our
population at 9 youth to allow for social distancing. We have recently increased that cap to 14 youth and so our staff are adjusting to supervising a
larger population of high-risk youth. With restrictions on the size of gatherings over the last two years and the staff transition, it has been difficult to
provide and offer training to the entire team on a structured, regular basis.
Changes that have occurred in the last 2 years: The program shares the following changes: Changes reported by the program include our
facility from a BRS Shelter Evaluation program to a BRS basic residential program in the summer of 2020. This requires our staff to provide
additional services and results in an increased workload. We have also experienced a large turnover during the pandemic and still have three
vacant Juvenile Counselor 1 positions. The hiring pools are getting smaller and the experience level in applicants overall has decreased. Despite
this we have been able to hire a number of smart, talented team members who have a passion for this work. In addition, we have recently hired a
Juvenile Services Supervisor for Harkins House who will assist the Program Manager in guiding and directing the work our staff members do for the
youth and families.
Lawsuits: None reported as per the program.
Grievances and complaints filed in the last two years: As reported by the program: We have had grievances filed. The vast majority, if not all,
are grievances due to consequences the youth have received and the youth are unhappy. On two occasions I spoke with the parents about their
concerns regarding consequences and/or staff actions. All grievances were resolved through conversations and listening to the concerns of
youth/parents. On two or three occasions, youth exited the program prior the grievance being addressed due to my lack of availability during those
times. We have changed our policy to allow any lead or supervisory staff to respond to grievances. Grievances are put in the youth’s files.
Corrective Actions and Timeframes: Please submit the following to verify compliance.
Within 45 days of receipt of this report Washington County Juvenile Department must submit a letter of verification indicating the agency is in
compliance with the specific rules cited above and describing how compliance will be maintained going forward. Along with the letter of verification,
the agency must submit any and all specific documentation requested in the body of this report. The letter of verification and any additional
requested documents can be emailed directly to Mary Torres at mary.torres@odhsoha.oregon.gov or sent by regular mail to the following address:
Department of Human Services, Children’s Care Licensing Program
Attn: Mary Torres
201 High St SE, Suite 500
Salem, OR 97301
Exceptions: There have been no requested exceptions over the last licensing period.
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 A copy of the program’s quality improvement plan was not
(2)(l) Meeting minutes X submitted to Licensing for review.
CORRECTIVE ACTION: Submit a copy of the program’s
quality improvement plan to Licensing.
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 A new criminal background check is required for the Shelter
(3)(g) Approval from BCU X Manager for the new licensing period.
CORRECTIVE ACTION: Request and submit a copy of the
Shelter Manager’s newly approved background check for this
new licensing period.
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
4
(3)(e) Agency uses seclusion
X
appropriately/consistent with policy
(4) Agency has adequate plan in place to
X
respond to suicidal behavior/warning signs
Contractors (if applicable) Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0061(6) Completed
(a) Agency ensures the contractor meets the
requirements of this rule and Chapter 413 X
division 215
(b)(B) Contract includes the following:
(i) Services provided
(ii) Contractor fees
(iii) Disclosure of information from contractor
to agency
(iv) Lines of authority X
(v) Adherence to rules, including background
check
(vi) Any liability of the agency for acts of the
contractor, rights of indemnity and limitations
on liability
Supplemental Information Provided by Corrective Action
Yes No N/A Corrective Actions/Comments
CCA Completed
Documents as indicated on the form titled - Certification of Occupancy was not submitted
“Renewal Licensing Required Documents” - Submitted Environmental Health Inspection was
incomplete.
X CORRECTIVE ACTION:
- Submit copy of Certificate of Occupancy.
- Resubmit completed inspection form that is signed,
dated, and indicates if the inspection was approved
or not approved.
Documents as indicated on form titled
“Required Financial Documents and X
Information”
All required policies and procedures as - Conflict of Interest was not submitted for review.
identified in the “Umbrella Rules” - Youth and Parent Rights requires modification.
- Grievance Policy requires modification.
- Mandatory Reporting Policy requires modification.
CORRECTIVE ACTION:
- Submit copy of Conflict-of-Interest Policy
- Revise 6.2.1 Youth and Parent Rights to include
highlighted information.
5
413-215-0046 Licensing Umbrella Rules: Children
and Families Rights Policy and Grievance
Procedures (Amended 1/1/19)
(a) Except as provided in paragraph (B) of this
subsection, the child in care's right to uncensored
communication with legal guardians, caseworkers, legal
representatives, and other persons approved for
communication by the legal guardian or as provided in a
court order.
(A) This right cannot be waived, including voluntarily.
Restriction on communication between a child in care
and his or her legal guardian may not be a condition of
participation in the program.
(B) A child-caring agency may place reasonable limits
on communication, but only as provided in the child-
caring agency's policy. Reasonable limits include, but
are not limited to, having set time periods during the day
for visitation and phone calls and imposing moderate
limits on the duration of calls or visits. However, a
limitation is not considered reasonable if it prevents the
ability to meaningfully communicate, such as not
allowing contact with a child in care's attorney during
regular business hours.
(b) The child in care's right to privacy.
(c) The child in care's right to participate in service
planning or educational program planning.
(d) The child in care's right to fair and equitable
treatment.
(e) The child in care's right to file a grievance (as
provided in section (2) of this rule) if the child in care or
family feels that they are treated unfairly or if they are
not in agreement with the services provided.
(h) The child in care's right to an appropriate education.
(i) The child in care's right to participate in recreation
and leisure activities.
(j) The child in care's right to have timely access to
physical and behavioral health care services
6
- Revise 6.2.4 Grievance Policy to include
highlighted information.
413-215-0046 Licensing Umbrella Rules: Children
and Families Rights Policy and Grievance
Procedures (Amended 1/1/19)
2) Grievance Procedures.
(a) The procedures must include all of the following:
(B) A prohibition of reprisal or retaliation against any
individual who files a grievance.
(C) A procedure to follow, in the event the grievance is
filed against the executive director, that ensures that the
executive director does not make the final decision on
the grievance.
(D) The name, address, and phone number of: (i) A
Department licensing coordinator; Mary Torres, 201
High St SE Suite 500 Salem OR 97301 503-798-5300
(ii) Any other governmental entities with oversight
responsibilities.
- Revise 6.4.3 Mandatory Reporting Policy to
include highlighted information.
413-215-0056 Licensing Umbrella Rules: Policies and
Procedures (Amended 1/1/19)
(B) Receive child-caring agency-provided training on
mandatory abuse reporting requirements as part of
employee orientation and at least annually thereafter as
described in OAR 413-215-0061.
(C) Receive child-caring agency-provided training on
the definitions of child abuse in ORS 418.257 and
419B.005 that apply in child-caring agencies
Update hotline # to the current Oregon Child Abuse
Hotline (ORCAH) as the number listed in the policy is
disconnected. ORCAH # 855-503-7233
All required policies and procedures as
X
identified in “Agency Type Specific Rules”
7
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 Window sills located in the wellness room and in bedroom
smoke free, clean and in good repair #281 located in the blue dorm are damaged and/or have
413-215-0511(2)(d) Rooms are free of X etched in words/symbols associated with gang affiliation.
harmful drafts, odors, and excessive noise
413-215-0511(2)(e) Rooms are adequate in X
CORRECTIVE ACTION: Repair damaged window sills and
size and arrangement
submit photos of repaired areas
413-215-0511(2)(f) System provides a X
continuous supply of hot and cold water to
taps located throughout the facility
Staff report that during the summer, the facility’s air
413-215-0511(2)(h) Building is well X
conditioner does not effectively cool the facility.
ventilated and room temperature is within a
normal comfort range
CORRECTIVE ACTION: Address concern with facilities to
413-215-0516(1) All parts of the facility X
resolve or improve the facility’s cooling system.
ensure the safety of children
Room and Space Requirements Corrective Action
Yes No N/A Corrective Actions/Comments
Bedrooms 413-215-0516(3) Completed
(a) Adequate furnishings and personal items X
(b) Separate from rooms used for dining, X
living, laundry, kitchen, and storage
(c) Outside room with window allowing X
egress from building
(d) Ceiling at least 90 inches X
(e) Minimum 60 SF per bed X
(f) No more than 25 if dorm style X
(g) Permanently wired fixtures X
(h) Window covering X
(i) Beds are 3 feet apart and maintained to X
ensure safety
Room and Space Requirements Corrective Action
Yes No N/A Corrective Actions/Comments
Bathrooms 413-215-0516(4) Completed
(a)(A)&(B) 1:8 ratio for toilets and sinks X
(a)(D) Hot and cold running water, soap, and X
approved hand drying options
(a)(E) 1:10 ratio for shower or bathtub X
8
(a)(E) Individual privacy X
(a)(F) Window covering X
(a)(G) Permanently wired fixtures X The bathroom and shower areas do not appear to have a
(a)(H) Adequate ventilation X working ventilation system.
(b)&(c) Wooden racks on floors are X
prohibited and impervious shower mats are CORRECTIVE ACTION: Follow up with facilities and explore
disinfected & dried daily ventilation options for the bathrooms and shower areas.
Room and Space Requirements Corrective Action
Yes No N/A Corrective Actions/Comments
Kitchen 413-215-0516(6) Completed
(a) Used exclusively for storage, food X
preparation, dish washing and activities
related to eating
(b) Walls, floors are easily cleanable X
(c) Equipment and utensils are easily X
cleanable, durable, nontoxic, and kept clean
(e) Equipment is easy to clean beneath, X
between and behind
Room and Space Requirements Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0516 Completed
(2) There is a separate living room or lounge X
area – 15 SF minimum per child
(5) There is a separate dining room with X
capacity for ½ of children in care and 15 SF
per child in care
(7) Laundry is separate from living areas, X
kitchen, and dining
(8) Separate storage areas are provided for X
food, kitchen supplies, utensils, clean linens,
soiled linens and clothing, cleaning supplies
and equip, poisons, chemicals, outdoor
recreational and maintenance equipment
(9) Outdoor activity area is protected from X
vehicles and other hazards and of a size and
availability appropriate to the age and needs
of children in care
(11) & 413-215-0076(3)(c)(C)Time out rooms X
have adequate space, heat, light and
ventilation and is not capable of locking
Furnishings and Personal Items Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0521 Completed
(1) There is a bed with frame, clean mattress X
and pillow and personal storage (dresser,
closet)
9
(2) Linens are in good repair. There is a X
waterproof mattress cover or mattress.
Linens are appropriate and towels and
washcloths are provided
(3) Bedding is changed weekly or when X
soiled
(4)&(5) Personal hygiene supplies and X
appropriate clothing are provided
Food Services Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0536(1)&(2) Completed
(1)(a) Meals are arranged daily, consistent X
with normal mealtimes that occur during the
hours of operation
(1)(b) Menus are prepared in advance in X
accordance with USDA guidelines, provide a
variety of foods and are adjusted for
seasonal changes.
(1)(b) Menus are kept for at least 6 months X
(1)(c) Drinking water is freely available X
(2)(a) Food is stored, prepared & served in a X
sanitary manner
(2)(c) & (d) Food products are obtained from X
commercial suppliers (exception of fruits &
vegetables), unpasteurized juice is
prohibited, and only Grade A pasteurized
and fortified milk in appropriate container.
Safety Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0541 Completed
(2)(a) Written emergency plan X
(2)(b) Telephone numbers for local police X
and fire are posted near all telephones
(2)(c) Operative flashlights sufficient in X
number are readily available to staff
(3)(a) Evacuation drill occurs monthly under X Evacuation drills were not submitted for review
varying conditions, is retained 2 yrs., and
contains; CORRECTIVE ACTION: Submit a copy of evacuation drills
(A) identify of person conducting drill for 2020 thru May of 2022.
(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
10
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.
(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 The program’s existing medication logs maintained for each
medication includes: youth does not reflect possible adverse reactions related to
(a) name the medication being taken.
(b) description
(c) dates and times CORRECTIVE ACTION: Develop a process where possible
(d) missed doses adverse reactions are documented on youths’ medication
(e) medication disposed logs.
(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
11
Minimum Staffing Requirements Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0561 Completed
(1)&(2) Supervision is adequate for the type X
of program, location, age and type of
children, ability of supervisor to respond,
electronic back-up systems.
Minimum ratios are maintained:
Under 30 months of age: 1:4
30 months to ˃ 6 yrs. or non-ambulatory: 1:6
Ages 6 and older: 1:7
Overnight (staff awake)
1:10
(4)(a) When one staff on duty, there is X
additional staff immediately available with
max response time of 30 minutes
(5) There is at least one on-site employee X
authorized to apply the reasonable and
prudent parent standard
Separation of Residents Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0566 Completed
(1) Children are in separate bedrooms than X
adults, unless parent and child, or there is
written approval from guardian/parent and
licensing coordinator
(2) There is adequate supervision of children X
if both males and females are served by the
program
Personnel Files Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0061 Completed
Staff Name/Position 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
12
(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
(b) Ethical and professional guidelines X
One out of three new hire files did not reflect training in the
(c) Organizational lines of authority X
following areas:
(d) Attributes of population served X
- Agency policies and procedures
(e) & (5)(a) to (c) Mandatory reporting that
- Ethical and professional guidelines
includes:
- Organizational lines of Authority
(a) legal definition of child abuse ORS
- Attributes of Population Served
419B.005, Oregon Laws 2016, chapter 106,
X - Privacy Laws
section 36
(b) legal responsibility to immediately report
CORRECTIVE ACTION: Ensure that new hires are receiving
(c) legal responsibility to report is personal to
the required training and the completed training is
the employee
appropriately documented in their respective personnel file.
(f) Privacy laws X
(g) Emergency procedures X
New Employee Orientation – Residential
Corrective Action
(30 days) Yes No N/A Corrective Actions/Comments
Completed
413-215-0556
(1)(a) Discipline and behavior management
including de-escalation, crisis prevention,
positive behavior management, and X
disciplinary techniques that are non-punitive
in nature
(1)(b) Restraint and seclusion (if applicable) X
Ongoing Training Corrective Action
Yes No N/A Corrective Actions/Comments
Completed
413-215-0536(2)(b) Employees who handle X
food served to children have a valid food
handler’s card
13
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 One out of two established staff members did not reflect
emergencies
completion of required annual training in the following areas:
413-215-0556(2)(b) Universal Precautions X - Discipline and Behavior Management
413-215-0556(2)(c) Discipline and Behavior - CPR/1st Aid
X
Management - Mandatory Reporting
413-215-0556(3) Staff providing direct care
must maintain current CPR/First Aid X
CORRECTIVE ACTION: Ensure that employees are
certification
receiving the required annual training and the completed
413-215-0556(4) Designated staff authorized
training is appropriately documented in their respective
to apply reasonable and prudent parent
X
personnel file.
standard are trained in application of the
standard
413-215-0061(5) Mandatory reporting
(annually) that includes:
(a) legal definition of child abuse ORS
419B.005, Oregon Laws 2016, chapter 106,
X
section 36
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to
the employee
Comments:
Children’s Records Corrective Action
Yes No N/A Corrective Actions/Comments
Completed
Health Services
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)
14
(2)(e) Documentation of age-appropriate Confirmation regarding the documentation of age-appropriate
instruction – pregnancy prevention, nutrition, instruction could not be found after the review of youth files.
prevention of HIV & AIDS, and prevention X
and treatment of sexually transmitted CORRECTIVE ACTION: Create a process where age-
disease appropriate instruction in the areas listed is documented in
(4)(a) to (f) Medical exams (3 in first year of the youth’s respective files.
life, 2,4,6,9,14) X
Consents Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0576(1) Completed
(a) Provide routine and emergency medical
X
care
(b) Use the discipline and behavior Consent to provide routine and emergency medical care
management system X could not be located in the program’s intake packet.
(c) Use restraint or seclusion (if applicable).
CORRECTIVE ACTION: Demonstrate that this consent
Must specify the reasons for the intervention X
exists within the program’s intake process. If one does not
and how staff are trained and supervised
exist, create, and implement the required consent.
(d) Restrict contact with persons outside of
X
the agency
(e) Allow access as defined in 413-215-0091
& 0101
X
See comment section below regarding intake consent
(f) Impose a dress code X
packet.
(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
15
Authorization for pre-approved potentially hazardous
(d) Activity specific authorizations are pre- activities could not be found in the youth files reviewed.
approved to allow children to participate in
potentially hazardous activities, including but X CORRECTIVE ACTION: Create an authorization related to
not limited to using motorized yard potentially hazardous activities and ensure this authorization
equipment, swimming, and horseback riding. is signed at the time of intake by the youth and/or legal
guardian.
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 There is no designated space to capture a youth’s religious
X
preference, and previous address preference on the youth’s summary sheet.
(b) Name and location of previous and
X
current school CORRECTIVE ACTION: Modify the existing summary/face
(c) Date of admission X sheet to include religious preference.
(d) Legal custody X
(e) The name, address, and telephone
number of:
(A) The child in care's parents.
(B) The child in care's legal guardian, if
different than the parents, and a copy of
X
the document that provides for his or her
authority over the child in care.
(C) Other persons significant to child
(D) Other professionals to be involved in
service planning (if applicable)
Service Planning Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0581(2) Completed
(b) Intake document is completed the date
child accepted into care (emergency X
placement 48 hours)
(d) Assessment is completed within 30 days
and contains relevant historical info., current
behavioral observations, identified need for X
services, and how agency will provide
services
(e) (A)&(B) Service plan within 60 days
(parent, guardian and child actively
involved). Describes how child’s issues will X
be addressed, anticipated outcomes, and
reviewed by child and guardian/parent.
16
(e)(C)&(D) Service plan is reviewed quarterly Given the short length of stay for most youth, youth are
and revised when information indicates other X discharged prior to their service plan being reviewed on a
services should be provided quarterly basis.
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
See comment section below regarding incident reports.
(b)-(d) discharge planning and instructions X
(f) Incident Reports X
Financial Records Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0581(4) Completed
Records contain date, amount, source,
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
complete, containing all required info. No
eraser tape or white out.
(7) Permanent registry for each child
includes:
Name
Gender
X
Birth date
Names, addresses of parents or guardians
Dates of admission
Placement upon discharge
Comments:
The program was advised to forward all critical events documented in incident reports to Licensing as required by rule effective immediately. See related
licensing rule for reference.
413-215-0091 Licensing Umbrella Rules: Responsibilities of Licensees (Amended 1/1/19)
A licensee is responsible to do all of the following:
(11) Notify the Department in the following circumstances:
17
(b) Within one business day if a critical event occurs. As used in this section, "critical event" means a significant event occurring in the operation of a child-
caring agency that is considered likely to cause complaints, generate concerns, or come to the attention of the media, law enforcement agencies, first
responders, Child Protective Services, or other regulatory agencies. Compliance with this notification requirement does not satisfy mandatory child abuse
reporting requirements under ORS 419B.005 to 419B.045.
The program provides a consent intake form in Spanish for their monolingual Spanish speaking youth and families. A review of these Spanish forms indicate
that some information is missing and does not match the English consent intake forms provided to English speaking and/or bilingual youth and families.
CORRECTIVE ACTION: Review the translated forms and ensure the document holds that same information that is provided to English.
Licensing Coordinator’s Signature: ________________________ Date: ___________________
Manager Review: ______________________________________ Date: _0_7_/0_8_/_2_0_2_2_________
18

program_type: (RC) Residential Care Programs

report_type: License Renewals

view_code: RC

facility_type: Residential Care

licensing_coordinator: Mary Torres

program_description:
As written on the program's website, the Washington County Juvenile Shelter (Harkins House) is a short term temporary
residential shelter care and evaluation program. The program provides evaluation and individual care for delinquent youth pending alleged
violations of the law who volunteer to participate in lieu of detention. The program has capacity for eighteen youth, both boys and girls between the
ages of twelve and seventeen years old. Professional staff work 24/7 assisting in the daily care and supervision of each youth while documenting
and reporting their observation and recommendations in a final report to the Juvenile Court. The program performs a comprehensive evaluation of
each youth assessing the youth's response to a well-defined set of rules and expectations, opportunities for positive recreational, artistic, and
cultural activities, school, and individual and family counseling. Both personal responsibility and maintaining respectful behavior are strongly
emphasized. The program partners with Hillsboro School District for the operation of an on-site year-round public school. Family counseling
services are provided to all youth and their family through Youth Contact.

capacity_age_range: 18 youth, ages 12 - 17 years old Funding, Contracts, and referral sources: Washington County general fund, Oregon Department of Education (ODE), Oregon Health Authority (OHA), Oregon Department of Human Services (ODHS)

average_length_of_stay: 57 days

average_daily_population_served: 7 youth

number_of_children_served_annually: 45 youth

use_of_seclusion_or_restraint: The program does not utilize the use of seclusion and/or restraint. Staff are trained in Crisis Prevention Institute (CPI) - Nonviolent Crisis Prevention

interviews_observations:
The tour of the facility was led by the Juvenile Services Supervisor. Conversations were held with various staff
members and three youth were interviewed. Managers identify COVID as a major struggle this last licensing period. This translated to limited
employee training, transitional visits for residents and staffing shortages. Despite challenges, the program remains forward thinking, looking at
creating a youth advisory council and revising the program's curriculum. There are currently 14 youth in program. The program works closely with a
nearby farm where youth are allowed to work and harvest seasonal fruit and vegetables. Youth will also prepare meals for peers with this produce.
All youth report having positive experiences in the program. Youth report feeling safe and are comfortable approaching any staff member with
concerns and/or questions. Staff are reportedly well trained and are readily available to youth. Identified strengths of the program include outings,
group sessions, the amount of family contact and being able to wear their own clothing. Areas of improvement include being able to double up
mattresses as a single mattress does not provide enough support and the length of "down time" youth are expected to take alone in their bedrooms,
another youth encouraged staff to provide "more supervision" when youth circle up and talk among themselves. This youth stressed the importance
of staff knowing what youth are talking about for safety reasons. Management was advised of this very specific request. It was acknowledged that
this particular youth is triggered when there is a sense that their safety could be compromised. Staff understand this particular youth's needs and
are prepared to intervene if needed. Youth report daily contact with family members. Given the program's current milieu size, phone calls are
limited to ten minutes, allowing all youth to have some family contact daily. When census is low, youth are given more phone time.

program_strengths:
Strengths summarized by the program are as follows: The core of the leadership and residential staff has remained consistent
for the last 5 years. Staff that work in the facility have a passion to serve the high-risk youth that come into our facility. All staff are trained in
trauma informed care and discussions routinely occur in regard to issues of equity for the youth we serve. We consider our program a hands-off
facility - the only times staff have needed to assist in intervening physically has been when the Juvenile Department Custody Services Unit is taking
our youth into custody for violating conditions of release/probation. We are continuing to improve at giving youth and families more of a voice in
their planning and setting goals. We strive to create as much of a home-like environment as possible where the youth participate in daily chores to
help keep the facility clean. While the pandemic has been difficult on all of us, the staff have been resilient. In the summer of 2020, we changed
from a BRS Shelter Evaluation Facility to a Basic Residential Facility and now offer additional services to the youth in our care.

lawsuits: None reported as per the program.

grievances_and_complaints:
As reported by the program: We have had grievances filed. The vast majority, if not all,
are grievances due to consequences the youth have received and the youth are unhappy. On two occasions I spoke with the parents about their
concerns regarding consequences and/or staff actions. All grievances were resolved through conversations and listening to the concerns of
youth/parents. On two or three occasions, youth exited the program prior the grievance being addressed due to my lack of availability during those
times. We have changed our policy to allow any lead or supervisory staff to respond to grievances. Grievances are put in the youth's files.

changes_in_license:
None
3

excerpt:
(1)(a) Minimum of 5 board members A copy of the program’s quality improvement plan was not
submitted to Licensing for review.
CORRECTIVE ACTION: Submit a copy of the program’s
quality improvement plan to Licensing.

excerpt:
(3)(a) knowledge of requirements for
providing care and treatment appropriate to
programs A new criminal background check is required for the Shelter
Manager for the new licensing period.
CORRECTIVE ACTION: Request and submit a copy of the
Shelter Manager’s newly approved background check for this
new licensing period.

excerpt: (3)(g) Approval from BCU

excerpt:
Documents as indicated on the form titled
“Renewal Licensing Required Documents” - Certification of Occupancy was not submitted
- Submitted Environmental Health Inspection was
incomplete.
CORRECTIVE ACTION:
- Submit copy of Certificate of Occupancy.
- Resubmit completed inspection form that is signed,
dated, and indicates if the inspection was approved
or not approved.

excerpt:
All required policies and procedures as
identified in the “Umbrella Rules” - Conflict of Interest was not submitted for review.
- Youth and Parent Rights requires modification.
- Grievance Policy requires modification.
- Mandatory Reporting Policy requires modification.
CORRECTIVE ACTION:
- Submit copy of Conflict-of-Interest Policy
- Revise 6.2.1 Youth and Parent Rights to include
highlighted information.

excerpt:
Foster Rights Posted (if
children in DHS custody) Window sills located in the wellness room and in bedroom
#281 located in the blue dorm are damaged and/or have
etched in words/symbols associated with gang affiliation.
CORRECTIVE ACTION: Repair damaged window sills and
submit photos of repaired areas
Staff report that during the summer, the facility’s air
conditioner does not effectively cool the facility.
CORRECTIVE ACTION: Address concern with facilities to
resolve or improve the facility’s cooling system.

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

excerpt:
Building is well
ventilated and room temperature is within a
normal comfort range

excerpt:
(a)(E) Individual privacy The bathroom and shower areas do not appear to have a
working ventilation system.
CORRECTIVE ACTION: Follow up with facilities and explore
ventilation options for the bathrooms and shower areas.

excerpt: (a)(H) Adequate ventilation

excerpt:
(2)(a) Written emergency plan Evacuation drills were not submitted for review
CORRECTIVE ACTION: Submit a copy of evacuation drills
for 2020 thru May of 2022.

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:
(3)&(7)(e) Medications have a prescription
and are stored in the original container with
prescription label The program’s existing medication logs maintained for each
youth does not reflect possible adverse reactions related to
the medication being taken.
CORRECTIVE ACTION: Develop a process where possible
adverse reactions are documented on youths’ medication
logs.

excerpt:
(10) Written record of the administration of
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

excerpt:
(a) Agency policies and procedures One out of three new hire files did not reflect training in the
following areas:
- Agency policies and procedures
- Ethical and professional guidelines
- Organizational lines of Authority
- Attributes of Population Served
- Privacy Laws
CORRECTIVE ACTION: Ensure that new hires are receiving
the required training and the completed training is
appropriately documented in their respective personnel file.

excerpt: (b) Ethical and professional guidelines

excerpt: (c) Organizational lines of authority

excerpt: (d) Attributes of population served

excerpt: (f) Privacy laws

excerpt:
(2)(e) Documentation of age-appropriate
instruction – pregnancy prevention, nutrition,
prevention of HIV & AIDS, and prevention
and treatment of sexually transmitted
disease Confirmation regarding the documentation of age-appropriate
instruction could not be found after the review of youth files.
CORRECTIVE ACTION: Create a process where age-
appropriate instruction in the areas listed is documented in
the youth’s respective files.

excerpt:
(a) Provide routine and emergency medical
care Consent to provide routine and emergency medical care
could not be located in the program’s intake packet.
CORRECTIVE ACTION: Demonstrate that this consent
exists within the program’s intake process. If one does not
exist, create, and implement the required consent.
See comment section below regarding intake consent
packet.

excerpt:
(d) Activity specific authorizations are pre-
approved to allow children to participate in
potentially hazardous activities, including but
not limited to using motorized yard
equipment, swimming, and horseback riding. Authorization for pre-approved potentially hazardous
activities could not be found in the youth files reviewed.
CORRECTIVE ACTION: Create an authorization related to
potentially hazardous activities and ensure this authorization
is signed at the time of intake by the youth and/or legal
guardian.

excerpt:
(a)The name, gender, date of birth, religious
preference, and previous address There is no designated space to capture a youth’s religious
preference on the youth’s summary sheet.
CORRECTIVE ACTION: Modify the existing summary/face
sheet to include religious preference.