summary: Unannounced - 1 finding

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Residential Care
Licensee: St. Mary’s Home for Boys Date of Unannounced: November 14, 2022
Executive Director: Francis Maher Licensing Coordinator: Robin DuVal
Assistant Director: Jeff Pinelli
Other Regulatory or Accrediting Agencies: Oregon Department of Human Services (ODHS) Child Welfare Treatment Services and Oregon
Youth Authority (OYA).
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 Findings Comments
Unannounced Site Visit 12/08/2021
Further Action
Needed?
413-215-0551(10) Written record of the administration of Yes No☐ The medication administration records in Meyer
medication: cottage had several blanks. Despite the blanks, staff
who were asked about the documentation process
reported there should always be an entry.
The agency shall ensure the written record of the medication
This is a repeat finding.
administration are filled out accurately without blanks. The
medication administration records (MARs) in each cottage had
 This requirement is unmet and further
varying levels of blanks. Staff were asked about the blanks, and
corrective action is needed.
some were unaware of the legend noted on the MAR for proper
documentation.
New Findings from Site Visit
None
Page 1 of 2
Interview Summary
Two youth were individually interviewed, ages 16 and 15, and have been in the program approximately 2 months and 1 year, respectively. Both
report feeling safe and that staff are trusting, and they shared how the program is benefiting them. The youth said school is going well, and they
meet regularly with their counselor and case manager. They said the food is good, they get seconds, but sometimes the food is not fully heated
or is burnt. They said they have regular unrestricted contact with family, they receive medications as prescribed, and the agency does well at
being supportive, building relationships, teaching skills, and making sure youth have what they need. They like that most everyone is welcoming
and the variety of physical activity that is offered. One youth desires to learn some life skills like doing laundry, car repair, ordering at restaurants,
etc. Both report peer relationships are going ok except for one peer who has been making racial remarks. It’s reported that staff and management
are aware, and steps are being taken to mitigate the issue. This coordinator verified this with management. It’s also reported that a kitchen staff
person is rude to staff and youth and has a strict and rigid nature about them. This coordinator discussed with management and they’re aware
and taking appropriate steps to mitigate the issue. Both report that they see minimal use of peers using the seclusion and isolation rooms, and
the one longer-term youth has observed that there are fewer instances than when they first came to this program. Their understanding of the
purpose of the isolation room is to provide an opportunity to calm down and refocus in an unlocked room without peer or environmental distractions.
Observations
The four living units were observed and were clean, welcoming, and in good repair. One youth’s bedding was off for laundering, and the mattress
cover was observed to be ripped. The agency has some in stock and will replace the ripped cover. I observed staff interacting with a few youth,
and it appeared calm and respectful.
Corrective Actions and Timeframes: Please submit the following to verify compliance.
Within 45 days of receipt of this report St. Mary’s Home for Boys must submit a letter of verification indicating the agency is in compliance with the
specific rules cited above and describing how compliance will be maintained going forward. Along with the letter of verification, the agency must
submit any and all specific documentation requested in the body of this report. The letter of verification and any additional requested documents are
to be emailed directly to ROBIN.M.DuVal@dhsoha.state.or.us.
Licensing Coordinator’s Signature: ________________________ Date: _1_1_/3_0_/_2_0_2_2_ _________
Manager Review: ______________________________________ Date: _1_1_-_3_0_-_2_0_2_2_ _______
Page 2 of 2

licensee: St. Mary's Home for Boys Date of Unannounced: November 14, 2022

visit_date: November 14, 2022

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 Findings Comments
Unannounced Site Visit 12/08/2021
Further Action
Needed?
413-215-0551(10) Written record of the administration of Yes No[ ] The medication administration records in Meyer
medication: cottage had several blanks. Despite the blanks, staff
who were asked about the documentation process
reported there should always be an entry.
The agency shall ensure the written record of the medication
This is a repeat finding.
administration are filled out accurately without blanks. The
medication administration records (MARs) in each cottage had
- This requirement is unmet and further
varying levels of blanks. Staff were asked about the blanks, and
corrective action is needed.
some were unaware of the legend noted on the MAR for proper
documentation.
New Findings from Site Visit
None
Page 1 of 2
Interview Summary
Two youth were individually interviewed, ages 16 and 15, and have been in the program approximately 2 months and 1 year, respectively. Both
report feeling safe and that staff are trusting, and they shared how the program is benefiting them. The youth said school is going well, and they
meet regularly with their counselor and case manager. They said the food is good, they get seconds, but sometimes the food is not fully heated
or is burnt. They said they have regular unrestricted contact with family, they receive medications as prescribed, and the agency does well at
being supportive, building relationships, teaching skills, and making sure youth have what they need. They like that most everyone is welcoming
and the variety of physical activity that is offered. One youth desires to learn some life skills like doing laundry, car repair, ordering at restaurants,
etc. Both report peer relationships are going ok except for one peer who has been making racial remarks. It's reported that staff and management
are aware, and steps are being taken to mitigate the issue. This coordinator verified this with management. It's also reported that a kitchen staff
person is rude to staff and youth and has a strict and rigid nature about them. This coordinator discussed with management and they're aware
and taking appropriate steps to mitigate the issue. Both report that they see minimal use of peers using the seclusion and isolation rooms, and
the one longer-term youth has observed that there are fewer instances than when they first came to this program. Their understanding of the

interview_summary:
Two youth were individually interviewed, ages 16 and 15, and have been in the program approximately 2 months and 1 year, respectively. Both
report feeling safe and that staff are trusting, and they shared how the program is benefiting them. The youth said school is going well, and they
meet regularly with their counselor and case manager. They said the food is good, they get seconds, but sometimes the food is not fully heated
or is burnt. They said they have regular unrestricted contact with family, they receive medications as prescribed, and the agency does well at
being supportive, building relationships, teaching skills, and making sure youth have what they need. They like that most everyone is welcoming
and the variety of physical activity that is offered. One youth desires to learn some life skills like doing laundry, car repair, ordering at restaurants,
etc. Both report peer relationships are going ok except for one peer who has been making racial remarks. It's reported that staff and management
are aware, and steps are being taken to mitigate the issue. This coordinator verified this with management. It's also reported that a kitchen staff
person is rude to staff and youth and has a strict and rigid nature about them. This coordinator discussed with management and they're aware
and taking appropriate steps to mitigate the issue. Both report that they see minimal use of peers using the seclusion and isolation rooms, and
the one longer-term youth has observed that there are fewer instances than when they first came to this program. Their understanding of the
purpose of the isolation room is to provide an opportunity to calm down and refocus in an unlocked room without peer or environmental distractions.

observations:
The four living units were observed and were clean, welcoming, and in good repair. One youth's bedding was off for laundering, and the mattress
cover was observed to be ripped. The agency has some in stock and will replace the ripped cover. I observed staff interacting with a few youth,
and it appeared calm and respectful.


state: OR

facility_name: St. Mary's Home For Boys

summary: Unannounced - 20 findings

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Residential Care
Licensee: St. Mary’s Home for Boys Date of Unannounced: December 8, 2023
Executive Director: Francis Maher Licensing Coordinator: Robin DuVal
Other Regulatory or Accrediting Agencies: Oregon Department of Human Services (ODHS) Child Welfare Treatment Services and Oregon Youth
Authority (OYA).
Purpose: Per OAR 419-400-0240 (1)(b) Children’s Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Findings Corrective Actions / Comments
License Renewal Site Visit 06/20-21/2023 Further Action Needed
Supplemental Information Provided by CCA Yes☐ No✓ The tax compliance certificate has been
Documents as indicated on form titled “Required Financial Documents and submitted.
Information” • No further corrective action needed at
• The agency shall submit the tax compliance certificate once received. this time.
Supplemental Information Provided by CCA Yes☐ No✓ Policies and procedures have been updated.
All required policies and procedures as identified in the “Umbrella Rules” • No further corrective action needed at
this time.
Corrective Action: The agency shall update the following policies and
procedures pursuant to each OAR and submit for review.*
• Conflict of interest in OAR419-400-0070.
• Incident reporting – all elements per OAR 419-400-0110(b)(A-D)
• Grievance Procedures in OAR 419-400-0090(2), specifically (C) and
(D).
• Personnel in OAR 419-400-0120
• Mandatory Abuse Reporting in OAR 419-400-0110(1)(a)
*Please document the revision date and highlight or utilize “track changes” for
areas changed.
Corrective Action: Ensure policies are updated when needed to align with
changes to ODHS licensing rules for child-caring agencies.
Form Rev. 11/14/2023 P age 1| 7
Supplemental Information Provided by CCA Yes☐ No✓ The Medication policy and procedure has been
All required policies and procedures as identified in Residential Care Specific updated.
Rules. • No further corrective action needed at
• Corrective Action: The agency shall update the Medication policy this time.
and procedure (#M-230) specifically outlining the process of managers
preparing medications in advance, utilizing the sealed envelope
method, how many days in advance is appropriate and safe, etc.
Note: an exception request has been submitted for permitting
medication to be prepared in advance for more than one
administration time or for more than one child in care. Upon receipt
and review of the requested updated policy, licensing will make an
exception determination.
Room and Space Requirements 419-470-0030(8) Separate storage areas Yes☐ No✓ A locking mechanism was installed on the
are provided for food, kitchen supplies, utensils, clean linens, soiled linens and cabinets and was observed to be in place and
clothing, cleaning supplies and equip, poisons, chemicals, outdoor recreational locked during the walk-thru.
and maintenance equipment. (Hazardous materials are properly labeled, in • No further corrective action needed at
original container and locked) this time.
• Bickmore Hall: In the open and unlocked laundry room, laundry
detergent was not kept in a locked storage. A spray cleaner bottle was
left unattended in one of the milieu rooms.
Corrective Action: The agency shall ensure laundry detergent and cleaning
supplies are locked and inaccessible to children in care or replace and provide
labeled non-hazardous products.
Room and Space Requirements Bedrooms 419-470-0030(3)(h) Window N/A✓
covering.
• Exception on file. Due to the physical structure, privacy is assured.
Residential Care Safety 419-470-0080(5)(a) Evacuation drill occurs monthly Yes✓No☐ November evacuation drill logs were observed.
under varying conditions, is retained 2 years and contains: Three cottages used the current updated form;
(A) identify of person conducting drill however, one cottage used an outdated form.
(B) date & time One cottage drill log was missing an entry for
(C) notification method time of drill.
(D) staff participating
(E) # of children & staff evacuated Corrective Action:
(F) special conditions simulated The agency shall ensure all cottages are utilizing
(G) problems encountered the updated form and ensure that all required
(H) time to complete elements are documented. This is a repeat
• Various monthly drill logs were missing from the four living units. finding.
Required elements were missing or incorrectly recorded on the log. On
at least two drill logs reviewed, a drill was not conducted due to the
Form Rev. 11/14/2023 P age 2| 7
alarm pull not working or malfunctioning. Alternative notification
methods can be a verbal command, bell, turning lights on/off, etc.
Corrective Actions:
The agency shall ensure an evacuation drill is conducted monthly, following
requirements set forth in (A – H), document appropriately, and retained for 2
years.
Specific to the Evacuation drill log, the agency shall ensure the following for
each drill and properly documented.
• (A) printed name of person conducting the drill
• (C) notification method, i.e. alarm pull, verbal command, bell, etc.
• (D) staff participating need to be listed out by name.
• (E) list number of children and staff evacuated (vs. # in cottage)
• (F) special conditions simulated – conduct various simulated special
conditions, i.e. milieu, youth in bedrooms, lunch room, outside
recreation time, etc.
Medication 419-470-0100(10) Written record of the administration of Yes✓No☐ 1)Medication administration logs were observed
medication includes: to have no white-out or correction tape.
(a) name • No further corrective action needed at
(b) description this time.
(c) dates and times
(d) missed doses
(e) medication disposed
(f) method of administration
(g) ID of person administering 2)Possible adverse reactions (i.e., side effects)
(h) possible adverse reactions for each prescribed medication were not included
(i) medication taken outside facility with each child’s medication record. Some
records had a list if there was a medication
Corrective Actions: change, but not for all medications per child.
1)White-out correction was observed on a medication administration record.
The agency shall ensure the written record of the medication administration Corrective action: The agency shall ensure that
are filled out accurately without white-out. Medication errors, or anomalies in each prescribed medication for each child in care
documentation or administration, can be documented by adding a notation to shall be listed. The agency utilizes a binder with
the medication administration record. a tab separator for each child’s record and can
be stored along with the medication
2)Possible adverse reactions (i.e. side effects) for each prescribed medication administration log. This is a repeat finding.
shall be listed on the written record of the medication administration (i.e. log),
or on a separate document immediately attached or behind the log.
All four living units utilize a binder with a tab separator for each child in care’s
medication record log, therefore possible adverse reaction documentation can
be stored along with the log.
Form Rev. 11/14/2023 P age 3| 7
Personnel Files 419-400-0120(1)(b) & (3)(b) reference checks completed and Yes☐ No✓ This requirement was met. No further corrective
documented. action needed at this time.
• The agency shall ensure reference checks are conducted,
documented, and retained in the personnel file. If attempts to obtain
reference checks are unsuccessful, document the dates and times the
requests occurred.
New Employee Orientation – Umbrella Requirements (30 days) Yes☐ No✓ This requirement was met. No further corrective
419-400-0120(4)(g) Emergency procedures action needed at this time.
• This training was either provided after 30 days or there was no record
of training. The agency shall ensure this training is conducted within
30 days of hire.
Crisis Intervention Training Standards and Certification Yes☐ No✓ This requirement was met. No further corrective
419-400-0160(4) (as applicable) (a)Complete a minimum of 12 hours of initial action needed at this time.
training in person from a certified instructor, including but not limited to a
minimum of six hours of training focused on positive behavior support,
nonviolent crisis intervention and other methods of nonphysical intervention to
support children in care during a crisis
• Documentation of 12 hours was unclear. The agency shall ensure a
minimum of 12 hours of initial training in person from a certified
instructor occurs and is properly documented via a certificate (see
below).
Crisis Intervention Training Standards and Certification 419-400-0160(4) Yes☐ No✓ This requirement was met. No further corrective
(as applicable) action needed at this time.
(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
(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.
• Upon completion of a minimum of 12 hours (noted above), the agency
shall ensure a certificate is documented capturing all required data
elements. This licensor provided an example.
Ongoing Training 419-470-0120 (2)(a) Environmental emergencies Yes✓No☐ The agency lacked documentation to
• The agency shall ensure this training is provided annually and demonstrate employees’ training occurred.
appropriately documented.
Corrective Action: The agency shall ensure all
forms and tracking mechanisms are updated to
Form Rev. 11/14/2023 P age 4| 7
include this specific training and appropriately
documented. This is a repeat finding.
Ongoing Training 419-470-0120 (2)(d) Agency’s policy on suicide prevention Yes✓No☐ The agency lacked documentation to
and risk assessment tool. demonstrate employees’ training occurred.
• The agency shall ensure this training is provided annually and
appropriately documented. Corrective Action: The agency shall ensure all
Comment: shortly after the on-site review, the agency implemented steps to forms and tracking mechanisms are updated to
ensure this occurs. include this specific training and appropriately
documented. This is a repeat finding.
Children’s Records Consents 419-470-0160(1)(c) Use restraint or seclusion Yes☐ No✓ This requirement was met. No further corrective
(if applicable). Must specify the reasons for the intervention and how staff are action needed at this time.
trained and supervised.
• Information is provided; although documentation was unclear
regarding whether parents or guardians provided actual consent. The
agency shall ensure appropriate signatures indicating consent are
obtained from the child in care’s parent or guardian and documented
appropriately.
Children’s Records Consents 419-470-0160(1)(e) Allow access as defined Yes☐ No✓ This requirement was met. No further corrective
in 419-400-0230 & 0240. action needed at this time.
• The agency shall ensure this consent is included at intake and obtain
appropriate signatures from the child in care’s parent or guardian and
document appropriately.
Children’s Records Disclosures 419-470-0160(2) Parent/guardian has Yes☐ No✓ This requirement was met. No further corrective
acknowledged in writing: (c) Any policies and procedures upon request. action needed at this time.
• The agency shall ensure this disclosure is included at intake and
obtain appropriate signatures from the child in care’s parent or
guardian and document appropriately.
Children’s Records Information about Children in Care 419-400-0190(1) Yes☐ No✓ This requirement was met. No further corrective
Summary sheet contains the following: (a)The name, gender, date of birth, action needed at this time.
religious preference, and previous address.
• The agency shall ensure a category for “gender” is listed on the
summary sheet (aka face sheet) and completed going forward.
Form Rev. 11/14/2023 P age 5| 7
Children’s Records Relating to Restraint & Involuntary Seclusion 419- Yes☐ No✓ This requirement was met. No further corrective
400-0180(13)(e) Each child caring agency shall provide notice regarding how action needed at this time.
to access the quarterly reports to the parents or guardians of children in care in
the program. The child caring agency shall provide the notice upon the child in
care’s admission and at least two times each year thereafter.
• This information was not consistently documented as being provided.
Corrective Action: The agency shall ensure this notice is provided to parents
or guardians of children in care upon admission and at least two times each
year thereafter and documented appropriately as being provided.
Children’s Records Relating to Restraint & Involuntary Seclusion 419- Yes☐ No✓ This requirement was met. No further corrective
400-0190(1) Information provided to children in care relating to Restraint & action needed at this time.
Involuntary Seclusion.
• This information was not consistently documented as being provided
to children in care.
Corrective Action: The agency shall ensure this notice is provided to children
in care and document appropriately as being provided.
Children’s Records and Documentation 419-400-0140(3)&(4) Uniform in Yes☐ No✓ Medication administration logs were observed to
organization, readily identifiable and accessible, current, and complete, have no white-out or correction tape.
containing all required info. No eraser tape or white out.
• Use of white-out on a medication administration record is captured in a • No further corrective action needed at
finding above. this time.
New Findings from Site Visit
None
Interview Summary
Two youth were individually interviewed ages 15 and 16 with stays in the program of 3 months and 18 months, respectively. Both gave examples of how the
agency is helping them, that they feel safe, and staff are trusting. Their peer community is good, food is good and plentiful, school is good and they get help
when needed, and there’s been no issues getting medications as prescribed. They report the agency does well at caring for and helping the youth, providing a
safety net and being supportive, as well as the activities and off-campus outings. They have regular phone calls with approved contact people, and calls are
mostly private, meaning a staff is nearby monitoring but not actively listening. One youth reported voluntarily utilizing the isolation room once as it helped them
have a distraction free area to regulate and process their feelings. When asked if they could change anything about the program, they reported the inconsistency
of staff’s expectations. It’s relatively manageable but can cause some dysregulation among peers. The longer-term youth reported having watched a restraint
performed once, and they felt the staff worked with the other youth to deescalate and encourage them to make other choices, but a restraint became necessary
despite their efforts to deescalate the situation.. The restraint appeared to be done with care and concern.
Form Rev. 11/14/2023 P age 6| 7
Observations
The walk-through consisted of all four living units, including a random selection of approximately 4 youth bedrooms per hall, living unit bathrooms, milieu, and
isolation/seclusion rooms.
Corrective Actions and Timeframes: Please submit the following to verify compliance.
Within 45 days of receipt of this report St. Mary’s Home for Boys must submit a letter of verification indicating the agency is in compliance with the
specific rules cited above and describing how compliance will be maintained going forward. Along with the letter of verification, the agency must
submit any and all specific documentation requested in the body of this report. The letter of verification and any additional requested documents can
be emailed directly to Robin.M.DuVal@odhsoha.oregon.gov.
Licensing Coordinator’s Signature: ________________________ Date: _1_2_/_1_8_/2_0__2_3_________
Manager Review: ______________________________________ Date: _1_2_-1_8_-_2_0_2_3_ ________
Form Rev. 11/14/2023 P age 7| 7

agency_name: St. Mary's Home for Boys (SMHB)

program_name: St. Mary's Home For Boys

program_type: (RC) Residential Care Programs

report_type: Unannounced

view_code: RC

facility_type: Residential Care

licensee: St. Mary's Home for Boys Date of Unannounced: December 8, 2023

visit_date: December 8, 2023

licensing_coordinator: Robin DuVal

purpose:
Per OAR 419-400-0240 (1)(b) Children's Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Findings Corrective Actions / Comments
License Renewal Site Visit 06/20-21/2023 Further Action Needed
Supplemental Information Provided by CCA Yes[ ] No✓ The tax compliance certificate has been
Documents as indicated on form titled "Required Financial Documents and submitted.
Information" - No further corrective action needed at
- The agency shall submit the tax compliance certificate once received. this time.
Supplemental Information Provided by CCA Yes[ ] No✓ Policies and procedures have been updated.
All required policies and procedures as identified in the "Umbrella Rules" - No further corrective action needed at
this time.
Corrective Action: The agency shall update the following policies and
procedures pursuant to each OAR and submit for review.*
- Conflict of interest in OAR419-400-0070.
- Incident reporting - all elements per OAR 419-400-0110(b)(A-D)
- Grievance Procedures in OAR 419-400-0090(2), specifically (C) and
(D).
- Personnel in OAR 419-400-0120
- Mandatory Abuse Reporting in OAR 419-400-0110(1)(a)
*Please document the revision date and highlight or utilize "track changes" for
areas changed.
Corrective Action: Ensure policies are updated when needed to align with
changes to ODHS licensing rules for child-caring agencies.

Supplemental Information Provided by CCA Yes[ ] No✓ The Medication policy and procedure has been
All required policies and procedures as identified in Residential Care Specific updated.
Rules. - No further corrective action needed at
- Corrective Action: The agency shall update the Medication policy this time.
and procedure (#M-230) specifically outlining the process of managers
preparing medications in advance, utilizing the sealed envelope
method, how many days in advance is appropriate and safe, etc.
Note: an exception request has been submitted for permitting
medication to be prepared in advance for more than one
administration time or for more than one child in care. Upon receipt
and review of the requested updated policy, licensing will make an
exception determination.
Room and Space Requirements 419-470-0030(8) Separate storage areas Yes[ ] No✓ A locking mechanism was installed on the
are provided for food, kitchen supplies, utensils, clean linens, soiled linens and cabinets and was observed to be in place and
clothing, cleaning supplies and equip, poisons, chemicals, outdoor recreational locked during the walk-thru.
and maintenance equipment. (Hazardous materials are properly labeled, in - No further corrective action needed at
original container and locked) this time.
- Bickmore Hall: In the open and unlocked laundry room, laundry
detergent was not kept in a locked storage. A spray cleaner bottle was
left unattended in one of the milieu rooms.
Corrective Action: The agency shall ensure laundry detergent and cleaning
supplies are locked and inaccessible to children in care or replace and provide
labeled non-hazardous products.
Room and Space Requirements Bedrooms 419-470-0030(3)(h) Window N/A✓
covering.
- Exception on file. Due to the physical structure, privacy is assured.
Residential Care Safety 419-470-0080(5)(a) Evacuation drill occurs monthly Yes✓No[ ] November evacuation drill logs were observed.
under varying conditions, is retained 2 years and contains: Three cottages used the current updated form;
(A) identify of person conducting drill however, one cottage used an outdated form.
(B) date & time One cottage drill log was missing an entry for
(C) notification method time of drill.
(D) staff participating
(E) # of children & staff evacuated Corrective Action:
(F) special conditions simulated The agency shall ensure all cottages are utilizing
(G) problems encountered the updated form and ensure that all required
(H) time to complete elements are documented. This is a repeat
- Various monthly drill logs were missing from the four living units. finding.
Required elements were missing or incorrectly recorded on the log. On
at least two drill logs reviewed, a drill was not conducted due to the

alarm pull not working or malfunctioning. Alternative notification
methods can be a verbal command, bell, turning lights on/off, etc.
Corrective Actions:
The agency shall ensure an evacuation drill is conducted monthly, following
requirements set forth in (A - H), document appropriately, and retained for 2
years.
Specific to the Evacuation drill log, the agency shall ensure the following for
each drill and properly documented.
- (A) printed name of person conducting the drill
- (C) notification method, i.e. alarm pull, verbal command, bell, etc.
- (D) staff participating need to be listed out by name.
- (E) list number of children and staff evacuated (vs. # in cottage)
- (F) special conditions simulated - conduct various simulated special
conditions, i.e. milieu, youth in bedrooms, lunch room, outside
recreation time, etc.
Medication 419-470-0100(10) Written record of the administration of Yes✓No[ ] 1)Medication administration logs were observed
medication includes: to have no white-out or correction tape.
(a) name - No further corrective action needed at
(b) description this time.
(c) dates and times
(d) missed doses
(e) medication disposed
(f) method of administration
(g) ID of person administering 2)Possible adverse reactions (i.e., side effects)
(h) possible adverse reactions for each prescribed medication were not included
(i) medication taken outside facility with each child's medication record. Some
records had a list if there was a medication
Corrective Actions: change, but not for all medications per child.
1)White-out correction was observed on a medication administration record.
The agency shall ensure the written record of the medication administration Corrective action: The agency shall ensure that
are filled out accurately without white-out. Medication errors, or anomalies in each prescribed medication for each child in care
documentation or administration, can be documented by adding a notation to shall be listed. The agency utilizes a binder with
the medication administration record. a tab separator for each child's record and can
be stored along with the medication
2)Possible adverse reactions (i.e. side effects) for each prescribed medication administration log. This is a repeat finding.
shall be listed on the written record of the medication administration (i.e. log),
or on a separate document immediately attached or behind the log.
All four living units utilize a binder with a tab separator for each child in care's
medication record log, therefore possible adverse reaction documentation can
be stored along with the log.

Personnel Files 419-400-0120(1)(b) & (3)(b) reference checks completed and Yes[ ] No✓ This requirement was met. No further corrective
documented. action needed at this time.
- The agency shall ensure reference checks are conducted,
documented, and retained in the personnel file. If attempts to obtain
reference checks are unsuccessful, document the dates and times the
requests occurred.
New Employee Orientation - Umbrella Requirements (30 days) Yes[ ] No✓ This requirement was met. No further corrective
419-400-0120(4)(g) Emergency procedures action needed at this time.
- This training was either provided after 30 days or there was no record
of training. The agency shall ensure this training is conducted within
30 days of hire.
Crisis Intervention Training Standards and Certification Yes[ ] No✓ This requirement was met. No further corrective
419-400-0160(4) (as applicable) (a)Complete a minimum of 12 hours of initial action needed at this time.
training in person from a certified instructor, including but not limited to a
minimum of six hours of training focused on positive behavior support,
nonviolent crisis intervention and other methods of nonphysical intervention to
support children in care during a crisis
- Documentation of 12 hours was unclear. The agency shall ensure a
minimum of 12 hours of initial training in person from a certified
instructor occurs and is properly documented via a certificate (see
below).
Crisis Intervention Training Standards and Certification 419-400-0160(4) Yes[ ] No✓ This requirement was met. No further corrective
(as applicable) action needed at this time.
(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
(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.
- Upon completion of a minimum of 12 hours (noted above), the agency
shall ensure a certificate is documented capturing all required data
elements. This licensor provided an example.
Ongoing Training 419-470-0120 (2)(a) Environmental emergencies Yes✓No[ ] The agency lacked documentation to
- The agency shall ensure this training is provided annually and demonstrate employees' training occurred.
appropriately documented.
Corrective Action: The agency shall ensure all
forms and tracking mechanisms are updated to

include this specific training and appropriately
documented. This is a repeat finding.
Ongoing Training 419-470-0120 (2)(d) Agency's policy on suicide prevention Yes✓No[ ] The agency lacked documentation to
and risk assessment tool. demonstrate employees' training occurred.
- The agency shall ensure this training is provided annually and
appropriately documented. Corrective Action: The agency shall ensure all
Comment: shortly after the on-site review, the agency implemented steps to forms and tracking mechanisms are updated to
ensure this occurs. include this specific training and appropriately
documented. This is a repeat finding.
Children's Records Consents 419-470-0160(1)(c) Use restraint or seclusion Yes[ ] No✓ This requirement was met. No further corrective
(if applicable). Must specify the reasons for the intervention and how staff are action needed at this time.
trained and supervised.
- Information is provided; although documentation was unclear
regarding whether parents or guardians provided actual consent. The
agency shall ensure appropriate signatures indicating consent are
obtained from the child in care's parent or guardian and documented
appropriately.
Children's Records Consents 419-470-0160(1)(e) Allow access as defined Yes[ ] No✓ This requirement was met. No further corrective
in 419-400-0230 & 0240. action needed at this time.
- The agency shall ensure this consent is included at intake and obtain
appropriate signatures from the child in care's parent or guardian and
document appropriately.
Children's Records Disclosures 419-470-0160(2) Parent/guardian has Yes[ ] No✓ This requirement was met. No further corrective
acknowledged in writing: (c) Any policies and procedures upon request. action needed at this time.
- The agency shall ensure this disclosure is included at intake and
obtain appropriate signatures from the child in care's parent or
guardian and document appropriately.
Children's Records Information about Children in Care 419-400-0190(1) Yes[ ] No✓ This requirement was met. No further corrective
Summary sheet contains the following: (a)The name, gender, date of birth, action needed at this time.
religious preference, and previous address.
- The agency shall ensure a category for "gender" is listed on the
summary sheet (aka face sheet) and completed going forward.

Children's Records Relating to Restraint & Involuntary Seclusion 419- Yes[ ] No✓ This requirement was met. No further corrective
400-0180(13)(e) Each child caring agency shall provide notice regarding how action needed at this time.
to access the quarterly reports to the parents or guardians of children in care in
the program. The child caring agency shall provide the notice upon the child in
care's admission and at least two times each year thereafter.
- This information was not consistently documented as being provided.
Corrective Action: The agency shall ensure this notice is provided to parents
or guardians of children in care upon admission and at least two times each
year thereafter and documented appropriately as being provided.
Children's Records Relating to Restraint & Involuntary Seclusion 419- Yes[ ] No✓ This requirement was met. No further corrective
400-0190(1) Information provided to children in care relating to Restraint & action needed at this time.
Involuntary Seclusion.
- This information was not consistently documented as being provided
to children in care.
Corrective Action: The agency shall ensure this notice is provided to children
in care and document appropriately as being provided.
Children's Records and Documentation 419-400-0140(3)&(4) Uniform in Yes[ ] No✓ Medication administration logs were observed to
organization, readily identifiable and accessible, current, and complete, have no white-out or correction tape.
containing all required info. No eraser tape or white out.
- Use of white-out on a medication administration record is captured in a - No further corrective action needed at
finding above. this time.
New Findings from Site Visit
None
Interview Summary
Two youth were individually interviewed ages 15 and 16 with stays in the program of 3 months and 18 months, respectively. Both gave examples of how the
agency is helping them, that they feel safe, and staff are trusting. Their peer community is good, food is good and plentiful, school is good and they get help
when needed, and there's been no issues getting medications as prescribed. They report the agency does well at caring for and helping the youth, providing a
safety net and being supportive, as well as the activities and off-campus outings. They have regular phone calls with approved contact people, and calls are
mostly private, meaning a staff is nearby monitoring but not actively listening. One youth reported voluntarily utilizing the isolation room once as it helped them
have a distraction free area to regulate and process their feelings. When asked if they could change anything about the program, they reported the inconsistency
of staff's expectations. It's relatively manageable but can cause some dysregulation among peers. The longer-term youth reported having watched a restraint
performed once, and they felt the staff worked with the other youth to deescalate and encourage them to make other choices, but a restraint became necessary
despite their efforts to deescalate the situation.. The restraint appeared to be done with care and concern.

Observations
The walk-through consisted of all four living units, including a random selection of approximately 4 youth bedrooms per hall, living unit bathrooms, milieu, and
isolation/seclusion rooms.


summary: Unannounced - 7 findings

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Residential Care
Licensee: St Mary’s Home for Boys
Executive Director: Francis Maher Date of Unannounced: August 14, 2024
Program Director(s): Cindy Krieger and John Stacy Licensing Coordinator: Robin DuVal
Other Regulatory or Accrediting Agencies: Oregon Department of Human Services (ODHS) Child Welfare Treatment Services and Oregon
Youth Authority (OYA). Tracie Stone from OYA was present for this unannounced.
Purpose: Per OAR 419-400-0240 (1)(b) Children’s Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Findings
Comments
Unannounced Site Visit 12-08-2023 Further Action Needed
Residential Care Safety Yes☐ No✓ Records were reviewed, and this requirement was
419-470-0080(5)(a) Evacuation drill occurs monthly under varying met. There’s no further corrective action needed at
conditions, is retained 2 years and contains: this time.
(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
November evacuation drill logs were observed. Three cottages used
the current updated form; however, one cottage used an outdated form.
One cottage drill log was missing an entry for time of drill.
Corrective Action: The agency shall ensure all cottages are utilizing
the updated form and ensure that all required elements are
documented. This is a repeat finding.
Form Rev. 11/14/2023 P age 1 | 4
Medication 419-470-0100(10) Written record of the administration of Yes☐ No✓ Records were reviewed, and this requirement was
medication includes: met. There’s no further corrective action needed at
(a) name this time.
(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
1)Medication administration logs were observed to have no white-out or
correction tape. No further corrective action needed at this time.
2)Possible adverse reactions (i.e., side effects) for each prescribed
medication were not included with each child’s medication record.
Some records had a list if there was a medication change, but not for all
medications per child.
Corrective Action: The agency shall ensure that each prescribed
medication for each child in care shall be listed. The agency utilizes a
binder with a tab separator for each child’s record and can be stored
along with the medication administration log. This is a repeat finding.
Ongoing Training 419-470-0120 (2)(a) Environmental emergencies Yes☐ No✓ Records were reviewed, and this requirement was
met. There’s no further corrective action needed at
The agency lacked documentation to demonstrate employees’ training this time.
occurred.
Corrective Action: The agency shall ensure all forms and tracking
mechanisms are updated to include this specific training and
appropriately documented. This is a repeat finding.
Ongoing Training 419-470-0120 (2)(d) Agency’s policy on suicide Yes☐ No✓ Records were reviewed, and this requirement was
prevention and risk assessment tool. met. There’s no further corrective action needed at
this time.
The agency lacked documentation to demonstrate employees’ training
occurred.
Corrective Action: The agency shall ensure all forms and tracking
mechanisms are updated to include this specific training and
appropriately documented. This is a repeat finding.
Form Rev. 11/14/2023 P age 2 | 4
New Findings from Site Visit Corrective Actions / Comments
Medication 419-470-0100(10) Written record of the administration of Corrective Action: The agency shall ensure medication errors, or anomalies in
medication includes: documentation, are documented by adding a notation to the medication
(a) name administration records (MARs).
(b) description
(c) dates and times While this was more significantly observed in Meyer cottage, the agency shall
(d) missed doses ensure this practice is occurring in all the living units with their respective MAR
(e) medication disposed documentation.
(f) method of administration
(g) ID of person administering This finding has been intermittently occurring over recent years. The agency shall
(h) possible adverse reactions provide an administrative oversight plan and timeline that includes, at minimum:
(i) medication taken outside facility • Review current policies and procedures.
• Survey staff and managers for input on any changes.
Blanks were observed on the Medication Administration Records (MARs) • Identify any needed improvements to policy, procedure or practice.
with no corresponding notation. This was observed more significantly in • Update policies, procedures and practice where needed.
Myer cottage.
• Communicate and implement improvements.
• Identify who will be directly responsible for ensuring ongoing compliance.
Room and Space Requirements 419-470-0030(8) Separate storage areas Corrective Action: The agency shall ensure laundry detergent is inaccessible to
are provided for food, kitchen supplies, utensils, clean linens, soiled linens children in care by utilizing the established locked cabinets in the laundry room.
and clothing, cleaning supplies and equip, poisons, chemicals, outdoor
recreational and maintenance equipment. (Hazardous materials are This was also a finding from June 2023; the agency corrected the finding by
properly labeled, in original container and locked). installing a locking mechanism on the cabinets, and the locked cabinets were
observed during the December 2023 unannounced visit, resulting in a corrected
Bickmore Hall: In the open and unlocked laundry room, an opened bottle of finding with no further action at that time.
liquid laundry detergent was not kept in the locked storage.
Physical Plan Requirements 419-470-0020(2) (c) All areas of buildings Corrective Actions: The agency shall ensure these repairs occur timely and
where children in care are present must be kept clean and in good repair. submit photos when corrected.
• Some bedroom door handles were not functioning to easily open
the door.
• Meyer Cottage: the North Hall bathroom stall doors were damaged
and one anchor point cover was off which exposing screws and
sharp metal.
Form Rev. 11/14/2023 P age 3 | 4
Interview Summary
Two youth were individually interviewed, ages 13 and 16, with stays in the program of 6 months and 11 months respectively. Both gave examples of how the
agency is helping them, that they feel safe in this place with these people, staff are trusting, and they feel listened to during treatment meetings. The peer
community is good, food is good and plentiful, school is good, but now on summer break, and there’s been no issues getting medications as prescribed.
Activities on campus and outings were described. Phone calls to approved persons on their contact sheet are offered twice daily. They report the agency does
well at addressing past trauma. When asked for one of their favorite things about being in this program, one shared that it’s less restrictive than being at home,
and the other identified their treatment team as their favorite thing. The areas to improve on are staff consistency in “fairness” among peers, and having “so
many rules”, although this youth shared they understand the rules and why they’re in place. Both youth were pleasant and respectful to talk with.
Observations
The walk-through consisted of all four living units, including a random selection of youth bedrooms per hall, living unit bathrooms, milieus, and
isolation/seclusion rooms. The facility was clean and in good repair, except noted above in new findings, and free from odor. Interactions with staff were
welcoming, and youth were doing various in-door activities. Youth bedrooms in the three cottages were clean and tidy with individualized décor and free from
odor. Unlike previous visits, to note, Bickmore Hall youth bedrooms were messier than average but not to an unsanitary level.
Corrective Actions and Timeframes: Please submit the following to verify compliance.
Within 45 days of receipt of this report St. Mary’s Home for Boys must submit a letter of verification indicating the agency is in compliance with
the specific rules cited above and describing how compliance will be maintained going forward. Along with the letter of verification, the agency
must submit any and all specific documentation requested in the body of this report. The letter of verification and any additional requested
documents are to be emailed directly to Robin DuVal at robin.m.duval@odhsoha.oregon.gov.
Licensing Coordinator’s Signature: ________________________ Date: _8_/_1_9_/2_0_2__4__________
Manager Review: ______________________________________ Date: __________________
Form Rev. 11/14/2023 P age 4 | 4

licensee: St Mary's Home for Boys

purpose:
Per OAR 419-400-0240 (1)(b) Children's Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Findings
Comments
Unannounced Site Visit 12-08-2023 Further Action Needed
Residential Care Safety Yes[ ] No✓ Records were reviewed, and this requirement was
419-470-0080(5)(a) Evacuation drill occurs monthly under varying met. There's no further corrective action needed at
conditions, is retained 2 years and contains: this time.
(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
November evacuation drill logs were observed. Three cottages used
the current updated form; however, one cottage used an outdated form.
One cottage drill log was missing an entry for time of drill.
Corrective Action: The agency shall ensure all cottages are utilizing
the updated form and ensure that all required elements are
documented. This is a repeat finding.

Medication 419-470-0100(10) Written record of the administration of Yes[ ] No✓ Records were reviewed, and this requirement was
medication includes: met. There's no further corrective action needed at
(a) name this time.
(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
1)Medication administration logs were observed to have no white-out or
correction tape. No further corrective action needed at this time.
2)Possible adverse reactions (i.e., side effects) for each prescribed
medication were not included with each child's medication record.
Some records had a list if there was a medication change, but not for all
medications per child.
Corrective Action: The agency shall ensure that each prescribed
medication for each child in care shall be listed. The agency utilizes a
binder with a tab separator for each child's record and can be stored
along with the medication administration log. This is a repeat finding.
Ongoing Training 419-470-0120 (2)(a) Environmental emergencies Yes[ ] No✓ Records were reviewed, and this requirement was
met. There's no further corrective action needed at
The agency lacked documentation to demonstrate employees' training this time.
occurred.
Corrective Action: The agency shall ensure all forms and tracking
mechanisms are updated to include this specific training and
appropriately documented. This is a repeat finding.
Ongoing Training 419-470-0120 (2)(d) Agency's policy on suicide Yes[ ] No✓ Records were reviewed, and this requirement was
prevention and risk assessment tool. met. There's no further corrective action needed at
this time.
The agency lacked documentation to demonstrate employees' training
occurred.
Corrective Action: The agency shall ensure all forms and tracking
mechanisms are updated to include this specific training and
appropriately documented. This is a repeat finding.

New Findings from Site Visit Corrective Actions / Comments
Medication 419-470-0100(10) Written record of the administration of Corrective Action: The agency shall ensure medication errors, or anomalies in
medication includes: documentation, are documented by adding a notation to the medication
(a) name administration records (MARs).
(b) description
(c) dates and times While this was more significantly observed in Meyer cottage, the agency shall
(d) missed doses ensure this practice is occurring in all the living units with their respective MAR
(e) medication disposed documentation.
(f) method of administration
(g) ID of person administering This finding has been intermittently occurring over recent years. The agency shall
(h) possible adverse reactions provide an administrative oversight plan and timeline that includes, at minimum:
(i) medication taken outside facility - Review current policies and procedures.
- Survey staff and managers for input on any changes.
Blanks were observed on the Medication Administration Records (MARs) - Identify any needed improvements to policy, procedure or practice.
with no corresponding notation. This was observed more significantly in - Update policies, procedures and practice where needed.
Myer cottage.
- Communicate and implement improvements.
- Identify who will be directly responsible for ensuring ongoing compliance.
Room and Space Requirements 419-470-0030(8) Separate storage areas Corrective Action: The agency shall ensure laundry detergent is inaccessible to
are provided for food, kitchen supplies, utensils, clean linens, soiled linens children in care by utilizing the established locked cabinets in the laundry room.
and clothing, cleaning supplies and equip, poisons, chemicals, outdoor
recreational and maintenance equipment. (Hazardous materials are This was also a finding from June 2023; the agency corrected the finding by
properly labeled, in original container and locked). installing a locking mechanism on the cabinets, and the locked cabinets were
observed during the December 2023 unannounced visit, resulting in a corrected
Bickmore Hall: In the open and unlocked laundry room, an opened bottle of finding with no further action at that time.
liquid laundry detergent was not kept in the locked storage.
Physical Plan Requirements 419-470-0020(2) (c) All areas of buildings Corrective Actions: The agency shall ensure these repairs occur timely and
where children in care are present must be kept clean and in good repair. submit photos when corrected.
- Some bedroom door handles were not functioning to easily open
the door.
- Meyer Cottage: the North Hall bathroom stall doors were damaged
and one anchor point cover was off which exposing screws and
sharp metal.

Interview Summary
Two youth were individually interviewed, ages 13 and 16, with stays in the program of 6 months and 11 months respectively. Both gave examples of how the
agency is helping them, that they feel safe in this place with these people, staff are trusting, and they feel listened to during treatment meetings. The peer
community is good, food is good and plentiful, school is good, but now on summer break, and there's been no issues getting medications as prescribed.
Activities on campus and outings were described. Phone calls to approved persons on their contact sheet are offered twice daily. They report the agency does
well at addressing past trauma. When asked for one of their favorite things about being in this program, one shared that it's less restrictive than being at home,
and the other identified their treatment team as their favorite thing. The areas to improve on are staff consistency in "fairness" among peers, and having "so
many rules", although this youth shared they understand the rules and why they're in place. Both youth were pleasant and respectful to talk with.
Observations
The walk-through consisted of all four living units, including a random selection of youth bedrooms per hall, living unit bathrooms, milieus, and
isolation/seclusion rooms. The facility was clean and in good repair, except noted above in new findings, and free from odor. Interactions with staff were
welcoming, and youth were doing various in-door activities. Youth bedrooms in the three cottages were clean and tidy with individualized décor and free from
odor. Unlike previous visits, to note, Bickmore Hall youth bedrooms were messier than average but not to an unsanitary level.


facility_name: Team Bailey - Patricia

summary: 6-month - 15 findings

raw_content:
Licensed Child Caring Agency Site Visit Report
Residential Care
Licensee: Team Bailey Date of site visit: 07/10/2023
Executive Director: Kathy Bailey Licensing Coordinator: Jeff Minden, Aubrey Kelly
Board Chairperson: Jordan Craig
Other Regulatory or Accrediting Agencies: Oregon Youth Authority
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): Residential program providing Independent Living Skills to youth in OYA custody.
Program type and services: Residential – Independent Living Services
Capacity and Age Range: 5, male ages 17-24
Funding sources: Oregon Youth Authority
Contracts and sources for referrals: Oregon Youth Authority Independent Living Program (ILP) Contract. Oregon Youth Authority provides all
program referrals
Average length of stay: 6-9 months
Average daily population served: 5
Number of children served annually: 9
Use of seclusion or restraint: No
P a g e 1 | 17
Form Rev. 04/18/2023
Interviews, Observations: As a part of the review a tour of Team Bailey was conducted, along with 2 staff interviews. Interviews with youth were
attempted. However, none of the youth present in the program were willing to be interviewed. The facility was clean and in good repair, including
the bathrooms, laundry area, kitchen and staff offices.
Staff both spoke positively about the program. One staff was new to the program having only been hired approximately 3 weeks earlier and the
other has been with Team Bailey since opening. Both staff reported liking working for the program. Both staff reported the best part of the job is
interacting with youth and learning about them. One staff reported that the biggest challenge is there isn’t enough time in the day, and that it can be
challenging balancing the schedules for 5 youth. Both staff reported feeling management was readily available, supportive, and that the training
was helpful. Neither staff reported anything they thought could be changed or improved.
Program Strengths: Program is self-described as diverse and culturally aware. The program adapts to youth’s varying schedules and has a focus
on positively coexisting in the space.
Program Challenges: Program reports that transportation for youth to and from work has been noted as an ongoing challenge. Although the
program can access public transportation for youth, OYA Probation Officers prefer the program to handle youth transportation so youth
whereabouts are known.
Changes that have occurred in the last 2 years: N/A Initial 6 month review
Lawsuits: None
Grievances and complaints filed in the last two years: None since opening.
Corrective Actions and Timeframes: Please submit the following to verify compliance.
Within 45 days of receipt of this report Team Bailey must submit a letter of verification indicating the agency is in compliance with the specific rules
cited above and describing how compliance will be maintained going forward. Along with the letter of verification, the agency must submit any and
all specific documentation requested in the body of this report. The letter of verification and any additional requested documents can be emailed
directly to Jeff Minden, Jeffrey.E.Minden@odhsoha.oregon.gov
Recommendations: The program provided all policies as requested, however there appeared to be several duplicates with similar names, as well
as some policies that were no longer in effect. It is recommended that the program update the organization of their policies to better indicate current
versions.
P a g e 2 | 17
Form Rev. 04/18/2023
Exceptions: Exception filed for Food Service regulations to support the program in providing ILP services in a residential care setting
Changes in License: None
Summary of Review
Program and Services
Yes No N/A Corrective Actions/Comments
419-400-0020 (2)
Program and services are in scope of license X
Governance of the Agency
Yes No N/A Corrective Actions/Comments
419-400-0040
(1)(a) Minimum of 5 board members X
(2)(f) Formally evaluate the exec. Director’s Compliance verified at time initial license was issued. Not reviewed as a part of the
X
performance annually 6 month licensing period.
(2)(g) Approves annual budget Compliance verified at time initial license was issued. Not reviewed as a part of the
X
6 month licensing period.
(2)(h) Obtain and review an annual
Compliance verified at time initial license was issued. Not reviewed as a part of the
independent financial review or audit of X
6 month licensing period.
financial records.
(2)(k) Written quality improvement program Compliance verified at time initial license was issued. Not reviewed as a part of the
X
6 month licensing period.
(2)(l) Meeting minutes Compliance verified at time initial license was issued. Not reviewed as a part of the
X
6 month licensing period.
Executive Director or Program Director
Yes No N/A Corrective Actions/Comments
419-400-0040
(3)(a) knowledge of requirements for
providing care and treatment appropriate to X Reviewed during application process
programs
(3)(g) Approval from BCU X Reviewed during application process
Discipline, Behavior Management, and
Suicide Prevention Yes No N/A Corrective Actions/Comments
419-400-0150
(3) Agency uses appropriate and positive
methods of behavior management and
X
nationally recognized non-violent crisis
intervention
(3)(b)(C) Agency does not use chemical and
mechanical restraint (excluding medically X Agency does not utilize restraint or seclusion
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 Agency does not utilize restraint or seclusion
documents use in child’s record when
applicable
P a g e 3 | 17
Form Rev. 04/18/2023
(3)(e) Agency uses seclusion
X Agency does not utilize restraint or seclusion
appropriately/consistent with policy
(4) Agency has adequate plan in place to
X
respond to suicidal behavior/warning signs
Contractors (if applicable)
Yes No N/A Corrective Actions/Comments
419-400-0120(6)
(a) Agency ensures the contractor meets the
requirements of this rule and Chapter 413 X Agency does not utilize contractors
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 Agency does not utilize 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
Restraints and Involuntary Seclusion
Yes No N/A Corrective Actions/Comments
419-400-0180
(11)(d) Each child caring agency that
submits a report under this section shall
make its quarterly report available to the
X Agency does not have a website.
public upon request at the Child Caring
Agency’s main office and on the child caring
agency’s website if applicable.
Supplemental Information Provided by
Yes No N/A Corrective Actions/Comments
CCA
Documents as indicated on the form titled Document were reviewed at time of initial license. Documents not requested or
X
“Renewal Licensing Required Documents” reviewed during 6 month review
Documents as indicated on form titled
Document were reviewed at time of initial license. Documents not requested or
“Required Financial Documents and X
reviewed during 6 month review
Information”
All required policies and procedures as
X
identified in the “Umbrella Rules”
All required policies and procedures as
X
identified in “Agency Type Specific Rules”
Physical Plant
Yes No N/A Corrective Actions/Comments
419-400-0090(3)(a) Foster Rights Posted (if
X
children in DHS custody)
419-400-0100(1) Sufficient safe space,
X
equipment, and office equipment
P a g e 4 | 17
Form Rev. 04/18/2023
419-400-0230(12) License is posted in
X
common area at each facility
419-470-0020(2)(a) &(c) Buildings are
X
smoke free, clean and in good repair
419-470-0020 (2)(d) Rooms are free of
X
harmful drafts, odors, and excessive noise
419-470-0020 (2)(e) Rooms are adequate in
X
size and arrangement
419-470-0020 (2)(f) System provides a
continuous supply of hot and cold water to X
taps located throughout the facility
419-470-0020 (2)(h) Building is well
ventilated and room temperature is within a X
normal comfort range
419-470-0030 (1) All parts of the facility
X
ensure the safety of children
Room and Space Requirements
Yes No N/A Corrective Actions/Comments
419-470-0030
(2) There is a separate living room or lounge X
area – 15 SF minimum per child
(5) There is a separate dining room with X
capacity for ½ of children in care and 15 SF
per child in care
(7) Laundry is separate from living, kitchen, X
and dining areas
(8) Separate storage areas are provided for X
food, kitchen supplies, utensils, clean linens,
soiled linens and clothing, cleaning supplies
and equip, poisons, chemicals, outdoor
recreational and maintenance equipment.
(Hazardous materials are properly labeled, in
original container and locked)
(9) Outdoor activity area is protected from X
vehicles and other hazards and of a size and
availability appropriate to the age and needs
of children in care
(11) Time-out rooms: Rooms used for time X
out or quiet time must have adequate space,
heat, light and ventilation and must not be
capable of locking.
Room and Space Requirements
Bedrooms Yes No N/A Corrective Actions/Comments
419-470-0030(3)
(a) Adequate furnishings and personal items X
(b) Separate from rooms used for dining,
X
living, laundry, kitchen, and storage
P a g e 5 | 17
Form Rev. 04/18/2023
(c) Meet Oregon Fire Code Requirements X Fire Marshall Approval received during application process.
(d) Be an outside room, with a window that
operates as designed. If the window is
modified from its original design, the fire
X
marshal must approve the modification and
indicate this room still meets applicable
Oregon Fire Code.
(d) Ceiling at least 90 inches X
(e) Minimum 60 SF per occupant X
(f) No more than 25 if dorm style X All rooms are single occupancy
(g) Permanently wired fixtures X
(h) Window covering X
Room and Space Requirements
Bathrooms Yes No N/A Corrective Actions/Comments
419-470-0030(4)
(a)(A)&(B) 1:8 ratio for toilets and sinks X
(a)(D) Hot and cold running water, soap, and
X
approved hand drying options
(a)(E) 1:10 ratio for shower or bathtub X
(a)(E) Individual privacy X
(a)(F) Window covering X
(a)(G) Permanently wired fixtures X
(a)(H) Adequate ventilation X
(b)&(c) Wooden racks on floors are
prohibited and impervious shower mats are
X Racks and Mats are not utilized.
disinfected & dried daily be in good condition
and free of mold
Room and Space Requirements
Kitchen Yes No N/A Corrective Actions/Comments
419-470-0030(6)
(a) Used exclusively for storage, food
preparation, dishwashing, and activities
X
related to eating and food preparation
activities
(b) Walls, floors are easily cleanable X
(c) Equipment and utensils are easily
X
cleanable, durable, nontoxic, and kept clean
(e) Equipment is easy to clean beneath,
X
between and behind
Furnishings and Personal Items
Yes No N/A Corrective Actions/Comments
419-470-0040
(1) There is a bed with frame, X
(1)(b) clean mattress in good condition,
X
with a minimum thickness of five inches
(1)(c) a pillow in good condition X
P a g e 6 | 17
Form Rev. 04/18/2023
(1)(d) a private dresser, closet, or similar
storage area for personal belongings that X
is readily accessible
(2) Linens are in good repair. There is a
waterproof mattress cover or mattress.
X
Linens are appropriate and towels and
washcloths are provided
(3) Bedding is changed weekly or when
X
soiled
(4)&(5) Personal hygiene supplies and
X
appropriate clothing are provided
Food Services
Yes No N/A Corrective Actions/Comments
419-470-0070
(1)(a) Meals are arranged daily, consistent
with normal mealtimes that occur during the Agency requested and received an exception for this requirement to promote
X
hours of operation and provide snacks providing ILP Services to Youth.
between mealtimes
(1)(b) Menus are prepared in advance in
accordance with USDA guidelines, provide a Agency requested and received an exception for this requirement to promote
X
variety of foods and are adjusted for providing ILP Services to Youth.
seasonal changes including snacks
(1)(b) Menus are kept for at least 6 months Agency requested and received an exception for this requirement to promote
X
providing ILP Services to Youth.
(1)(c) Drinking water is freely available X
(2)(a) Food is stored, prepared & served in a
X
sanitary manner
(2)(c) & (d) Food products are obtained from
commercial suppliers (exception of fruits &
vegetables), unpasteurized juice is X
prohibited, and only Grade A pasteurized
and fortified milk in appropriate container.
Residential Care Safety
Yes No N/A Corrective Actions/Comments
419-470-0080
(2) Written emergency plan that includes X
(a) Identifying the types of emergencies most
likely to happen where the residential care X
agency is located
(b) Identifying a place to meet for each type
X
of emergency identified
(c) Identifying an alternate shelter if
X
necessary
(d) Ensuring access to necessary
X
medications or medical equipment
(e) How to help each child in care recover
X
after a disaster
P a g e 7 | 17
Form Rev. 04/18/2023
(3) Telephone numbers for local police, fire
department, poison control, after hours
medical advice and other appropriate X
emergency numbers must be posted near all
telephones.
(4) Operative flashlights sufficient in number
X
are readily available to staff
(5)(a) Evacuation drill occurs monthly under
varying conditions, is retained 2 years and
contains:
(A) identify of person conducting drill
(B) date & time Evacuation form is very thorough. Agency had only conducted 1 drill as they
(C) notification method X believed the requirement to be quarterly. This has been clarified and Agency
(D) staff participating confirms they will be conducted monthly moving forward.
(E) # of children & staff evacuated
(F) special conditions simulated
(G) problems encountered
(H) time to complete
Umbrella Safety
Yes No N/A Corrective Actions/Comments
419-400-0200
(5)(b) Vehicle has insurance policy, is smoke X
free, safe operating condition, and has first
aid kit and fire extinguisher 2-A:10-BC
(1)(b)(A) Each vehicle used to transport a X
child in care must be: properly registered,
covered by an insurance policy in full force
and effect, maintained in safe operating
condition, and smoke-free.
(3) If a child-caring agency has a swimming X
pool on the premises that is accessible to
children in care or if a child-caring agency
plans to have children in care engage in
swimming, the child-caring agency must
have and adhere to policies and procedures
that address, at a minimum, providing
disclosures and obtaining consents,
assessing swimming ability of children in
care, and ensuring the safety of pool access.
(4)(a) The program protects children from X
potentially harmful items and materials.
(4)(b) Direct supervision of children who do X
not have the ability to adjust and control
water temperature
(4)(c) Light fixtures have protective covers X
unless designed to be used without one
Medication Yes No N/A Corrective Actions/Comments
P a g e 8 | 17
Form Rev. 04/18/2023
419-470-0100
(3)&(7)(e) Medications have a prescription
and are stored in the original container with X
prescription label
(4)&(5) Herbal supplements and remedies,
medical treatments, special diets, physical
therapy, physical aides or limitations have a
written order signed by a physician or
qualified medical professional. A written X
order, signed by a physician or qualified
medical professional, is also required before
a restriction on diet or physical activity is
imposed.
(7)(c) Medications are inaccessible to
Medications were being stored in a cabinet behind only 1 lock, and cabinet was
children and stored behind at least two
X unlocked during the visit. Prior to completion of the visit Agency adjusted
locking mechanisms. This does not apply to
medication storage to ensure 2 locks were in place to secure medications.
Naloxone.
(8) Medications are disposed in accordance
X
with state and federal law
(9) Written record of the disposal of
medications is maintained and includes:
(a) description and amount
No medications have been disposed by the agency, but they had a form and
(b) name X
procedure in place when needed.
(c) reason
(d) method
(e) staff & witness signature
(10) Written record of the administration of
medication includes:
(a) name
(b) description
(c) dates and times
(d) missed doses X
(e) medication disposed
(f) method of administration
(g) ID of person administering
(h) possible adverse reactions
(i) medication taken outside facility
Extracurricular, Enrichment, Cultural &
Social Activities Yes No N/A Corrective Actions/Comments
419-470-0110
(2) Children have ongoing opportunities to X
participate in at least one age-appropriate or
developmentally appropriate activity
Minimum Staffing Requirements
Yes No N/A Corrective Actions/Comments
419-470-0130
P a g e 9 | 17
Form Rev. 04/18/2023
(1)&(2) Supervision is adequate for the type X
of program, location, age and type of
children, ability of supervisor to respond,
electronic back-up systems.
Minimum ratios are maintained:
Under 30 months of age: 1:4
30 months to ˃ 6 years or non-ambulatory:
1:6
Ages 6 and older: 1:7
Overnight (staff awake)
1:10
(4)(a) When one staff on duty, there is X
additional staff immediately available with
max response time of 30 minutes
(5) There is at least one on-site employee X
authorized to apply the reasonable and
prudent parent standard
Sleeping Arrangements
Yes No N/A Corrective Actions/Comments
419-470-0140
(1) Children are in separate bedrooms than X
adults, unless parent and child, or there is
written approval from guardian/parent and
licensing coordinator
(2) There is adequate supervision of children X
when sleeping
(3) When assigning bedrooms a residential X Agency only utilizes single occupancy bedrooms.
care agency must consider all of the
following:
(a) Chronological age
(b) Developmental age
(c) Gender identity
(d) Personal history, including medical,
mental health, behavioral health, and past
adverse experiences including any physical
or sexual abuse
Personnel Files
Yes No N/A Corrective Actions/Comments
419-400-0120
Staff Name/Position X
(3)(g) Date of Hire X
(3)(a) record of education, training, and Personnel Files contained information on education and training, but not previous
X
previous employment employment
P a g e 10 | 17
Form Rev. 04/18/2023
(1)(b) & (3)(b) reference checks completed Reference checks were reported as completed however documentation of
X
and documented reference checks was not being maintained in files
(1)(a) & (3)(c) Background check completed
X
and documented
(3)(d) Annual performance evaluations X Program has only been in operation 6 months
(3)(f) Record of personnel actions X Program has not conducted any personnel actions during their initial 6 months
(3)(g) Termination date, reason for
X No employees have been terminated from the program.
termination
(3)(h) Current job description (1)(c)
Employee meets minimum qualifications X Job descriptions were not recorded in personnel files
stated in current job description
New Employee Orientation – Umbrella
Requirements (30 days) Yes No N/A Corrective Actions/Comments
419-400-0120(4)
(a) Agency policies and procedures X
(b) Ethical and professional guidelines X
(c) Suicide prevention and intervention X
(d) Attributes of population served X
(e) & (5)(a) to (c) Mandatory reporting that
includes:
(a) legal definition of child abuse in ORS
418.257 and 419B.005 X
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to
the employee
(f) Privacy laws X
(g) Emergency procedures X
New Employee Orientation
Residential (Prior to working alone and
Yes No N/A Corrective Actions/Comments
within 30 days)
419-470-0120(1)
(a) Discipline and behavior management
including de-escalation, crisis prevention,
positive behavior management, and X Behavior Management training was not included in Personnel files
disciplinary techniques that are non-punitive
in nature
(b) CPR and First Aid sufficient to retain a
X
current certification
(c) Universal precautions and hygiene X
(d) Application of the reasonable and
X
prudent parent standard
(e) Training on the agency’s policy on
suicide prevention and suicide risk X
assessment tool
P a g e 11 | 17
Form Rev. 04/18/2023
Crisis Intervention Training Standards
and Certification Yes No N/A Corrective Actions/Comments
419-400-0160(4) (as applicable)
(a)Complete a minimum of 12 hours of initial
training in person from a certified instructor,
including but not limited to a minimum of six
hours of training focused on positive
X Agency does not utilize restraint or seclusion and does not train staff on it.
behavior support, nonviolent crisis
intervention and other methods of
nonphysical intervention to support children
in care during a crisis
(d) Receive a certificate that states:
(A) The dates during which the certification
is current
(B) The type of restraint which the individual
is certified to perform if applicable
(C) The type of training the individual is
certified to conduct if applicable X
(D) Any special endorsements earned by the
individual
(E) The level of training
(F) The name of the certified instructor who
conducted the training and administered the
assessment of proficiency.
(e) A certification issued:
(A) Must be personal to the individual
certified by the training provider X
(B) May be valid for no more than two years
with recertification
Ongoing Training Yes No N/A Corrective Actions/Comments
419-470-0070(2)(b) Employees who handle
food served to children have a valid food X Staff do not prepare food for youth. Youth do all their own food preparation.
handler’s card
419-400-0200 (1) Employees transporting
children have: current driver’s license,
Ongoing training documentation not reviewed as program has only been in
insurance, trained in emergency procedures X
operation 6 months.
and behavior management, and training for
15+ passenger vans if applicable)
419-470-0120 (2)(a) Environmental
X
emergencies
419-470-0120 (2)(b) Universal Precautions X
P a g e 12 | 17
Form Rev. 04/18/2023
419-470-0120 (2)(c) Discipline and Behavior
X
Management
419-470-0120 (2)(d) Agency’s policy on
X
suicide prevention and risk assessment tool
419-470-0120 (3) Staff providing direct care
must maintain current CPR/First Aid X
certification
419-470-0120 (4) Designated staff
authorized to apply reasonable and prudent
X
parent standard are trained in application of
the standard
419-400-0120(5) Mandatory reporting
(annually) that includes:
(a) legal definition of child abuse in ORS
418.257 and 419B.005 X
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to
the employee
419-400-0160(4)(b) Receive continuing
education (as applicable on crisis
X
intervention training) from a certified
instructor on an annual basis
Comments:
Children’s Records Yes No N/A Corrective Actions/Comments
Health Services
419-470-0090
(2) Medical history obtained within 30 days
(significant findings, current immunizations,
history of surgical procedures-health issues- X Medical history is not being documented in youth files
injuries, allergies, dental, vision, hearing,
behavioral health, and physician orders)
(4)(a) to (f) Medical exams (3 in first year of
life, 2,4,6,9,14) X
P a g e 13 | 17
Form Rev. 04/18/2023
(g) Have a physical examination within the
first 60 days after admission of a child in
Physical examinations, or documentation of physical examinations within the
care. Documentation of a physical X
calendar year are not documented in the youth files.
examination having occurred within the
calendar year will meet this requirement.
Consents
Yes No N/A Corrective Actions/Comments
419-470-0160(1)
(a) Provide routine and emergency medical
X Consents are clear and well documented in youth files.
care
(b) Use the discipline and behavior
X
management system
(c) Use restraint or seclusion (if applicable).
Must specify the reasons for the intervention X
and how staff are trained and supervised
(d) Restrict contact with persons outside of
X
the agency
(e) Allow access as defined in 419-400-0230
X
& 0240
(f) Impose a dress code X
(g) Apply the reasonable and prudent parent
X
standard
Disclosures
419-470-0160(2) Yes No N/A Corrective Actions/Comments
Parent/guardian has acknowledged in writing:
(a) Information regarding personal or room
searches and protocols for confiscation of X Disclosures are clear and well documented in youth files.
contraband
(b) Statement of Rights of Children and
X
Parents/Guardians
(c) Any policies and procedures upon request X
Authorizations
Yes No N/A Corrective Actions/Comments
419-470-0160(3)
(a) Disclose or exchange information with
X Authorizations are clear and well documented in youth files
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
419-400-0190(1) Yes No N/A Corrective Actions/Comments
Summary sheet contains the following:
P a g e 14 | 17
Form Rev. 04/18/2023
(a)The name, gender, date of birth, religious Some information contained in youth files, but not all required data is clearly
X
preference, and previous address available
(b) Name and location of previous and
X School information was not located in youth files.
current school
(c) Date of admission X
(d) Legal custody X
(e) The name, address, and telephone
number of:
(A) The child in care's parents.
(B) The child in care's legal guardian, if
different than the parents, and a copy of
X This documentation was not clearly available in youth files.
the document that provides for his or her
authority over the child in care.
(C) Other persons significant to child
(D) Other professionals to be involved in
service planning (if applicable)
Service Planning
Yes No N/A Corrective Actions/Comments
419-470-0170(2)
(b) Intake document is completed the date
child accepted into care (emergency X
placement 48 hours)
(d) Assessment is completed within 30 days
and contains relevant historical info., current
behavioral observations, identified need for X
services, and how agency will provide
services
(e) (A)&(B) Service plan within 60 days
(parent, guardian and child actively involved).
Describes how child’s issues will be X
addressed, anticipated outcomes, and
reviewed by child and guardian/parent.
(e)(C)&(D) Service plan is reviewed quarterly
and revised when information indicates other X
services should be provided
Case Management
Yes No N/A Corrective Actions/Comments
419-470-0170(3)
(a) Services are documented, progress
X
toward achieving goals is tracked
(c) Discharge summary must include:
(A)Current medications
(B)Name of the physician or qualified medical
X None of the reviewed files included youth who had discharged the program.
professional who prescribed each medication
(C)Any outstanding medical or other
appointments
P a g e 15 | 17
Form Rev. 04/18/2023
(D)Summary of the child’s participation in the
program and progress achieved
(E)Results of evaluations
(F)Recommendations regarding services
(G)Discharge destination
(e) Follow up services X
(f) Incident Reports X Program has incident reports, but they were not maintained in the youth files.
Records Relating to Restraint &
Yes No N/A Corrective Actions/Comments
Involuntary Seclusion
419-400-0180 (12) Records X
419-400-0180(13)(e) Each child caring
agency shall provide notice regarding how to
access the quarterly reports to the parents or
guardians of children in care in the program. X Notices regarding quarterly restraint reporting were not included in youth files.
The child caring agency shall provide the
notice upon the child in care’s admission and
at least two times each year thereafter.
419-400-0190(1) Information provided to
Files did not indicate information was provided to children in care relating to
children in care relating to Restraint & X
Restraint and Seclusion
Involuntary Seclusion
Financial Records
Yes No N/A Corrective Actions/Comments
419-470-0170(4)
Records contain date, amount, source,
X Program does not receive funds for youth.
purpose, signatures
Personal Possessions Records
Yes No N/A Corrective Actions/Comments
419-470-0170 (5)
Individual written inventory of all personal 1 reviewed file did not include a property log. Logs were not clear about property
possessions is maintained and updated as X added after intake, including currency in youth possession. Program needs a
needed procedure for tracking currency in youth possession.
Records and Documentation
Yes No N/A Corrective Actions/Comments
419-400-0140
(1) Stored safely X
(2) Permanent, legible, dated, and signed X
(3)&(4) Uniform in organization, readily
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
P a g e 16 | 17
Form Rev. 04/18/2023
Placement upon discharge
Comments:
Licensing Coordinator’s Signature: ________________________ Date: _7_-_2_4_-2__0_2_3__________
Manager Review: ______________________________________ Date: _7_-_2_4_-2_0_2_3__________
P a g e 17 | 17
Form Rev. 04/18/2023

agency_name: Team Bailey (TB)

board_chairperson: Jordan Craig

licensing_coordinator: Jeff Minden, Aubrey Kelly

other_regulatory_agencies: Oregon Youth Authority

program_services: Residential - Independent Living Services

capacity_age_range: 5, male ages 17-24

funding_sources: Oregon Youth Authority

average_length_of_stay: 6-9 months

use_of_seclusion_or_restraint: No P a g e 1 | 17

interviews_observations:
As a part of the review a tour of Team Bailey was conducted, along with 2 staff interviews. Interviews with youth were
attempted. However, none of the youth present in the program were willing to be interviewed. The facility was clean and in good repair, including
the bathrooms, laundry area, kitchen and staff offices.
Staff both spoke positively about the program. One staff was new to the program having only been hired approximately 3 weeks earlier and the
other has been with Team Bailey since opening. Both staff reported liking working for the program. Both staff reported the best part of the job is
interacting with youth and learning about them. One staff reported that the biggest challenge is there isn't enough time in the day, and that it can be
challenging balancing the schedules for 5 youth. Both staff reported feeling management was readily available, supportive, and that the training
was helpful. Neither staff reported anything they thought could be changed or improved.

program_strengths:
Program is self-described as diverse and culturally aware. The program adapts to youth's varying schedules and has a focus
on positively coexisting in the space.

changes_in_last_two_years: N/A Initial 6 month review

grievances_and_complaints: None since opening.

excerpt:
(5)(a) Evacuation drill occurs monthly under
varying conditions, is retained 2 years and
contains:
(A) identify of person conducting drill
(B) date & time
(C) notification method
(D) staff participating
(E) # of children & staff evacuated
(F) special conditions simulated
(G) problems encountered
(H) time to complete Evacuation form is very thorough. Agency had only conducted 1 drill as they
believed the requirement to be quarterly. This has been clarified and Agency
confirms they will be conducted monthly moving forward.

excerpt:
(7)(c) Medications are inaccessible to
children and stored behind at least two
locking mechanisms. This does not apply to
Naloxone. Medications were being stored in a cabinet behind only 1 lock, and cabinet was
unlocked during the visit. Prior to completion of the visit Agency adjusted
medication storage to ensure 2 locks were in place to secure medications.

excerpt:
(3)(a) record of education, training, and
previous employment Personnel Files contained information on education and training, but not previous
employment

excerpt:
(1)(b) & (3)(b) reference checks completed
and documented Reference checks were reported as completed however documentation of
reference checks was not being maintained in files

excerpt:
(3)(h) Current job description (1)(c)
Employee meets minimum qualifications
stated in current job description Job descriptions were not recorded in personnel files

excerpt:
(a) Discipline and behavior management
including de-escalation, crisis prevention,
positive behavior management, and
disciplinary techniques that are non-punitive
in nature Behavior Management training was not included in Personnel files

excerpt:
(2) Medical history obtained within 30 days
(significant findings, current immunizations,
history of surgical procedures-health issues-
injuries, allergies, dental, vision, hearing,
behavioral health, and physician orders) Medical history is not being documented in youth files

excerpt:
(g) Have a physical examination within the
first 60 days after admission of a child in
care. Documentation of a physical
examination having occurred within the
calendar year will meet this requirement. Physical examinations, or documentation of physical examinations within the
calendar year are not documented in the youth files.

excerpt:
(a)The name, gender, date of birth, religious
preference, and previous address Some information contained in youth files, but not all required data is clearly
available

excerpt:
(b) Name and location of previous and
current school School information was not located in youth files.

excerpt:
(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
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) This documentation was not clearly available in youth files.

excerpt: (f) Incident Reports Program has incident reports, but they were not maintained in the youth files.

excerpt:
Each child caring
agency shall provide notice regarding how to
access the quarterly reports to the parents or
guardians of children in care in the program.
The child caring agency shall provide the
notice upon the child in care’s admission and
at least two times each year thereafter. Notices regarding quarterly restraint reporting were not included in youth files.

excerpt:
Information provided to
children in care relating to Restraint &
Involuntary Seclusion Files did not indicate information was provided to children in care relating to
Restraint and Seclusion

excerpt:
Individual written inventory of all personal
possessions is maintained and updated as
needed 1 reviewed file did not include a property log. Logs were not clear about property
added after intake, including currency in youth possession. Program needs a
procedure for tracking currency in youth possession.