state: OR

facility_name: Downtown ORR Shelter/LTGH

summary: Unannounced - 18 findings

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Licensee: Morrison Child and Family Services
Executive Director: Nick Gallo
Program Director(s): Alina Maldonado
Date of Unannounced: 9.20-21.23
Licensing Coordinator: Jorge Pelinski, and Holly Ivey
Other Regulatory or Accrediting Agencies: DHS Treatment Services, The Oregon Youth Authority, and The Federal Government
Purpose: Per OAR 419-400-0240 (1)(b) Children’s Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings: Repeat Comments
License Renewal Site Visit Findings
November 14-16, 2022 Further
Action
Needed
419-400-0040(3)(g) Approval from BCU: Yes☐ No
 DHS Licensing Coordinator received all of the above stated
Executive Director or Program Director Approval from BCU background checks. The agency is in compliance.
 Kelli Doolittle, Sage Program Director’s Background Check was
submitted by Morrison to the ODHS Background Check Unit
(BCU) at the time of the review. The fitness determination was
in process at the time of the review.
Documents as indicated on the form titled “Renewal Licensing Required Yes☐ No Documents as indicated on the form titled “Renewal Licensing
Documents”: Required Documents”:
 Certificates of Occupancy: Sage, and the Downtown Building. Certificates of Occupancy: Sage, and the Downtown Building.
 Fire Marshal Inspections for all sites were completed, violations  DHS Licensing Coordinator received all of the listed
were found at all sites. The agency must submit verification that documents. The agency is in compliance.
the violations have been remedied.
 Environmental Inspections for all sites.
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419-470-0020(2)(a)&(c) Buildings are smoke free, clean and in good Yes☐ No
repair:  The agency made needed repairs and is in
compliance.
Buildings are smoke free, clean and in good repair
The following was identified in need of repair:
Downtown ORR Shelter:
 (LTGH) 4th Floor touch up paint needed in small areas in the
hallway.
 (LTGH) Bedroom 40A Two holes needed to be filled and paint
needed
413-470-0030(3)(c) Outside room with window allowing egress from Yes☐ No
building:  The agency submitted an exception request regarding the
egress requirement. DHS Licensing approved the
 Sage, LTGH, and the ORR residential programs, windows do not exception until the next renewal review.. The exception
allow egress was approved since widows are fixed by design and not
openable, and the building has been inspected and
approved by the Fire Marshal. The agency is in
compliance.
419-400-0120(1)(a) & (3)(c) Background check completed and Yes☐ No
documented:  DHS Licensing Coordinator received all the above
stated background checks. The agency is in
 One Background Check was not found in the personnel files compliance with the above requirement.
reviewed for a Sage Staff.
 Two Background Checks were not found in the personnel files
reviewed for the ORR Program.
All required policies and procedures as identified in the “Umbrella Yes☐ No
Rules”: 419-400-0150 Licensing Umbrella Rules: Discipline,
Behavior Management & Training, and Suicide Prevention: (1) A
child-caring agency, except a child-caring agency licensed only to  The agency submitted policies to the licensing
provide adoption services under OAR 419-420-0010 to 419-420-0160, coordinator that are in compliance with all applicable
must adopt and adhere to written policies and procedures on discipline, requirements.
behavior management, and suicide prevention that meet all of the
requirements of this rule. (b) The discipline and behavior management
policies and procedures must prohibit the following: (A) Spanking, hitting,
or striking with an instrument. (B) Committing an act designed to
humiliate, ridicule, or degrade a child in care or undermine the self-
respect of a child in care. (C) Punishing a child in care in the presence of
a group or punishment of a group for the behavior of one child in care.
(D) Depriving a child in care of food, clothing, shelter, bedding, rest,
sleep, toilet access, or parental contact. (E) Assigning extremely
strenuous exercise or work or requiring a child in care to spend
prolonged time in one position likely to produce unreasonable discomfort.
(F) Using restraint or involuntary seclusion as discipline. (G) Permitting or
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directing a child in care to punish another child in care. (H) Using any
other kind of harsh punishment.
(I) Denying a parent, guardian, or sibling the right to visit or communicate
with a child in care solely as a disciplinary measure against the child in
care. (J) Aversive conditions, which includes, but is not limited to, any
technique designed to or likely to cause a child physical pain, the
application of startling stimuli, and the release of noxious stimuli or toxic
sprays, mists, or substances in proximity to the child in care. (K)
Removing or limiting the use of a mobility aid or other assistive device for
the purpose of controlling a child in care's behavior. (3) Behavior
Management. (C) Use of restraints, if applicable. (i) Chemical restraint,
meaning the administration of medication for the management of
uncontrolled behavior, is prohibited. Chemical restraint is different from
the use of medication for treatment of symptoms of severe emotional
disturbances or disorders. (4) Suicide Prevention. The policy must
include the following: (f) Suicide risk assessment procedures on the day
of intake; (g) Documentation requirements for suicide ideation, self-harm,
and special observation precautions to ensure immediate communication
to all staff
The programs were out of compliance with some of the above
requirements for Behavior Management Policies, and the following
must be added:
 Sage:1(K)
 LTGH: 1(A-K), 3(C)(i)
 ORR:1(A-K), 3(C)(i)
The programs were out of compliance with some of the above
requirements for Suicide Prevention Policies, and the following
must be added:
 LTGH:4(f)
 ORR: 4(g) Missing ”…. to ensure immediate communication to
all staff”
419-470-0150 Referral and Initial Evaluation of Children (Technical Yes☐ No
Amended 01/14/20) (1) Referral. A residential care agency must have a  The agency submitted a policy to the licensing coordinator
policy that addresses the process by which children in care are referred that is in compliance with all applicable requirements.
to the residential care agency. The policy must include all of the
following: (a) From whom referrals are accepted. (c) How information
necessary to provide for the safety and care of children in care will be
provided to the appropriate care staff:
 Sage: The Referral Policy was missing the above required
information.
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419-470-0160 Consents, Disclosures, and Authorizations (Amended Yes☐ No
02/01/2022) (1) Consents. For each child in care in placement with a The agency submitted policies to the licensing coordinator that
residential care agency, the residential care agency must ensure that a are in compliance with the requirements.
parent or legal guardian signs a consent that authorizes the residential
care agency to undertake each of the following: (a) To provide routine The ODHS Licensing Coordinators reviewed some consents
and emergency medical care. However, if the parent or legal guardian verifying they are in compliance with applicable requirements.
relies on prayer or spiritual means for healing in accordance with the
creed or tenets of a well-recognized religion or denomination, the
residential care agency is not required to use medical, psychological, or
rehabilitative procedures, unless the child in care is old enough to
consent to these procedures and does so. The residential care agency
must have policies and procedures for this practice, which are reviewed
and approved by the child in care's parent or legal guardian.
 ORR and LTGH: The Consent Policies were missing the above
required information.
419-400-0180 Licensing Umbrella Rules: Restraints and Involuntary Yes☐ No .
Seclusion: (Amended 07/01/2022) (1) A child-caring agency may
only place child in care in a restraint or involuntary seclusion if the  The agency submitted policies to the licensing coordinator
child in care’s behavior poses a reasonable risk of imminent serious that are in compliance with applicable requirements.
bodily injury to the child in care or others and less restrictive
interventions would not effectively reduce the risk. (2) A child-caring
agency may not place a child in care in a restraint or involuntary
seclusion as a form of discipline, punishment, or retaliation or for the
convenience of staff, contractors or volunteers of the child-caring
agency. (3) If the child-caring agency utilizes restraints or involuntary
seclusion as part of its practices, its use of restraints and involuntary
seclusion must be in compliance with all applicable federal and state
laws, regulations and rules. (4) A child in care placed in a restraint or
involuntary seclusion must be continuously monitored by staff of the
child-caring agency for the duration of the restraint or involuntary
seclusion. (5) Any restraint or involuntary seclusion used on a child in
care must be performed in a manner that is safe, proportionate and
appropriate, taking into consideration the child in care’s chronological
and developmental age, size, gender identity, physical, medical and
psychiatric condition and personal history, including any history of
physical or sexual abuse. (6) The removal or limitation of the use of a
mobility aid or other assistive device in a restraint is prohibited unless
there is a risk of imminent serious bodily injury and less restrictive
interventions would not effectively reduce the risk. (7) Removing or
limiting the use of a mobility aid or other assistive device for the
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purpose of controlling a child in care’s behavior is prohibited and (8)
If any restraint or involuntary seclusion lasts for more than 10
minutes, the child-caring must provide adequate access to the
bathroom and water at least every thirty minutes to the child in care.
(9) For any restraint or involuntary seclusion lasting more than 10
minutes a supervisor, trained in the non-violent crisis intervention
system used by the child-caring agency must provide written
authorization for the continuation of the restraint or involuntary
seclusion every five minutes. (a) If the supervisor is not on-site at the
time the restraint is used, the supervisor may provide the written
authorization electronically. (b) The written authorization must
document why the restraint or involuntary seclusion continues to be
the least restrictive intervention to reduce the risk of imminent serious
bodily injury in the given circumstances. (10) Restraint. (a) The
following types of restraint of a child in care are prohibited: (A)
Chemical restraint. (B) Mechanical restraint. (C) Prone restraint. (D)
Supine restraint, except: (i) Supine restraint may be used only when
the child in care is currently admitted to a secure children’s inpatient
treatment program or secure adolescent inpatient treatment
program…(E) Any restraint that includes the nonincidental use of a
solid object, including the ground, a wall or the floor, to impede a
child in care’s movement, except: (i) This type of restraint may be
used if the restraint is necessary to gain control of a weapon or; (F)
Any restraint that places or creates a risk of placing pressure on a
child in care’s neck or throat. (G) Any restraint that places or creates a
risk of placing, pressure on a child in care’s mouth, except: (i) This
type of restraint may be used if the restraint is necessary for the
purpose of extracting a body part from a bite. (H) Any restraint that
impedes, or creates a risk of impeding, a child in care’s breathing. (I)
Any restraint that involves the intentional placement of hands, feet,
elbows, knees or any object on a child in care’s neck, throat, genitals
or other intimate parts. (J) Any restraint that causes pressure to be
placed or creates a risk of causing pressure to be placed, on a child in
care’s stomach, chest, joints, throat or back by a knee, foot or elbow.
(K) Any other restraint which the primary purpose is to inflict pain.
(b) Permissible use of restraint. A restraint may be used on a child in
care in the following situations: (A) Holding a child in care’s hand or
arm to escort the child in care safely and without the use of force from
one area to another; (B) Assisting the child in care to complete a task
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if the child in care does not resist the physical contact; or (C) Using a
physical intervention if: (i) The intervention is necessary to break up a
physical fight or to effectively protect a person from an assault,
serious bodily injury or sexual contact; (ii) The intervention uses the
least amount of physical force and contact possible: and (iii) The
intervention is not a prohibited restraint identified in OAR 413-215-
0077(8)(a). (c) Only child-caring agency staff and proctor foster
parents who have been trained in a nationally recognized nonviolent
crisis-intervention system may use restraint and only when necessary,
as a last resort to prevent a child in care from inflicting harm to self or
others. The restraint must be conducted within the parameters of the
nationally recognized system in which the staff or proctor foster
parent is trained. (d) Any use of restraint by a staff member or proctor
foster parent of the child-caring agency, if the member is not trained
in a nationally recognized nonviolent crisis intervention system, must
also be reported to a Department licensing coordinator within one
business day of occurrence. (e) Limitations. The child-caring agency
must have a policy that prohibits the application of a nonviolent
restraint to a child in care who has a documented physical condition
that would contraindicate the use of that particular restraint, unless a
qualified medical professional has previously and specifically
authorized its use in writing for the child in care. Documentation of
the authorization must be maintained in the child of care’s record. (12)
Records (a) A program shall maintain a record of each incident in
which a reportable injury arises from the use of a restraint or
involuntary seclusion. The record must include any audio or video
recording immediately preceding, during and following the incident.
(b) If a program places a child in care in a restraint, except as
described in OAR 419-400-0180(8)(b)(A) or 419-400-0180(8)(b)(B)
or involuntary seclusion, the program shall provide the child in care’s
case manager, attorney, court appointed special advocate and parent
or guardian with: (A) Verbal or electronic notice that the restraint or
involuntary seclusion was used as soon as practicable following the
incident but not later than the end of the next business day; and (B)
Written notice in compliance with OAR 419-400-0180(10)(c) that the
restraint or involuntary seclusion was used as soon as practicable
following the incident but not later than the end of the next business
day.(c) The written notice must include: (A) A description of the
restraint or involuntary seclusion, the date of the restraint or
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involuntary seclusion, the times when the restraint or involuntary
seclusion began and ended and the location of the restraint or
involuntary seclusion; (B) A description of the child in care’s activity
that necessitated the use of restraint or involuntary seclusion; (D) The
names of each of individual who placed the child in care in the
restraint or involuntary seclusion or who monitored or approved the
placement of the child in care in the restraint or involuntary seclusion;
(i) For each individual identified whether the individual was trained,
as required by the Department of Human Services by rule, in the use
of the type of restraint or involuntary seclusion used, the date of the
individual’s most recent training and a description of the types of
restraint the individual is trained to use, if any. (ii) If an individual
identified was not trained in the type of restraint or involuntary
seclusion used, or if the individual’s training was not current, a
description of the individual’s training deficiency and the reason an
individual without the proper training was involved in the restraint or
involuntary seclusion. (d) If an incident requires notice under 419-
400-0180(b), not later than two business days following the date of
the restraint or involuntary seclusion, the program shall hold a
debriefing meeting with each individual who was involved in the
incident and with any other appropriate program staff, shall take
written notes of the debriefing meeting and shall provide copies of the
written notes to the child in care’s case manager, attorney, court
appointed special advocate and parents or guardians. (e) If a program
places a child in care in a restraint or involuntary seclusion and the
child in care suffers a reportable injury arising from the restraint or
involuntary seclusion, the program shall immediately provide the
department and the child in care’s attorney, court appointed special
advocate and parents or guardians with written notification of the
incident and access to and, upon request, copies of all records related
to the restraint or involuntary seclusion, including any photographs
and audio or video recordings. (f) If serious bodily injury or the death
of staff occurs in connection to the use of the restraint or involuntary
seclusion, the program shall provide the department with written
notification of the incident not later than 24 hours following the
incident.
See Sage, LTGH, and ORR below for details:
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 Sage: (1)”….less restrictive interventions would not effectively reduce
the risk.” (2), (3), (5), (6), (7), (8), (9)(a)(b),
(10)(a)(A)(B)(C)(D)(E)(i)(F)(G)(H)(I)(J)(K)(b)(A)(B)(C)(i)(ii)(iii)(c)”
nonviolent crisis-intervention system may use restraint and only
when necessary, as a last resort to prevent a child in care from
inflicting harm to self or others. The restraint must be conducted
within the parameters of the nationally recognized system in which
the staff or proctor foster parent is trained.”(d) (12)(a)(b)(A)(B)(c)(A)”
the date of the restraint and the location of the
restraint”(B)(D)(i)(ii)(d)( e)(f)
 LTGH: (3),(4),(6),(7), (8), (9)(a)(b),
(10)(a)(A)(C)(D)(E)(i)(F)(G)(i)(H)(I)(J)(K)(b)(A)(B)(C)(i)(ii)(iii)
)(c)”nonviolent crisis-intervention system may use restraint and only
when necessary, as a last resort to prevent a child in care from
inflicting harm to self or others. The restraint must be conducted
within the parameters of the nationally recognized system in which
the staff or proctor foster parent is trained.”(d)( e) 12(a)(b)(A)(B)(c)(A)
)” the date of the restraint and the location of the restraint”
(D)(i)(ii)(d)(e)(f)
 ORR: (3),(4),(6),(7), (8), (9)(a)(b),
(10)(a)(A)(C)(D)(E)(i)(F)(G)(i)(H)(I)(J)(K)(b)(A)(B)(C)(i)(ii)(iii)
)(c)”nonviolent crisis-intervention system may use restraint and only
when necessary, as a last resort to prevent a child in care from
inflicting harm to self or others. The restraint must be conducted
within the parameters of the nationally recognized system in which
the staff or proctor foster parent is trained.”(d)( e) 12(a)(b)(A)(B)(c)(A)
)” the date of the restraint and the location of the restraint”
(D)(i)(ii)(d)(e)(f)
419-400-0190 Licensing Umbrella Rules: Information Provided to Yes No☐ .
Children in Care
(Adopted 02/01/2022 (1) Each child in care receiving services from a  On September 20th, 2023, the licensing coordinator
child-caring agency must be given the following: (a) Instruction regarding reviewed some of the youth records. Sage was found to be
how a child in care may report suspected inappropriate use of restraint or in compliance with the requirement. Mi Futuro and LTGH
involuntary seclusion; (b) Assurance that the child in care will not were not providing all of the above required information to
experience retaliation for reporting suspected inappropriate uses of the youth. The agency must submit a revised document
restraint or involuntary seclusion and; (c) The telephone number for the that has all of the above requirements to the licensing
toll-free child abuse hotline described in ORS 417.805 and the telephone coordinator.
numbers and electronic mail addresses for the program’s licensing Repeat Finding from 2022
agency, the child in care’s caseworker and attorney, the child in care’s
court appointed special advocate and Disability Rights Oregon. (2) The
information must be provided by: (a) The Department of Human Services
if the department placed the child in care in the child-caring agency; (b)
The Oregon Youth Authority if the child in care has been committed to
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the custody of the authority; or (c) The child-caring agency for all other
children in care.
 Documentation was not found to verify that the agency
had provided the above required information to the youth
in all Morrison programs at admission.
419-470-0100 Medication (Technical Amended 01/13/20) A Yes☐ No
residential care agency must meet all of the following requirements:  The agency submitted a policy to the licensing coordinator
(1) Policy and procedures. The residential care agency must have that is in compliance with the requirements.
policies and procedures that cover all prescription and non-
prescription medications that address all of the following: (h) How the
foster care agency and the proctor foster home will ensure compliance
with OAR 413-070-0470 if it serves children in Department custody.
 Sage: The Medication Policy was missing the above required
information.
New Findings from Site Visit Comments
419-470-0020(2)(a)&(c) Buildings are smoke 419-470-0020(2)(a)&(c) Buildings are smoke free, clean and in good repair:
free, clean and in good repair:
The following was identified as being in need of repair:
Downtown Mi Futuro and Long-Term Group Home (LTGH):
 The following rooms were found to need touch up paint:
Room #411, 414a, 415a, 420a, 508a, 510, 511a, 512
 The following rooms were found to need small holes repaired and touch up paint.
Room #403, 418a
 Room 511a was missing an electrical outlet cover that must be replaced.
 Room 522a had a wall that was dirty and must be cleaned.
Interview Summary
At the Unannounced Inspection, Jorge Pelinski, and Holly Ivey, ODHS Licensing Coordinators, conducted private interviews with two youth who were residing
at SAGE. A Teams Meeting occurred with Jorge Pelinski, Holly Ivey, ODHS Licensing Coordinator, and two youth from Mi Futuro, and two youth from the
LTGH Program on September 21, 2023. Each of the youth spoke with the Licensing Coordinators privately with a translator present. The following
information was obtained from the interviews:
 Most of the youth stated things were going well for them while residing in the programs.
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 When asked what they appreciated most about living in the programs the youth stated: “Watching documentaries, liked the exercise area, the big yard
(playground), the courtyard garden, all of the things she has learned from the groups at the program, likes having private conversations with her
mom.” Another youth stated, “Feeling grateful for the staff and the program.”
 Fun activities and recreation reported by the youth: Slip and slid and water balloons, the big recreation space in the backyard, getting time for parent
visits, playing soccer, and playing games with the other youth in the gym.
 All youth mentioned that they receive three meals a day, with multiple snacks. The youth reported fresh fruit and vegetables are always available. One
youth reported that he really enjoys eating the chicken that the program serves.
 All the youth stated there are no privacy restrictions in contacting their approved contacts. They stated they could have daily phone calls with
approved contacts.
 All youth reported the program provides hygiene products, which includes, soap, shampoo, feminine products, and toothpaste.
 All youth reported that they could talk to staff if they had a concern or need. At SAGE it was reported that some of the staff would yell on occasion
and that one staff is passive aggressive. One youth reported that a staff member told her, “She was fat and had an eating problem and eats too
much.” DHS Licensing Coordinator, Jorge Pelinski and Holly Ivey, spoke with the SAGE Program Director, Kelli Doolittle about the above
stated concerns in an exit meeting on September 20, 2023. The Program Director stated she would follow up with the staff regarding the
concerns raised. The Licensing Coordinator asked the Program Director to communicate the outcome of the follow up with licensing staff.
Due to the alleged youth concerns, upon leaving, DHS Licensing Coordinator called the Child Welfare Hotline on September 20, 2023.
 When asked what changes the youth would make to the programs, the following was reported: “Nothing, Double portion for the entrees at lunch on the
weekends, an unlocked program to come and go as they please.”
 When asked if the youth feel safe in the programs the following was stated: “Yes, and no.” She feels unsafe when other youth have “outbursts or
break things.” Three youth stated that they felt safe in the program and felt comfortable talking to staff about any concerns they may have. One youth
stated they felt unsafe thirty percent of the time. When asked to clarify the thirty percent, youth stated, “I don’t like to be around a lot of people. I am
use to living with just my mom and couple other people.” This youth stated that they do not have any concerns about getting physically hurt from peers
or staff. This youth also shared that when staff knock on the door as a reminder to finish up showering, it startles her; which makes her feel unsafe.
This writer asked youth if she felt comfortable talking to staff about her concerns. This youth shared that she could talk to staff about it. This youth had
no other problems or concerns to report during interview.
Observations
At the Unannounced Inspections, the Program Director’s assisted with the walk through of the programs with Jorge Pelinski and Holly Ivey, ODHS Licensing
Coordinators. Staff and youth were observed at the programs during the inspection walk through. The youth that were at the programs that day were
observed to be at ease and comfortable in the environment. All areas of the programs (inside and outside) where youth had access were observed, to be well
kept, clean and in good repair. The downtown program needed minor repairs, as stated above. The agency vehicles that the youth ride in were observed and
meet the requirements per Licensing Rules. Food was observed to be in the refrigerators and in the pantries at both sites. The programs have chefs who are
responsible for the meals, and meal are prepared fresh onsite. Medication was observed to be kept in locked cabinets inaccessible to youth.
Corrective Actions and Timeframes:
Please submit the following to verify compliance.
Within 45 days of receipt of this report Morrison Youth and Family, 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
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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 Jorge Pelinski, Licensing Coordinator at: Jorge.l.pelinski@odhsoha.oregon.gov
Licensing Coordinator’s Signature: ________________________ Date: _1_0_-_3_-2__0_2_3__________
Manager Review: ______________________________________ Date: _1_0_-_2_-2__0_2_3_ ________
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agency_name: Morrison Child and Family Services (MCFS)

program_type: (RC) Residential Care Programs

report_type: Unannounced

view_code: RC

licensee: Morrison Child and Family Services

executive_director: Nick Gallo

program_director: Alina Maldonado

licensing_coordinator: Jorge Pelinski, and Holly Ivey

purpose:
Per OAR 419-400-0240 (1)(b) Children's Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings: Repeat Comments
License Renewal Site Visit Findings
November 14-16, 2022 Further
Action
Needed
419-400-0040(3)(g) Approval from BCU: Yes[ ] No
- DHS

interview_summary:
At the Unannounced Inspection, Jorge Pelinski, and Holly Ivey, ODHS Licensing Coordinators, conducted private interviews with two youth who were residing
at SAGE. A Teams Meeting occurred with Jorge Pelinski, Holly Ivey, ODHS Licensing Coordinator, and two youth from Mi Futuro, and two youth from the
LTGH Program on September 21, 2023. Each of the youth spoke with the Licensing Coordinators privately with a translator present. The following
information was obtained from the interviews:
- Most of the youth stated things were going well for them while residing in the programs.

- When asked what they appreciated most about living in the programs the youth stated: "Watching documentaries, liked the exercise area, the big yard
(playground), the courtyard garden, all of the things she has learned from the groups at the program, likes having private conversations with her
mom." Another youth stated, "Feeling grateful for the staff and the program."
- Fun activities and recreation reported by the youth: Slip and slid and water balloons, the big recreation space in the backyard, getting time for parent
visits, playing soccer, and playing games with the other youth in the gym.
- All youth mentioned that they receive three meals a day, with multiple snacks. The youth reported fresh fruit and vegetables are always available. One
youth reported that he really enjoys eating the chicken that the program serves.
- All the youth stated there are no privacy restrictions in contacting their approved contacts. They stated they could have daily phone calls with
approved contacts.
- All youth reported the program provides hygiene products, which includes, soap, shampoo, feminine products, and toothpaste.
- All youth reported that they could talk to staff if they had a concern or need. At SAGE it was reported that some of the staff would yell on occasion
and that one staff is passive aggressive. One youth reported that a staff member told her, "She was fat and had an eating problem and eats too
much." DHS Licensing Coordinator, Jorge Pelinski and Holly Ivey, spoke with the SAGE Program Director, Kelli Doolittle about the above
stated concerns in an exit meeting on September 20, 2023. The Program Director stated she would follow up with the staff regarding the
concerns raised. The Licensing Coordinator asked the Program Director to communicate the outcome of the follow up with licensing staff.
Due to the alleged youth concerns, upon leaving, DHS Licensing Coordinator called the Child Welfare Hotline on September 20, 2023.
- When asked what changes the youth would make to the programs, the following was reported: "Nothing, Double portion for the entrees at lunch on the
weekends, an unlocked program to come and go as they please."
- When asked if the youth feel safe in the programs the following was stated: "Yes, and no." She feels unsafe when other youth have "outbursts or
break things." Three youth stated that they felt safe in the program and felt comfortable talking to staff about any concerns they may have. One youth
stated they felt unsafe thirty percent of the time. When asked to clarify the thirty percent, youth stated, "I don't like to be around a lot of people. I am
use to living with just my mom and couple other people." This youth stated that they do not have any concerns about getting physically hurt from peers
or staff. This youth also shared that when staff knock on the door as a reminder to finish up showering, it startles her; which makes her feel unsafe.
This writer asked youth if she felt comfortable talking to staff about her concerns. This youth shared that she could talk to staff about it. This youth had
no other problems or concerns to report during interview.

observations:
At the Unannounced Inspections, the Program Director's assisted with the walk through of the programs with Jorge Pelinski and Holly Ivey, ODHS Licensing
Coordinators. Staff and youth were observed at the programs during the inspection walk through. The youth that were at the programs that day were
observed to be at ease and comfortable in the environment. All areas of the programs (inside and outside) where youth had access were observed, to be well
kept, clean and in good repair. The downtown program needed minor repairs, as stated above. The agency vehicles that the youth ride in were observed and
meet the requirements per Licensing Rules. Food was observed to be in the refrigerators and in the pantries at both sites. The programs have chefs who are
responsible for the meals, and meal are prepared fresh onsite. Medication was observed to be kept in locked cabinets inaccessible to youth.

previous_findings:
Repeat Comments
License Renewal Site Visit Findings
November 14-16, 2022 Further
Action
Needed
419-400-0040(3)(g) Approval from BCU: Yes[ ] No
- DHS Licensing Coordinator received all of the above stated
Executive Director or Program Director Approval from BCU background checks. The agency is in compliance.
- Kelli Doolittle, Sage Program Director's Background Check was
submitted by Morrison to the ODHS Background Check Unit
(BCU) at the time of the review. The fitness determination was
in process at the time of the review.
Documents as indicated on the form titled "Renewal Licensing Required Yes[ ] No Documents as indicated on the form titled "Renewal Licensing
Documents": Required Documents":
- Certificates of Occupancy: Sage, and the Downtown Building. Certificates of Occupancy: Sage, and the Downtown Building.
- Fire Marshal Inspections for all sites were completed, violations - DHS Licensing Coordinator received all of the listed
were found at all sites. The agency must submit verification that documents. The agency is in compliance.
the violations have been remedied.
- Environmental Inspections for all sites.

419-470-0020(2)(a)&(c) Buildings are smoke free, clean and in good Yes[ ] No
repair: - The agency made needed repairs and is in
compliance.
Buildings are smoke free, clean and in good repair
The following was identified in need of repair:
Downtown ORR Shelter:
- (LTGH) 4th Floor touch up paint needed in small areas in the
hallway.
- (LTGH) Bedroom 40A Two holes needed to be filled and paint
needed
413-470-0030(3)(c) Outside room with window allowing egress from Yes[ ] No
building: - The agency submitted an exception request regarding the
egress requirement. DHS Licensing approved the
- Sage, LTGH, and the ORR residential programs, windows do not exception until the next renewal review.. The exception
allow egress was approved since widows are fixed by design and not
openable, and the building has been inspected and
approved by the Fire Marshal. The agency is in
compliance.
419-400-0120(1)(a) & (3)(c) Background check completed and Yes[ ] No
documented: - DHS Licensing Coordinator received all the above
stated background checks. The agency is in
- One Background Check was not found in the personnel files compliance with the above requirement.
reviewed for a Sage Staff.
- Two Background Checks were not found in the personnel files
reviewed for the ORR Program.
All required policies and procedures as identified in the "Umbrella Yes[ ] No
Rules": 419-400-0150 Licensing Umbrella Rules: Discipline,
Behavior Management & Training, and Suicide Prevention: (1) A
child-caring agency, except a child-caring agency licensed only to - The agency submitted policies to the licensing
provide adoption services under OAR 419-420-0010 to 419-420-0160, coordinator that are in compliance with all applicable
must adopt and adhere to written policies and procedures on discipline, requirements.
behavior management, and suicide prevention that meet all of the
requirements of this rule. (b) The discipline and behavior management
policies and procedures must prohibit the following: (A) Spanking, hitting,
or striking with an instrument. (B) Committing an act designed to
humiliate, ridicule, or degrade a child in care or undermine the self-
respect of a child in care. (C) Punishing a child in care in the presence of
a group or punishment of a group for the behavior of one child in care.
(D) Depriving a child in care of food, clothing, shelter, bedding, rest,
sleep, toilet access, or parental contact. (E) Assigning extremely
strenuous exercise or work or requiring a child in care to spend
prolonged time in one position likely to produce unreasonable discomfort.
(F) Using restraint or involuntary seclusion as discipline. (G) Permitting or

directing a child in care to punish another child in care. (H) Using any
other kind of harsh punishment.
(I) Denying a parent, guardian, or sibling the right to visit or communicate
with a child in care solely as a disciplinary measure against the child in
care. (J) Aversive conditions, which includes, but is not limited to, any
technique designed to or likely to cause a child physical pain, the
application of startling stimuli, and the release of noxious stimuli or toxic
sprays, mists, or substances in proximity to the child in care. (K)
Removing or limiting the use of a mobility aid or other assistive device for
the purpose of controlling a child in care's behavior. (3) Behavior
Management. (C) Use of restraints, if applicable. (i) Chemical restraint,
meaning the administration of medication for the management of
uncontrolled behavior, is prohibited. Chemical restraint is different from
the use of medication for treatment of symptoms of severe emotional
disturbances or disorders. (4) Suicide Prevention. The policy must
include the following: (f) Suicide risk assessment procedures on the day
of intake; (g) Documentation requirements for suicide ideation, self-harm,
and special observation precautions to ensure immediate communication
to all staff
The programs were out of compliance with some of the above
requirements for Behavior Management Policies, and the following
must be added:
- Sage:1(K)
- LTGH: 1(A-K), 3(C)(i)
- ORR:1(A-K), 3(C)(i)
The programs were out of compliance with some of the above
requirements for Suicide Prevention Policies, and the following
must be added:
- LTGH:4(f)
- ORR: 4(g) Missing "…. to ensure immediate communication to
all staff"
419-470-0150 Referral and Initial Evaluation of Children (Technical Yes[ ] No
Amended 01/14/20) (1) Referral. A residential care agency must have a - The agency submitted a policy to the licensing coordinator
policy that addresses the process by which children in care are referred that is in compliance with all applicable requirements.
to the residential care agency. The policy must include all of the
following: (a) From whom referrals are accepted. (c) How information
necessary to provide for the safety and care of children in care will be
provided to the appropriate care staff:
- Sage: The Referral Policy was missing the above required
information.

419-470-0160 Consents, Disclosures, and Authorizations (Amended Yes[ ] No
02/01/2022) (1) Consents. For each child in care in placement with a The agency submitted policies to the licensing coordinator that
residential care agency, the residential care agency must ensure that a are in compliance with the requirements.
parent or legal guardian signs a consent that authorizes the residential
care agency to undertake each of the following: (a) To provide routine The ODHS Licensing Coordinators reviewed some consents
and emergency medical care. However, if the parent or legal guardian verifying they are in compliance with applicable requirements.
relies on prayer or spiritual means for healing in accordance with the
creed or tenets of a well-recognized religion or denomination, the
residential care agency is not required to use medical, psychological, or
rehabilitative procedures, unless the child in care is old enough to
consent to these procedures and does so. The residential care agency
must have policies and procedures for this practice, which are reviewed
and approved by the child in care's parent or legal guardian.
- ORR and LTGH: The Consent Policies were missing the above
required information.
419-400-0180 Licensing Umbrella Rules: Restraints and Involuntary Yes[ ] No .
Seclusion: (Amended 07/01/2022) (1) A child-caring agency may
only place child in care in a restraint or involuntary seclusion if the - The agency submitted policies to the licensing coordinator
child in care's behavior poses a reasonable risk of imminent serious that are in compliance with applicable requirements.
bodily injury to the child in care or others and less restrictive
interventions would not effectively reduce the risk. (2) A child-caring
agency may not place a child in care in a restraint or involuntary
seclusion as a form of discipline, punishment, or retaliation or for the
convenience of staff, contractors or volunteers of the child-caring
agency. (3) If the child-caring agency utilizes restraints or involuntary
seclusion as part of its practices, its use of restraints and involuntary
seclusion must be in compliance with all applicable federal and state
laws, regulations and rules. (4) A child in care placed in a restraint or
involuntary seclusion must be continuously monitored by staff of the
child-caring agency for the duration of the restraint or involuntary
seclusion. (5) Any restraint or involuntary seclusion used on a child in
care must be performed in a manner that is safe, proportionate and
appropriate, taking into consideration the child in care's chronological
and developmental age, size, gender identity, physical, medical and
psychiatric condition and personal history, including any history of
physical or sexual abuse. (6) The removal or limitation of the use of a
mobility aid or other assistive device in a restraint is prohibited unless
there is a risk of imminent serious bodily injury and less restrictive
interventions would not effectively reduce the risk. (7) Removing or
limiting the use of a mobility aid or other assistive device for the

purpose of controlling a child in care's behavior is prohibited and (8)
If any restraint or involuntary seclusion lasts for more than 10
minutes, the child-caring must provide adequate access to the
bathroom and water at least every thirty minutes to the child in care.
(9) For any restraint or involuntary seclusion lasting more than 10
minutes a supervisor, trained in the non-violent crisis intervention
system used by the child-caring agency must provide written
authorization for the continuation of the restraint or involuntary
seclusion every five minutes. (a) If the supervisor is not on-site at the
time the restraint is used, the supervisor may provide the written
authorization electronically. (b) The written authorization must
document why the restraint or involuntary seclusion continues to be
the least restrictive intervention to reduce the risk of imminent serious
bodily injury in the given circumstances. (10) Restraint. (a) The
following types of restraint of a child in care are prohibited: (A)
Chemical restraint. (B) Mechanical restraint. (C) Prone restraint. (D)
Supine restraint, except: (i) Supine restraint may be used only when
the child in care is currently admitted to a secure children's inpatient
treatment program or secure adolescent inpatient treatment
program…(E) Any restraint that includes the nonincidental use of a
solid object, including the ground, a wall or the floor, to impede a
child in care's movement, except: (i) This type of restraint may be
used if the restraint is necessary to gain control of a weapon or; (F)
Any restraint that places or creates a risk of placing pressure on a
child in care's neck or throat. (G) Any restraint that places or creates a
risk of placing, pressure on a child in care's mouth, except: (i) This
type of restraint may be used if the restraint is necessary for the
purpose of extracting a body part from a bite. (H) Any restraint that
impedes, or creates a risk of impeding, a child in care's breathing. (I)
Any restraint that involves the intentional placement of hands, feet,
elbows, knees or any object on a child in care's neck, throat, genitals
or other intimate parts. (J) Any restraint that causes pressure to be
placed or creates a risk of causing pressure to be placed, on a child in
care's stomach, chest, joints, throat or back by a knee, foot or elbow.
(K) Any other restraint which the primary purpose is to inflict pain.
(b) Permissible use of restraint. A restraint may be used on a child in
care in the following situations: (A) Holding a child in care's hand or
arm to escort the child in care safely and without the use of force from
one area to another; (B) Assisting the child in care to complete a task

if the child in care does not resist the physical contact; or (C) Using a
physical intervention if: (i) The intervention is necessary to break up a
physical fight or to effectively protect a person from an assault,
serious bodily injury or sexual contact; (ii) The intervention uses the
least amount of physical force and contact possible: and (iii) The
intervention is not a prohibited restraint identified in OAR 413-215-
0077(8)(a). (c) Only child-caring agency staff and proctor foster
parents who have been trained in a nationally recognized nonviolent
crisis-intervention system may use restraint and only when necessary,
as a last resort to prevent a child in care from inflicting harm to self or
others. The restraint must be conducted within the parameters of the
nationally recognized system in which the staff or proctor foster
parent is trained. (d) Any use of restraint by a staff member or proctor
foster parent of the child-caring agency, if the member is not trained
in a nationally recognized nonviolent crisis intervention system, must
also be reported to a Department licensing coordinator within one
business day of occurrence. (e) Limitations. The child-caring agency
must have a policy that prohibits the application of a nonviolent
restraint to a child in care who has a documented physical condition
that would contraindicate the use of that particular restraint, unless a
qualified medical professional has previously and specifically
authorized its use in writing for the child in care. Documentation of
the authorization must be maintained in the child of care's record. (12)
Records (a) A program shall maintain a record of each incident in
which a reportable injury arises from the use of a restraint or
involuntary seclusion. The record must include any audio or video
recording immediately preceding, during and following the incident.
(b) If a program places a child in care in a restraint, except as
described in OAR 419-400-0180(8)(b)(A) or 419-400-0180(8)(b)(B)
or involuntary seclusion, the program shall provide the child in care's
case manager, attorney, court appointed special advocate and parent
or guardian with: (A) Verbal or electronic notice that the restraint or
involuntary seclusion was used as soon as practicable following the
incident but not later than the end of the next business day; and (B)
Written notice in compliance with OAR 419-400-0180(10)(c) that the
restraint or involuntary seclusion was used as soon as practicable
following the incident but not later than the end of the next business
day.(c) The written notice must include: (A) A description of the
restraint or involuntary seclusion, the date of the restraint or

involuntary seclusion, the times when the restraint or involuntary
seclusion began and ended and the location of the restraint or
involuntary seclusion; (B) A description of the child in care's activity
that necessitated the use of restraint or involuntary seclusion; (D) The
names of each of individual who placed the child in care in the
restraint or involuntary seclusion or who monitored or approved the
placement of the child in care in the restraint or involuntary seclusion;
(i) For each individual identified whether the individual was trained,
as required by the Department of Human Services by rule, in the use
of the type of restraint or involuntary seclusion used, the date of the
individual's most recent training and a description of the types of
restraint the individual is trained to use, if any. (ii) If an individual
identified was not trained in the type of restraint or involuntary
seclusion used, or if the individual's training was not current, a
description of the individual's training deficiency and the reason an
individual without the proper training was involved in the restraint or
involuntary seclusion. (d) If an incident requires notice under 419-
400-0180(b), not later than two business days following the date of
the restraint or involuntary seclusion, the program shall hold a
debriefing meeting with each individual who was involved in the
incident and with any other appropriate program staff, shall take
written notes of the debriefing meeting and shall provide copies of the
written notes to the child in care's case manager, attorney, court
appointed special advocate and parents or guardians. (e) If a program
places a child in care in a restraint or involuntary seclusion and the
child in care suffers a reportable injury arising from the restraint or
involuntary seclusion, the program shall immediately provide the
department and the child in care's attorney, court appointed special
advocate and parents or guardians with written notification of the
incident and access to and, upon request, copies of all records related
to the restraint or involuntary seclusion, including any photographs
and audio or video recordings. (f) If serious bodily injury or the death
of staff occurs in connection to the use of the restraint or involuntary
seclusion, the program shall provide the department with written
notification of the incident not later than 24 hours following the
incident.
See Sage, LTGH, and ORR below for details:

- Sage: (1)"….less restrictive interventions would not effectively reduce
the risk." (2), (3), (5), (6), (7), (8), (9)(a)(b),
(10)(a)(A)(B)(C)(D)(E)(i)(F)(G)(H)(I)(J)(K)(b)(A)(B)(C)(i)(ii)(iii)(c)"
nonviolent crisis-intervention system may use restraint and only
when necessary, as a last resort to prevent a child in care from
inflicting harm to self or others. The restraint must be conducted
within the parameters of the nationally recognized system in which
the staff or proctor foster parent is trained."(d) (12)(a)(b)(A)(B)(c)(A)"
the date of the restraint and the location of the
restraint"(B)(D)(i)(ii)(d)( e)(f)
- LTGH: (3),(4),(6),(7), (8), (9)(a)(b),
(10)(a)(A)(C)(D)(E)(i)(F)(G)(i)(H)(I)(J)(K)(b)(A)(B)(C)(i)(ii)(iii)
)(c)"nonviolent crisis-intervention system may use restraint and only
when necessary, as a last resort to prevent a child in care from
inflicting harm to self or others. The restraint must be conducted
within the parameters of the nationally recognized system in which
the staff or proctor foster parent is trained."(d)( e) 12(a)(b)(A)(B)(c)(A)
)" the date of the restraint and the location of the restraint"
(D)(i)(ii)(d)(e)(f)
- ORR: (3),(4),(6),(7), (8), (9)(a)(b),
(10)(a)(A)(C)(D)(E)(i)(F)(G)(i)(H)(I)(J)(K)(b)(A)(B)(C)(i)(ii)(iii)
)(c)"nonviolent crisis-intervention system may use restraint and only
when necessary, as a last resort to prevent a child in care from
inflicting harm to self or others. The restraint must be conducted
within the parameters of the nationally recognized system in which
the staff or proctor foster parent is trained."(d)( e) 12(a)(b)(A)(B)(c)(A)
)" the date of the restraint and the location of the restraint"
(D)(i)(ii)(d)(e)(f)
419-400-0190 Licensing Umbrella Rules: Information Provided to Yes No[ ] .
Children in Care
(Adopted 02/01/2022 (1) Each child in care receiving services from a - On September 20th, 2023, the licensing coordinator
child-caring agency must be given the following: (a) Instruction regarding reviewed some of the youth records. Sage was found to be
how a child in care may report suspected inappropriate use of restraint or in compliance with the requirement. Mi Futuro and LTGH
involuntary seclusion; (b) Assurance that the child in care will not were not providing all of the above required information to
experience retaliation for reporting suspected inappropriate uses of the youth. The agency must submit a revised document
restraint or involuntary seclusion and; (c) The telephone number for the that has all of the above requirements to the licensing
toll-free child abuse hotline described in ORS 417.805 and the telephone coordinator.
numbers and electronic mail addresses for the program's licensing Repeat Finding from 2022
agency, the child in care's caseworker and attorney, the child in care's
court appointed special advocate and Disability Rights Oregon. (2) The
information must be provided by: (a) The Department of Human Services
if the department placed the child in care in the child-caring agency; (b)
The Oregon Youth Authority if the child in care has been committed to

the custody of the authority; or (c) The child-caring agency for all other
children in care.
- Documentation was not found to verify that the agency
had provided the above required information to the youth
in all Morrison programs at admission.
419-470-0100 Medication (Technical Amended 01/13/20) A Yes[ ] No
residential care agency must meet all of the following requirements: - The agency submitted a policy to the licensing coordinator
(1) Policy and procedures. The residential care agency must have that is in compliance with the requirements.
policies and procedures that cover all prescription and non-
prescription medications that address all of the following: (h) How the
foster care agency and the proctor foster home will ensure compliance
with OAR 413-070-0470 if it serves children in Department custody.
- Sage: The Medication Policy was missing the above required
information.
New Findings from Site Visit Comments
419-470-0020(2)(a)&(c) Buildings are smoke 419-470-0020(2)(a)&(c) Buildings are smoke free, clean and in good repair:
free, clean and in good repair:
The following was identified as being in need of repair:
Downtown Mi Futuro and Long-Term Group Home (LTGH):
- The following rooms were found to need touch up paint:
Room #411, 414a, 415a, 420a, 508a, 510, 511a, 512
- The following rooms were found to need small holes repaired and touch up paint.
Room #403, 418a
- Room 511a was missing an electrical outlet cover that must be replaced.
- Room 522a had a wall that was dirty and must be cleaned.


summary: Unannounced - 3 findings

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Residential Care
Licensee: Morrison Child & Family Services
Executive Director: Nick Gallo
Program Director(s): Ana Serano, Kelli Doolittle, Maria Ramirez-Gutierrez
Date of Unannounced: 2.27.2024
Licensing Coordinator: Jorge Pelinski & Holly Ivey
Other Regulatory or Accrediting Agencies: DHS Treatment Services, The Oregon Youth Authority, and The Federal Government
Purpose: Per OAR 419-400-0240 (1)(b) Children’s Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Comments
Unannounced Site Visit 09/20-21/2023 Findings
Further Action
Needed
419-400-0190 Licensing Umbrella Rules: Yes✓ No☐ At the unannounced review on February 27th, 2024, the licensing coordinator reviewed
Information Provided to Children in Care some files of youth records. Mi Futuro was found to be in compliance.
(Adopted 02/01/2022 (1) Each child in care
receiving services from a child-caring agency • The Long-Term Group Home (LTGH) program was found to be out of compliance.
must be given the following: (a) Instruction
regarding how a child in care may report Corrective Action: Repeat finding from 2022 and 2023.
suspected inappropriate use of restraint or
involuntary seclusion; (b) Assurance that the LTGH will ensure that the program consistently provides the approved SB 710 Form that
child in care will not experience retaliation for was previously approved by licensing to children in care. The agency submitted a revised
reporting suspected inappropriate uses of document to licensing after the 2023 unannounced site visit that was approved by
restraint or involuntary seclusion and; (c) The licensing. LTGH must resubmit the revised document to licensing as part of their corrective
telephone number for the toll-free child abuse action plan. The program must ensure that all youth that are in the program receive the
hotline described in ORS 417.805 and the approved SB 710 information document regarding restraint and seclusion.
telephone numbers and electronic mail
addresses for the program’s licensing
agency, the child in care’s caseworker and
attorney, the child in care’s court appointed
special advocate and Disability Rights
Oregon. (2) The information must be provided
by: (a) The Department of Human Services
Form Rev. 11/14/2023 P age 1 | 5
if the department placed the child in care in
the child-caring agency; (b)The Oregon Youth
Authority if the child in care has been
committed to the custody of the authority; or
(c) The child-caring agency for all other
children in care.
✓ Documentation was not found to
verify that the agency had provided
the above required information to the
youth in all Morrison programs at
admission.
• On September 20th, 2023, the
licensing coordinator reviewed some
of the youth records. Sage was found
to be in compliance with the
requirement. Mi Futuro and LTGH
were not providing all of the above
required information to the youth. The
agency must submit a revised
document that has all of the above
requirements to the licensing
coordinator.
Repeat Finding from 2022
419-470-0020(2)(a)&(c) Buildings are smoke Yes☐ No✓ • Agency made needed repairs and is in compliance.
free, clean and in good repair:
The following was identified as being in need
of repair:
Downtown Mi Futuro and Long-Term Group
Home (LTGH):
• The following rooms were found to
need touch up paint:
Room #411, 414a, 415a, 420a, 508a,
510, 511a, 512
• The following rooms were found to
need small holes repaired and touch
up paint.
Room #403, 418a
• Room 511a was missing an electrical
outlet cover that must be replaced.
• Room 522a had a wall that was dirty
and must be cleaned.
Form Rev. 11/14/2023 P age 2 | 5
New Findings from Site Visit Comments
419-470-0020(2)(a)&(c) Buildings are smoke LTGH Program & Mi Futuro:
free, clean and in good repair: Dormitory hallways:
Vents need cleaning in dormitory areas on the 4th and 5 floor.
Mi Futuro:
Bathroom:
Boys’ restroom on 2nd floor has a long horizontal crack in the dry wall next to one of the bathroom stall doors.
Interview Summary
At the Unannounced Inspection Holly Ivey, ODHS Licensing Coordinator, conducted private interviews with two youth who were at
the SAGE Program and two youth at the Downtown Program. Each of the youth spoke with the Licensing Coordinator privately with
a translator present at the Downtown Program.
The following information was obtained from the interviews:
All the youth stated things were going well for them while residing in the programs.
When asked what they appreciated most about living in the programs the youth stated: “pop corn movie night, spa days, playing
Just Dance, celebrating holidays, getting to know myself more and getting a chance to turn things around. They teach us about
jobs, English, and math. They treat us very well.
Fun activities and recreation reported by the youth: “Playing basketball, activities with staff, celebrating birthdays and holidays,
going to the gym on site, recreation room, playing air hockey, playing in the big field and courtyard, board games, soccer, and
exercising.
All youth mentioned that they receive three meals a day, with multiple snacks. The youth reported fresh fruit and vegetables are
always available.
All the youth stated there are no privacy restrictions in contacting their approved contacts. They stated they have regular calls with
approved contacts.
All youth reported the program provides hygiene products, which includes, soap, shampoo, feminine products, and toothpaste.
All youth reported that they could talk to staff if they had a concern or need. At SAGE one youth reported a concern regarding a staff
member. The concern was discussed Program Director, Kelli Doolittle, regarding the concern during the exit meeting on 2.27.2024.
Holley Ivey, Licensing Coordinator, contacted the child abuse hotline regarding the alleged concern that was reported in the child
interview.
much.”
When asked what changes the youth would make to the programs, the following was reported: “Nothing, everything is good.” “I
wouldn’t change anything, everything is fine.” “Better mattresses.”
Form Rev. 11/14/2023 P age 3 | 5
When asked if the youth feel safe in the programs the following was stated: “Yes x2” Yes, I do. “Staff are really good at being
reassuring. They do such a good job of making us feel safe here.” “Yes and no.” Yes, because we are behind closed doors. No,
because some staff talk and yell at us for doing something wrong.” This was also discussed at the exit meeting with Kelli Doolittle.
Observations
LTGH & Mi Futuro Program:
There are currently 11 youth in the LTGH Program and 10 youth residing in the Mi Futuro Program. Mi Futuro did not have youth
residing in the program from November 2023 to January 2024. This resulted due to the program losing both of their clinicians
(mental health providers). Currently, the program has one full time and one part time clinician.
One of the program directors shared that in the future the agency plans on repainting all youths’ rooms and dormitory hallways.
Licensing will follow up with the agency at the next review to check on status of repainting project. The LTGH and Mi Futuro
Program vehicles that the youth ride in were observed and met the requirements per Licensing Rules. All areas of the programs
(inside and out) were youth had access were observed to be well kept, clean, and mostly in good repair. Please read above in the
“new findings from site visit” section for more information.
Sage Program:
Licensing coordinator met with Program Director and went on walk through of the program for the inspection. Program Director
shared that things are going well in the program in general. Program Director also shared that one of the rooms was converted into
a recreational room for the youth living in the program. Staff and youth were observed at the programs during the inspection. The
youth that were at the program, appeared to be at ease and comfortable in the environment. All areas of the Sage Program (inside
and out) were youth had access were observed, to be well kept, clean, and in good repair. The kitchen was observed to have
enough food on hand. Medication was observed to be in a locked medication cart behind a locked room which was inaccessible to
the youth.
Corrective Actions and Timeframes:
Please submit the following to verify compliance.
Within 45 days of receipt of this report Morrison Child & Family Services must submit a letter of verification indicating the agency is in compliance
with the specific rules cited above and describing how compliance will be maintained going forward. Along with the letter of verification, the agency
must submit any and all specific documentation requested in the body of this report. The letter of verification and any additional requested
documents can be emailed directly to Jorge Pelinski at Jorge.l.pelinski@odhsoha.oregon.gov.
Form Rev. 11/14/2023 P age 4 | 5
Licensing Coordinator’s Signature: ________________________ Date: ___0_3_/_1_1_/2_0__2_4_______
Manager Review: ______________________________________ Date: _3_-8_-_2_0_2_4___________
Form Rev. 11/14/2023 P age 5 | 5

facility_type: Residential Care

licensee: Morrison Child & Family Services

licensing_coordinator: Jorge Pelinski & Holly Ivey

purpose:
Per OAR 419-400-0240 (1)(b) Children's Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Comments
Unannounced Site Visit 09/20-21/2023 Findings
Further Action
Needed
419-400-0190 Licensing Umbrella Rules: Yes✓ No[ ] At the unannounced review on February 27th, 2024, the

interview_summary:
At the Unannounced Inspection Holly Ivey, ODHS Licensing Coordinator, conducted private interviews with two youth who were at
the SAGE Program and two youth at the Downtown Program. Each of the youth spoke with the Licensing Coordinator privately with
a translator present at the Downtown Program.
The following information was obtained from the interviews:
All the youth stated things were going well for them while residing in the programs.
When asked what they appreciated most about living in the programs the youth stated: "pop corn movie night, spa days, playing
Just Dance, celebrating holidays, getting to know myself more and getting a chance to turn things around. They teach us about
jobs, English, and math. They treat us very well.
Fun activities and recreation reported by the youth: "Playing basketball, activities with staff, celebrating birthdays and holidays,
going to the gym on site, recreation room, playing air hockey, playing in the big field and courtyard, board games, soccer, and
exercising.
All youth mentioned that they receive three meals a day, with multiple snacks. The youth reported fresh fruit and vegetables are
always available.
All the youth stated there are no privacy restrictions in contacting their approved contacts. They stated they have regular calls with
approved contacts.
All youth reported the program provides hygiene products, which includes, soap, shampoo, feminine products, and toothpaste.
All youth reported that they could talk to staff if they had a concern or need. At SAGE one youth reported a concern regarding a staff
member. The concern was discussed Program Director, Kelli Doolittle, regarding the concern during the exit meeting on 2.27.2024.
Holley Ivey, Licensing Coordinator, contacted the child abuse hotline regarding the alleged concern that was reported in the child
interview.
much."
When asked what changes the youth would make to the programs, the following was reported: "Nothing, everything is good." "I
wouldn't change anything, everything is fine." "Better mattresses."

When asked if the youth feel safe in the programs the following was stated: "Yes x2" Yes, I do. "Staff are really good at being
reassuring. They do such a good job of making us feel safe here." "Yes and no." Yes, because we are behind closed doors. No,
because some staff talk and yell at us for doing something wrong." This was also discussed at the exit meeting with Kelli Doolittle.

observations:
LTGH & Mi Futuro Program:
There are currently 11 youth in the LTGH Program and 10 youth residing in the Mi Futuro Program. Mi Futuro did not have youth
residing in the program from November 2023 to January 2024. This resulted due to the program losing both of their clinicians
(mental health providers). Currently, the program has one full time and one part time clinician.
One of the program directors shared that in the future the agency plans on repainting all youths' rooms and dormitory hallways.
Licensing will follow up with the agency at the next review to check on status of repainting project. The LTGH and Mi Futuro
Program vehicles that the youth ride in were observed and met the requirements per Licensing Rules. All areas of the programs
(inside and out) were youth had access were observed to be well kept, clean, and mostly in good repair. Please read above in the
"new findings from site visit" section for more information.
Sage Program:
Licensing coordinator met with Program Director and went on walk through of the program for the inspection. Program Director
shared that things are going well in the program in general. Program Director also shared that one of the rooms was converted into
a recreational room for the youth living in the program. Staff and youth were observed at the programs during the inspection. The
youth that were at the program, appeared to be at ease and comfortable in the environment. All areas of the Sage Program (inside
and out) were youth had access were observed, to be well kept, clean, and in good repair. The kitchen was observed to have
enough food on hand. Medication was observed to be in a locked medication cart behind a locked room which was inaccessible to
the youth.

previous_findings:
Repeat Comments
Unannounced Site Visit 09/20-21/2023 Findings
Further Action
Needed
419-400-0190 Licensing Umbrella Rules: Yes✓ No[ ] At the unannounced review on February 27th, 2024, the licensing coordinator reviewed
Information Provided to Children in Care some files of youth records. Mi Futuro was found to be in compliance.
(Adopted 02/01/2022 (1) Each child in care
receiving services from a child-caring agency - The Long-Term Group Home (LTGH) program was found to be out of compliance.
must be given the following: (a) Instruction
regarding how a child in care may report Corrective Action: Repeat finding from 2022 and 2023.
suspected inappropriate use of restraint or
involuntary seclusion; (b) Assurance that the LTGH will ensure that the program consistently provides the approved SB 710 Form that
child in care will not experience retaliation for was previously approved by licensing to children in care. The agency submitted a revised
reporting suspected inappropriate uses of document to licensing after the 2023 unannounced site visit that was approved by
restraint or involuntary seclusion and; (c) The licensing. LTGH must resubmit the revised document to licensing as part of their corrective
telephone number for the toll-free child abuse action plan. The program must ensure that all youth that are in the program receive the
hotline described in ORS 417.805 and the approved SB 710 information document regarding restraint and seclusion.
telephone numbers and electronic mail
addresses for the program's licensing
agency, the child in care's caseworker and
attorney, the child in care's court appointed
special advocate and Disability Rights
Oregon. (2) The information must be provided
by: (a) The Department of Human Services

if the department placed the child in care in
the child-caring agency; (b)The Oregon Youth
Authority if the child in care has been
committed to the custody of the authority; or
(c) The child-caring agency for all other
children in care.
✓ Documentation was not found to
verify that the agency had provided
the above required information to the
youth in all Morrison programs at
admission.
- On September 20th, 2023, the
licensing coordinator reviewed some
of the youth records. Sage was found
to be in compliance with the
requirement. Mi Futuro and LTGH
were not providing all of the above
required information to the youth. The
agency must submit a revised
document that has all of the above
requirements to the licensing
coordinator.
Repeat Finding from 2022
419-470-0020(2)(a)&(c) Buildings are smoke Yes[ ] No✓ - Agency made needed repairs and is in compliance.
free, clean and in good repair:
The following was identified as being in need
of repair:
Downtown Mi Futuro and Long-Term Group
Home (LTGH):
- The following rooms were found to
need touch up paint:
Room #411, 414a, 415a, 420a, 508a,
510, 511a, 512
- The following rooms were found to
need small holes repaired and touch
up paint.
Room #403, 418a
- Room 511a was missing an electrical
outlet cover that must be replaced.
- Room 522a had a wall that was dirty
and must be cleaned.

New Findings from Site Visit Comments
419-470-0020(2)(a)&(c) Buildings are smoke LTGH Program & Mi Futuro:
free, clean and in good repair: Dormitory hallways:
Vents need cleaning in dormitory areas on the 4th and 5 floor.
Mi Futuro:
Bathroom:
Boys' restroom on 2nd floor has a long horizontal crack in the dry wall next to one of the bathroom stall doors.