summary: Unannounced - 21 findings

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Residential Care
Licensee: Janus Youth Programs
Executive Director: Dennis Morrow
Date of Unannounced: December 11, 2024
Licensing Coordinator: Aubrey Kelly
Other Regulatory or Accrediting Agencies: DHS Treatment Services & Oregon Youth Authority
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 4/22-24/2024 Findings
Further Action
Needed
Supplemental Information Provided by Yes☐ No✓ Cordero: The environmental health inspection and fire marshal inspection have been
CCA completed.
Documents as indicated on the form titled
“Renewal Licensing Required Documents”
• Cordero: The program does not have
documentation of a fire marshal or
environmental health inspection being
completed. The program shall ensure
the inspections are completed.
Physical Plant Yes✓ No☐ Buckman: The inside of the house has not been painted but is scheduled to be painted in
419-470-0020(2)(a) &(c) Buildings are smoke February 2025. (repeat finding)
free, clean and in good repair
• Buckman: The inside of the house
needs to be completely repainted.
There are holes in the walls from nails
and screws sticking out of the walls.
The program shall ensure all parts of
the house are in good repair.
Form Rev. 11/14/2023 P age 1 | 9
Residential Care Safety 419-470-0080 Yes☐ No✓ Buckman: Evacuation drills were reviewed, and the program is completing evacuation
(5)(a) Evacuation drill occurs monthly under drills on a monthly basis.
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
• Buckman: The program was missing
evacuation drills in February 2023
and May 2023. The program shall
ensure evacuation drills are
conducted on a monthly basis and
documented.
New Employee Orientation – Umbrella Yes☐ No✓ Cordero: Documentation was reviewed for two staff recently hired, and all orientation
Requirements (30 days) 419-400-0120(4) trainings were completed within 30 days of hire.
(a) Agency policies and procedures
• Cordero: Orientation trainings were
either not completed or were
completed after the first 30 days of
hire for trainings a, b, c, and d.
The programs shall ensure all orientation
trainings are completed within 30 days of hire
and documented in each staff’s personnel file.
New Employee Orientation – Umbrella Yes✓ No☐ Buckman: Documentation was reviewed for two staff recently hired. One staff did not
Requirements (30 days) 419-400-0120(4) complete the required trainings within 30 days of hire. The program shall ensure all
(b) Ethical and professional guidelines orientation trainings are completed within 30 days of hire. (repeat finding)
• Buckman: Orientation trainings were
either not completed or were Cordero: Documentation was reviewed for two staff recently hired, and all orientation
completed after the first 30 days of trainings were completed within 30 days of hire.
hire for trainings b, c, d, f and g.
• Cordero: Orientation trainings were
either not completed or were
completed after the first 30 days of
hire for trainings a, b, c, and d.
The programs shall ensure all orientation
trainings are completed within 30 days of hire
and documented in each staff’s personnel file.
Form Rev. 11/14/2023 P age 2 | 9
New Employee Orientation – Umbrella Yes✓ No☐ Buckman: Documentation was reviewed for two staff recently hired. One staff did not
Requirements (30 days) 419-400-0120(4) complete the required trainings within 30 days of hire. The program shall ensure all
(c) Suicide prevention and intervention orientation trainings are completed within 30 days of hire. (repeat finding)
• Buckman: Orientation trainings were
either not completed or were Cordero: Documentation was reviewed for two staff recently hired and all orientation
completed after the first 30 days of trainings were completed within 30 days of hire.
hire for trainings b, c, d, f and g.
• Cordero: Orientation trainings were
either not completed or were
completed after the first 30 days of
hire for trainings a, b, c, and d.
The programs shall ensure all orientation
trainings are completed within 30 days of hire
and documented in each staff’s personnel file.
New Employee Orientation – Umbrella Yes✓ No☐ Buckman: Documentation was reviewed for two staff recently hired. One staff did not
Requirements (30 days) 419-400-0120(4) complete the required trainings within 30 days of hire. The program shall ensure all
(d) Attributes of population served orientation trainings are completed within 30 days of hire. (repeat finding)
• Buckman: Orientation trainings were
either not completed or were Cordero: Documentation was reviewed for two staff recently hired and all orientation
completed after the first 30 days of trainings were completed within 30 days of hire.
hire for trainings b, c, d, f and g.
• Cordero: Orientation trainings were Atlas: Documentation was reviewed for two staff recently hired and all orientation trainings
either not completed or were were completed within 30 days of hire.
completed after the first 30 days of
hire for trainings a, b, c, and d.
• Atlas: Orientation trainings were
either not completed or were
completed after the first 30 days of
hire for trainings d and f.
The programs shall ensure all orientation
trainings are completed within 30 days of hire
and documented in each staff’s personnel file.
New Employee Orientation – Umbrella Yes✓ No☐ Buckman: Documentation was reviewed for two staff recently hired. One staff did not
Requirements (30 days) 419-400-0120(4) complete the required trainings within 30 days of hire. The program shall ensure all
(f) Privacy laws orientation trainings are completed within 30 days of hire. (repeat finding)
New Employee Orientation – Umbrella Yes✓ No☐ Buckman: Documentation was reviewed for two staff recently hired. One staff did not
Requirements (30 days) 419-400-0120(4) complete the required trainings within 30 days of hire. The program shall ensure all
(g) Emergency procedures orientation trainings are completed within 30 days of hire. (repeat finding)
Form Rev. 11/14/2023 P age 3 | 9
New Employee Orientation Residential Yes✓ No☐ Buckman: Documentation was reviewed for two staff recently hired. One staff did not
(Prior to working alone and within 30 days) complete the required trainings within 30 days of hire. The program shall ensure all
419-470-0120(1) orientation trainings are completed within 30 days of hire. (repeat finding)
(a) Discipline and behavior management
including de-escalation, crisis prevention,
positive behavior management, and
disciplinary techniques that are non-punitive in
nature
• Buckman: Orientation trainings were
either not completed or were
completed after the first 30 days of
hire for trainings a, b and c.
The programs shall ensure all orientation
trainings are completed within 30 days of hire
and documented in each staff’s personnel file.
New Employee Orientation Residential Yes✓ No☐ Buckman: Documentation was reviewed for two staff recently hired. One staff did not
(Prior to working alone and within 30 days) complete the required trainings within 30 days of hire. The program shall ensure all
419-470-0120(1) orientation trainings are completed within 30 days of hire. (repeat finding)
(b) CPR and First Aid sufficient to retain a
current certification
• Buckman: Orientation trainings were
either not completed or were Cordero: Documentation was reviewed for two staff recently hired and all orientation
completed after the first 30 days of trainings were completed within 30 days of hire.
hire for trainings a, b and c
• Cordero: Orientation trainings were Atlas: Documentation was reviewed for two staff recently hired and all orientation trainings
either not completed or were were completed within 30 days of hire.
completed after the first 30 days of
hire for trainings b and d.
• Atlas: Orientation trainings were
either not completed or were
completed after the first 30 days of
hire for trainings b and d.
The programs shall ensure all orientation
trainings are completed within 30 days of hire
and documented in each staff’s personnel file.
New Employee Orientation Residential Yes✓ No☐ Buckman: Documentation was reviewed for two staff recently hired. One staff did not
(Prior to working alone and within 30 days) complete the required trainings within 30 days of hire. The program shall ensure all
419-470-0120(1) orientation trainings are completed within 30 days of hire. (repeat finding)
(c) Universal precautions and hygiene
• Buckman: Orientation trainings were
either not completed or were
completed after the first 30 days of
hire for trainings a, b and c.
Form Rev. 11/14/2023 P age 4 | 9
The programs shall ensure all orientation
trainings are completed within 30 days of hire
and documented in each staff’s personnel file.
New Employee Orientation Residential Yes✓ No☐ Buckman: Documentation was reviewed for two staff recently hired. One staff did not
(Prior to working alone and within 30 days) complete the required trainings within 30 days of hire. The program shall ensure all
419-470-0120(1) orientation trainings are completed within 30 days of hire. (repeat finding)
(d) Application of the reasonable and prudent
parent standard
• Cordero: Orientation trainings were Atlas: Documentation was reviewed for two staff recently hired and all orientation trainings
either not completed or were were completed within 30 days of hire.
completed after the first 30 days of
hire for trainings b and d.
• Atlas: Orientation trainings were
either not completed or were
completed after the first 30 days of
hire for trainings b and d.
The programs shall ensure all orientation
trainings are completed within 30 days of hire
and documented in each staff’s personnel file.
Ongoing Training Yes☐ No✓ Atlas: Staff have completed all ongoing trainings.
419-470-0120 (2)(c) Discipline and Behavior
Management
• Atlas: Two of the staff personnel files
reviewed did not contain
documentation discipline and
behavior management ongoing
trainings were completed.
The program shall ensure all staff have
completed trainings on discipline and behavior
management on an ongoing basis.
Ongoing Training Yes☐ No✓ Atlas: Staff have completed all ongoing trainings.
419-470-0120 (2)(d) Agency’s policy on
suicide prevention and risk assessment tool
• Atlas: Three of the staff personnel
files reviewed did not contain
documentation the agency’s policy on
suicide prevention and risk
assessment tool trainings were
completed on an ongoing basis.
The program shall ensure all staff have
completed trainings on the agency’s policy on
suicide prevention and risk assessment tool
on an ongoing basis.
Form Rev. 11/14/2023 P age 5 | 9
Ongoing Training Yes☐ No✓ Cordero: Staff have completed all ongoing trainings.
419-470-0120 (3) Staff providing direct care
must maintain current CPR/First Aid
certification
• Cordero: Three of the staff personnel
files reviewed did not contain
documentation of current CPR/First
Aid certifications.
The program shall ensure all staff have
current CPR/First Aid certifications.
Consents 419-470-0160(1) Yes☐ No✓ Atlas: Documentation was reviewed for two clients and both files contained the required
(e) Allow access as defined in 419-400-0230 consents.
& 0240
• Atlas: Three of the client files
reviewed were missing consents
regarding allowing access.
The program shall ensure all required
consents are signed by the legal guardian.
Authorizations 419-470-0160(3) Yes☐ No✓ Buckman: Documentation was reviewed for two clients and both files contained the
(a) Disclose or exchange information with required authorizations.
others
• Buckman: Two of the client files
reviewed were missing authorizations
to disclose or exchange information
with others.
The program shall ensure all required
disclosures are signed by the legal guardian.
Authorizations 419-470-0160(3) Yes☐ No✓ Buckman: Documentation was reviewed for two clients and both files contained the
(c) Visitation resources are pre-approved required authorizations.
• Buckman: Two of the client files
reviewed were missing authorizations
for pre-approving visitation resources.
The program shall ensure all required
disclosures are signed by the legal guardian.
419-400-0090 (2)(a)(D)(i) Grievance Yes☐ No✓ The grievance procedure has been updated to include all the required information.
Procedures. (a) A child-caring agency must
enact and adhere to written procedures for the
children in care and families the child-caring
agency serves to submit a grievance.
• The procedures must include all of
the following: (D) The name, address
and phone number of: (i) A
Department licensing coordinator.
Form Rev. 11/14/2023 P age 6 | 9
• Janus Youth Programs shall ensure
the grievance procedure is updated to
include the following information:
Licensing Coordinator Aubrey Kelly
ODHS Office of Training,
Investigations and Safety
4600 25th Ave. NE, Suite 150
Salem, OR 97301
(503) 602-8913
New Findings from Site Visit Comments
419-470-0020 (2)(c) Physical Plant Buckman: Bedroom A and bedroom C were dirty and messy, to include clothes and food all over the
Requirements: (2) A residential care agency bedrooms. The program shall ensure all buildings are clean and in good repair.
must meet all of the following requirements:
(c) All areas of buildings where children in Atlas: The basement of the program recently flooded. The carpet has been torn out and the program is
care are present must be kept clean and in working to get the tile with asbestos removed as well.
good repair.
In the dining room, there was one large hole in the ceiling, directly above the dining room table. There were
several smaller holes in the ceiling as well. The program reported there was a leak and they were trying to
determine were the leak was coming from. The program shall ensure the holes in the ceiling are repaired
within 30 days.
Form Rev. 11/14/2023 P age 7 | 9
Interview Summary
Buckman: Client #1 interview – They have been at the program for one week, they previously were at several other programs. They graduated another Janus
program and then came to Buckman. Staff are supporting them, however, wishes there was more support for transgender clients. Sunday – Thursday the staff
make dinner. Clients are responsible for their own breakfast and lunch. Friday and Saturday the clients are also responsible to make dinner. They are
currently an intern at Janus’ offices.
Client #2 interview – They have been at the program for two and a half months, they like it here. Clients will behave badly and they believe staff does not
intervene, some of the clients need a stricter environment. They are currently working parttime. They have frequent contact with family through phone calls
and visits.
Cordero: Client #1 interview – They have been at the program for two years and four months. They like it here, and it has helped a lot. Treatment has been
great. Staff make breakfast and lunch. Clients help prep for dinner, and clients make brunch for the whole house on Sundays. They are able to concentrate at
school a lot more here than in public school. They have phone calls and in-person visits with their family. They feel safe here. Staff are available and they get
along with staff. They feel like some of the rules are petty, such as asking youth not to fidget during group.
Atlas: Client #1 interview – They have been at the program for 8 months. They were previously at two other programs. They currently work fulltime. They get
along with the other clients and staff. They feel safe here. Clients are responsible for making breakfast and lunch, and staff make dinner. They have contact
with family through phone calls and in person visits. They are not currently in treatment, as they already graduated treatment. They don’t like living in the city.
Observations
Buckman: The interior of Buckman is scheduled to be painted in February 2025, and the program had paint samples on the wall as clients were giving their
opinions on what colors to paint the house. Staff and clients had positive interactions during the visit. Aside from two bedrooms, the program was clean and in
good repair.
Cordero: Clients were in the school building during the visit. The program was very clean and in good repair. Staff and the client interviewed had positive
interactions during the visit.
Atlas: The basement of the program recently flooded. The carpet has been torn out, and the program is working to get the tile with asbestos removed as well.
Clients are currently allowed only in the basement with a staff to do laundry. In the dining room, there was one large hole in the ceiling, directly above the
dining room table. There were several smaller holes in the ceiling as well. The program reported there was a leak, and they were trying to determine where
the leak was coming from.
Corrective Actions and Timeframes:
Please submit the following to verify compliance.
Within 45 days of receipt of this report Janus Youth Programs 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
Form Rev. 11/14/2023 P age 8 | 9
submit any and all specific documentation requested in the body of this report. The letter of verification and any additional requested documents can
be emailed directly to Aubrey Kelly at Aubrey.J.Kelly@odhsoha.oregon.gov.
Licensing Coordinator’s Signature: ________________________ Date: ____1_-_1_3_-2_0_2_5________
Manager Review: ______________________________________ Date: ___1_-_1_0_-2_0__2_5_______
Form Rev. 11/14/2023 P age 9 | 9

visit_date: December 11, 2024

licensing_coordinator: Aubrey Kelly

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 4/22-24/2024 Findings
Further Action
Needed
Supplemental Information Provided by Yes[ ] No✓ Cordero: The environmental health inspection and fire marshal inspection have been
CCA completed.
Documents as indicated on the form titled
"Renewal Licensing Required Documents"
- Cordero: The program does not have
documentation of a fire marshal or
environmental health inspection being
completed. The program shall ensure
the inspections are completed.
Physical Plant Yes✓ No[ ] Buckman: The inside of the house has not been painted but is scheduled to be painted in
419-470-0020(2)(a) &(c) Buildings are smoke February 2025. (repeat finding)
free, clean and in good repair
- Buckman: The inside of the house
needs to be completely repainted.
There are holes in the walls from nails
and screws sticking out of the walls.
The program shall ensure all parts of
the house are in good repair.

Residential Care Safety 419-470-0080 Yes[ ] No✓ Buckman: Evacuation drills were reviewed, and the program is completing evacuation
(5)(a) Evacuation drill occurs monthly under drills on a monthly basis.
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
- Buckman: The program was missing
evacuation drills in February 2023
and May 2023. The program shall
ensure evacuation drills are
conducted on a monthly basis and
documented.
New Employee Orientation - Umbrella Yes[ ] No✓ Cordero: Documentation was reviewed for two staff recently hired, and all orientation
Requirements (30 days) 419-400-0120(4) trainings were completed within 30 days of hire.
(a) Agency policies and procedures
- Cordero: Orientation trainings were
either not completed or were
completed after the first 30 days of
hire for trainings a, b, c, and d.
The programs shall ensure all orientation
trainings are completed within 30 days of hire
and documented in each staff's personnel file.
New Employee Orientation - Umbrella Yes✓ No[ ] Buckman: Documentation was reviewed for two staff recently hired. One staff did not
Requirements (30 days) 419-400-0120(4) complete the required trainings within 30 days of hire. The program shall ensure all
(b) Ethical and professional guidelines orientation trainings are completed within 30 days of hire. (repeat finding)
- Buckman: Orientation trainings were
either not completed or were Cordero: Documentation was reviewed for two staff recently hired, and all orientation
completed after the first 30 days of trainings were completed within 30 days of hire.
hire for trainings b, c, d, f and g.
- Cordero: Orientation trainings were
either not completed or were
completed after the first 30 days of
hire for trainings a, b, c, and d.
The programs shall ensure all orientation
trainings are completed within 30 days of hire
and documented in each staff's personnel file.

New Employee Orientation - Umbrella Yes✓ No[ ] Buckman: Documentation was reviewed for two staff recently hired. One staff did not
Requirements (30 days) 419-400-0120(4) complete the required trainings within 30 days of hire. The program shall ensure all
(c) Suicide prevention and intervention orientation trainings are completed within 30 days of hire. (repeat finding)
- Buckman: Orientation trainings were
either not completed or were Cordero: Documentation was reviewed for two staff recently hired and all orientation
completed after the first 30 days of trainings were completed within 30 days of hire.
hire for trainings b, c, d, f and g.
- Cordero: Orientation trainings were
either not completed or were
completed after the first 30 days of
hire for trainings a, b, c, and d.
The programs shall ensure all orientation
trainings are completed within 30 days of hire
and documented in each staff's personnel file.
New Employee Orientation - Umbrella Yes✓ No[ ] Buckman: Documentation was reviewed for two staff recently hired. One staff did not
Requirements (30 days) 419-400-0120(4) complete the required trainings within 30 days of hire. The program shall ensure all
(d) Attributes of population served orientation trainings are completed within 30 days of hire. (repeat finding)
- Buckman: Orientation trainings were
either not completed or were Cordero: Documentation was reviewed for two staff recently hired and all orientation
completed after the first 30 days of trainings were completed within 30 days of hire.
hire for trainings b, c, d, f and g.
- Cordero: Orientation trainings were Atlas: Documentation was reviewed for two staff recently hired and all orientation trainings
either not completed or were were completed within 30 days of hire.
completed after the first 30 days of
hire for trainings a, b, c, and d.
- Atlas: Orientation trainings were
either not completed or were
completed after the first 30 days of
hire for trainings d and f.
The programs shall ensure all orientation
trainings are completed within 30 days of hire
and documented in each staff's personnel file.
New Employee Orientation - Umbrella Yes✓ No[ ] Buckman: Documentation was reviewed for two staff recently hired. One staff did not
Requirements (30 days) 419-400-0120(4) complete the required trainings within 30 days of hire. The program shall ensure all
(f) Privacy laws orientation trainings are completed within 30 days of hire. (repeat finding)
New Employee Orientation - Umbrella Yes✓ No[ ] Buckman: Documentation was reviewed for two staff recently hired. One staff did not
Requirements (30 days) 419-400-0120(4) complete the required trainings within 30 days of hire. The program shall ensure all
(g) Emergency procedures orientation trainings are completed within 30 days of hire. (repeat finding)

New Employee Orientation Residential Yes✓ No[ ] Buckman: Documentation was reviewed for two staff recently hired. One staff did not
(Prior to working alone and within 30 days) complete the required trainings within 30 days of hire. The program shall ensure all
419-470-0120(1) orientation trainings are completed within 30 days of hire. (repeat finding)
(a) Discipline and behavior management
including de-escalation, crisis prevention,
positive behavior management, and
disciplinary techniques that are non-punitive in
nature
- Buckman: Orientation trainings were
either not completed or were
completed after the first 30 days of
hire for trainings a, b and c.
The programs shall ensure all orientation
trainings are completed within 30 days of hire
and documented in each staff's personnel file.
New Employee Orientation Residential Yes✓ No[ ] Buckman: Documentation was reviewed for two staff recently hired. One staff did not
(Prior to working alone and within 30 days) complete the required trainings within 30 days of hire. The program shall ensure all
419-470-0120(1) orientation trainings are completed within 30 days of hire. (repeat finding)
(b) CPR and First Aid sufficient to retain a
current certification
- Buckman: Orientation trainings were
either not completed or were Cordero: Documentation was reviewed for two staff recently hired and all orientation
completed after the first 30 days of trainings were completed within 30 days of hire.
hire for trainings a, b and c
- Cordero: Orientation trainings were Atlas: Documentation was reviewed for two staff recently hired and all orientation trainings
either not completed or were were completed within 30 days of hire.
completed after the first 30 days of
hire for trainings b and d.
- Atlas: Orientation trainings were
either not completed or were
completed after the first 30 days of
hire for trainings b and d.
The programs shall ensure all orientation
trainings are completed within 30 days of hire
and documented in each staff's personnel file.
New Employee Orientation Residential Yes✓ No[ ] Buckman: Documentation was reviewed for two staff recently hired. One staff did not
(Prior to working alone and within 30 days) complete the required trainings within 30 days of hire. The program shall ensure all
419-470-0120(1) orientation trainings are completed within 30 days of hire. (repeat finding)
(c) Universal precautions and hygiene
- Buckman: Orientation trainings were
either not completed or were
completed after the first 30 days of
hire for trainings a, b and c.

The programs shall ensure all orientation
trainings are completed within 30 days of hire
and documented in each staff's personnel file.
New Employee Orientation Residential Yes✓ No[ ] Buckman: Documentation was reviewed for two staff recently hired. One staff did not
(Prior to working alone and within 30 days) complete the required trainings within 30 days of hire. The program shall ensure all
419-470-0120(1) orientation trainings are completed within 30 days of hire. (repeat finding)
(d) Application of the reasonable and prudent
parent standard
- Cordero: Orientation trainings were Atlas: Documentation was reviewed for two staff recently hired and all orientation trainings
either not completed or were were completed within 30 days of hire.
completed after the first 30 days of
hire for trainings b and d.
- Atlas: Orientation trainings were
either not completed or were
completed after the first 30 days of
hire for trainings b and d.
The programs shall ensure all orientation
trainings are completed within 30 days of hire
and documented in each staff's personnel file.
Ongoing Training Yes[ ] No✓ Atlas: Staff have completed all ongoing trainings.
419-470-0120 (2)(c) Discipline and Behavior
Management
- Atlas: Two of the staff personnel files
reviewed did not contain
documentation discipline and
behavior management ongoing
trainings were completed.
The program shall ensure all staff have
completed trainings on discipline and behavior
management on an ongoing basis.
Ongoing Training Yes[ ] No✓ Atlas: Staff have completed all ongoing trainings.
419-470-0120 (2)(d) Agency's policy on
suicide prevention and risk assessment tool
- Atlas: Three of the staff personnel
files reviewed did not contain
documentation the agency's policy on
suicide prevention and risk
assessment tool trainings were
completed on an ongoing basis.
The program shall ensure all staff have
completed trainings on the agency's policy on
suicide prevention and risk assessment tool
on an ongoing basis.

Ongoing Training Yes[ ] No✓ Cordero: Staff have completed all ongoing trainings.
419-470-0120 (3) Staff providing direct care
must maintain current CPR/First Aid
certification
- Cordero: Three of the staff personnel
files reviewed did not contain
documentation of current CPR/First
Aid certifications.
The program shall ensure all staff have
current CPR/First Aid certifications.
Consents 419-470-0160(1) Yes[ ] No✓ Atlas: Documentation was reviewed for two clients and both files contained the required
(e) Allow access as defined in 419-400-0230 consents.
& 0240
- Atlas: Three of the client files
reviewed were missing consents
regarding allowing access.
The program shall ensure all required
consents are signed by the legal guardian.
Authorizations 419-470-0160(3) Yes[ ] No✓ Buckman: Documentation was reviewed for two clients and both files contained the
(a) Disclose or exchange information with required authorizations.
others
- Buckman: Two of the client files
reviewed were missing authorizations
to disclose or exchange information
with others.
The program shall ensure all required
disclosures are signed by the legal guardian.
Authorizations 419-470-0160(3) Yes[ ] No✓ Buckman: Documentation was reviewed for two clients and both files contained the
(c) Visitation resources are pre-approved required authorizations.
- Buckman: Two of the client files
reviewed were missing authorizations
for pre-approving visitation resources.
The program shall ensure all required
disclosures are signed by the legal guardian.
419-400-0090 (2)(a)(D)(i) Grievance Yes[ ] No✓ The grievance procedure has been updated to include all the required information.
Procedures. (a) A child-caring agency must
enact and adhere to written procedures for the
children in care and families the child-caring
agency serves to submit a grievance.
- The procedures must include all of
the following: (D) The name, address
and phone number of: (i) A
Department licensing coordinator.

- Janus Youth Programs shall ensure
the grievance procedure is updated to
include the following information

interview_summary:
Buckman: Client #1 interview - They have been at the program for one week, they previously were at several other programs. They graduated another Janus
program and then came to Buckman. Staff are supporting them, however, wishes there was more support for transgender clients. Sunday - Thursday the staff
make dinner. Clients are responsible for their own breakfast and lunch. Friday and Saturday the clients are also responsible to make dinner. They are
currently an intern at Janus' offices.
Client #2 interview - They have been at the program for two and a half months, they like it here. Clients will behave badly and they believe staff does not
intervene, some of the clients need a stricter environment. They are currently working parttime. They have frequent contact with family through phone calls
and visits.
Cordero: Client #1 interview - They have been at the program for two years and four months. They like it here, and it has helped a lot. Treatment has been
great. Staff make breakfast and lunch. Clients help prep for dinner, and clients make brunch for the whole house on Sundays. They are able to concentrate at
school a lot more here than in public school. They have phone calls and in-person visits with their family. They feel safe here. Staff are available and they get
along with staff. They feel like some of the rules are petty, such as asking youth not to fidget during group.
Atlas: Client #1 interview - They have been at the program for 8 months. They were previously at two other programs. They currently work fulltime. They get
along with the other clients and staff. They feel safe here. Clients are responsible for making breakfast and lunch, and staff make dinner. They have contact
with family through phone calls and in person visits. They are not currently in treatment, as they already graduated treatment. They don't like living in the city.

previous_findings:
Repeat Comments
License Renewal Site Visit 4/22-24/2024 Findings
Further Action
Needed
Supplemental Information Provided by Yes[ ] No✓ Cordero: The environmental health inspection and fire marshal inspection have been
CCA completed.
Documents as indicated on the form titled
"Renewal Licensing Required Documents"
- Cordero: The program does not have
documentation of a fire marshal or
environmental health inspection being
completed. The program shall ensure
the inspections are completed.
Physical Plant Yes✓ No[ ] Buckman: The inside of the house has not been painted but is scheduled to be painted in
419-470-0020(2)(a) &(c) Buildings are smoke February 2025. (repeat finding)
free, clean and in good repair
- Buckman: The inside of the house
needs to be completely repainted.
There are holes in the walls from nails
and screws sticking out of the walls.
The program shall ensure all parts of
the house are in good repair.

Residential Care Safety 419-470-0080 Yes[ ] No✓ Buckman: Evacuation drills were reviewed, and the program is completing evacuation
(5)(a) Evacuation drill occurs monthly under drills on a monthly basis.
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
- Buckman: The program was missing
evacuation drills in February 2023
and May 2023. The program shall
ensure evacuation drills are
conducted on a monthly basis and
documented.
New Employee Orientation - Umbrella Yes[ ] No✓ Cordero: Documentation was reviewed for two staff recently hired, and all orientation
Requirements (30 days) 419-400-0120(4) trainings were completed within 30 days of hire.
(a) Agency policies and procedures
- Cordero: Orientation trainings were
either not completed or were
completed after the first 30 days of
hire for trainings a, b, c, and d.
The programs shall ensure all orientation
trainings are completed within 30 days of hire
and documented in each staff's personnel file.
New Employee Orientation - Umbrella Yes✓ No[ ] Buckman: Documentation was reviewed for two staff recently hired. One staff did not
Requirements (30 days) 419-400-0120(4) complete the required trainings within 30 days of hire. The program shall ensure all
(b) Ethical and professional guidelines orientation trainings are completed within 30 days of hire. (repeat finding)
- Buckman: Orientation trainings were
either not completed or were Cordero: Documentation was reviewed for two staff recently hired, and all orientation
completed after the first 30 days of trainings were completed within 30 days of hire.
hire for trainings b, c, d, f and g.
- Cordero: Orientation trainings were
either not completed or were
completed after the first 30 days of
hire for trainings a, b, c, and d.
The programs shall ensure all orientation
trainings are completed within 30 days of hire
and documented in each staff's personnel file.

New Employee Orientation - Umbrella Yes✓ No[ ] Buckman: Documentation was reviewed for two staff recently hired. One staff did not
Requirements (30 days) 419-400-0120(4) complete the required trainings within 30 days of hire. The program shall ensure all
(c) Suicide prevention and intervention orientation trainings are completed within 30 days of hire. (repeat finding)
- Buckman: Orientation trainings were
either not completed or were Cordero: Documentation was reviewed for two staff recently hired and all orientation
completed after the first 30 days of trainings were completed within 30 days of hire.
hire for trainings b, c, d, f and g.
- Cordero: Orientation trainings were
either not completed or were
completed after the first 30 days of
hire for trainings a, b, c, and d.
The programs shall ensure all orientation
trainings are completed within 30 days of hire
and documented in each staff's personnel file.
New Employee Orientation - Umbrella Yes✓ No[ ] Buckman: Documentation was reviewed for two staff recently hired. One staff did not
Requirements (30 days) 419-400-0120(4) complete the required trainings within 30 days of hire. The program shall ensure all
(d) Attributes of population served orientation trainings are completed within 30 days of hire. (repeat finding)
- Buckman: Orientation trainings were
either not completed or were Cordero: Documentation was reviewed for two staff recently hired and all orientation
completed after the first 30 days of trainings were completed within 30 days of hire.
hire for trainings b, c, d, f and g.
- Cordero: Orientation trainings were Atlas: Documentation was reviewed for two staff recently hired and all orientation trainings
either not completed or were were completed within 30 days of hire.
completed after the first 30 days of
hire for trainings a, b, c, and d.
- Atlas: Orientation trainings were
either not completed or were
completed after the first 30 days of
hire for trainings d and f.
The programs shall ensure all orientation
trainings are completed within 30 days of hire
and documented in each staff's personnel file.
New Employee Orientation - Umbrella Yes✓ No[ ] Buckman: Documentation was reviewed for two staff recently hired. One staff did not
Requirements (30 days) 419-400-0120(4) complete the required trainings within 30 days of hire. The program shall ensure all
(f) Privacy laws orientation trainings are completed within 30 days of hire. (repeat finding)
New Employee Orientation - Umbrella Yes✓ No[ ] Buckman: Documentation was reviewed for two staff recently hired. One staff did not
Requirements (30 days) 419-400-0120(4) complete the required trainings within 30 days of hire. The program shall ensure all
(g) Emergency procedures orientation trainings are completed within 30 days of hire. (repeat finding)

New Employee Orientation Residential Yes✓ No[ ] Buckman: Documentation was reviewed for two staff recently hired. One staff did not
(Prior to working alone and within 30 days) complete the required trainings within 30 days of hire. The program shall ensure all
419-470-0120(1) orientation trainings are completed within 30 days of hire. (repeat finding)
(a) Discipline and behavior management
including de-escalation, crisis prevention,
positive behavior management, and
disciplinary techniques that are non-punitive in
nature
- Buckman: Orientation trainings were
either not completed or were
completed after the first 30 days of
hire for trainings a, b and c.
The programs shall ensure all orientation
trainings are completed within 30 days of hire
and documented in each staff's personnel file.
New Employee Orientation Residential Yes✓ No[ ] Buckman: Documentation was reviewed for two staff recently hired. One staff did not
(Prior to working alone and within 30 days) complete the required trainings within 30 days of hire. The program shall ensure all
419-470-0120(1) orientation trainings are completed within 30 days of hire. (repeat finding)
(b) CPR and First Aid sufficient to retain a
current certification
- Buckman: Orientation trainings were
either not completed or were Cordero: Documentation was reviewed for two staff recently hired and all orientation
completed after the first 30 days of trainings were completed within 30 days of hire.
hire for trainings a, b and c
- Cordero: Orientation trainings were Atlas: Documentation was reviewed for two staff recently hired and all orientation trainings
either not completed or were were completed within 30 days of hire.
completed after the first 30 days of
hire for trainings b and d.
- Atlas: Orientation trainings were
either not completed or were
completed after the first 30 days of
hire for trainings b and d.
The programs shall ensure all orientation
trainings are completed within 30 days of hire
and documented in each staff's personnel file.
New Employee Orientation Residential Yes✓ No[ ] Buckman: Documentation was reviewed for two staff recently hired. One staff did not
(Prior to working alone and within 30 days) complete the required trainings within 30 days of hire. The program shall ensure all
419-470-0120(1) orientation trainings are completed within 30 days of hire. (repeat finding)
(c) Universal precautions and hygiene
- Buckman: Orientation trainings were
either not completed or were
completed after the first 30 days of
hire for trainings a, b and c.

The programs shall ensure all orientation
trainings are completed within 30 days of hire
and documented in each staff's personnel file.
New Employee Orientation Residential Yes✓ No[ ] Buckman: Documentation was reviewed for two staff recently hired. One staff did not
(Prior to working alone and within 30 days) complete the required trainings within 30 days of hire. The program shall ensure all
419-470-0120(1) orientation trainings are completed within 30 days of hire. (repeat finding)
(d) Application of the reasonable and prudent
parent standard
- Cordero: Orientation trainings were Atlas: Documentation was reviewed for two staff recently hired and all orientation trainings
either not completed or were were completed within 30 days of hire.
completed after the first 30 days of
hire for trainings b and d.
- Atlas: Orientation trainings were
either not completed or were
completed after the first 30 days of
hire for trainings b and d.
The programs shall ensure all orientation
trainings are completed within 30 days of hire
and documented in each staff's personnel file.
Ongoing Training Yes[ ] No✓ Atlas: Staff have completed all ongoing trainings.
419-470-0120 (2)(c) Discipline and Behavior
Management
- Atlas: Two of the staff personnel files
reviewed did not contain
documentation discipline and
behavior management ongoing
trainings were completed.
The program shall ensure all staff have
completed trainings on discipline and behavior
management on an ongoing basis.
Ongoing Training Yes[ ] No✓ Atlas: Staff have completed all ongoing trainings.
419-470-0120 (2)(d) Agency's policy on
suicide prevention and risk assessment tool
- Atlas: Three of the staff personnel
files reviewed did not contain
documentation the agency's policy on
suicide prevention and risk
assessment tool trainings were
completed on an ongoing basis.
The program shall ensure all staff have
completed trainings on the agency's policy on
suicide prevention and risk assessment tool
on an ongoing basis.

Ongoing Training Yes[ ] No✓ Cordero: Staff have completed all ongoing trainings.
419-470-0120 (3) Staff providing direct care
must maintain current CPR/First Aid
certification
- Cordero: Three of the staff personnel
files reviewed did not contain
documentation of current CPR/First
Aid certifications.
The program shall ensure all staff have
current CPR/First Aid certifications.
Consents 419-470-0160(1) Yes[ ] No✓ Atlas: Documentation was reviewed for two clients and both files contained the required
(e) Allow access as defined in 419-400-0230 consents.
& 0240
- Atlas: Three of the client files
reviewed were missing consents
regarding allowing access.
The program shall ensure all required
consents are signed by the legal guardian.
Authorizations 419-470-0160(3) Yes[ ] No✓ Buckman: Documentation was reviewed for two clients and both files contained the
(a) Disclose or exchange information with required authorizations.
others
- Buckman: Two of the client files
reviewed were missing authorizations
to disclose or exchange information
with others.
The program shall ensure all required
disclosures are signed by the legal guardian.
Authorizations 419-470-0160(3) Yes[ ] No✓ Buckman: Documentation was reviewed for two clients and both files contained the
(c) Visitation resources are pre-approved required authorizations.
- Buckman: Two of the client files
reviewed were missing authorizations
for pre-approving visitation resources.
The program shall ensure all required
disclosures are signed by the legal guardian.
419-400-0090 (2)(a)(D)(i) Grievance Yes[ ] No✓ The grievance procedure has been updated to include all the required information.
Procedures. (a) A child-caring agency must
enact and adhere to written procedures for the
children in care and families the child-caring
agency serves to submit a grievance.
- The procedures must include all of
the following: (D) The name, address
and phone number of: (i) A
Department licensing coordinator.

- Janus Youth Programs shall ensure
the grievance procedure is updated to
include the following information:
Licensing Coordinator Aubrey Kelly
ODHS Office of Training,
Investigations and Safety
4600 25th Ave. NE, Suite 150
Salem, OR 97301
(503) 602-8913
New Findings from Site Visit Comments
419-470-0020 (2)(c) Physical Plant Buckman: Bedroom A and bedroom C were dirty and messy, to include clothes and food all over the
Requirements: (2) A residential care agency bedrooms. The program shall ensure all buildings are clean and in good repair.
must meet all of the following requirements:
(c) All areas of buildings where children in Atlas: The basement of the program recently flooded. The carpet has been torn out and the program is
care are present must be kept clean and in working to get the tile with asbestos removed as well.
good repair.
In the dining room, there was one large hole in the ceiling, directly above the dining room table. There were
several smaller holes in the ceiling as well. The program reported there was a leak and they were trying to
determine were the leak was coming from. The program shall ensure the holes in the ceiling are repaired
within 30 days.


state: OR

facility_name: Buckman House

summary: Unannounced - 11 findings

raw_content:
Licensed Child Caring Agency Site Visit Report
Residential Care - Unannounced
Licensee: Janus Youth Programs Date of site visit: April 3, 2025
Executive Director: Dennis Morrow Licensing Coordinator: Aubrey Kelly
Program Director: Claudia Shebloski (Buckman), & Trina
Strand (Cordero & Atlas)
Other regulatory or accrediting agencies: DHS Treatment Services & Oregon Youth Authority
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 – 12/11/2024 findings
further action
needed
Physical Plant
419-470-0020(2)(a) &(c) Buildings are smoke free,
clean and in good repair The inside of the house has been painted. Each client
No
420-Buckman: The inside of the house has not been has a new wardrobe to keep their belongings in.
painted but is scheduled to be painted in February
2025. (repeat finding)
New Employee Orientation – Umbrella
Requirements (30 days) 419-400-0120(4)
(b) Ethical and professional guidelines
• Buckman: Documentation was reviewed for two One staff has been hired at Buckman since January
staff recently hired. One staff did not complete No 2025 and completed ethical and professional
the required trainings within 30 days of hire. The guidelines training within 30 days of hire.
program shall ensure all orientation trainings are
completed within 30 days of hire. (repeat
finding)
Form Rev. 3/12/2025 P a g e 1 | 7
Previous findings Repeat Comments
Unannounced Site Visit – 12/11/2024 findings
further action
needed
New Employee Orientation – Umbrella
Requirements (30 days) 419-400-0120(4)
(c) Suicide prevention and intervention One staff has been hired at Buckman since January
• Buckman: Documentation was reviewed for two 2025. Suicide prevention and intervention training was
staff recently hired. One staff did not complete Yes completed by the staff; however, it was not within 30
the required trainings within 30 days of hire. The days of hire. The program shall ensure all orientation
program shall ensure all orientation trainings are trainings are completed within 30 days of hire.
completed within 30 days of hire. (repeat
finding)
New Employee Orientation – Umbrella
Requirements (30 days) 419-400-0120(4)
(d) Attributes of population served One staff has been hired at Buckman since January
• Buckman: Documentation was reviewed for two 2025. Attributes of population served training was
staff recently hired. One staff did not complete Yes completed by the staff; however, it was not within 30
the required trainings within 30 days of hire. The days of hire. The program shall ensure all orientation
program shall ensure all orientation trainings are trainings are completed within 30 days of hire.
completed within 30 days of hire. (repeat
finding)
New Employee Orientation – Umbrella
Requirements (30 days) 419-400-0120(4)
(f) Privacy laws
• Buckman: Documentation was reviewed for two One staff has been hired at Buckman since January
staff recently hired. One staff did not complete No 2025 and completed Privacy laws training within 30
the required trainings within 30 days of hire. The days of hire.
program shall ensure all orientation trainings are
completed within 30 days of hire. (repeat
finding)
New Employee Orientation – Umbrella One staff has been hired at Buckman since January
Requirements (30 days) 419-400-0120(4) Yes 2025. There was no documentation indicating the staff
(g) Emergency procedures completed emergency procedures training. The
Form Rev. 3/12/2025 P a g e 2 | 7
Previous findings Repeat Comments
Unannounced Site Visit – 12/11/2024 findings
further action
needed
• Buckman: Documentation was reviewed for two program shall ensure all orientation trainings are
staff recently hired. One staff did not complete completed within 30 days of hire.
the required trainings within 30 days of hire. The
program shall ensure all orientation trainings are
completed within 30 days of hire. (repeat
finding)
New Employee Orientation Residential
(Prior to working alone and within 30 days)
419-470-0120(1)
(a) Discipline and behavior management One staff has been hired at Buckman since January
including de-escalation, crisis prevention, 2025. There was no documentation indicating the staff
positive behavior management, and completed discipline and behavior management
disciplinary techniques that are non-punitive in including de-escalation, crisis prevention, positive
Yes
nature behavior management, and disciplinary techniques
• Buckman: Documentation was reviewed for two that are non-punitive in nature. The program shall
staff recently hired. One staff did not complete ensure all orientation trainings are completed within 30
the required trainings within 30 days of hire. The days of hire.
program shall ensure all orientation trainings are
completed within 30 days of hire. (repeat
finding)
New Employee Orientation Residential (Prior to
working alone and within 30 days) 419-470-0120(1)
(b) CPR and First Aid sufficient to retain a
One staff has been hired at Buckman since January
current certification
2025. There was no documentation indicating the staff
• Buckman: Documentation was reviewed for two
Yes completed CPR and First Aid training. The program
staff recently hired. One staff did not complete
shall ensure all orientation trainings are completed
the required trainings within 30 days of hire. The
within 30 days of hire.
program shall ensure all orientation trainings are
completed within 30 days of hire. (repeat
finding)
Form Rev. 3/12/2025 P a g e 3 | 7
Previous findings Repeat Comments
Unannounced Site Visit – 12/11/2024 findings
further action
needed
New Employee Orientation Residential
(Prior to working alone and within 30 days)
419-470-0120(1)
(c) Universal precautions and hygiene
One staff has been hired at Buckman since January
• Buckman: Documentation was reviewed for two
No 2025 and completed universal precautions and
staff recently hired. One staff did not complete
hygiene training within 30 days of hire.
the required trainings within 30 days of hire. The
program shall ensure all orientation trainings are
completed within 30 days of hire. (repeat
finding)
New Employee Orientation Residential (Prior to
working alone and within 30 days)
419-470-0120(1)
One staff has been hired at Buckman since January
(d) Application of the reasonable and prudent
2025. There was no documentation indicating the staff
parent standard
completed application of the reasonable and prudent
• Buckman: Documentation was reviewed for two Yes
parent standard training. The program shall ensure all
staff recently hired. One staff did not complete
orientation trainings are completed within 30 days of
the required trainings within 30 days of hire. The
hire.
program shall ensure all orientation trainings are
completed within 30 days of hire. (repeat
finding)
Physical Plant Requirements
419-470-0020 (2) A residential care agency must meet
Buckman: All bedrooms were clean and in good
all of the following requirements:
repair.
(c) All areas of buildings where children in care are
present must be kept clean and in good repair. Major No
Atlas: Repairs are continuing in the basement
appliances and heating, ventilation, plumbing, and
following the flood. The holes in the dining room
electrical systems must be functional and in good repair.
ceiling have been repaired.
• Buckman: Bedroom A and bedroom C were dirty
and messy, to include clothes and food all over
Form Rev. 3/12/2025 P a g e 4 | 7
Previous findings Repeat Comments
Unannounced Site Visit – 12/11/2024 findings
further action
needed
the bedrooms. The program shall ensure all
buildings are clean and in good repair.
• Atlas: The basement of the program recently
flooded. The carpet has been torn out and the
program is working to get the tile with asbestos
removed as well.
In the dining room, there was one large hole in the
ceiling, directly above the dining room table. There were
several smaller holes in the ceiling as well. The program
reported there was a leak and they were trying to
determine were the leak was coming from. The program
shall ensure the holes in the ceiling are repaired within
30 days.
New findings from site visit Comments
None
Form Rev. 3/12/2025 P a g e 5 | 7
Interview summary
Cordero -
Client #1: They are 18 years old and have been at the program for just over 1 year. They have been at several other programs in
Oregon. This program is their favorite because of the very structured schedule, staff are willing to be supportive and staff holds
everyone accountable. They feel safe here. They get along with other the clients and staff. Breakfast and lunch are ok but boring.
Staff makes dinner, and clients at a certain level help with dinner. They get enough food and snacks, and water is always
available.
Client #2: They are 15 years old and have been at the program 5 months. This is their first program. The program has lots of
benefits; it teaches them to do better. They said, “This is the best program in the state of Oregon.” They love the staff. One staff
was fired, but they felt like management of the program handled the situation very well and assured the clients they were safe.
The food is really good, and they get enough to eat. They have ups and downs with the other clients, and they sometimes argue
over small things. They get along with the staff. They have phone calls every night with their family. They would like to change the
positive peer culture model.
Atlas –
Client #1 – They are 19 years old and have been at the program for 10 months. They were previously at Cordero. They were
previously taking classes at PCC, but they are currently taking a break to find a job. They want to take online classes while
working. They get along with the other clients. They get along with staff, but, at times, they become frustrated with staff, as staff
makes decisions they don’t always understand. The clients are responsible for breakfast and lunch. Staff and clients together
make dinner. They wish the food was healthier, wishes there were more vegetables. They feel safe here and feel supported by
staff, though sometimes staff can be overbearing. The behaviors of other clients can make them uncomfortable.
Form Rev. 3/12/2025 P a g e 6 | 7
Observations
Cordero –
The program was very clean and in good repair. The house was nicely decorated for the Easter holiday.
Buckman –
The inside of the house has been painted and looks fresh and clean. The client bedrooms were clean and in good repair.
Atlas –
Clients are not allowed in the basement without staff supervision due to the work being done following a flood. The program is
clean and has a homelike feel to it.
Corrective actions and timeframes:
Please submit the following to verify compliance.
Within 45 days of receipt of this report Janus Youth Programs – residential care must submit a letter of verification indicating the
agency is in compliance with the specific rules cited above and describing how compliance will be maintained going forward. Along
with the letter of verification, the agency must submit any and all specific documentation requested in the body of this report. The
letter of verification and any additional requested documents can be emailed directly to Aubrey Kelly at
Aubrey.J.Kelly@odhsoha.oregon.gov.
Licensing Coordinator’s signature: ________________________ Date: __5_/_1_/2_0_2_5___________
Manager review: ______________________________________ Date: __4_-2_9_-_2_0_25__________
Form Rev. 3/12/2025 P a g e 7 | 7

agency_name: Janus Youth Programs (JYP)

program_name: Buckman House

program_type: (RC) Residential Care Programs

report_type: Unannounced

view_code: RC

facility_type: Residential Care - 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 Comments
Unannounced Site Visit - 12/11/2024 findings
further action
needed
Physical Plant
419-470-0020(2)(a) &(c) Buildings are smoke free,
clean and in good repair The inside of the house has been painted. Each client
No
420-Buckman: The inside of the house has not been has a new wardrobe to keep their belongings in.
painted but is scheduled to be painted in February
2025. (repeat finding)
New Employee Orientation - Umbrella
Requirements (30 days) 419-400-0120(4)
(b) Ethical and professional guidelines
- Buckman: Documentation was reviewed for two One staff has been hired at Buckman since January
staff recently hired. One staff did not complete No 2025 and completed ethical and professional
the required trainings within 30 days of hire. The guidelines training within 30 days of hire.
program shall ensure all orientation trainings are
completed within 30 days of hire. (repeat
finding)

Previous findings Repeat Comments
Unannounced Site Visit - 12/11/2024 findings
further action
needed
New Employee Orientation - Umbrella
Requirements (30 days) 419-400-0120(4)
(c) Suicide prevention and intervention One staff has been hired at Buckman since January
- Buckman: Documentation was reviewed for two 2025. Suicide prevention and intervention training was
staff recently hired. One staff did not complete Yes completed by the staff; however, it was not within 30
the required trainings within 30 days of hire. The days of hire. The program shall ensure all orientation
program shall ensure all orientation trainings are trainings are completed within 30 days of hire.
completed within 30 days of hire. (repeat
finding)
New Employee Orientation - Umbrella
Requirements (30 days) 419-400-0120(4)
(d) Attributes of population served One staff has been hired at Buckman since January
- Buckman: Documentation was reviewed for two 2025. Attributes of population served training was
staff recently hired. One staff did not complete Yes completed by the staff; however, it was not within 30
the required trainings within 30 days of hire. The days of hire. The program shall ensure all orientation
program shall ensure all orientation trainings are trainings are completed within 30 days of hire.
completed within 30 days of hire. (repeat
finding)
New Employee Orientation - Umbrella
Requirements (30 days) 419-400-0120(4)
(f) Privacy laws
- Buckman: Documentation was reviewed for two One staff has been hired at Buckman since January
staff recently hired. One staff did not complete No 2025 and completed Privacy laws training within 30
the required trainings within 30 days of hire. The days of hire.
program shall ensure all orientation trainings are
completed within 30 days of hire. (repeat
finding)
New Employee Orientation - Umbrella One staff has been hired at Buckman since January
Requirements (30 days) 419-400-0120(4) Yes 2025. There was no documentation indicating the staff
(g) Emergency procedures completed emergency procedures training. The

Previous findings Repeat Comments
Unannounced Site Visit - 12/11/2024 findings
further action
needed
- Buckman: Documentation was reviewed for two program shall ensure all orientation trainings are
staff recently hired. One staff did not complete completed within 30 days of hire.
the required trainings within 30 days of hire. The
program shall ensure all orientation trainings are
completed within 30 days of hire. (repeat
finding)
New Employee Orientation Residential
(Prior to working alone and within 30 days)
419-470-0120(1)
(a) Discipline and behavior management One staff has been hired at Buckman since January
including de-escalation, crisis prevention, 2025. There was no documentation indicating the staff
positive behavior management, and completed discipline and behavior management
disciplinary techniques that are non-punitive in including de-escalation, crisis prevention, positive
Yes
nature behavior management, and disciplinary techniques
- Buckman: Documentation was reviewed for two that are non-punitive in nature. The program shall
staff recently hired. One staff did not complete ensure all orientation trainings are completed within 30
the required trainings within 30 days of hire. The days of hire.
program shall ensure all orientation trainings are
completed within 30 days of hire. (repeat
finding)
New Employee Orientation Residential (Prior to
working alone and within 30 days) 419-470-0120(1)
(b) CPR and First Aid sufficient to retain a
One staff has been hired at Buckman since January
current certification
2025. There was no documentation indicating the staff
- Buckman: Documentation was reviewed for two
Yes completed CPR and First Aid training. The program
staff recently hired. One staff did not complete
shall ensure all orientation trainings are completed
the required trainings within 30 days of hire. The
within 30 days of hire.
program shall ensure all orientation trainings are
completed within 30 days of hire. (repeat
finding)

Previous findings Repeat Comments
Unannounced Site Visit - 12/11/2024 findings
further action
needed
New Employee Orientation Residential
(Prior to working alone and within 30 days)
419-470-0120(1)
(c) Universal precautions and hygiene
One staff has been hired at Buckman since January
- Buckman: Documentation was reviewed for two
No 2025 and completed universal precautions and
staff recently hired. One staff did not complete
hygiene training within 30 days of hire.
the required trainings within 30 days of hire. The
program shall ensure all orientation trainings are
completed within 30 days of hire. (repeat
finding)
New Employee Orientation Residential (Prior to
working alone and within 30 days)
419-470-0120(1)
One staff has been hired at Buckman since January
(d) Application of the reasonable and prudent
2025. There was no documentation indicating the staff
parent standard
completed application of the reasonable and prudent
- Buckman: Documentation was reviewed for two Yes
parent standard training. The program shall ensure all
staff recently hired. One staff did not complete
orientation trainings are completed within 30 days of
the required trainings within 30 days of hire. The
hire.
program shall ensure all orientation trainings are
completed within 30 days of hire. (repeat
finding)
Physical Plant Requirements
419-470-0020 (2) A residential care agency must meet
Buckman: All bedrooms were clean and in good
all of the following requirements:
repair.
(c) All areas of buildings where children in care are
present must be kept clean and in good repair. Major No
Atlas: Repairs are continuing in the basement
appliances and heating, ventilation, plumbing, and
following the flood. The holes in the dining room
electrical systems must be functional and in good repair.
ceiling have been repaired.
- Buckman: Bedroom A and bedroom C were dirty
and messy, to include clothes and food all over

Previous findings Repeat Comments
Unannounced Site Visit - 12/11/2024 findings
further action
needed
the bedrooms. The program shall ensure all
buildings are clean and in good repair.
- Atlas: The basement of the program recently
flooded. The carpet has been torn out and the
program is working to get the tile with asbestos
removed as well.
In the dining room, there was one large hole in the
ceiling, directly above the dining room table. There were
several smaller holes in the ceiling as well. The program
reported there was a leak and they were trying to
determine were the leak was coming from. The program
shall ensure the holes in the ceiling are repaired within
30 days.
New findings from site visit Comments
None

Interview summary
Cordero -
Client #1: They are 18 years old and have been at the program for just over 1 year. They have been at several other programs in
Oregon. This program is their favorite because of the very structured schedule, staff are willing to be supportive and staff holds
everyone accountable. They feel safe here. They get along with other the clients and staff. Breakfast and lunch are ok but boring.
Staff makes dinner, and clients at a certain level help with dinner. They get enough food and snacks, and water is always
available.
Client #2: They are 15 years old and have been at the program 5 months. This is their first program. The program has lots of
benefits; it teaches them to do better. They said, "This is the best program in the state of Oregon." They love the staff. One staff
was fired, but they felt like management of the program handled the situation very well and assured the clients they were safe.
The food is really good, and they get enough to eat. They have ups and downs with the other clients, and they sometimes argue
over small things. They get along with the staff. They have phone calls every night with their family. They would like to change the
positive peer culture model.
Atlas -
Client #1 - They are 19 years old and have been at the program for 10 months. They were previously at Cordero. They were
previously taking classes at PCC, but they are currently taking a break to find a job. They want to take online classes while
working. They get along with the other clients. They get along with staff, but, at times, they become frustrated with staff, as staff
makes decisions they don't always understand. The clients are responsible for breakfast and lunch. Staff and clients together
make dinner. They wish the food was healthier, wishes there were more vegetables. They feel safe here and feel supported by
staff, though sometimes staff can be overbearing. The behaviors of other clients can make them uncomfortable.

Observations
Cordero -
The program was very clean and in good repair. The house was nicely decorated for the Easter holiday.
Buckman -
The inside of the house has been painted and looks fresh and clean. The client bedrooms were clean and in good repair.
Atlas -
Clients are not allowed in the basement without staff supervision due to the work being done following a flood. The program is
clean and has a homelike feel to it.

excerpt:
419-470-0020 (2) A residential care agency must meet
Buckman: All bedrooms were clean and in good
all of the following requirements:
repair.
(c) All areas of buildings where children in care are
present must be kept clean and in good repair. Major No
Atlas: Repairs are continuing in the basement
appliances and heating, ventilation, plumbing, and
following the flood. The holes in the dining room
electrical systems must be functional and in good repair.
ceiling have been repaired.
- Buckman: Bedroom A and bedroom C were dirty
and messy, to include clothes and food all over
Previous findings Repeat Comments
Unannounced Site Visit - 12/11/2024 findings
further action
needed
the bedrooms. The program shall ensure all
buildings are clean and in good repair.
- Atlas: The basement of the program recently
flooded. The carpet has been torn out and the
program is working to get the tile with asbestos
removed as well.
In the dining room, there was one large hole in the
ceiling, directly above the dining room table. There were
several smaller holes in the ceiling as well. The program
reported there was a leak and they were trying to
determine were the leak was coming from. The program
shall ensure the holes in the ceiling are repaired within
30 days.
New findings from site visit Comments
None
None


facility_name: Jasper Mountain

summary: Unannounced - 4 findings

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Licensee: Jasper Mountain
Executive Director: Beau Garner
Assistant Director: Sarah Huff
Date of Unannounced: 4/7/2021
Licensing Coordinator: Mary Torres
Other Regulatory or Accrediting Agencies: Oregon Health Authority (OHA), Disability Oregon, Council on Accreditation (COA) for Services to
Children and Families, other states utilizing Jasper Mountain as a placement resource include Alaska, California, Washington, Florida, Hawaii,
Georgia, Alabama, Nevada, and Idaho.
Purpose: Per OAR 413-215-0101 (1) (b) Children’s Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Comments
Findings
Further Action
Needed
413-215-0516 Yes No☐ The bathroom located on the girls’ floor in the Castle continues to use a plastic shower mat
Room and Space Requirements Bathrooms and it is unclear how the mats are being disinfected and dried daily. The mats need to be
(b)&(c) Wooden racks on floors are prohibited removed or a process needs to be developed as to how the mats will be disinfected and
and impervious shower mats are disinfected & dried daily.
dried daily
See below
413-215-0079 Yes☐ No The program confirmed that the 15-passenger van is properly insured providing visual
Licensing Umbrella Rules: Safety confirmation via email. This vehicle may be retired soon.
(1) Transportation. If a child-caring agency
transports child in care in a vehicle, the
agency must have policies and procedures
that address all of the following:
(b) Vehicle requirements.
(A) Each vehicle used to transport a child in
care must be:
(i) Properly registered;
1
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 200115)
(ii) Covered by an insurance policy in
full force and effect;
(iii) Maintained in safe operating
condition; and
(iv) Smoke-free.
The Castle’s 15 passenger van did not have
proof of insurance located in the vehicle.
Yes☐ No☐
New Findings from Site Visit Comments
413-215-0516 The bathrooms located on the girls’ floor in the Castle continue to use plastic shower mats and it is unclear
Room and Space Requirements Bathrooms how the mats are being disinfected and dried daily.
(b)&(c) Wooden racks on floors are
prohibited and impervious shower mats are CORRECTIVE ACTION: The mats need to be removed or a process needs to be developed as to how the
disinfected & dried daily mats will be disinfected and dried daily.
413-215-0091 The program is not, on a regular basis, forwarding reports of critical events, specifically when a youth is placed
Licensing Umbrella Rules: Responsibilities of in a physical restraint.
Licensees
A licensee is responsible to do all of the CORRECTIVE ACTION: Ensure that Licensing is receiving all appropriate critical events as identified by the
following: referenced Licensing Rule. For the time being, the program has collaboratively agreed to forward all incident
(11) Notify the Department in the following reports involving the use of a physical restraint to their Licensing Coordinator until further notice.
circumstances:
(b) Within one business day if a critical event
occurs. As used in this section, "critical
event" means a significant event occurring in
the operation of a child-caring agency that is
considered likely to cause complaints,
generate concerns, or come
to the attention of the media, law
enforcement agencies, first responders,
Child Protective Services, or other regulatory
agencies. Compliance with this
notification requirement does not satisfy
mandatory child abuse reporting
requirements under ORS 419B.005 to
419B.045.
2
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 200115)
Interview Summary
Tours of The Castle and Crystal Creek were conducted by the program’s Business Manager, Janet Gielow. Tour of the Safe Center was conducted by
Executive Director, Beau Garner. Informal interviews with staff were held during the tours. This licensor spoke with one member of the maintenance crew,
the program’s food service coordinator, Janet, and Beau.
During the site visit, the following information was learned:
- Jasper Mountain has various open positions to include a member on the treatment team, night shift, a Human Resources (HR) Coordinator, and a
therapist. In 2020, the program experienced a 30% staff turnover on their treatment team. With the hiring of an HR Coordinator, Janet will be able to
focus on program compliance, marketing and contracting.
- In an attempt to reduce turnover and promote staff retention, the program has developed a promotion trajectory program for employees where
longevity within the program will be recognized and compensated.
- The program employs 15 therapists, allowing a ratio of 8 youth to one therapist.
- A new intake coordinator was hired 2 months prior.
- Jasper Mountain will conduct their review with the Oregon Health Authority (OHA) this summer.
- Crystal Creek currently has 6 residents. This new facility is designed to be a short-term setting (3-4 months max) for youth transitioning from the
Castle and preparing for discharge from Jasper Mountain.
- Issues with new major appliances at Crystal Creek were addressed. A smaller kitchen sanitizer was replaced with a larger one. One of the new
refrigerators that was not holding a temperature was replaced with a new industrial refrigerator. Crystal Creek also had its’ initial water heater
replaced with a larger capacity water heater.
- Various youth have food sensitivities. The program’s nutritionist and food service coordinator are able to accommodate these dietary needs through
menus that are developed 2 months in advance. Crystal Creek has a gluten free youth, 2 dairy free youth and other youth who have seafood
allergies. Similar dietary needs are accommodated in Jasper Mountain’s two other programs, The Castle, and the Safe Center.
- The Castle has 16 residents. Referral sources remain slow since the COVID-19 pandemic.
- Jasper Mountain contracts with two local cleaning services for their facilities and has full time maintenance teams at each site.
- The Safe Center has 14 residents with one pending intake.
- The program has plans to bring community day treatment youth back to the Safe Center building four days out of the week. There are conservative
plans to keep community youth separate from Safe Center residents to reduce/avoid potential COVID exposure.
Youth from each facility were interviewed. A total of four youths were individually interviewed. Youths’ time at Jasper Mountain ranged from 1 month to over
two years. Three out of the four youth reported feeling safe within their program’s setting. The fourth youth made no comment regarding a sense of safety.
Each youth shared an experience where they felt unsafe. Three report feeling unsafe when witnessing peers acting unsafe, one peer throwing a chair at staff,
others physically fighting each other, or when others generally “go off.” Another youth admitted to feeling unsafe when placed in a two staff hold months prior.
Youth feel that staff are properly trained to do their job. One youth felt that newer staff lacked experience when first arriving but are partnered with senior staff.
Youth report feeling comfortable reporting concerns to any staff member on duty. A longer-term resident named specific staff members who they would feel
comfortable reporting concerns to. All youth had a good understanding of their treatment goals, listing them freely and quickly. Youth were also able to
identify how progress in meeting those goals is measured. Some of the youth understood their after-care plans while others were too new to identify what
3
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 200115)
leaving the program may look like. Program strengths include scheduled activities, such as art, dodgeball, and bike riding. One youth appreciates how the
program pushes residents “harder” to do better. Suggestions made by youth included being allowed to play in their bedroom during the day, having their own
room, and replacing the youth’s bed in the apartment located on the Jasper campus as the bed “squeaks” with any movement. A youth who has been in the
program for over a year was very blunt about areas of improvement. These included, having bigger meal portions, providing new shoes when tread becomes
low, better toilets, quicker response in addressing building maintenance issues, the removal of a wasps nest near the picnic tables at The Castle’s entrance,
the addition of more staff and pay increases for existing staff as this youth has overheard staff talking among themselves about how little they are paid. This
youth also pointed out that staff “yell” directions during transition times when youth are not listening and that this “triggers kids.” Youth report daily family
contact as well as additional family time during weekly therapy sessions via zoom. Some youth have family members visiting on site on the weekends.
Observations
This unannounced visit also completed the Licensing requirement related to the new program, Crystal Creek. This facility was given a temporary 6-month
license in November of 2020 when construction was completed, and the facility was ready for youth. Crystal Creek has been open for just under 6 months
and there were no outstanding licensing issues that prevents the facility from receiving a 2-year license. In addition to touring the building, youth files were
reviewed and were found to be in good standing.
Over the last few months, Jasper Mountain had been working closely with their local Health Department as COVID risk and potential exposures were being
managed on campus. The program acted swiftly in isolating staff and youth potentially exposed, conducting on site rapid testing and getting those completed
tests to their local hospital for further evaluation. Staff put in extra hours during this time, keeping risk factors and exposure to a minimum while Jasper
Mountain’s nursing staff were instrumental in weekly testing and daily monitoring of youth. Everyone pitched in, to include the Exec. Director who was often
transporting personal protective equipment (PPE) and/or COVID tests back and forth. Jasper Mountain did an excellent job reaching out for assistance and
took each suggestion by the Health Department seriously.
Jasper Mountain maintains an open door to all regulatory entities. The program is often hosting some sort of site review by state agencies or other states
throughout the year and do so with no complaint. In March of this year, the State of Alaska completed their annual review and gave the program a favorable
outcome. Jasper Mountain continues to be ahead/aware of programmatic issues through regular and ongoing meetings to include Management Team
Meetings that occur twice a month. During these meetings, all program areas are discussed and evaluated and goals and opportunities to enhance the
program are frequently discussed. Additional committees, including the Quality Control and Safety Committee, also offer opportunities for evaluation and
assessments. Licensing acknowledges Jasper Mountain’s continued commitment to improving in all areas and setting high standards as part of their daily
practice. The program’s level of collaboration and transparency is appreciated.
Corrective Actions and Timeframes:
Please submit the following to verify compliance.
Within 45 days of receipt of this report Agency Name 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 Licensing Coordinator email address or sent by regular mail to the following address:
Department of Human Services
4
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 200115)
Children’s Care Licensing Program
Attn: Licensing Coordinator
201 High St. SE Suite 500
Salem, OR 97301
Licensing Coordinator’s Signature: ________________________ Date: ___________________
Manager Review: ______________________________________ Date: ____0_4_-_2_1__-2_0__2_1____
5
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 200115)

agency_name: Jasper Mountain (JM)

program_name: Castle

licensee: Jasper Mountain

executive_director: Beau Garner

licensing_coordinator: Mary Torres

purpose:
Per OAR 413-215-0101 (1) (b) Children's Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Comments
Findings
Further Action
Needed
413-215-0516 Yes No[ ] The bathroom located on the girls' floor in the Castle continues to use a plastic shower mat
Room and Space Requirements Bathrooms and it is unclear how the mats are being disinfected and dried daily. The mats need to be
(b)&(c) Wooden racks on floors are prohibited removed or a process needs to be developed as to how the mats will be disinfected and
and impervious shower mats are disinfected & dried daily.
dried daily
See below
413-215-0079 Yes[ ] No The program confirmed that the 15-passenger van is properly insured providing visual
Licensing Umbrella Rules: Safety confirmation via email. This vehicle may be retired soon.
(1) Transportation. If a child-caring agency
transports child in care in a vehicle, the
agency must have policies and procedures
that address all of the following:
(b) Vehicle requirements.
(A) Each vehicle used to transport a child in
care must be:
(i) Properly registered;
1

(ii) Covered by an insurance policy in
full force and effect;
(iii) Maintained in safe operating
condition; and
(iv) Smoke-free.
The Castle's 15 passenger van did not have
proof of insurance located in the vehicle.
Yes[ ] No[ ]
New Findings from Site Visit Comments
413-215-0516 The bathrooms located on the girls' floor in the Castle continue to use plastic shower mats and it is unclear
Room and Space Requirements Bathrooms how the mats are being disinfected and dried daily.
(b)&(c) Wooden racks on floors are
prohibited and impervious shower mats are CORRECTIVE ACTION: The mats need to be removed or a process needs to be developed as to how the
disinfected & dried daily mats will be disinfected and dried daily.
413-215-0091 The program is not, on a regular basis, forwarding reports of critical events, specifically when a youth is placed
Licensing Umbrella Rules: Responsibilities of in a physical restraint.
Licensees
A licensee is responsible to do all of the CORRECTIVE ACTION: Ensure that Licensing is receiving all appropriate critical events as identified by the
following: referenced Licensing Rule. For the time being, the program has collaboratively agreed to forward all incident
(11) Notify the Department in the following reports involving the use of a physical restraint to their Licensing Coordinator until further notice.
circumstances:
(b) Within one business day if a critical event
occurs. As used in this section, "critical
event" means a significant event occurring in
the operation of a child-caring agency that is
considered likely to cause complaints,
generate concerns, or come
to the attention of the media, law
enforcement agencies, first responders,
Child Protective Services, or other regulatory
agencies. Compliance with this
notification requirement does not satisfy
mandatory child abuse reporting
requirements under ORS 419B.005 to
419B.045.
2

Interview Summary
Tours of The Castle and Crystal Creek were conducted by the program's Business Manager, Janet Gielow. Tour of the Safe Center was conducted by

interview_summary:
Tours of The Castle and Crystal Creek were conducted by the program's Business Manager, Janet Gielow. Tour of the Safe Center was conducted by
Executive Director, Beau Garner. Informal interviews with staff were held during the tours. This licensor spoke with one member of the maintenance crew,
the program's food service coordinator, Janet, and Beau.
During the site visit, the following information was learned:
- Jasper Mountain has various open positions to include a member on the treatment team, night shift, a Human Resources (HR) Coordinator, and a
therapist. In 2020, the program experienced a 30% staff turnover on their treatment team. With the hiring of an HR Coordinator, Janet will be able to
focus on program compliance, marketing and contracting.
- In an attempt to reduce turnover and promote staff retention, the program has developed a promotion trajectory program for employees where
longevity within the program will be recognized and compensated.
- The program employs 15 therapists, allowing a ratio of 8 youth to one therapist.
- A new intake coordinator was hired 2 months prior.
- Jasper Mountain will conduct their review with the Oregon Health Authority (OHA) this summer.
- Crystal Creek currently has 6 residents. This new facility is designed to be a short-term setting (3-4 months max) for youth transitioning from the
Castle and preparing for discharge from Jasper Mountain.
- Issues with new major appliances at Crystal Creek were addressed. A smaller kitchen sanitizer was replaced with a larger one. One of the new
refrigerators that was not holding a temperature was replaced with a new industrial refrigerator. Crystal Creek also had its' initial water heater
replaced with a larger capacity water heater.
- Various youth have food sensitivities. The program's nutritionist and food service coordinator are able to accommodate these dietary needs through
menus that are developed 2 months in advance. Crystal Creek has a gluten free youth, 2 dairy free youth and other youth who have seafood
allergies. Similar dietary needs are accommodated in Jasper Mountain's two other programs, The Castle, and the Safe Center.
- The Castle has 16 residents. Referral sources remain slow since the COVID-19 pandemic.
- Jasper Mountain contracts with two local cleaning services for their facilities and has full time maintenance teams at each site.
- The Safe Center has 14 residents with one pending intake.
- The program has plans to bring community day treatment youth back to the Safe Center building four days out of the week. There are conservative
plans to keep community youth separate from Safe Center residents to reduce/avoid potential COVID exposure.
Youth from each facility were interviewed. A total of four youths were individually interviewed. Youths' time at Jasper Mountain ranged from 1 month to over
two years. Three out of the four youth reported feeling safe within their program's setting. The fourth youth made no comment regarding a sense of safety.
Each youth shared an experience where they felt unsafe. Three report feeling unsafe when witnessing peers acting unsafe, one peer throwing a chair at staff,
others physically fighting each other, or when others generally "go off." Another youth admitted to feeling unsafe when placed in a two staff hold months prior.
Youth feel that staff are properly trained to do their job. One youth felt that newer staff lacked experience when first arriving but are partnered with senior staff.
Youth report feeling comfortable reporting concerns to any staff member on duty. A longer-term resident named specific staff members who they would feel
comfortable reporting concerns to. All youth had a good understanding of their treatment goals, listing them freely and quickly. Youth were also able to
identify how progress in meeting those goals is measured. Some of the youth understood their after-care plans while others were too new to identify what
3

leaving the program may look like. Program strengths include scheduled activities, such as art, dodgeball, and bike riding. One youth appreciates how the
program pushes residents "harder" to do better. Suggestions made by youth included being allowed to play in their bedroom during the day, having their own
room, and replacing the youth's bed in the apartment located on the Jasper campus as the bed "squeaks" with any movement. A youth who has been in the
program for over a year was very blunt about areas of improvement. These included, having bigger meal portions, providing new shoes when tread becomes
low, better toilets, quicker response in addressing building maintenance issues, the removal of a wasps nest near the picnic tables at The Castle's entrance,
the addition of more staff and pay increases for existing staff as this youth has overheard staff talking among themselves about how little they are paid. This
youth also pointed out that staff "yell" directions during transition times when youth are not listening and that this "triggers kids." Youth report daily family
contact as well as additional family time during weekly therapy sessions via zoom. Some youth have family members visiting on site on the weekends.

observations:
This unannounced visit also completed the Licensing requirement related to the new program, Crystal Creek. This facility was given a temporary 6-month
license in November of 2020 when construction was completed, and the facility was ready for youth. Crystal Creek has been open for just under 6 months
and there were no outstanding licensing issues that prevents the facility from receiving a 2-year license. In addition to touring the building, youth files were
reviewed and were found to be in good standing.
Over the last few months, Jasper Mountain had been working closely with their local Health Department as COVID risk and potential exposures were being
managed on campus. The program acted swiftly in isolating staff and youth potentially exposed, conducting on site rapid testing and getting those completed
tests to their local hospital for further evaluation. Staff put in extra hours during this time, keeping risk factors and exposure to a minimum while Jasper
Mountain's nursing staff were instrumental in weekly testing and daily monitoring of youth. Everyone pitched in, to include the Exec. Director who was often
transporting personal protective equipment (PPE) and/or COVID tests back and forth. Jasper Mountain did an excellent job reaching out for assistance and
took each suggestion by the Health Department seriously.
Jasper Mountain maintains an open door to all regulatory entities. The program is often hosting some sort of site review by state agencies or other states
throughout the year and do so with no complaint. In March of this year, the State of Alaska completed their annual review and gave the program a favorable
outcome. Jasper Mountain continues to be ahead/aware of programmatic issues through regular and ongoing meetings to include Management Team
Meetings that occur twice a month. During these meetings, all program areas are discussed and evaluated and goals and opportunities to enhance the
program are frequently discussed. Additional committees, including the Quality Control and Safety Committee, also offer opportunities for evaluation and
assessments. Licensing acknowledges Jasper Mountain's continued commitment to improving in all areas and setting high standards as part of their daily
practice. The program's level of collaboration and transparency is appreciated.