summary: License Renewals - 14 findings

raw_content:
Licensed Child Caring Agency Site Visit Report
Residential Care
Licensee: Ed Wyller Date of site visit: March 9th, 2022
Executive Director: Dan Golden Licensing Coordinator: Ed Wyller
Other Regulatory or Accrediting Agencies: Oregon Youth Authority (OYA)
Program Compliance: The program was found to be compliant or will be compliant with OAR 413-215-0001 to 413-215-0131, Licensing Umbrella
Rules, and OAR 413-215-0501 to 413-215-0586, Licensing Residential Care Agencies Rules. Personnel records were reviewed and compliance
with required background checks was documented for employees in all programs.
Program Description(s): Klamath County reports the following program description for Crimson Rose:
“The Klamath Crimson Rose (KCR) serves females, ages 12-20, in need of behavioral stabilization services and provides Individualized Treatment
Plans to these youth while also keeping them connected to their community support networks and families. The program provides an environment
for youth, who are struggling to maintain in the community or community placement, to receive services aimed at developing personal responsibility,
and appropriate and assertive behavioral skills development.
KCR is a culturally sensitive, intensive, trauma informed program that targets behaviors intended to improve psychosocial and behavioral
functioning for the participants. This program will provide youth with an array of rehabilitation services appropriate to meet their unique and
individualized needs and goals as defined in their assessment and ISSP. Daily services encourage, support and reinforce appropriate behaviors
using evidence-based methods as documented in the individual’s treatment plan. The Program will provide a minimum of 13 hours of individual and
group counseling in an environment for change, targeting behaviors such as substance use, thinking errors, anger management, and other
behaviors that have hindered their success thus far. The minimum 13 hours will include at least 2 hours of individual counseling, 10 hours of group
counseling and skill building, 1 hour of consultation, and 1 hour of family counseling or parent education when appropriate. The evidence-based
curriculum and screening tools are through Texas Christian University (TCU) and Change Companies, Forward Thinking and Voices curriculum.
TCU Mapping-Enhanced Counseling has been chosen as a treatment modality due to the continued and overwhelming evidence on the
effectiveness in increasing client motivation, engagement, participation, and retention in treatment. This cognitive-behavioral therapy utilizes node-
link mapping as a visual tool to enhance a heightened level of awareness for an individual’s thoughts, feelings, and actions improving the
psychosocial and behavioral functioning of an adolescent upon completion of the program. Forward Thinking and Voices are also evidence-based
CBT curriculum used in KCR and many other programs around the country.
Program also partners with Klamath Basin Behavioral Health to provide additional mental health services such as, Mental Health assessments,
appropriate risk assessments and behavioral skills building. Cascades East Family Practice and a contracted Family Nurse Practitioner also
provide medical support to the program.
Academically, client records are requested from prior schools to obtain the most current transcripts. Clients are enrolled in online courses using
Odysseyware to fulfill credits toward their graduation requirements. Official GED pre-testing and official testing is available to those students who
(rev. 03/25/2021)
are working toward their GED. Middle school students and those needing remedial work are offered Let’s Go Learn, a program to strengthen math
and reading skills. Students are in class three hours each school day with teachers available to help and guide them through the process.”
Program type and services: Residential Care / Behavioral Health – BRS Level 5
Capacity and Age Range: 9 / ages 12-20
Funding sources: Oregon Youth Authority (OYA) – Behavior Rehabilitation Services (BRS)
Contracts and sources for referrals: Oregon Youth Authority (OYA)
Average length of stay: 90 days
Average daily population served: 7
Number of children served annually: 40-50
Use of seclusion or restraint: N/A
Interviews, Observations: I interviewed two clients separately in the visitation area of Crimson Rose to ensure privacy. When asked how Klamath
County Juvenile Department – Crimson Rose ranks on a scale from (0-10 where 0=worst program and 10=best program), the client’s reported
program to be an 8 and 8.5 on that scale. Client’s reported learning the following skills at Crimson Rose: regulate emotions, coping skills, learned
their triggers, communication skills, and healthy boundaries. Both clients were able to discuss their treatment goals and discharge placement plans.
Both clients reported attending multiple treatment groups a day and reported meeting with therapist individually. Drug and alcohol services are
provided by Klamath Basin Behavioral Health. Clients reported feeling safe in the program and reported food to be good. Outings were reported to
include parks, hiking, bowling, and movies. Both client’s reported enjoying self-care night. The youth reported self-care nigh includes mud/clay
masks, soak feet in Epsom salts, and braiding hair. Youth reported being respected by program staff and identified liking their case manager.
Crimson Rose continues to make their space feel less institutional. Achievements such as program graduation, attaining a GED, or High School
diploma are recognized by youth having their name on the wall and being allowed to paint on the wall as well. Facility was clean. Currently
construction is occurring around the Juvenile Detention building in creating new road, parking, and leveling areas for future development. Lottery
dollars were attained for building an education center, kitchen, new independent program (house like setting), and possibly a transition program as
well. Space has been created for a possible solar field and this, coupled with preexisting geothermal program, would make the site energy
independent.
2
Program Strengths: Crimson Rose reports, “Program provides a continuum of behavioral health care services to up to nine Oregon Youth
Authority female clients. Clients can be on probation or parole and in need of diversion from the correctional facility or general behavioral
stabilization. Program provides safety, security, structure, and treatment unavailable in lower levels of care.”
Program Challenges: Crimson Rose reports, “Program has recently had some minor issues maintaining quality staff due to the pandemic at
times.”
Changes that have occurred in the last 2 years: Crimson Rose reports, “Hired three full time direct care staff.”
Lawsuits: Crimson Rose reports no lawsuits.
Grievances and complaints filed in the last two years: Crimson Rose reports no formal grievances in last two years. Program Director Steve
Quick has followed up on 57 complaints from youth over the last two years. Steve reports the nature of these complaints are typically a complaint
about another youth’s behavior. Steve reports he will follow up on these complaints and talk to youth, staff, and work out a resolution regarding the
matter. Crimson Rose reports of these 57 complaints zero have escalated to a formal grievance.
Corrective Actions and Timeframes: Please submit the following to verify compliance.
Within 45 days of receipt of this report Klamath County Juvenile Department – Crimson Rose 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 Ed Wyller at Edward.Wyller@dhsoha.state.or.us or sent by regular mail to the following
address:
Due to Covid-19 pandemic and working remotely the preferred method is to send directly to Ed Wyller at his email address
Department of Human Services, Children’s Care Licensing Unit
Attn: Ed Wyller
500 Summer St NE (E-94)
Salem, OR 97301
Exceptions: Current exception on file regarding bedroom egress with fixed bedroom windows.
Changes in License: N/A
3
Summary of Review
Program and Services Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0011(2) Completed
Program and services are in scope of license x
Governance of the Agency Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0021 Completed
(1)(a) Minimum of 5 board members x  Klamath County Juvenile Department does not have
(2)(f) Formally evaluate the exec. Director’s x a board but is governed by County Commissioners.
performance annually
(2)(g) Approves annual budget x
(2)(h) Obtain and review an annual x
independent financial review or audit of
financial records.
(2)(k) Written quality improvement program x
(2)(l) Meeting minutes x
Executive Director or Program Director Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0021 Completed
(3)(a) knowledge of requirements for x  Missing Dan Golden’s Background Check
providing care and treatment appropriate to
programs
(3)(g) Approval from BCU x
Discipline, Behavior Management, and Corrective Action
Yes No N/A Corrective Actions/Comments
Suicide Prevention 413-215-0076 Completed
(3) Agency uses appropriate and positive
methods of behavior management and
x
nationally recognized non-violent crisis
intervention
(3)(b)(C) Agency does not use chemical and
mechanical restraint (excluding medically x
necessary devices/prescriptions)
(3)(c) Agency uses appropriate time-out
rooms (adequate space, heat, light and
ventilation and is not capable of locking) and x
documents use in child’s record when
applicable
(3)(e) Agency uses seclusion
x
appropriately/consistent with policy
4
(4) Agency has adequate plan in place to
x
respond to suicidal behavior/warning signs
Contractors (if applicable) Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0061(6) Completed
(a) Agency ensures the contractor meets the
requirements of this rule and Chapter 413 x
division 215
(b)(B) Contract includes the following:
(i) Services provided
(ii) Contractor fees
(iii) Disclosure of information from contractor
to agency
(iv) Lines of authority x
(v) Adherence to rules, including background
check
(vi) Any liability of the agency for acts of the
contractor, rights of indemnity and limitations
on liability
Supplemental Information Provided by Corrective Action
Yes No N/A Corrective Actions/Comments
CCA Completed
Documents as indicated on the form titled
x
“Renewal Licensing Required Documents”
Documents as indicated on form titled
“Required Financial Documents and x
Information”
All required policies and procedures as
x
identified in the “Umbrella Rules”
All required policies and procedures as
x
identified in “Agency Type Specific Rules”
Physical Plant Corrective Action
Yes No N/A Corrective Actions/Comments
Completed
413-215-0046(3)(a) Foster Rights Posted (if x
children in DHS custody)
413-215-0051(1) Sufficient safe space, x
equipment, and office equipment
413-215-0091(12) License is posted in x
common area at each facility
413-215-0001(5)(d), 0516(4(a)(I) & 0521(1) x
Adequate furnishings and personal items
413-215-0511(2)(a) &(c) Buildings are x
smoke free, clean and in good repair
413-215-0511(2)(d) Rooms are free of x
harmful drafts, odors, and excessive noise
413-215-0511(2)(e) Rooms are adequate in x
size and arrangement
5
413-215-0511(2)(f) System provides a x
continuous supply of hot and cold water to
taps located throughout the facility
413-215-0511(2)(h) Building is well x
ventilated and room temperature is within a
normal comfort range
413-215-0516(1) All parts of the facility x
ensure the safety of children
Room and Space Requirements Corrective Action
Yes No N/A Corrective Actions/Comments
Bedrooms 413-215-0516(3) Completed
(a) Adequate furnishings and personal items  Crimson Rose bedrooms have detention grade
(b) Separate from rooms used for dining, x windows that do not allow egress, a current
living, laundry, kitchen, and storage exception is in place regarding this matter.
(c) Outside room with window allowing x
egress from building
(d) Ceiling at least 90 inches x
(e) Minimum 60 SF per bed x
(f) No more than 25 if dorm style x
(g) Permanently wired fixtures x
(h) Window covering x
(i) Beds are 3 feet apart and maintained to x
ensure safety
Room and Space Requirements Corrective Action
Yes No N/A Corrective Actions/Comments
Bathrooms 413-215-0516(4) Completed
(a)(A)&(B) 1:8 ratio for toilets and sinks x
(a)(D) Hot and cold running water, soap, and x
approved hand drying options
(a)(E) 1:10 ratio for shower or bathtub x
(a)(E) Individual privacy x
(a)(F) Window covering x
(a)(G) Permanently wired fixtures x
(a)(H) Adequate ventilation x
(b)&(c) Wooden racks on floors are x
prohibited and impervious shower mats are
disinfected & dried daily
Room and Space Requirements Corrective Action
Yes No N/A Corrective Actions/Comments
Kitchen 413-215-0516(6) Completed
(a) Used exclusively for storage, food x
preparation, dish washing and activities
related to eating
(b) Walls, floors are easily cleanable x
(c) Equipment and utensils are easily x
cleanable, durable, nontoxic, and kept clean
6
(e) Equipment is easy to clean beneath, x
between and behind
Room and Space Requirements Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0516 Completed
(2) There is a separate living room or lounge x
area – 15 SF minimum per child
(5) There is a separate dining room with x
capacity for ½ of children in care and 15 SF
per child in care
(7) Laundry is separate from living areas, x
kitchen and dining
(8) Separate storage areas are provided for x
food, kitchen supplies, utensils, clean linens,
soiled linens and clothing, cleaning supplies
and equip, poisons, chemicals, outdoor
recreational and maintenance equipment
(9) Outdoor activity area is protected from x
vehicles and other hazards and of a size and
availability appropriate to the age and needs
of children in care
(11) & 413-215-0076(3)(c)(C)Time out rooms x
have adequate space, heat, light and
ventilation and is not capable of locking
Furnishings and Personal Items Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0521 Completed
(1) There is a bed with frame, clean mattress x
and pillow and personal storage (dresser,
closet)
(2) Linens are in good repair. There is a x
waterproof mattress cover or mattress.
Linens are appropriate and towels and
washcloths are provided
(3) Bedding is changed weekly or when x
soiled
(4)&(5) Personal hygiene supplies and x
appropriate clothing are provided
Food Services Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0536(1)&(2) Completed
(1)(a) Meals are arranged daily, consistent x  Currently menus are not being kept for 6 months.
with normal mealtimes that occur during the
hours of operation
(1)(b) Menus are prepared in advance in x
accordance with USDA guidelines, provide a
variety of foods and are adjusted for
seasonal changes.
7
(1)(b) Menus are kept for at least 6 months x
(1)(c) Drinking water is freely available x
(2)(a) Food is stored, prepared & served in a x
sanitary manner
(2)(c) & (d) Food products are obtained from x
commercial suppliers (exception of fruits &
vegetables), unpasteurized juice is
prohibited, and only Grade A pasteurized
and fortified milk in appropriate container.
Safety Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0541 Completed
(2)(a) Written emergency plan x
(2)(b) Telephone numbers for local police x
and fire are posted near all telephones
(2)(c) Operative flashlights sufficient in x
number are readily available to staff
(3)(a) Evacuation drill occurs monthly under x
varying conditions, is retained 2 yrs and
contains;
(A) identify of person conducting drill
(B) date & time
(C) notification method
(D) staff participating
(E) # of children & staff evacuated
(F) special conditions simulated
(G) problems encountered
(H) time to complete
Safety – Transportation Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0541 Completed
(5)(b) Vehicle has insurance policy, is smoke x
free, safe operating condition, and has first
aid kit and fire extinguisher 2-A:10-BC
Medication Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0551 Completed
(3)&(7)(e) Medications have a prescription x
and are stored in the original container with
prescription label
(4)&(5) Herbal supplements and remedies, x
medical treatments, special diets, physical
therapy, physical aides or limitations have a
written order signed by a physician or
qualified medical professional.
(7)(c) Medications are inaccessible to x
children
8
(8) Medications are disposed in accordance x
with state and federal law
(9) Written record of the disposal of x
medications is maintained and includes:
(a) description and amount
(b) name
(c) reason
(d) method
(e) staff & witness signature
(10) Written record of the administration of x
medication includes:
(a) name
(b) description
(c) dates and times
(d) missed doses
(e) medication disposed
(f) method of administration
(g) ID of person administering
(h) possible adverse reactions
(i) medication taken outside facility
Extracurricular, Enrichment, Cultural &
Corrective Action
Social Activities Yes No N/A Corrective Actions/Comments
Completed
413-215-0554
(2) Children have ongoing opportunities to x
participate in at least one age-appropriate or
developmentally appropriate activity
Minimum Staffing Requirements Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0561 Completed
(1)&(2) Supervision is adequate for the type x
of program, location, age and type of
children, ability of supervisor to respond,
electronic back-up systems.
Minimum ratios are maintained:
Under 30 months of age: 1:4
30 months to ˃ 6 yrs or non-ambulatory: 1:6
Ages 6 and older: 1:7
Overnight (staff awake)
1:10
(4)(a) When one staff on duty, there is x
additional staff immediately available with
max response time of 30 minutes
9
(5) There is at least one on-site employee x
authorized to apply the reasonable and
prudent parent standard
Separation of Residents Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0566 Completed
(1) Children are in separate bedrooms than x
adults, unless parent and child, or there is
written approval from guardian/parent and
licensing coordinator
(2) There is adequate supervision of children x
if both males and females are served by the
program
Personnel Files Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0061 Completed
Staff Name/Position
(3)(g) Date of Hire x
(3)(a) record of education, training and
x
previous employment
(1)(b) & (3)(b) reference checks completed
x
and documented
(1)(a) & (3)(c) Background check completed
x
and documented
(3)(d) Annual performance evaluations x
(3)(f) Record of personnel actions x
(3)(g) Termination date, reason for
x
termination
(3)(h) Current job description (1)(c)
Employee meets minimum qualifications x
stated in current job description
New Employee Orientation – Umbrella
Corrective Action
Requirements (30 days) Yes No N/A Corrective Actions/Comments
Completed
413-215-0061(4)
(a) Agency policies and procedures x
(b) Ethical and professional guidelines x
(c) Organizational lines of authority x  Reviewer unable to see evidence of these required
(d) Attributes of population served x trainings occurring within 30 days of hire.
(e) & (5)(a) to (c) Mandatory reporting that
x
includes:
10
(a) legal definition of child abuse ORS
419B.005, Oregon Laws 2016, chapter 106,
section 36
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to
the employee
(f) Privacy laws x
(g) Emergency procedures x
New Employee Orientation – Residential
Corrective Action
(30 days) Yes No N/A Corrective Actions/Comments
Completed
413-215-0556
(1)(a) Discipline and behavior management
including de-escalation, crisis prevention,
positive behavior management, and x  Reviewer unable to see evidence of these required
disciplinary techniques that are non-punitive
trainings occurring within 30 days of hire.
in nature
(1)(b) Restraint and seclusion (if applicable) x
Ongoing Training Corrective Action
Yes No N/A Corrective Actions/Comments
Completed
413-215-0536(2)(b) Employees who handle x  Since the pandemic program reports they have
food served to children have a valid food found it difficult in conducting CPR training.
handler’s card
413-215-0541(5)(a) Employees transporting
children have: current driver’s license,
insurance, trained in emergency procedures x
and behavior management, and training for
15+ passenger vans if applicable)
413-215-0556(2)(a) Environmental
x
emergencies
413-215-0556(2)(b) Universal Precautions x
413-215-0556(2)(c) Discipline and Behavior
x
Management
413-215-0556(3) Staff providing direct care
must maintain current CPR/First Aid x
certification
413-215-0556(4) Designated staff authorized
to apply reasonable and prudent parent
x
standard are trained in application of the
standard
413-215-0061(5) Mandatory reporting
x
(annually) that includes:
11
(a) legal definition of child abuse ORS
419B.005, Oregon Laws 2016, chapter 106,
section 36
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to
the employee
Comments:
Children’s Records Corrective Action
Yes No N/A Corrective Actions/Comments
Completed
Health Services
413-215-0546
(2) Medical history obtained within 30 days
(significant findings, current immunizations,
history of surgical procedures-health issues- x
injuries, allergies, dental, vision, hearing,
behavioral health, and physician orders)
(2)(e) Documentation of age appropriate
instruction – pregnancy prevention, nutrition,
prevention of HIV & AIDS, and prevention x
and treatment of sexually transmitted
disease
(4)(a) to (f) Medical exams (3 in first year of
life, 2,4,6,9,14) x
Consents Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0576(1) Completed
12
(a) Provide routine and emergency medical
x
care
(b) Use the discipline and behavior
x
management system
(c) Use restraint or seclusion (if applicable).
Must specify the reasons for the intervention x
and how staff are trained and supervised  Consents had section on recreation and activities
however were missing any reference to the
(d) Restrict contact with persons outside of
x reasonable and prudent parent standard.
the agency
(e) Allow access as defined in 413-215-0091
x
& 0101
(f) Impose a dress code x
(g) Apply the reasonable and prudent parent
x
standard
Disclosures
Corrective Action
413-215-0576(2) Parent/guardian has Yes No N/A Corrective Actions/Comments
Completed
acknowledged in writing:
(a) Information regarding personal or room
searches and protocols for confiscation of x
contraband
(b) Statement of Rights of Children and
x
Parents/Guardians
(c) Any policies and procedures upon
x
request
Authorizations Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0576(3) Completed
(a) Disclose or exchange information with
x
others
(b) Child specific visitors x
(c) Visitation resources are pre-approved x
(d) Activity specific authorizations are pre-
approved to allow children to participate in
potentially hazardous activities, including but x
not limited to using motorized yard
equipment, swimming, and horseback riding.
Information about Children in Care
Corrective Action
413-215-0581(1) Summary sheet contains Yes No N/A Corrective Actions/Comments
Completed
the following:
(a)The name, gender, date of birth, religious
x
preference, and previous address
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(b) Name and location of previous and
x
current school
(c) Date of admission x
(d) Legal custody x
(e) The name, address, and telephone
number of:
(A) The child in care's parents.
(B) The child in care's legal guardian, if
different than the parents, and a copy of
x
the document that provides for his or her
authority over the child in care.
(C) Other persons significant to child
(D) Other professionals to be involved in
service planning (if applicable)
Service Planning Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0581(2) Completed
(b) Intake document is completed the date
child accepted into care (emergency x
placement 48 hours)
(d) Assessment is completed within 30 days
and contains relevant historical info., current
behavioral observations, identified need for x
services, and how agency will provide
services
(e) (A)&(B) Service plan within 60 days
(parent, guardian and child actively
involved). Describes how child’s issues will x
be addressed, anticipated outcomes and
reviewed by child and guardian/parent.
(e)(C)&(D) Service plan is reviewed quarterly
and revised when information indicates other x
services should be provided
Case Management Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0581(3) Completed
(a) Services are documented, progress
x
toward achieving goals is tracked
(b)-(d) discharge planning and instructions x
(f) Incident Reports x
Financial Records Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0581(4) Completed
14
Records contain date, amount, source,
x
purpose, signatures
Personal Possessions Records Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0581(5) Completed
Individual written inventory of all personal
possessions is maintained and updated as x
needed
Records and Documentation Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0071 Completed
(1) Stored safely x
(2) Permanent, legible, dated, and signed x
(3)&(4) Uniform in organization, readily
identifiable and accessible, current, and
x
complete, containing all required info. No
eraser tape or white out.
(7) Permanent registry for each child
includes:
Name
Gender
Birth date
Names, addresses of parents or guardians
Dates of admission
Placement upon discharge
Comments:
Licensing Coordinator’s Signature: ________________________ Date: ____3_/_1_0_/2_2__________
Manager Review: ______________________________________ Date: _0_3_-1_0_-_2_0_2_2_ ________
15

report_type: License Renewals

facility_type: Residential Care

visit_date: March 9th, 2022

other_regulatory_agencies: Oregon Youth Authority (OYA)

program_description:
Klamath County reports the following program description for Crimson Rose:
"The Klamath Crimson Rose (KCR) serves females, ages 12-20, in need of behavioral stabilization services and provides Individualized Treatment
Plans to these youth while also keeping them connected to their community support networks and families. The program provides an environment
for youth, who are struggling to maintain in the community or community placement, to receive services aimed at developing personal responsibility,
and appropriate and assertive behavioral skills development.
KCR is a culturally sensitive, intensive, trauma informed program that targets behaviors intended to improve psychosocial and behavioral
functioning for the participants. This program will provide youth with an array of rehabilitation services appropriate to meet their unique and
individualized needs and goals as defined in their assessment and ISSP. Daily services encourage, support and reinforce appropriate behaviors
using evidence-based methods as documented in the individual's treatment plan. The Program will provide a minimum of 13 hours of individual and
group counseling in an environment for change, targeting behaviors such as substance use, thinking errors, anger management, and other
behaviors that have hindered their success thus far. The minimum 13 hours will include at least 2 hours of individual counseling, 10 hours of group
counseling and skill building, 1 hour of consultation, and 1 hour of family counseling or parent education when appropriate. The evidence-based
curriculum and screening tools are through Texas Christian University (TCU) and Change Companies, Forward Thinking and Voices curriculum.
TCU Mapping-Enhanced Counseling has been chosen as a treatment modality due to the continued and overwhelming evidence on the
effectiveness in increasing client motivation, engagement, participation, and retention in treatment. This cognitive-behavioral therapy utilizes node-
link mapping as a visual tool to enhance a heightened level of awareness for an individual's thoughts, feelings, and actions improving the
psychosocial and behavioral functioning of an adolescent upon completion of the program. Forward Thinking and Voices are also evidence-based
CBT curriculum used in KCR and many other programs around the country.
Program also partners with Klamath Basin Behavioral Health to provide additional mental health services such as, Mental Health assessments,
appropriate risk assessments and behavioral skills building. Cascades East Family Practice and a contracted Family Nurse Practitioner also
provide medical support to the program.
Academically, client records are requested from prior schools to obtain the most current transcripts. Clients are enrolled in online courses using
Odysseyware to fulfill credits toward their graduation requirements. Official GED pre-testing and official testing is available to those students who

are working toward their GED. Middle school students and those needing remedial work are offered Let's Go Learn, a program to strengthen math
and reading skills. Students are in class three hours each school day with teachers available to help and guide them through the process."

program_services: Residential Care / Behavioral Health - BRS Level 5

funding_sources: Oregon Youth Authority (OYA) - Behavior Rehabilitation Services (BRS)

contracts_and_referrals: Oregon Youth Authority (OYA)

average_length_of_stay: 90 days

interviews_observations:
I interviewed two clients separately in the visitation area of Crimson Rose to ensure privacy. When asked how Klamath
County Juvenile Department - Crimson Rose ranks on a scale from (0-10 where 0=worst program and 10=best program), the client's reported
program to be an 8 and 8.5 on that scale. Client's reported learning the following skills at Crimson Rose: regulate emotions, coping skills, learned
their triggers, communication skills, and healthy boundaries. Both clients were able to discuss their treatment goals and discharge placement plans.
Both clients reported attending multiple treatment groups a day and reported meeting with therapist individually. Drug and alcohol services are
provided by Klamath Basin Behavioral Health. Clients reported feeling safe in the program and reported food to be good. Outings were reported to
include parks, hiking, bowling, and movies. Both client's reported enjoying self-care night. The youth reported self-care nigh includes mud/clay
masks, soak feet in Epsom salts, and braiding hair. Youth reported being respected by program staff and identified liking their case manager.
Crimson Rose continues to make their space feel less institutional. Achievements such as program graduation, attaining a GED, or High School
diploma are recognized by youth having their name on the wall and being allowed to paint on the wall as well. Facility was clean. Currently
construction is occurring around the Juvenile Detention building in creating new road, parking, and leveling areas for future development. Lottery
dollars were attained for building an education center, kitchen, new independent program (house like setting), and possibly a transition program as
well. Space has been created for a possible solar field and this, coupled with preexisting geothermal program, would make the site energy
independent.
2

program_strengths:
Crimson Rose reports, "Program provides a continuum of behavioral health care services to up to nine Oregon Youth
Authority female clients. Clients can be on probation or parole and in need of diversion from the correctional facility or general behavioral
stabilization. Program provides safety, security, structure, and treatment unavailable in lower levels of care."

program_challenges:
Crimson Rose reports, "Program has recently had some minor issues maintaining quality staff due to the pandemic at
times."

changes_in_last_two_years: Crimson Rose reports, "Hired three full time direct care staff."

lawsuits: Crimson Rose reports no lawsuits.

grievances_and_complaints:
Crimson Rose reports no formal grievances in last two years. Program Director Steve
Quick has followed up on 57 complaints from youth over the last two years. Steve reports the nature of these complaints are typically a complaint
about another youth's behavior. Steve reports he will follow up on these complaints and talk to youth, staff, and work out a resolution regarding the
matter. Crimson Rose reports of these 57 complaints zero have escalated to a formal grievance.

changes_in_license:
N/A
3

excerpt: (3)(g) Approval from BCU

excerpt:
(a) Agency policies and procedures  Reviewer unable to see evidence of these required
trainings occurring within 30 days of hire.

excerpt: (b) Ethical and professional guidelines

excerpt: (c) Organizational lines of authority

excerpt: (d) Attributes of population served

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

excerpt: (f) Privacy laws

excerpt: (g) Emergency procedures

excerpt:
(1)(a) Discipline and behavior management
including de-escalation, crisis prevention,
positive behavior management, and
disciplinary techniques that are non-punitive
in nature  Reviewer unable to see evidence of these required
trainings occurring within 30 days of hire.

excerpt:
Environmental
emergencies

excerpt: Universal Precautions

excerpt:
Staff providing direct care
must maintain current CPR/First Aid
certification  Consents had section on recreation and activities
however were missing any reference to the
reasonable and prudent parent standard.

excerpt:
(g) Apply the reasonable and prudent parent
standard


state: OR

facility_name: Crimson Rose

summary: Unannounced - 8 findings

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Licensee: Klamath County Juvenile Department, Crimson Rose
Executive Director: Dan Golden
Program Director(s): Steve Quick
Date of Unannounced: 9-07-22
Licensing Coordinator: Ed Wyller
Other Regulatory or Accrediting Agencies: Oregon Youth Authority (OYA)
Purpose: Per OAR 413-215-0101 (1) (b) Children’s Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Comments
Findings
Further Action
Needed
Executive Director or Program Director Yes☐ No On 3-16-22 Dan Golden was approved by BCU.
413-215-0021 (3)(g) Approval from BCU
Missing Dan Golden’s Background Check
Food Services 413-215-0536(1)&(2) Yes☐ No Ed Wyller verified on site menus dating back to March 2022. Crimson Rose program has
(1)(b) Menus are kept for at least 6 months implemented process for keeping menus.
Currently menus are not being kept for 6
months
New Employee Orientation – Umbrella Yes☐ No Crimson Rose has not had new staff to verify training. Ed Wyller reviewed the training
Requirements (30 days) checklist for first 30 days and checklist now has the required trainings that are
413-215-0061(4) requirements by CCLP.
(a) Agency policies and procedures
(b) Ethical and professional guidelines
(c) Organizational lines of authority
(d) Attributes of population served
(e) & (5)(a) to (c) Mandatory reporting that
includes:
1
(rev. 200115)
(a) legal definition of child abuse ORS
419B.005, Oregon Laws 2016, chapter 106,
section 36
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to
the employee
(f) Privacy laws
(g) Emergency procedures
Reviewer unable to see evidence of these
required trainings occurring within 30 days of
hire.
New Employee Orientation – Residential Yes☐ No Crimson Rose has not had new staff to verify training. Ed Wyller reviewed the training
(30 days) 413-215-0556 checklist for first 30 days and checklist now has the required trainings that are
requirements by CCLP.
(1)(a) Discipline and behavior management
including de-escalation, crisis prevention,
positive behavior management, and
disciplinary techniques that are non-punitive in
nature
Reviewer unable to see evidence of these
required trainings occurring within 30 days of
hire.
Ongoing Training Yes☐ No Crimson Rose has completed these ongoing trainings through Relias and CPR through
413-215-0556(2)(a) Environmental local SkyLakes hospital, CPR cards through American Heart Association.
emergencies
413-215-0556(2)(b) Universal Precautions
413-215-0556(3) Staff providing direct care
must maintain current CPR/First Aid
certification
Since the pandemic program reports they
have found it difficult in conducting CPR
training.
Consents 413-215-0576(1) Yes☐ No Crimson Rose youth charts now contained signed prudent parent standard in consents
(g) Apply the reasonable and prudent parent section.
standard
Consents had section on recreation and
activities however were missing any reference
to the reasonable and prudent parent
standard.
(rev. 07/21/2022)
New Findings from Site Visit Comments
N/A No new findings, good work.
Interview Summary
I interviewed two youth separately in the front foyer where youth make private phone calls. Youth reported feeling safe in the program. One youth reported if
you file a grievance, Steve Quick will follow up immediately and “handle it”. One youth reported that staff treat us like humans and support us. On a scale
from 0-10 (0=worst program, 10=best program) youth reported Crimson Rose to be a 7, and 7.5. One of the youths reported feeling that the program will not
give up on you as they have been to Crimson Rose three times. Youth reported learning from the groups and “actually like groups”. When asked what they
have learned the following was reported as learnt at Crimson Rose: using coping skills, assertive communication, being more open minded, and not to engage
in drama. One youth reported the program being short is great as you learn skills and get to practice the skills in real life situations. Food was reported to be
“Amazing”, and another youth reported “alright”. The youth reported amazing only other program experience was a detention setting. Youth reported getting
plenty to eat and having a variety of food.
Youth reported the following community outings: library, parks, lakes, going to play video games in town, ice skating, and ice cream after outings. Reported
on-site activities playing cards, read, crochet, color, watching tv, and conversations with staff. Regarding school one youth reported working towards their
GED and how the program supports them on taking pretests and tests for the GED. Teachers were reported to be “super hands on and respectful.” Staff
make youth feel comfortable at Crimson Rose. The other youth reported, “Staff are good”. One youth reported Lisa Sparks as a great staff. When youth were
asked about if they had a magic wand and could change the program, they reported the following. “Maybe groups about independent living skills” and other
youth reported, “Change that program is not in a detention or Klamath Falls”. The youth was referring to the fact that the program is located in the same
building as the county’s juvenile detention facility.
Observations
During the tour I noted new gas stove and range. Program has added an air fryer. The classroom has a new indoor garden for student learning. When
speaking with staff I learned of a new practice of management spending 1-2 hours on site at the program in the evenings. This time is used to check in with
youth individually to reflect on how the youth is doing on their goals. Staff and youth reported this new practice to be positively impacting the program’s milieu.
Corrective Actions and Timeframes:
Good work no new findings and all previous findings have been addressed.
Licensing Coordinator’s Signature: ________________________ Date: _9_/2__2_/2_2_ ____________
Manager Review: ______________________________________ Date: __9_/2__0_/2_2_ __________
(rev. 07/21/2022)

agency_name: Klamath County Juvenile Department (KCJD)

program_name: Crimson Rose

program_type: (RC) Residential Care Programs

report_type: Unannounced

view_code: RC

executive_director: Dan Golden

program_director: Steve Quick

licensing_coordinator: Ed Wyller

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

interview_summary:
I interviewed two youth separately in the front foyer where youth make private phone calls. Youth reported feeling safe in the program. One youth reported if
you file a grievance, Steve Quick will follow up immediately and "handle it". One youth reported that staff treat us like humans and support us. On a scale
from 0-10 (0=worst program, 10=best program) youth reported Crimson Rose to be a 7, and 7.5. One of the youths reported feeling that the program will not
give up on you as they have been to Crimson Rose three times. Youth reported learning from the groups and "actually like groups". When asked what they
have learned the following was reported as learnt at Crimson Rose: using coping skills, assertive communication, being more open minded, and not to engage
in drama. One youth reported the program being short is great as you learn skills and get to practice the skills in real life situations. Food was reported to be
"Amazing", and another youth reported "alright". The youth reported amazing only other program experience was a detention setting. Youth reported getting
plenty to eat and having a variety of food.
Youth reported the following community outings: library, parks, lakes, going to play video games in town, ice skating, and ice cream after outings. Reported
on-site activities playing cards, read, crochet, color, watching tv, and conversations with staff. Regarding school one youth reported working towards their
GED and how the program supports them on taking pretests and tests for the GED. Teachers were reported to be "super hands on and respectful." Staff
make youth feel comfortable at Crimson Rose. The other youth reported, "Staff are good". One youth reported Lisa Sparks as a great staff. When youth were
asked about if they had a magic wand and could change the program, they reported the following. "Maybe groups about independent living skills" and other
youth reported, "Change that program is not in a detention or Klamath Falls". The youth was referring to the fact that the program is located in the same
building as the county's juvenile detention facility.

observations:
During the tour I noted new gas stove and range. Program has added an air fryer. The classroom has a new indoor garden for student learning. When
speaking with staff I learned of a new practice of management spending 1-2 hours on site at the program in the evenings. This time is used to check in with
youth individually to reflect on how the youth is doing on their goals. Staff and youth reported this new practice to be positively impacting the program's milieu.

previous_findings:
Repeat Comments
Findings
Further Action
Needed
Executive Director or Program Director Yes[ ] No On 3-16-22 Dan Golden was approved by BCU.
413-215-0021 (3)(g) Approval from BCU
Missing Dan Golden's Background Check
Food Services 413-215-0536(1)&(2) Yes[ ] No Ed Wyller verified on site menus dating back to March 2022. Crimson Rose program has
(1)(b) Menus are kept for at least 6 months implemented process for keeping menus.
Currently menus are not being kept for 6
months
New Employee Orientation - Umbrella Yes[ ] No Crimson Rose has not had new staff to verify training. Ed Wyller reviewed the training
Requirements (30 days) checklist for first 30 days and checklist now has the required trainings that are
413-215-0061(4) requirements by CCLP.
(a) Agency policies and procedures
(b) Ethical and professional guidelines
(c) Organizational lines of authority
(d) Attributes of population served
(e) & (5)(a) to (c) Mandatory reporting that
includes:
1

(a) legal definition of child abuse ORS
419B.005, Oregon Laws 2016, chapter 106,
section 36
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to
the employee
(f) Privacy laws
(g) Emergency procedures
Reviewer unable to see evidence of these
required trainings occurring within 30 days of
hire.
New Employee Orientation - Residential Yes[ ] No Crimson Rose has not had new staff to verify training. Ed Wyller reviewed the training
(30 days) 413-215-0556 checklist for first 30 days and checklist now has the required trainings that are
requirements by CCLP.
(1)(a) Discipline and behavior management
including de-escalation, crisis prevention,
positive behavior management, and
disciplinary techniques that are non-punitive in
nature
Reviewer unable to see evidence of these
required trainings occurring within 30 days of
hire.
Ongoing Training Yes[ ] No Crimson Rose has completed these ongoing trainings through Relias and CPR through
413-215-0556(2)(a) Environmental local SkyLakes hospital, CPR cards through American Heart Association.
emergencies
413-215-0556(2)(b) Universal Precautions
413-215-0556(3) Staff providing direct care
must maintain current CPR/First Aid
certification
Since the pandemic program reports they
have found it difficult in conducting CPR
training.
Consents 413-215-0576(1) Yes[ ] No Crimson Rose youth charts now contained signed prudent parent standard in consents
(g) Apply the reasonable and prudent parent section.
standard
Consents had section on recreation and
activities however were missing any reference
to the reasonable and prudent parent
standard.

New Findings from Site Visit Comments
N/A No new findings, good work.

new_findings: N/A No new findings, good work.

excerpt:
413-215-0576(1) Yes[ ] No Crimson Rose youth charts now contained signed prudent parent standard in consents
(g) Apply the reasonable and prudent parent section.
standard
Consents had section on recreation and
activities however were missing any reference
to the reasonable and prudent parent
standard.
New Findings from Site Visit Comments
N/A No new findings, good work.
N/A No new findings, good work.


summary: Unannounced - 03/21/2023

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Residential Care
Licensee: Klamath County Juvenile Department, Crimson Rose
Executive Director: Dan Golden
Program Director(s): Steve Quick
Date of Unannounced: March 21st, 2023
Licensing Coordinator: Ed Wyller, Jorge Pelinski assisted
Other Regulatory or Accrediting Agencies: Oregon Youth Authority (OYA)
Purpose: Per OAR 419-400-0240 (1)(b) Children’s Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Comments
09/07/2022 Unannounced Site Visit – Findings
No Findings Further Action
Needed
Yes☐ No☐
Yes☐ No☐
New Findings from Site Visit Comments
No new findings Good work!
1 |P ag e
Form Rev. 01/23/2023
Interview Summary
Two youth from Crimson Rose were interviewed individually in the visitation room without staff present. On a scale from 0-10 (0=worst program, 10=best
program) youth reported Crimson Rose to be an 8 and 8.5 on that scale. Both youths reported feeling safe in the program and the food to be good. One
youth reported program to be “really helpful, and staff do care”. Youths reported learning self-esteem, coping with anger, coping skills, and reported attending
drug and alcohol groups. Youth reported having treatment binders and attending groups and individual counseling. Youth reported these to be helpful. Youth
appreciated the school and reported that they are involved in credit recovery and feel successful in the school. Both youths reported Lisa Sparks as doing a
lot for them and being caring. Staff members and case managers were described as people that could be trusted. Youth reported in the past two weeks they
went to a local Shakespearian play, movies, and walks. Youth reported having access to family and friends though daily phone calls, zoom calls and visits on
weekends. When asked if given a magic wand to change something at Crimson Rose one youth reported eating on regular plates instead of food trays would
be preferable. The other youth reported if you have a book in a series, please have the complete series available.
Observations
I observed Crimson Rose to be clean, organized, and all youth bedrooms to clean. Crimson Rose continues to make the living space feel welcoming. I
observed the youth in school and interacting positively with the teacher and the staff in the classroom. I observed a youth going with a staff member to a
doctor’s appointment. Staff members talked about youth successfully graduating from the program and the school as well.
At the conclusion of visit I met with part of the treatment team and Juvenile Department Director Dan Golden. I reviewed the plans for the new program and
Crimson Rose’s plans for building a new program building with a dedicated indoor garden, vocational/ educational building, and a transitional program. Plans
include the use of geothermal and solar energy.
Corrective Actions and Timeframes:
Please submit the following to verify compliance. (Not required – No findings to follow up on)
Within 45 days of receipt of this report Klamath County Juvenile Department – Crimson Rose 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 Ed Wyller Edward.Wyller@dhsoha.state.or.us
Licensing Coordinator’s Signature: ________________________ Date: ____4_/_4_/2_3___________
Manager Review: ______________________________________ Date: _3_-2_7-_2_02_3_ ___________
2 | P a g e
Form Rev. 01/23/2023

visit_date: March 21st, 2023

licensing_coordinator: Ed Wyller, Jorge Pelinski assisted

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
09/07/2022 Unannounced Site Visit - Findings
No Findings Further Action
Needed
Yes[ ] No[ ]
Yes[ ] No[ ]
New Findings from Site Visit Comments
No new findings Good work!

Interview Summary
Two youth from Crimson Rose were interviewed individually in the visitation room without staff present. On a scale from 0-10 (0=worst program, 10=best
program) youth reported Crimson Rose to be an 8 and 8.5 on that scale. Both youths reported feeling safe in the program and the food to be good. One
youth reported program to be "really helpful, and staff do care". Youths reported learning self-esteem, coping with anger, coping skills, and reported attending
drug and alcohol groups. Youth reported having treatment binders and attending groups and individual counseling. Youth reported these to be helpful. Youth
appreciated the school and reported that they are involved in credit recovery and feel successful in the school. Both youths reported Lisa Sparks as doing a
lot for them and being caring. Staff members and case managers were described as people that could be trusted. Youth reported in the past two weeks they
went to a local Shakespearian play, movies, and walks. Youth reported having access to family and friends though daily phone calls, zoom calls and visits on
weekends. When asked if given a magic wand to change something at Crimson Rose one youth reported eating on regular plates instead of food trays would
be preferable. The other youth reported if you have a book in a series, please have the complete series available.
Observations
I observed Crimson Rose to be clean, organized, and all youth bedrooms to clean. Crimson Rose continues to make the living space feel welcoming. I
observed the youth in school and interacting positively with the teacher and the staff in the classroom. I observed a youth going with a staff member to a
doctor's appointment. Staff members talked about youth successfully graduating from the program and the school as well.
At the conclusion of visit I met with part of the treatment team and Juvenile Department Director Dan Golden. I reviewed the plans for the new program and
Crimson Rose's plans for building a new program building with a dedicated indoor garden, vocational/ educational building, and a transitional program. Plans
include the use of geothermal and solar energy.

new_findings: No new findings Good work!


summary: License Renewals - 6 findings

raw_content:
Licensed Child Caring Agency Site Visit Report
Residential Care
Licensee: Klamath County Juvenile Department – Crimson Rose Date of site visit: February 7th, 2024
Executive Director: Dan Golden Licensing Coordinator: Ed Wyller
Other Regulatory or Accrediting Agencies: Oregon Youth Authority (OYA)
Program Compliance: The program was found to be compliant or will be compliant with OAR 419-400-0005 to 419-400-0310, Licensing Umbrella
Rules, and OAR 419-470-0010 to 419-470-0180, Licensing Residential Care Agencies Rules. Personnel records were reviewed and compliance
with required background checks was documented for employees in all programs.
Program Description(s): Crimson Rose reports, “The Klamath Crimson Rose (KCR) serves females, ages 12-20, in need of behavioral
stabilization services and provides Individualized Treatment Plans to these youth while also keeping them connected to their community support
networks and families. The program provides an environment for youth, who are struggling to maintain in the community or community placement,
to receive services aimed at developing personal responsibility, and appropriate and assertive behavioral skills development.
KCR is a culturally sensitive, intensive, trauma informed program that targets behaviors intended to improve psychosocial and behavioral
functioning for the participants. This program will provide youth with an array of rehabilitation services appropriate to meet their unique and
individualized needs and goals as defined in their assessment and Individual Service and Supports Plan (ISSP). Daily services encourage, support
and reinforce appropriate behaviors using evidence-based methods as documented in the individual’s treatment plan. The Program will provide a
minimum of 13 hours of individual and group counseling in an environment for change, targeting behaviors such as substance use, thinking errors,
anger management, and other behaviors that have hindered their success thus far. The minimum 13 hours will include at least 2 hours of individual
counseling, 10 hours of group counseling and skill building, 1 hour of consultation, and 1 hour of family counseling or parent education when
appropriate. The evidence-based curriculum and screening tools are through Texas Christian University (TCU) and Change Companies, Forward
Thinking and Voices curriculum.
TCU Mapping-Enhanced Counseling has been chosen as a treatment modality due to the continued and overwhelming evidence on the
effectiveness in increasing client motivation, engagement, participation, and retention in treatment. This cognitive-behavioral therapy utilizes node-
link mapping as a visual tool to enhance a heightened level of awareness for an individual’s thoughts, feelings, and actions improving the
psychosocial and behavioral functioning of an adolescent upon completion of the program. Forward Thinking and Voices are also evidence-based
Cognitive Behavioral Therapy (CBT) curriculums used in KCR and many other programs around the country.
Program also partners with Klamath Basin Behavioral Health to provide additional mental health services such as, Mental Health assessments,
appropriate risk assessments and behavioral skills building. Cascades East Family Practice Clinic, a Family Nurse Practitioner, and Registered
Nurse also provide medical support to the program.
Academically, client records are requested from prior schools to obtain the most current transcripts. Clients are enrolled in online courses using
Odysseyware to fulfill credits toward their graduation requirements. Official GED pre-testing and official testing is available to those students who
are working toward their GED. Middle school students and those needing remedial work are offered Let’s Go Learn, a program to strengthen math
and reading skills. Students are in class three hours each school day with educators available to help and guide them through the process.”
P age 1 | 18
Form Rev. 1/2/2024
Program type and services: Residential Care / Behavior Rehabilitation Services - BRS Level 5
Capacity and Age Range: 9 / ages 12-20
Funding sources: Oregon Youth Authority (OYA) – Behavior Rehabilitation Services (BRS)
Contracts and sources for referrals: Oregon Youth Authority (OYA)
Average length of stay: 90 days
Average daily population served: 6
Number of children served annually: 40-50
Use of seclusion or restraint: N/A
Interviews, Observations: I interviewed two clients separately in the visitation area of Crimson Rose to ensure privacy. When asked how Klamath
County Juvenile Department – Crimson Rose ranks on a scale from (0-10 where 0=worst program and 10=best program), the client’s reported
program to be a 7.8 and a 9 on that scale. Both clients report the food to be “good” and “pretty darn good”. The client’s reported the program to be
clean and that they feel safe. Both reported feeling staff treat them with respect. One client reported, “Staff are very caring and kind”. Clients were
able to discuss their treatment goals and discharge placement plans. Client’s shared learning the following at Crimson Rose: how to regulate
emotions, drug, and alcohol – relapse prevention planning, DBT skills, effects of drugs, and coping skills. Clients spoke positively regarding the on-
site school. One client spoke about working towards their high school diploma. Clients reported going on the following community outings: theater,
movies, museums, park, and library. When asked if given a magic wand and could improve the program within reason what would you do. One
client reported going to Narcotics Anonymous / Church. The other client reported having the ability to listen to MP3 players in their room.
I spoke with Crimson Rose staff that were working for the day. All had positive things to report about working at Crimson Rose and enjoying
working with the clients and OYA. Many shared success stories of clients. Many of the staff have worked since the opening of Crimson Rose. All
reported excitement about the new building being built.
I observed staff interacting with the clients in a positive and supportive manner. I witnessed two intakes and the work of making the new clients feel
welcomed and putting their fears at ease. I observed the building to be clean and orderly. Crimson Rose continues to make their space feel less
institutional, such as allowing clients to personalize their bedrooms. Currently site prep has been completed for the new program and solar field.
This site will be energy independent with the use of its existing geothermal and the new on-site solar field.
P age 2 | 18
Form Rev. 1/2/2024
Program Strengths: Crimson Rose reports, “Program provides a continuum of behavioral health care services to up to nine Oregon Youth
Authority female clients. Clients can be on probation or parole and in need of diversion from the Oregon Youth Authority correctional facility or
general behavioral stabilization. Program provides safety, security, structure, and treatment unavailable in lower levels of care. Program also
boasts a strong academic program, which provides youth with strong credit make up and frequently graduates clients from high school.”
Program Challenges: Crimson Rose reports, “Program has had some issues maintaining quality staff at appropriate levels at times. Because of
new construction we have had to move the kitchen into the part of the facility that was built to be the classroom, so the clients are temporarily
attending school in the pod. KCR is currently recruiting a new case manager position and additional direct care staff made possible by the fee
increase granted by the Oregon legislature.”
Changes that have occurred in the last 2 years: Crimson Rose reports, “Klamath County Juvenile Department has started construction on a new
facility which will house the Klamath Crimson Rose program. When completed, the pod that is currently being used will be re-purposed. KCR
clients will move into the new facility with a new home-like setting, new school program classroom and arts room, indoor garden, new food service,
and recreational areas.”
Lawsuits: Crimson Rose reports no lawsuits.
Grievances and complaints filed in the last two years: Crimson Rose reports no formal grievances in that last two years. Crimson Rose did
report handling 33 complaints and all were resolved and did not escalate to a formal grievance.
Corrective Actions and Timeframes: Please submit the following to verify compliance.
Within 45 days of receipt of this report Klamath County Juvenile Department – Crimson Rose 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 Ed Wyller at edward.wyller@odhsoha.orgenon.gov.
Exceptions: N/A
Changes in License: Please update age range on license to 12-20 instead of the 14-20 years. Please update the street address of Vandenburg
to its’ correct spelling of Vandenberg.
P age 3 | 18
Form Rev. 1/2/2024
Summary of Review
Program and Services
Yes No N/A Corrective Actions/Comments
419-400-0020 (2)
Program and services are in scope of license x
Governance of the Agency
Yes No N/A Corrective Actions/Comments
419-400-0040
(1)(a) Minimum of 5 board members • Klamath County Juvenile Department does not have a board but is
x
governed by County Commissioners.
(2)(f) Formally evaluate the exec. Director’s
x • Finding: Missing Dan Golden’s 2023 performance evaluation
performance annually
(2)(g) Approves annual budget x
(2)(h) Obtain and review an annual
independent financial review or audit of x
financial records.
(2)(k) Written quality improvement program x
(2)(l) Meeting minutes x
Executive Director or Program Director
Yes No N/A Corrective Actions/Comments
419-400-0040
(3)(a) knowledge of requirements for
providing care and treatment appropriate to x
programs
(3)(g) Approval from BCU • Finding: Missing Dan Golden’s and Steve Quick’s completed
x
background checks
Installation and Use of Video Equipment
Used to Monitor or Record Children in
Yes No N/A Corrective Actions/Comments
Care
419-400-0145
(1) If a child-caring agency installs video
equipment to monitor or record a child in
care, all employees, volunteers, parents or • Finding: Crimson Rose does have video equipment and was missing this
x
guardians, and children in care must be new requirement.
informed about the intended use and
locations of the equipment.
P age 4 | 18
Form Rev. 1/2/2024
Discipline, Behavior Management, and
Suicide Prevention Yes No N/A Corrective Actions/Comments
419-400-0150
(3) Agency uses appropriate and positive
methods of behavior management and
x
nationally recognized non-violent crisis
intervention
(3)(b)(C) Agency does not use chemical and
mechanical restraint (excluding medically x
necessary devices/prescriptions)
(3)(c) Agency uses appropriate time-out
rooms (adequate space, heat, light and
ventilation and is not capable of locking) and x
documents use in child’s record when
applicable
(3)(e) Agency uses seclusion
x
appropriately/consistent with policy
(4) Agency has adequate plan in place to
x
respond to suicidal behavior/warning signs
Contractors (if applicable)
Yes No N/A Corrective Actions/Comments
419-400-0120(6)
(a) Agency ensures the contractor meets the
requirements of this rule and Chapter 413 x
division 215
(b)(B) Contract includes the following:
(i) Services provided
(ii) Contractor fees
(iii) Disclosure of information from contractor
to agency
(iv) Lines of authority x
(v) Adherence to rules, including background
check
(vi) Any liability of the agency for acts of the
contractor, rights of indemnity and limitations
on liability
Restraints and Involuntary Seclusion
Yes No N/A Corrective Actions/Comments
419-400-0180
(13)(d) Each child caring agency that
submits a report under this section shall
make its quarterly report available to the
x
public upon request at the Child Caring
Agency’s main office and on the child caring
agency’s website if applicable.
Supplemental Information Provided by
Yes No N/A Corrective Actions/Comments
CCA
P age 5 | 18
Form Rev. 1/2/2024
Documents as indicated on the form titled
x
“Renewal Licensing Required Documents”
Documents as indicated on form titled
“Required Financial Documents and x
Information”
All required policies and procedures as • Finding: Crimson Rose is missing policy on Interstate Compact on the
identified in the “Umbrella Rules” Placement of Children (ICPC) see (ORS 417.200 to 417.260). Missing
x
policy for Indian Child Welfare Act (ICWA) and OAR chapter 419, Division
400
All required policies and procedures as
x
identified in “Agency Type Specific Rules”
Physical Plant
Yes No N/A Corrective Actions/Comments
419-400-0090(3)(a) Foster Rights Posted (if
x
children in DHS custody)
419-400-0100(1) Sufficient safe space,
x
equipment, and office equipment
419-400-0230(12) License is posted in
x
common area at each facility
419-470-0020(2)(a) &(c) Buildings are
x
smoke free, clean and in good repair
419-470-0020 (2)(d) Rooms are free of
x
harmful drafts, odors, and excessive noise
419-470-0020 (2)(e) Rooms are adequate in
x
size and arrangement
419-470-0020 (2)(f) System provides a
continuous supply of hot and cold water to x
taps located throughout the facility
419-470-0020 (2)(h) Building is well
ventilated and room temperature is within a x
normal comfort range
419-470-0030 (1) All parts of the facility
x
ensure the safety of children
Room and Space Requirements
Yes No N/A Corrective Actions/Comments
419-470-0030
(2) There is a separate living room or lounge x
area – 15 SF minimum per child
(5) There is a separate dining room with x
capacity for ½ of children in care and 15 SF
per child in care
(7) Laundry is separate from living, kitchen, x
and dining areas
(8) Separate storage areas are provided for x
food, kitchen supplies, utensils, clean linens,
soiled linens and clothing, cleaning supplies
P age 6 | 18
Form Rev. 1/2/2024
and equip, poisons, chemicals, outdoor
recreational and maintenance equipment.
(Hazardous materials are properly labeled, in
original container and locked)
(9) Outdoor activity area is protected from x • Observation: Crimson Rose is building a new facility and current outdoor
vehicles and other hazards and of a size and area is impacted by this construction. Youth visit nearby recreational
availability appropriate to the age and needs areas and have an indoor gym. Program continues daily walks around
of children in care the campus.
(11) Time-out rooms: Rooms used for time x
out or quiet time must have adequate space,
heat, light and ventilation and must not be
capable of locking.
Room and Space Requirements
Bedrooms Yes No N/A Corrective Actions/Comments
419-470-0030(3)
(a) Adequate furnishings and personal items x
(b) Separate from rooms used for dining,
x
living, laundry, kitchen, and storage
(c) Meet Oregon Fire Code Requirements x
(d) Be an outside room, with a window that
operates as designed. If the window is
modified from its original design, the fire
x
marshal must approve the modification and
indicate this room still meets applicable
Oregon Fire Code.
(d) Ceiling at least 90 inches x
(e) Minimum 60 SF per occupant x
(f) No more than 25 if dorm style x
(g) Permanently wired fixtures x
(h) Window covering x
Room and Space Requirements
Bathrooms Yes No N/A Corrective Actions/Comments
419-470-0030(4)
(a)(A)&(B) 1:8 ratio for toilets and sinks x
(a)(D) Hot and cold running water, soap, and
x
approved hand drying options
(a)(E) 1:10 ratio for shower or bathtub x
(a)(E) Individual privacy x
(a)(F) Window covering x
(a)(G) Permanently wired fixtures x
(a)(H) Adequate ventilation x
(b)&(c) Wooden racks on floors are
prohibited and impervious shower mats are
x
disinfected & dried daily be in good condition
and free of mold
P age 7 | 18
Form Rev. 1/2/2024
Room and Space Requirements
Kitchen Yes No N/A Corrective Actions/Comments
419-470-0030(6)
(a) Used exclusively for storage, food
preparation, dishwashing, and activities
x
related to eating and food preparation
activities
(b) Walls, floors are easily cleanable x
(c) Equipment and utensils are easily
x
cleanable, durable, nontoxic, and kept clean
(e) Equipment is easy to clean beneath,
x
between and behind
Furnishings and Personal Items
Yes No N/A Corrective Actions/Comments
419-470-0040
(1) There is a bed with frame, x
(1)(b) clean mattress in good condition,
x
with a minimum thickness of five inches
(1)(c) a pillow in good condition x
(1)(d) a private dresser, closet, or similar
storage area for personal belongings that x
is readily accessible
(2) Linens are in good repair. There is a
waterproof mattress cover or mattress.
x
Linens are appropriate and towels and
washcloths are provided
(3) Bedding is changed weekly or when
x
soiled
(4)&(5) Personal hygiene supplies and
x
appropriate clothing are provided
Food Services
Yes No N/A Corrective Actions/Comments
419-470-0070
(1)(a) Meals are arranged daily, consistent
with normal mealtimes that occur during the
x
hours of operation and provide snacks
between mealtimes
(1)(b) Menus are prepared in advance in
accordance with USDA guidelines, provide a
x
variety of foods and are adjusted for
seasonal changes including snacks
(1)(b) Menus are kept for at least 6 months x
(1)(c) Drinking water is freely available x
(2)(a) Food is stored, prepared & served in a
x
sanitary manner
P age 8 | 18
Form Rev. 1/2/2024
(2)(c) & (d) Food products are obtained from
commercial suppliers (exception of fruits &
vegetables), unpasteurized juice is x
prohibited, and only Grade A pasteurized
and fortified milk in appropriate container.
Residential Care Safety
Yes No N/A Corrective Actions/Comments
419-470-0080
(2) Written emergency plan that includes x
(a) Identifying the types of emergencies most
likely to happen where the residential care x
agency is located
(b) Identifying a place to meet for each type
x
of emergency identified
(c) Identifying an alternate shelter if
x
necessary
(d) Ensuring access to necessary
x
medications or medical equipment
(e) How to help each child in care recover
x
after a disaster
(3) Telephone numbers for local police, fire
department, poison control, after hours
medical advice and other appropriate x
emergency numbers must be posted near all
telephones.
(4) Operative flashlights sufficient in number
x
are readily available to staff
(5)(a) Evacuation drill occurs monthly under
varying conditions, is retained 2 years and
contains:
(A) identify of person conducting drill
(B) date & time
• Crimson Rose conducts 3 fire drills a month, one for each shift. Good
(C) notification method x
work!
(D) staff participating
(E) # of children & staff evacuated
(F) special conditions simulated
(G) problems encountered
(H) time to complete
Umbrella Safety
Yes No N/A Corrective Actions/Comments
419-400-0200
(5)(b) Vehicle has insurance policy, is smoke x
free, safe operating condition, and has first
aid kit and fire extinguisher 2-A:10-BC
(1)(b)(A) Each vehicle used to transport a x
child in care must be: properly registered,
P age 9 | 18
Form Rev. 1/2/2024
covered by an insurance policy in full force
and effect, maintained in safe operating
condition, and smoke-free.
(3) If a child-caring agency has a swimming x
pool on the premises that is accessible to
children in care or if a child-caring agency
plans to have children in care engage in
swimming, the child-caring agency must
have and adhere to policies and procedures
that address, at a minimum, providing
disclosures and obtaining consents,
assessing swimming ability of children in
care, and ensuring the safety of pool access.
(4)(a) The program protects children from x
potentially harmful items and materials.
(4)(b) Direct supervision of children who do x
not have the ability to adjust and control
water temperature
(4)(c) Light fixtures have protective covers x
unless designed to be used without one
Medication
Yes No N/A Corrective Actions/Comments
419-470-0100
(3)&(7)(e) Medications have a prescription
and are stored in the original container with x
prescription label
(4)&(5) Herbal supplements and remedies,
medical treatments, special diets, physical
therapy, physical aides or limitations have a
written order signed by a physician or
qualified medical professional. A written x
order, signed by a physician or qualified
medical professional, is also required before
a restriction on diet or physical activity is
imposed.
(7)(c) Medications are inaccessible to
children and stored behind at least two
x
locking mechanisms. This does not apply to
Naloxone.
(8) Medications are disposed in accordance
x
with state and federal law
(9) Written record of the disposal of
medications is maintained and includes:
(a) description and amount
x
(b) name
(c) reason
(d) method
P age 10 | 18
Form Rev. 1/2/2024
(e) staff & witness signature
(10) Written record of the administration of
medication includes:
(a) name
(b) description
(c) dates and times
(d) missed doses x
(e) medication disposed
(f) method of administration
(g) ID of person administering
(h) possible adverse reactions
(i) medication taken outside facility
Extracurricular, Enrichment, Cultural &
Social Activities Yes No N/A Corrective Actions/Comments
419-470-0110
(2) Children have ongoing opportunities to x
participate in at least one age-appropriate or
developmentally appropriate activity
Minimum Staffing Requirements
Yes No N/A Corrective Actions/Comments
419-470-0130
(1)&(2) Supervision is adequate for the type x
of program, location, age and type of
children, ability of supervisor to respond,
electronic back-up systems.
Minimum ratios are maintained:
Under 30 months of age: 1:4
30 months to ˃ 6 years or non-ambulatory:
1:6
Ages 6 and older: 1:7
Overnight (staff awake)
1:10
(4)(a) When one staff on duty, there is x
additional staff immediately available with
max response time of 30 minutes
(5) There is at least one on-site employee x
authorized to apply the reasonable and
prudent parent standard
Sleeping Arrangements
Yes No N/A Corrective Actions/Comments
419-470-0140
(1) Children are in separate bedrooms than x
adults, unless parent and child, or there is
written approval from guardian/parent and
licensing coordinator
P age 11 | 18
Form Rev. 1/2/2024
(2) There is adequate supervision of children x
when sleeping
(3) When assigning bedrooms a residential x
care agency must consider all of the
following:
(a) Chronological age
(b) Developmental age
(c) Gender identity
(d) Personal history, including medical,
mental health, behavioral health, and past
adverse experiences including any physical
or sexual abuse
Personnel Files
Yes No N/A Corrective Actions/Comments
419-400-0120
Staff Name/Position
(3)(g) Date of Hire x
(3)(a) record of education, training, and
x
previous employment
(1)(b) & (3)(b) reference checks completed
x
and documented
(1)(a) & (3)(c) Background check completed
x
and documented
(3)(d) Annual performance evaluations x • Finding: Employees were missing 2023 performance evaluations.
(3)(f) Record of personnel actions x
(3)(g) Termination date, reason for
x
termination
(3)(h) Current job description (1)(c)
Employee meets minimum qualifications x
stated in current job description
New Employee Orientation – Umbrella
Requirements (30 days) Yes No N/A Corrective Actions/Comments
419-400-0120(4)
(a) Agency policies and procedures x
(b) Ethical and professional guidelines x
(c) Suicide prevention and intervention x
(d) Attributes of population served x
(e) & (5)(a) to (c) Mandatory reporting that
includes:
(a) legal definition of child abuse in ORS
418.257 and 419B.005 x
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to
the employee
P age 12 | 18
Form Rev. 1/2/2024
(f) Privacy laws x
(g) Emergency procedures x
New Employee Orientation
Residential (Prior to working alone and
Yes No N/A Corrective Actions/Comments
within 30 days)
419-470-0120(1)
(a) Discipline and behavior management
including de-escalation, crisis prevention,
positive behavior management, and x
disciplinary techniques that are non-punitive
in nature
(b) CPR and First Aid sufficient to retain a
x
current certification
(c) Universal precautions and hygiene x
(d) Application of the reasonable and
x
prudent parent standard
(e) Training on the agency’s policy on
suicide prevention and suicide risk x
assessment tool
Crisis Intervention Training Standards
and Certification Yes No N/A Corrective Actions/Comments
419-400-0160(4) (as applicable)
(a)Complete a minimum of 12 hours of initial
training in person from a certified instructor,
including but not limited to a minimum of six
hours of training focused on positive
x
behavior support, nonviolent crisis
intervention and other methods of
nonphysical intervention to support children
in care during a crisis
(d) Receive a certificate that states:
(A) The dates during which the certification
is current
(B) The type of restraint which the individual
is certified to perform if applicable
(C) The type of training the individual is
certified to conduct if applicable x
(D) Any special endorsements earned by the
individual
(E) The level of training
(F) The name of the certified instructor who
conducted the training and administered the
assessment of proficiency.
(e) A certification issued: x
P age 13 | 18
Form Rev. 1/2/2024
(A) Must be personal to the individual
certified by the training provider
(B) May be valid for no more than two years
with recertification
Ongoing Training Yes No N/A Corrective Actions/Comments
419-470-0070(2)(b) Employees who handle
food served to children have a valid food x
handler’s card
419-400-0200 (1) Employees transporting
children have: current driver’s license,
insurance, trained in emergency procedures x
and behavior management, and training for
15+ passenger vans if applicable)
419-470-0120 (2)(a) Environmental
x
emergencies
419-470-0120 (2)(b) Universal Precautions x
419-470-0120 (2)(c) Discipline and Behavior
x
Management
419-470-0120 (2)(d) Agency’s policy on
x
suicide prevention and risk assessment tool
419-470-0120 (3) Staff providing direct care
must maintain current CPR/First Aid x
certification
419-470-0120 (4) Designated staff
authorized to apply reasonable and prudent
x
parent standard are trained in application of
the standard
419-400-0120(5) Mandatory reporting
(annually) that includes:
(a) legal definition of child abuse in ORS
418.257 and 419B.005 x
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to
the employee
419-400-0160(4)(b) Receive continuing
education (as applicable on crisis
x
intervention training) from a certified
instructor on an annual basis
Comments:
P age 14 | 18
Form Rev. 1/2/2024
Children’s Records Yes No N/A Corrective Actions/Comments
Health Services
419-470-0090
(2) Medical history obtained within 30 days
(significant findings, current immunizations,
history of surgical procedures-health issues- x
injuries, allergies, dental, vision, hearing,
behavioral health, and physician orders)
(4)(a) to (f) Medical exams (3 in first year of
life, 2,4,6,9,14) x
(g) Have a physical examination within the
first 60 days after admission of a child in
care. Documentation of a physical x
examination having occurred within the
calendar year will meet this requirement.
Consents
Yes No N/A Corrective Actions/Comments
419-470-0160(1)
(a) Provide routine and emergency medical
x
care
(b) Use the discipline and behavior
x
management system
(c) Use restraint or seclusion (if applicable).
Must specify the reasons for the intervention x
and how staff are trained and supervised
(d) Restrict contact with persons outside of
x
the agency
(e) Allow access as defined in 419-400-0230
x
& 0240
(f) Impose a dress code x
(g) Apply the reasonable and prudent parent
x
standard
Disclosures
419-470-0160(2) Yes No N/A Corrective Actions/Comments
Parent/guardian has acknowledged in writing:
(a) Information regarding personal or room
searches and protocols for confiscation of x
contraband
P age 15 | 18
Form Rev. 1/2/2024
(b) Statement of Rights of Children and
x
Parents/Guardians
(c) Any policies and procedures upon request x
Authorizations
Yes No N/A Corrective Actions/Comments
419-470-0160(3)
(a) Disclose or exchange information with
x
others
(b) Child specific visitors x
(c) Visitation resources are pre-approved x
(d) Activity specific authorizations are pre-
approved to allow children to participate in
potentially hazardous activities, including but x
not limited to using motorized yard
equipment, swimming, and horseback riding.
Information about Children in Care
419-400-0190(1) Yes No N/A Corrective Actions/Comments
Summary sheet contains the following:
(a)The name, gender, date of birth, religious
x
preference, and previous address
(b) Name and location of previous and
x
current school
(c) Date of admission x
(d) Legal custody x
(e) The name, address, and telephone
number of:
(A) The child in care's parents.
(B) The child in care's legal guardian, if
different than the parents, and a copy of
x
the document that provides for his or her
authority over the child in care.
(C) Other persons significant to child
(D) Other professionals to be involved in
service planning (if applicable)
Service Planning
Yes No N/A Corrective Actions/Comments
419-470-0170(2)
(b) Intake document is completed the date
child accepted into care (emergency x
placement 48 hours)
(d) Assessment is completed within 30 days
and contains relevant historical info., current
behavioral observations, identified need for x
services, and how agency will provide
services
(e) (A)&(B) Service plan within 60 days
x
(parent, guardian and child actively involved).
P age 16 | 18
Form Rev. 1/2/2024
Describes how child’s issues will be
addressed, anticipated outcomes, and
reviewed by child and guardian/parent.
(e)(C)&(D) Service plan is reviewed quarterly
and revised when information indicates other x
services should be provided
Case Management
Yes No N/A Corrective Actions/Comments
419-470-0170(3)
(a) Services are documented, progress
x
toward achieving goals is tracked
(c) Discharge summary must include:
(A)Current medications
(B)Name of the physician or qualified medical
professional who prescribed each medication
(C)Any outstanding medical or other
appointments x • Finding: Current discharge summaries were missing a, b, c, and e.
(D)Summary of the child’s participation in the
program and progress achieved
(E)Results of evaluations
(F)Recommendations regarding services
(G)Discharge destination
(e) Follow up services x
(f) Incident Reports x
Records Relating to Restraint &
Yes No N/A Corrective Actions/Comments
Involuntary Seclusion
419-400-0180 (12) Records x
419-400-0180(13)(e) Each child caring
agency shall provide notice regarding how to
access the quarterly reports to the parents or
guardians of children in care in the program. x
The child caring agency shall provide the
notice upon the child in care’s admission and
at least two times each year thereafter.
419-400-0190(1) Information provided to
children in care relating to Restraint & x
Involuntary Seclusion
Financial Records
Yes No N/A Corrective Actions/Comments
419-470-0170(4)
Records contain date, amount, source,
x
purpose, signatures
Personal Possessions Records
Yes No N/A Corrective Actions/Comments
419-470-0170 (5)
P age 17 | 18
Form Rev. 1/2/2024
Individual written inventory of all personal
possessions is maintained and updated as x
needed
Records and Documentation
Yes No N/A Corrective Actions/Comments
419-400-0140
(1) Stored safely x
(2) Permanent, legible, dated, and signed x
(3)&(4) Uniform in organization, readily
identifiable and accessible, current, and
x
complete, containing all required info. No
eraser tape or white out.
(7) Permanent registry for each child
includes:
Name
Gender
x
Birth date
Names, addresses of parents or guardians
Dates of admission
Placement upon discharge
Comments:
Additional Finding: Need to develop a policy around camera use. Please see 419-400-0145 (2)
Licensing Coordinator’s Signature: ________________________ Date: _2_/_2_/2_4______________
Manager Review: ______________________________________ Date: _2_-2_1_-_2_0_2_4__________
P age 18 | 18
Form Rev. 1/2/2024

licensee: Klamath County Juvenile Department - Crimson Rose Date of site visit: February 7th, 2024

visit_date: February 7th, 2024

program_description:
Crimson Rose reports, "The Klamath Crimson Rose (KCR) serves females, ages 12-20, in need of behavioral
stabilization services and provides Individualized Treatment Plans to these youth while also keeping them connected to their community support
networks and families. The program provides an environment for youth, who are struggling to maintain in the community or community placement,
to receive services aimed at developing personal responsibility, and appropriate and assertive behavioral skills development.
KCR is a culturally sensitive, intensive, trauma informed program that targets behaviors intended to improve psychosocial and behavioral
functioning for the participants. This program will provide youth with an array of rehabilitation services appropriate to meet their unique and
individualized needs and goals as defined in their assessment and Individual Service and Supports Plan (ISSP). Daily services encourage, support
and reinforce appropriate behaviors using evidence-based methods as documented in the individual's treatment plan. The Program will provide a
minimum of 13 hours of individual and group counseling in an environment for change, targeting behaviors such as substance use, thinking errors,
anger management, and other behaviors that have hindered their success thus far. The minimum 13 hours will include at least 2 hours of individual
counseling, 10 hours of group counseling and skill building, 1 hour of consultation, and 1 hour of family counseling or parent education when
appropriate. The evidence-based curriculum and screening tools are through Texas Christian University (TCU) and Change Companies, Forward
Thinking and Voices curriculum.
TCU Mapping-Enhanced Counseling has been chosen as a treatment modality due to the continued and overwhelming evidence on the
effectiveness in increasing client motivation, engagement, participation, and retention in treatment. This cognitive-behavioral therapy utilizes node-
link mapping as a visual tool to enhance a heightened level of awareness for an individual's thoughts, feelings, and actions improving the
psychosocial and behavioral functioning of an adolescent upon completion of the program. Forward Thinking and Voices are also evidence-based
Cognitive Behavioral Therapy (CBT) curriculums used in KCR and many other programs around the country.
Program also partners with Klamath Basin Behavioral Health to provide additional mental health services such as, Mental Health assessments,
appropriate risk assessments and behavioral skills building. Cascades East Family Practice Clinic, a Family Nurse Practitioner, and Registered
Nurse also provide medical support to the program.
Academically, client records are requested from prior schools to obtain the most current transcripts. Clients are enrolled in online courses using
Odysseyware to fulfill credits toward their graduation requirements. Official GED pre-testing and official testing is available to those students who
are working toward their GED. Middle school students and those needing remedial work are offered Let's Go Learn, a program to strengthen math
and reading skills. Students are in class three hours each school day with educators available to help and guide them through the process."
P age 1 | 18

interviews_observations:
I interviewed two clients separately in the visitation area of Crimson Rose to ensure privacy. When asked how Klamath
County Juvenile Department - Crimson Rose ranks on a scale from (0-10 where 0=worst program and 10=best program), the client's reported
program to be a 7.8 and a 9 on that scale. Both clients report the food to be "good" and "pretty darn good". The client's reported the program to be
clean and that they feel safe. Both reported feeling staff treat them with respect. One client reported, "Staff are very caring and kind". Clients were
able to discuss their treatment goals and discharge placement plans. Client's shared learning the following at Crimson Rose: how to regulate
emotions, drug, and alcohol - relapse prevention planning, DBT skills, effects of drugs, and coping skills. Clients spoke positively regarding the on-
site school. One client spoke about working towards their high school diploma. Clients reported going on the following community outings: theater,
movies, museums, park, and library. When asked if given a magic wand and could improve the program within reason what would you do. One
client reported going to Narcotics Anonymous / Church. The other client reported having the ability to listen to MP3 players in their room.
I spoke with Crimson Rose staff that were working for the day. All had positive things to report about working at Crimson Rose and enjoying
working with the clients and OYA. Many shared success stories of clients. Many of the staff have worked since the opening of Crimson Rose. All
reported excitement about the new building being built.
I observed staff interacting with the clients in a positive and supportive manner. I witnessed two intakes and the work of making the new clients feel
welcomed and putting their fears at ease. I observed the building to be clean and orderly. Crimson Rose continues to make their space feel less
institutional, such as allowing clients to personalize their bedrooms. Currently site prep has been completed for the new program and solar field.
This site will be energy independent with the use of its existing geothermal and the new on-site solar field.
P age 2 | 18

program_strengths:
Crimson Rose reports, "Program provides a continuum of behavioral health care services to up to nine Oregon Youth
Authority female clients. Clients can be on probation or parole and in need of diversion from the Oregon Youth Authority correctional facility or
general behavioral stabilization. Program provides safety, security, structure, and treatment unavailable in lower levels of care. Program also
boasts a strong academic program, which provides youth with strong credit make up and frequently graduates clients from high school."

program_challenges:
Crimson Rose reports, "Program has had some issues maintaining quality staff at appropriate levels at times. Because of
new construction we have had to move the kitchen into the part of the facility that was built to be the classroom, so the clients are temporarily
attending school in the pod. KCR is currently recruiting a new case manager position and additional direct care staff made possible by the fee
increase granted by the Oregon legislature."

changes_in_last_two_years:
Crimson Rose reports, "Klamath County Juvenile Department has started construction on a new
facility which will house the Klamath Crimson Rose program. When completed, the pod that is currently being used will be re-purposed. KCR
clients will move into the new facility with a new home-like setting, new school program classroom and arts room, indoor garden, new food service,
and recreational areas."

changes_in_license:
Please update age range on license to 12-20 instead of the 14-20 years. Please update the street address of Vandenburg
to its' correct spelling of Vandenberg.
P age 3 | 18

excerpt:
(2)(f) Formally evaluate the exec. Director’s
performance annually • Finding: Missing Dan Golden’s 2023 performance evaluation

excerpt:
(3)(g) Approval from BCU • Finding: Missing Dan Golden’s and Steve Quick’s completed
background checks

excerpt:
(1) If a child-caring agency installs video
equipment to monitor or record a child in
care, all employees, volunteers, parents or
guardians, and children in care must be
informed about the intended use and
locations of the equipment. • Finding: Crimson Rose does have video equipment and was missing this
new requirement.

excerpt:
All required policies and procedures as
identified in the “Umbrella Rules” • Finding: Crimson Rose is missing policy on Interstate Compact on the
Placement of Children (ICPC) see (ORS 417.200 to 417.260). Missing
policy for Indian Child Welfare Act (ICWA) and OAR chapter 419, Division
400

excerpt: (3)(d) Annual performance evaluations • Finding: Employees were missing 2023 performance evaluations.

excerpt:
(c) Discharge summary must include:
(A)Current medications
(B)Name of the physician or qualified medical
professional who prescribed each medication
(C)Any outstanding medical or other
appointments
(D)Summary of the child’s participation in the
program and progress achieved
(E)Results of evaluations
(F)Recommendations regarding services
(G)Discharge destination • Finding: Current discharge summaries were missing a, b, c, and e.