summary: License Renewals - 76 findings

raw_content:
Licensed Child Caring Agency Site Visit Report
Residential Care - License Renewal
Licensee: Affect Youth Services Date of site visit: March 11 & 12, 2025
Executive Director: Mandy Augsburger Licensing Coordinator: Robin DuVal
Board Chairperson: Ben Putrin
Other Regulatory or Accrediting Agencies: Jennie Walker with Oregon Department of Human Services (ODHS) Child Welfare
Treatment Services participated during this review.
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 provided by Affect Youth Sevcices: The program offers an extended family care model where youth with higher needs
can still be placed within a family setting allowing for a family experience with additional staff for extra support. The program is contracted with Child
Welfare Treatment Services and is a non-BRS (Behavior Rehabilitation Services) provider. Youth are assisted in taking personal responsibility and
accountability for their actions and using positive behavior support to model appropriate responses. Youth will have more positive outcomes when
they know they are being supported in their plan to transition out of the program. Youth attend public schools.
Program type and services as described by Affect: Practical application of life skills, modifying negative behaviors through “do-overs”,
building trusting relationships, positive peer culture. These are accomplished through discussion and modeling. Other services such as
therapy, drug and alcohol treatment, mentoring and skills training are outsourced by referral of the caseworker.
Capacity and age range: 15, ages 10-17
Funding sources: ODHS Child Welfare
Contracts and sources for referrals: ODHS Child Welfare
Average length of stay: 7 months
Average daily population served: 11.5
Form revised 3/12/2025 Page 1 of 26
Number of children served annually: 20
Use of seclusion or restraint: Restraint only as a last resort utilizing Crisis Prevention Institute (CPI), a non-violent crisis intervention.
Youth Interviews: Four youth were individually interviewed, ages 12-17, with stays in the program ranging 2-12 months. They reported
feeling safe, staff are trusting, get their medications as prescribed, and the program is responsive taking youth to medical appointments
when needed. They described their daily routine, including recreation options in the rec building as well as outings. Youth have regular
phone contact with persons on their approved contact list, and youths listed the places in the program where they can have privacy for
those calls. The food is good, mostly dinners, as those are homemade, and they sit to eat like a big family. Some report wanting more of
a variety for breakfast, other than cereal, and less carbohydrates and more protein. The interaction with peers is going ok, as to be
expected with the amount of youth in one program. When asked if they could change anything about the program, they reported a desire
to go on outings more frequently. They report the program does well at taking care of the youth and providing a safe place to live.
Staff Interviews: Two staff were individually interviewed, one working in the program for approximately 8 months and the other since the
program opened in 2016. Both described the initial and ongoing training, including Mandatory Abuse Reporter requirements. They have
regular daily contact with their supervisor, they feel free to express concerns and management is responsive to those concerns. The
program provides recreation each day, including all the opportunities in the recreation building, as well as daily meals. Youth can
communicate with family members, caseworkers and other people outside the program on their approved contact list, and interviewees
listed the space options for youth to have privacy for a meaningful conversation. They report the program does well at supporting kids,
setting up needed services and appointments, and encouraging the youth to be supportive of one another. They both feel fortunate to
work in this program and with this population of youth.
Observations: The Executive Director accompanied this licensor for the walk-thru which consisted of the dorm rooms, bedrooms,
bathrooms, laundry room, common room, kitchen, conference room. The recreation building, known as the “barn”, was observed to be
spacious and clean with a pool table and other games, an open loft area with multiple TV and gaming set-ups with seating for each, and
corner exercise equipment. A converted room in an outbuilding is used for multiple purposes, such as a visitation room and to house
music equipment.
Program Strengths, as reported by the agency: Adapting to the needs of each individual child involving de-escalation, regulation, and
coping skills. Youth outings, community interaction and experiences. Giving youth a family feel while being placed in a program.
Form revised 3/12/2025 Page 2 of 26
Respecting that these are youth who deserve fun in their life, not just appointments. Youth attend regular public schools. Attempted to
coordinate visits with family outside of ODHS to extend weekend visit time when allowed. Majority of staff are long-term providing
consistency for you.
Program Challenges, as reported by the agency: Coordinating transportation for all youth appointments during the week. Note: OHP
covered transportation services are regularly unreliable. Volunteers to cover board positions. Hiring and staffing as it’s incredibly difficult
to fill positions with quality team members. Getting enough appropriate referrals. Youth team support and understanding, i.e. ongoing
issues with scheduling with CASAs, attorney’s, mentors, Boys & Girls Aid, etc.
Changes that have occurred in the last 2 years, as reported by the agency: Staffing and schedule changes to accommodate staff
needs. No other significant changes were reported.
Lawsuits: none disclosed by the agency.
Grievances and complaints filed in the last two years: none disclosed by the agency.
Exceptions: Financial Audit; and overnight awake staffing ratio.
Changes in License: None
Corrective actions and timeframes: Please submit the following to verify compliance.
Within 45 days of receipt of this report (Affect Youth Services) must submit a letter of verification indicating the agency is in compliance
with the specific rules cited above and describing how compliance will be maintained going forward. Along with the letter of verification,
the agency must submit any and all specific documentation requested in the body of this report. The letter of verification and any additional
requested documents can be emailed directly to (Robin DuVal, robin.m.duval@odhsoha.oregon.gov).
Summary of review
Program and services Yes/No or Corrective actions/comments
419-400-0020 (2) N/A
Program and services are in scope of license yes
Form revised 3/12/2025 Page 3 of 26
Governance of the agency Yes/No or Corrective actions/comments
419-400-0040 N/A
(1)(a) Minimum of 5 board members Yes
(2)(f) Formally evaluate the Executive Director’s Yes
performance annually
(2)(g) Approves annual budget Yes
(2)(h) Obtain and review an annual independent Yes Exception on file
financial review or audit of financial records.
(2)(k) Written quality improvement program Yes
(2)(l) Meeting minutes Yes
Executive Director or Program Director Yes/No or Corrective actions/comments
419-400-0040 N/A
(3)(a) knowledge of requirements for providing care Yes
and treatment appropriate to programs
(3)(g) Approval from BCU Yes
Installation and use of video equipment used to Yes/No Corrective actions/comments
monitor or record children in care or N/A
419-400-0145
(1) If a child-caring agency installs video equipment to No The agency’s policy and procedure must be updated to
monitor or record a child in care, all employees, state:
volunteers, parents or guardians and children in care • “all employees, volunteers, parents or guardians,
must be informed about the intended use and locations and children in care must be informed about the
of the equipment. intended use and locations of the equipment.”
Refer to page 25 of this report for more details.
Form revised 3/12/2025 Page 4 of 26
Discipline, behavior management and suicide Yes/No or Corrective actions/comments
prevention N/A
419-400-0150
(3) Agency uses appropriate and positive methods of Yes
behavior management and nationally recognized non-
violent crisis intervention
(3)(b)(C) Agency does not use chemical and N/A Agency does not utilize chemical or mechanical restraints
mechanical restraint (excluding medically necessary in their programming.
devices/prescriptions)
(3)(c) Agency uses appropriate time-out rooms N/A Agency does not utilize designated time-out rooms
(adequate space, heat, light and ventilation and is not specifically, however there are areas in the program for the
capable of locking) and documents use in child’s child in care to take space.
record when applicable
(3)(e) Agency uses seclusion appropriately/consistent N/A Agency does not utilize seclusion in their programming.
with policy
(4) Agency has adequate plan in place to respond to Yes
suicidal behavior/warning signs
Contractors (if applicable) Yes/No or Corrective actions/comments
419-400-0120(6) N/A
(a) Agency ensures the contractor meets the N/A None were disclosed by the CCA.
requirements of this rule and Chapter 413 division 215
(b)(B) Contract includes the following: N/A None were disclosed by the CCA.
(i) Services provided
(ii) Contractor fees
(iii) Disclosure of information from contractor to agency
(iv) Lines of authority
(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
Form revised 3/12/2025 Page 5 of 26
Restraints and Involuntary Seclusion Yes/No or Corrective actions/comments
419-400-0180 N/A
(13)(d) Each child caring agency that submits a report Yes Note: No agency website.
under this section shall make its quarterly report
available to the 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 CCA Yes/No Corrective actions/comments
or N/A
Documents as indicated on the form titled “Renewal Yes
Licensing Required Documents”
Documents as indicated on form titled “Required Yes
Financial Documents and Information”
All required policies and procedures as identified in No The agency shall update the following policies and
the “Umbrella Rules” procedures. Refer to pages 23-25 of this report for specifics.
• Grievance, OAR 419-400-0090
• Incident reporting, OAR 419-400-0110(a)
• Discipline, OAR 419-400-0150
• Transportation safety, OAR 419-400-0200
• Searches, OAR 419-400-0200(2)
• Hazards, OAR 419-400-0200(4)
• Personnel 419-400-0120
• Privacy OAR 419-400-0130
• Use of Video Equipment OAR 419-400-0145
All required policies and procedures as identified in No The agency shall update the following policies and
“Agency Type Specific Rules” procedures. Refer to pages 25 & 26 of this report for
specifics.
• Health Services, OAR 419-470-0090
• Medication, OAR 419-470-0100
Form revised 3/12/2025 Page 6 of 26
Physical plant Yes/No Corrective actions/comments
or N/A
419-400-0090(3)(a) Foster Rights Posted (if children Yes
in ODHS custody)
419-400-0100(1) Sufficient safe space, equipment Yes
and office equipment
419-400-0230(12) License is posted in common Yes
area at each facility
419-470-0020(2)(a) and (c) Buildings are smoke Yes
free, clean and in good repair
419-470-0020 (2)(d) Rooms are free of harmful Yes
drafts, odors and excessive noise
419-470-0020 (2)(e) Rooms are adequate in size Yes
and arrangement
419-470-0020 (2)(f) System provides a continuous Yes
supply of hot and cold water to taps located
throughout the facility
419-470-0020 (2)(h) Building is well ventilated and Yes
room temperature is within a normal comfort range
419-470-0030 (1) All parts of the facility ensure the Yes
safety of children
Room and space requirements Yes/No Corrective actions/comments
419-470-0030 or N/A
(2) There is a separate living room or lounge area – Yes
15 SF minimum per child
(5) There is a separate dining room with capacity for Yes
½ of children in care and 15 SF per child in care
(7) Laundry is separate from living, kitchen and Yes
dining areas
(8) Separate storage areas are provided for food, Yes
kitchen supplies, utensils, clean linens, soiled linens
Form revised 3/12/2025 Page 7 of 26
Room and space requirements Yes/No Corrective actions/comments
419-470-0030 or N/A
and clothing, cleaning supplies and equipment,
poisons, chemicals, outdoor recreational and
maintenance equipment. (Hazardous materials are
properly labeled, in original container and locked)
(9) Outdoor activity area is protected from vehicles Yes
and other hazards and of a size and availability
appropriate to the age and needs of children in care
(11) Time-out rooms: Rooms used for time out or N/A
quiet time must have adequate space, heat, light
and ventilation and must not be capable of locking.
Room and space requirements - bedrooms Yes/No Corrective actions/comments
419-470-0030(3) or N/A
(a) Adequate furnishings and personal items Yes
(b) Separate from rooms used for dining, living, Yes
laundry, kitchen and storage
(c) Meet Oregon Fire Code Requirements Yes
(d) Be an outside room, with a window that operates Yes
as designed. If the window is modified from its
original design, the fire marshal must approve the
modification and indicate this room still meets
applicable Oregon Fire Code.
(d) Ceiling at least 90 inches Yes
(e) Minimum 60 SF per occupant Yes
(f) No more than 25 if dorm style Yes
(g) Permanently wired fixtures Yes
(h) Window covering Yes
Form revised 3/12/2025 Page 8 of 26
Room and space requirements - bathrooms Yes/No Corrective actions/comments
419-470-0030(4) or N/A
(a)(A) and (B) 1:8 ratio for toilets and sinks Yes
(a)(D) Hot and cold running water, soap and Yes
approved hand drying options
(a)(E) 1:10 ratio for shower or bathtub Yes
(a)(E) Individual privacy Yes
(a)(F) Window covering N/A There are no windows in the bathrooms.
(a)(G) Permanently wired fixtures Yes
(a)(H) Adequate ventilation Yes
(b) and (c) Wooden racks on floors are prohibited Yes
and impervious shower mats are disinfected and
dried daily be in good condition and free of mold
Room and space requirements - kitchen Yes/No Corrective actions/comments
419-470-0030(6) or N/A
(a) Used exclusively for storage, food preparation, Yes
dishwashing and activities related to eating and food
preparation activities
(b) Walls, floors are easily cleanable Yes
(c) Equipment and utensils are easily cleanable, Yes
durable, nontoxic and kept clean
(e) Equipment is easy to clean beneath, between Yes
and behind
Furnishings and personal items Yes/No Corrective actions/comments
419-470-0040 or N/A
(1) There is a bed with frame Yes
(1)(b) clean mattress in good condition, with a Yes
minimum thickness of five inches
(1)(c) a pillow in good condition Yes
Form revised 3/12/2025 Page 9 of 26
Furnishings and personal items Yes/No Corrective actions/comments
419-470-0040 or N/A
(1)(d) a private dresser, closet, or similar storage Yes
area for personal belongings that is readily
accessible
(2) Linens are in good repair. There is a waterproof Yes
mattress cover or mattress. Linens are appropriate
and towels and washcloths are provided
(3) Bedding is changed weekly or when soiled Yes
(4) and (5) Personal hygiene supplies and Yes
appropriate clothing are provided
Food services Yes/No Corrective actions/comments
419-470-0070 or N/A
(1)(a) Meals are arranged daily, consistent with No The agency shall be consistent with providing snacks
normal mealtimes that occur during the hours of between mealtimes.
operation and provide snacks between mealtimes Note: The agency has already begun working with this
licensor to ensure compliance.
(1)(b) Menus are prepared in advance in accordance No The agency shall update their menus to be more reflective
with USDA guidelines, provide a variety of foods and of what is being served, including snacks, demonstrating a
are adjusted for seasonal changes including snacks variety of foods in accordance with USDA guidelines.
• Note: The agency has already begun working with
this licensor to ensure compliance.
(1)(b) Menus are kept for at least 6 months Yes
(1)(c) Drinking water is freely available Yes
(2)(a) Food is stored, prepared and served in a Yes
sanitary manner
(2)(c) and (d) Food products are obtained from Yes
commercial suppliers (exception of fruits and
vegetables), unpasteurized juice is prohibited, and
only Grade A pasteurized and fortified milk in
appropriate container.
Form revised 3/12/2025 Page 10 of 26
Residential care safety Yes/No Corrective actions/comments
419-470-0080 or N/A
(2) Written emergency plan that includes: No
(a) Identifying the types of emergencies most likely
to happen where the residential care agency is
located
(b) Identifying a place to meet for each type of
The agency shall update the written emergency plan to
emergency identified
include requirements (b), (c), and (d) and submit for review.
(c) Identifying an alternate shelter if necessary
(d) Ensuring access to necessary medications or
medical equipment
(e) How to help each child in care recover after a
disaster
(3) Telephone numbers for local police, fire Yes
department, poison control, after hours medical
advice and other appropriate emergency numbers
must be posted near all telephones.
(4) Operative flashlights sufficient in number are Yes
readily available to staff
(5)(a) Evacuation drill occurs monthly under varying Yes
conditions, is retained 2 years and contains:
(A) identify of person conducting drill
(B) date and time
(C) notification method
(D) staff participating
(E) number of children and staff evacuated
(F) special conditions simulated
(G) problems encountered
(H) time to complete
Form revised 3/12/2025 Page 11 of 26
Umbrella safety Yes/No Corrective actions/comments
419-400-0200 or N/A
(1)(b) Vehicle has insurance policy, is smoke free, Yes
safe operating condition, and has first aid kit and fire
extinguisher 2-A:10-BC
(1)(b)(A) Each vehicle used to transport a child in Yes
care must be: properly registered,
covered by an insurance policy in full force and
effect, maintained in safe operating condition and
smoke-free.
(3) Water safety. If a child-caring agency has a Yes The agency does not have a swimming pool; however, they
swimming pool on the premises that is accessible to take youth swimming at public pools and discloses this
children in care or if a child-caring agency plans to information to the guardian and obtains their consent.
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 potentially Yes
harmful items and materials.
(4)(b) Direct supervision of children who do not have Yes
the ability to adjust and control water temperature
(4)(c) Light fixtures have protective covers unless Yes
designed to be used without one
Medication Yes/No Corrective actions/comments
419-470-0100 or N/A
(3) and (7)(e) Medications have a prescription and are Yes
stored in the original container with prescription label
(4) and (5) Herbal supplements and remedies, Yes
medical treatments, special diets, physical therapy,
Form revised 3/12/2025 Page 12 of 26
Medication Yes/No Corrective actions/comments
419-470-0100 or N/A
physical aides or limitations have a written order
signed by a physician or qualified medical
professional. A written 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 Yes
stored behind at least two locking mechanisms. This
does not apply to Naloxone.
(8) Medications are disposed in accordance with Yes
state and federal law
(9) Written record of the disposal of medications is Yes
maintained and includes:
(a) description and amount
(b) name
(c) reason
(d) method
(e) staff and witness signature
(10) Written record of the administration of Yes
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
Form revised 3/12/2025 Page 13 of 26
Extracurricular, enrichment, cultural and social Yes/No Corrective actions/comments
activities or N/A
419-470-0110
(2) Children have ongoing opportunities to Yes
participate in at least one age-appropriate or
developmentally appropriate activity
Minimum staffing requirements Yes/No Corrective actions/comments
419-470-0130 or N/A
(1) and (2) Supervision is adequate for the type of Yes
program, location, age and type of children, ability of
supervisor to respond, electronic back-up systems. Exception on file for overnight staffing ratio.
Minimum ratios are maintained:
-Ages 6 and older: 1:7
-Overnight (staff awake): 1:10
(4)(a) When one staff on duty, there is additional Yes
staff immediately available with max response time
of 30 minutes
(5) There is at least one on-site employee authorized Yes
to apply the reasonable and prudent parent standard
Sleeping arrangements Yes/No Corrective actions/comments
419-470-0140 or N/A
(1) Children are in separate bedrooms than adults, Yes
unless parent and child, or there is written approval
from guardian/parent and licensing coordinator
(2) There is adequate supervision of children when Yes
sleeping
(3) When assigning bedrooms a residential care Yes
agency must consider all of the following:
(a) Chronological age
(b) Developmental age
Form revised 3/12/2025 Page 14 of 26
(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 Corrective actions/comments
419-400-0120 or N/A
Staff name/position Yes
(3)(g) Date of hire Yes
(3)(a) record of education, training and previous Yes
employment
(1)(b) and (3)(b) reference checks completed and Yes
documented
(1)(a) and (3)(c) Background check completed and Yes
documented
(3)(d) Annual performance evaluations Yes
(3)(f) Record of personnel actions Yes
(3)(g) Termination date, reason for termination Yes
(3)(h) Current job description (1)(c) Employee meets Yes
minimum qualifications stated in current job
description
New employee orientation – Umbrella Yes/No Corrective actions/comments
Requirements (30 days) or N/A
419-400-0120(4)
(a) Agency policies and procedures Yes
(b) Ethical and professional guidelines Yes
(c) Suicide prevention and intervention Yes
(d) Attributes of population served Yes
(e) and (5)(a) to (c) Mandatory reporting that includes: Yes
(a) legal definition of child abuse in ORS 418.257 and
419B.005
Form revised 3/12/2025 Page 15 of 26
New employee orientation – Umbrella Yes/No Corrective actions/comments
Requirements (30 days) or N/A
419-400-0120(4)
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to the
employee
(f) Privacy laws Yes
(g) Emergency procedures Yes
New employee orientation - residential (prior to Yes/No Corrective actions/comments
working alone and within 30 days) or N/A
419-470-0120(1)
(a) Discipline and behavior management including Yes
de-escalation, crisis prevention, positive behavior
management and disciplinary techniques that are
non-punitive in nature
(b) CPR and First Aid sufficient to retain a current Yes
certification
(c) Universal precautions and hygiene Yes
(d) Application of the reasonable and prudent parent Yes
standard
(e) Training on the agency’s policy on suicide Yes
prevention and suicide risk assessment tool
Crisis intervention training standards and Yes/No Corrective actions/comments
certification or N/A
419-400-0160(4) (as applicable)
(a)Complete a minimum of 12 hours of initial training No Records indicated 9 hours, therefore not meeting the
in person from a certified instructor, including but not minimum of 12 hours. The agency indicated that all staff
limited to a minimum of six hours of training focused will complete training within the next few months.
on positive behavior support, nonviolent crisis
Form revised 3/12/2025 Page 16 of 26
Crisis intervention training standards and Yes/No Corrective actions/comments
certification or N/A
419-400-0160(4) (as applicable)
intervention and other methods of nonphysical Corrective Action: The agency shall ensure this training
intervention to support children in care during a crisis requirement is met.
(d) Receive a certificate that states: No
(A) The dates during which the certification is current Corrective Action: Upon completion of a minimum of 12
(B) The type of restraint which the individual is hours of training, the agency shall ensure a certificate is
certified to perform if applicable documented capturing all required date elements. This
(C) The type of training the individual is certified to licensor provided an example.
conduct if applicable
(D) Any special endorsements earned by the At the completion of above noted training, the agency will
individual complete certifications for each employee and submit those
(E) The level of training for confirmation.
(F) The name of the certified instructor who
conducted the training and administered the
assessment of proficiency.
(e) A certification issued: No Corrective Action: The agency shall ensure a copy of the
(A) Must be personal to the individual certified by the employees CPI blue card shall be kept in the employee
training provider training record.
(B) May be valid for no more than two years with
recertification
Ongoing training Yes/No Corrective actions/comments
or N/A
419-470-0070(2)(b) Employees who handle food Yes
served to children have a valid food handler’s card
419-400-0200 (1) Employees transporting children Yes
have: current driver’s license, insurance, trained in
emergency procedures and behavior management
and training for 15+ passenger vans if applicable)
419-470-0120 (2)(a) Environmental emergencies Yes
Form revised 3/12/2025 Page 17 of 26
Ongoing training Yes/No Corrective actions/comments
or N/A
419-470-0120 (2)(b) Universal precautions Yes
419-470-0120 (2)(c) Discipline and behavior Yes
management
419-470-0120 (2)(d) Agency’s policy on suicide Yes
prevention and risk assessment tool
419-470-0120 (3) Staff providing direct care must No One staff persons certification had expired. Upon this
maintain current CPR/First Aid certification licensor sharing this information, the agency acted promptly
to get the staff person scheduled. All other staff have
current certifications; therefore, all shifts haver someone
certified in CPR/First Aid.
Corrective Action: The agency shall track expiration dates
to ensure certifications are kept current.
419-470-0120 (4) Designated staff authorized to Yes
apply reasonable and prudent parent standard are
trained in application of the standard
419-400-0120(5) Mandatory reporting (annually) that Yes
includes:
(a) legal definition of child abuse in ORS 418.257
and 419B.005
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to the
employee
419-400-0160(4)(b) Receive continuing education Yes
(as applicable on crisis intervention training) from a
certified instructor on an annual basis
Form revised 3/12/2025 Page 18 of 26
Children’s records Yes/No Corrective actions/comments
health services or N/A
419-470-0090
(2) Medical history obtained within 30 days Yes
(significant findings, current immunizations, history
of surgical procedures-health issues-injuries,
allergies, dental, vision, hearing, behavioral health
and physician orders)
(4)(a) to (f) Medical exams (3 in first year of life, Yes
2,4,6,9,14)
(g) Have a physical examination within the first 60 Yes
days after admission of a child in care.
Documentation of a physical examination having
occurred within the calendar year will meet this
requirement.
Consents Yes/No Corrective actions/comments
419-470-0160(1) or N/A
(a) Provide routine and emergency medical care Yes
(b) Use the discipline and behavior management Yes
system
(c) Use restraint or seclusion (if applicable). Must Yes
specify the reasons for the intervention and how
staff are trained and supervised
(d) Restrict contact with persons outside of the Yes
agency
(e) Allow access as defined in 419-400-0230 and Yes
0240
(f) Impose a dress code Yes
(g) Apply the reasonable and prudent parent standard Yes
Form revised 3/12/2025 Page 19 of 26
Disclosures Yes/No Corrective actions/comments
419-470-0160(2) or N/A
Parent/guardian has acknowledged in writing:
(a) Information regarding personal or room searches Yes
and protocols for confiscation of contraband
(b) Statement of Rights of Children and Yes
Parents/Guardians
(c) Any policies and procedures upon request Yes
Authorizations Yes/No Corrective actions/comments
419-470-0160(3) or N/A
(a) Disclose or exchange information with others Yes
(b) Child specific visitors Yes
(c) Visitation resources are pre-approved Yes
(d) Activity specific authorizations are pre-approved Yes
to allow children to participate in potentially
hazardous activities, including but not limited to
using motorized yard equipment, swimming and
horseback riding.
Information about children in care Yes/No Corrective actions/comments
419-400-0190(1) Summary sheet contains the or N/A
following:
(a)The name, gender, date of birth, religious Yes
preference and previous address
(b) Name and location of previous and current school Yes
(c) Date of admission Yes
(d) Legal custody Yes
(e) The name, address and telephone number of: Yes
(A) The child in care's parents.
(B) The child in care's legal guardian, if different
than the parents and a copy of the document that
Form revised 3/12/2025 Page 20 of 26
Information about children in care Yes/No Corrective actions/comments
419-400-0190(1) Summary sheet contains the or N/A
following:
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 Corrective actions/comments
419-470-0170(2) or N/A
(b) Intake document is completed the date child Yes
accepted into care (emergency placement 48 hours)
(d) Assessment is completed within 30 days and Yes
contains relevant historical information, current
behavioral observations, identified need for services
and how agency will provide services
(e) (A) and (B) Service plan within 60 days (parent, No Guardian involvement was not clearly documented as being
guardian and child actively involved). Describes how provided to and reviewed by the guardian. While on-site,
child’s issues will be addressed, anticipated suggestions were provided to the agency. This is a repeat
outcomes and reviewed by child and guardian/parent. finding.
Corrective Action: The agency shall ensure
documentation of guardian involvement on service plans.
(e)(C) and (D) Service plan is reviewed quarterly Yes
and revised when information indicates other
services should be provided
Case management Yes/No Corrective actions/comments
419-470-0170(3) or N/A
(a) Services are documented, progress toward Yes
achieving goals is tracked
Form revised 3/12/2025 Page 21 of 26
Case management Yes/No Corrective actions/comments
419-470-0170(3) or N/A
(c) Discharge summary must include: No Discharge summaries were inconsistent not meeting all
(A)Current medications requirements. This is a repeat finding.
(B)Name of the physician or qualified medical
professional who prescribed each medication Corrective Action: The agency shall ensure all discharge
(C)Any outstanding medical or other appointments summaries include all requirements and edit the discharge
(D)Summary of the child’s participation in the form to correlate to the requirements.
program and progress achieved
(E)Results of evaluations
(F)Recommendations regarding services
(G)Discharge destination
(e) Follow up services Yes
(f) Incident reports Yes
Records relating to Restraint and Involuntary Yes/No Corrective actions/comments
Seclusion or N/A
419-400-0180 (12) Records Yes
419-400-0180(13)(e) Each child caring agency shall Yes
provide notice regarding how to access the quarterly
reports to the parents or guardians of children in care
in the program. The child caring agency shall provide
the notice upon the child in care’s admission and at
least two times each year thereafter.
419-400-0190(1) Information provided to children in N/A Comment: Youth served by ODHS, although the agency
care relating to Restraint and Involuntary Seclusion includes this information in their intake packet.
Financial records Yes/No Corrective actions/comments
419-470-0170(4) or N/A
Records contain date, amount, source, purpose, Yes
signatures
Form revised 3/12/2025 Page 22 of 26
Personal possessions records Yes/No Corrective actions/comments
419-470-0170 (5) or N/A
Individual written inventory of all personal possessions Yes
is maintained and updated as needed
Records and documentation Yes/No Corrective actions/comments
419-400-0140 or N/A
(1) Stored safely Yes
(2) Permanent, legible, dated and signed Yes
(3) and (4) Uniform in organization, readily identifiable Yes
and accessible, current and complete, containing all
required info. No eraser tape or white out.
(7) Permanent registry for each child includes: Yes
Name
Gender
Birth date
Names, addresses of parents or guardians
Dates of admission
Placement upon discharge
Policies and procedures to update:
Grievance: add board member contact information in the event the complaint is pertaining to the ED.
Incident reporting: Update this sentence, “Interviews of all involved parties will be conducted to ensure the accuracy of the report,
prior to submission, except reports made to the Child Abuse Hotline to not interfere with the investigation process.
Behavior Management, were prohibited discipline is noted: Add
• (K) Removing or limiting the use of a mobility aid or other assistive device for the purpose of controlling a child in care’s
behavior.
Discipline: recommend combing the Discipline and Behavior management policies and procedures.
• Note: (K) above is included in the discipline P&P.
Form revised 3/12/2025 Page 23 of 26
Transportation: Add information related to the following:
• (A) Each vehicle used to transport a child in care must be: (i) Properly registered.
• A statement regarding (E) The child-caring agency must take reasonable steps to ensure safety when using off-road
vehicles.
• That the fire extinguisher is “properly secured”.
Searches: Add information related to the following:
• (E) The staff member must then pat the clothing of the child in care using only enough contact to conduct an appropriate
search;
• (G) If the child in care refuses to comply, the executive director or designee must be notified immediately and be
responsible to resolve the matter;
• (H) All searches must be documented in writing.
• (f) If the child in care refuses to comply with a requirement of the search, the program must follow established policies to
determine if the child in care can be refused admission to or discharged from the program.
• (g) Information regarding any personal or room searches and protocols for confiscation of contraband items, including the
notification of law enforcement if illegal contraband is discovered. This information will include the procedures and
rationales of the child-caring agency for any program-initiated room or body search.
Hazards: Add
• (b) Direct supervision by staff must be provided for any child in care who does not have the ability to adjust and control
water temperature.
• (c) Each light fixture must have a protective cover unless it is designed to be used without one.
Personnel: Some requirements are referenced in the “Employee Training Manual” document, but missing all requirements set
forth in this rule. The agency shall either update this manual or create a new Personnel Policy and Procedure to capture all
requirements set forth in OAR 419-400-0120.
Privacy:
• Add “audio or video recording: to the sentence where it states, “Youth photos will not be used without a signed media
consent form by the ODHS Caseworker / legal guardian.”
Form revised 3/12/2025 Page 24 of 26
• Update the “Calls & Visitation Policy” where it states, “All calls will be made in a public area, there is no guarantee of
privacy.” This is in conflict with OAR 419-400-0090(1)(b) The child in care’s right to privacy.
• Recommend updating the title or opening sentence that includes privacy, disclosure of camera use, and youth private
communication; or see recommendation below.
Audio Video Monitoring:
• Recommend removing this section from the Privacy policy and procedure document and create a stand-alone for this topic,
which can refer to the privacy policy and procedure.
• Add a statement of: all employees, volunteers, parents or guardians, and children in care must be informed about the
intended use and locations of the equipment
Health Services, “Medical Care”: add information related to the following:
(2) Medical history. Within 30 days of a child in care being placed with a residential care agency, the residential care
agency must obtain available medical history and other health-related information on the child in care, including:
(a) Significant findings of the most current physical examination;
(b) The child in care's current immunizations, history of surgical procedures and significant health issues or injuries, and
past or present communicable diseases;
(c) Any known allergies;
(d) Dental, vision, hearing, and behavioral health; and
(e) Physician or qualified medical professional's orders, including those related to medications, if any.
(3) Health Services. The residential care agency must provide or arrange for the following health services, as applicable:
(a) Medical exams.
(b) Information on maintaining reproductive health and birth control.
(c) Prenatal care.
(d) Well-baby care.
(e) Fetal alcohol syndrome.
(f) Accessing child and infant health insurance programs.
(g) Screening for breast and other common cancers.
(h) Provide all necessary feminine hygiene products.
(i) Access to birth control, vaccinations, and information about preventing sexually transmitted diseases.
(j) Age-appropriate consultation is provided regarding nutrition, pregnancy prevention, prevention of HIV and AIDS and
general information about the prevention and treatment of sexually transmitted illnesses.
Form revised 3/12/2025 Page 25 of 26
Medications:
• Self-administration – add that the physician approval must be in writing.
• Documentation to include: (d) what to do if there is a charting documentation error, if a medication is refused, if a
medication is missed, or any other type of medication error that results in a medication not being administered as
prescribed.
• Storage – add information regarding being stored behind at least two locking mechanisms.
• (a) Prescription medications that are unused and medications that are expired or recalled may not be maintained with
current medication and must be disposed of as described in agency disposal policy.
• Medication Administration Record (MAR) form: dates and times, method of administration; and space to record any
possible adverse reactions to a medication.
• Add the medication record detail to the Medication policy and procedure, to match the MAR form.
Licensing Coordinator’s Signature: ________________________ Date: ______5_/8_/_2_0_2_5_______
Manager Review: ______________________________________ Date: __5_-_8_-_2_0_2_5_________
Form revised 3/12/2025 Page 26 of 26

report_type: License Renewals

report_title: Licensed Child Caring Agency Site Visit Report

facility_type: Residential Care - License Renewal

licensee: Affect Youth Services Date of site visit: March 11 & 12, 2025

executive_director: Mandy Augsburger Licensing Coordinator: Robin DuVal

board_chairperson: Ben Putrin

funding_sources: ODHS Child Welfare

contracts_and_referrals: ODHS Child Welfare

average_length_of_stay: 7 months

average_daily_population_served: 11.5 Form revised 3/12/2025 Page 1 of 26

use_of_seclusion_or_restraint: Restraint only as a last resort utilizing Crisis Prevention Institute (CPI), a non-violent crisis intervention. Youth Interviews: Four youth were individually interviewed, ages 12-17, with stays in the program ranging 2-12 months. They reported feeling safe, staff are trusting, get their medications as prescribed, and the program is responsive taking youth to medical appointments when needed. They described their daily routine, including recreation options in the rec building as well as outings. Youth have regular phone contact with persons on their approved contact list, and youths listed the places in the program where they can have privacy for those calls. The food is good, mostly dinners, as those are homemade, and they sit to eat like a big family. Some report wanting more of a variety for breakfast, other than cereal, and less carbohydrates and more protein. The interaction with peers is going ok, as to be expected with the amount of youth in one program. When asked if they could change anything about the program, they reported a desire to go on outings more frequently. They report the program does well at taking care of the youth and providing a safe place to live. Staff Interviews: Two staff were individually interviewed, one working in the program for approximately 8 months and the other since the program opened in 2016. Both described the initial and ongoing training, including Mandatory Abuse Reporter requirements. They have regular daily contact with their supervisor, they feel free to express concerns and management is responsive to those concerns. The program provides recreation each day, including all the opportunities in the recreation building, as well as daily meals. Youth can communicate with family members, caseworkers and other people outside the program on their approved contact list, and interviewees listed the space options for youth to have privacy for a meaningful conversation. They report the program does well at supporting kids, setting up needed services and appointments, and encouraging the youth to be supportive of one another. They both feel fortunate to work in this program and with this population of youth. Observations: The Executive Director accompanied this licensor for the walk-thru which consisted of the dorm rooms, bedrooms, bathrooms, laundry room, common room, kitchen, conference room. The recreation building, known as the "barn", was observed to be spacious and clean with a pool table and other games, an open loft area with multiple TV and gaming set-ups with seating for each, and corner exercise equipment. A converted room in an outbuilding is used for multiple purposes, such as a visitation room and to house music equipment.

lawsuits: none disclosed by the agency.

grievances_and_complaints: none disclosed by the agency.

exceptions: Financial Audit; and overnight awake staffing ratio.

excerpt:
419-400-0040 N/A
(1)(a) Minimum of 5 board members Yes
(2)(f) Formally evaluate the Executive Director's Yes
performance annually
(2)(g) Approves annual budget Yes
(2)(h) Obtain and review an annual independent Yes Exception on file
financial review or audit of financial records.
(2)(k) Written quality improvement program Yes
(2)(l) Meeting minutes Yes
Executive Director or Program Director Yes/No or Corrective actions/comments

excerpt:
419-400-0145
(1) If a child-caring agency installs video equipment to No The agency's policy and procedure must be updated to
monitor or record a child in care, all employees, state:
volunteers, parents or guardians and children in care - "all employees, volunteers, parents or guardians,
must be informed about the intended use and locations and children in care must be informed about the
of the equipment. intended use and locations of the equipment."
Refer to page 25 of this report for more details.
Form revised 3/12/2025 Page 4 of 26
Discipline, behavior management and suicide Yes/No or Corrective actions/comments
prevention N/A

excerpt:
419-400-0150
(3) Agency uses appropriate and positive methods of Yes
behavior management and nationally recognized non-
violent crisis intervention
(3)(b)(C) Agency does not use chemical and N/A Agency does not utilize chemical or mechanical restraints
mechanical restraint (excluding medically necessary in their programming.
devices/prescriptions)
(3)(c) Agency uses appropriate time-out rooms N/A Agency does not utilize designated time-out rooms
(adequate space, heat, light and ventilation and is not specifically, however there are areas in the program for the
capable of locking) and documents use in child's child in care to take space.
record when applicable
(3)(e) Agency uses seclusion appropriately/consistent N/A Agency does not utilize seclusion in their programming.
with policy
(4) Agency has adequate plan in place to respond to Yes
suicidal behavior/warning signs
Contractors (if applicable) Yes/No or Corrective actions/comments

excerpt:
419-400-0180 N/A
(13)(d) Each child caring agency that submits a report Yes Note: No agency website.
under this section shall make its quarterly report
available to the 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 CCA Yes/No Corrective actions/comments
or N/A
Documents as indicated on the form titled "Renewal Yes
Licensing Required Documents"
Documents as indicated on form titled "Required Yes
Financial Documents and Information"
All required policies and procedures as identified in No The agency shall update the following policies and
the "Umbrella Rules" procedures. Refer to pages 23-25 of this report for specifics.
- Grievance, OAR

excerpt:
419-400-0090
- Incident reporting, OAR

excerpt:
419-400-0150
- Transportation safety, OAR

excerpt:
419-400-0130
- Use of Video Equipment OAR

excerpt:
419-400-0145
All required policies and procedures as identified in No The agency shall update the following policies and
"Agency Type Specific Rules" procedures. Refer to pages 25 & 26 of this report for
specifics.
- Health Services, OAR

excerpt:
419-400-0090(3)(a) Foster Rights Posted (if children Yes
in ODHS custody)

excerpt:
419-400-0100(1) Sufficient safe space, equipment Yes
and office equipment

excerpt:
419-400-0230(12) License is posted in common Yes
area at each facility

excerpt:
419-470-0020(2)(a) and (c) Buildings are smoke Yes
free, clean and in good repair

excerpt:
419-470-0020 (2)(e) Rooms are adequate in size Yes
and arrangement

excerpt:
419-470-0030 or N/A
(2) There is a separate living room or lounge area - Yes
15 SF minimum per child
(5) There is a separate dining room with capacity for Yes
½ of children in care and 15 SF per child in care
(7) Laundry is separate from living, kitchen and Yes
dining areas
(8) Separate storage areas are provided for food, Yes
kitchen supplies, utensils, clean linens, soiled linens
Form revised 3/12/2025 Page 7 of 26
Room and space requirements Yes/No Corrective actions/comments

excerpt:
419-470-0070 or N/A
(1)(a) Meals are arranged daily, consistent with No The agency shall be consistent with providing snacks
normal mealtimes that occur during the hours of between mealtimes.
operation and provide snacks between mealtimes Note: The agency has already begun working with this
licensor to ensure compliance.
(1)(b) Menus are prepared in advance in accordance No The agency shall update their menus to be more reflective
with USDA guidelines, provide a variety of foods and of what is being served, including snacks, demonstrating a
are adjusted for seasonal changes including snacks variety of foods in accordance with USDA guidelines.
- Note: The agency has already begun working with
this licensor to ensure compliance.
(1)(b) Menus are kept for at least 6 months Yes
(1)(c) Drinking water is freely available Yes
(2)(a) Food is stored, prepared and served in a Yes
sanitary manner
(2)(c) and (d) Food products are obtained from Yes
commercial suppliers (exception of fruits and
vegetables), unpasteurized juice is prohibited, and
only Grade A pasteurized and fortified milk in
appropriate container.
Form revised 3/12/2025 Page 10 of 26
Residential care safety Yes/No Corrective actions/comments

excerpt:
419-400-0120 or N/A
Staff name/position Yes
(3)(g) Date of hire Yes
(3)(a) record of education, training and previous Yes
employment
(1)(b) and (3)(b) reference checks completed and Yes
documented
(1)(a) and (3)(c) Background check completed and Yes
documented
(3)(d) Annual performance evaluations Yes
(3)(f) Record of personnel actions Yes
(3)(g) Termination date, reason for termination Yes
(3)(h) Current job description (1)(c) Employee meets Yes
minimum qualifications stated in current job
description
New employee orientation - Umbrella Yes/No Corrective actions/comments
Requirements (30 days) or N/A

excerpt:
419-400-0120(4)
(a) Agency policies and procedures Yes
(b) Ethical and professional guidelines Yes
(c) Suicide prevention and intervention Yes
(d) Attributes of population served Yes
(e) and (5)(a) to (c) Mandatory reporting that includes: Yes
(a) legal definition of child abuse in ORS 418.257 and
419B.005
Form revised 3/12/2025 Page 15 of 26
New employee orientation - Umbrella Yes/No Corrective actions/comments
Requirements (30 days) or N/A

excerpt:
419-470-0120(1)
(a) Discipline and behavior management including Yes
de-escalation, crisis prevention, positive behavior
management and disciplinary techniques that are
non-punitive in nature
(b) CPR and First Aid sufficient to retain a current Yes
certification
(c) Universal precautions and hygiene Yes
(d) Application of the reasonable and prudent parent Yes
standard
(e) Training on the agency's policy on suicide Yes
prevention and suicide risk assessment tool
Crisis intervention training standards and Yes/No Corrective actions/comments
certification or N/A

excerpt:
419-470-0070(2)(b) Employees who handle food Yes
served to children have a valid food handler's card

excerpt:
419-400-0200 (1) Employees transporting children Yes
have: current driver's license, insurance, trained in
emergency procedures and behavior management
and training for 15+ passenger vans if applicable)

excerpt: 419-470-0120 (2)(b) Universal precautions Yes

excerpt:
419-470-0120 (2)(c) Discipline and behavior Yes
management

excerpt:
419-470-0120 (2)(d) Agency's policy on suicide Yes
prevention and risk assessment tool

excerpt:
419-400-0160(4)(b) Receive continuing education Yes
(as applicable on crisis intervention training) from a
certified instructor on an annual basis
Form revised 3/12/2025 Page 18 of 26
Children's records Yes/No Corrective actions/comments
health services or N/A

excerpt:
419-470-0170(2) or N/A
(b) Intake document is completed the date child Yes
accepted into care (emergency placement 48 hours)
(d) Assessment is completed within 30 days and Yes
contains relevant historical information, current
behavioral observations, identified need for services
and how agency will provide services
(e) (A) and (B) Service plan within 60 days (parent, No Guardian involvement was not clearly documented as being
guardian and child actively involved). Describes how provided to and reviewed by the guardian. While on-site,
child's issues will be addressed, anticipated suggestions were provided to the agency. This is a repeat
outcomes and reviewed by child and guardian/parent. finding.
Corrective Action: The agency shall ensure
documentation of guardian involvement on service plans.
(e)(C) and (D) Service plan is reviewed quarterly Yes
and revised when information indicates other
services should be provided
Case management Yes/No Corrective actions/comments

excerpt:
419-470-0170(3) or N/A
(c) Discharge summary must include: No Discharge summaries were inconsistent not meeting all
(A)Current medications requirements. This is a repeat finding.
(B)Name of the physician or qualified medical
professional who prescribed each medication Corrective Action: The agency shall ensure all discharge
(C)Any outstanding medical or other appointments summaries include all requirements and edit the discharge
(D)Summary of the child's participation in the form to correlate to the requirements.
program and progress achieved
(E)Results of evaluations
(F)Recommendations regarding services
(G)Discharge destination
(e) Follow up services Yes
(f) Incident reports Yes
Records relating to Restraint and Involuntary Yes/No Corrective actions/comments
Seclusion or N/A

excerpt:
419-400-0180(13)(e) Each child caring agency shall Yes
provide notice regarding how to access the quarterly
reports to the parents or guardians of children in care
in the program. The child caring agency shall provide
the notice upon the child in care's admission and at
least two times each year thereafter.

excerpt:
419-400-0140 or N/A
(1) Stored safely Yes
(2) Permanent, legible, dated and signed Yes
(3) and (4) Uniform in organization, readily identifiable Yes
and accessible, current and complete, containing all
required info. No eraser tape or white out.
(7) Permanent registry for each child includes: Yes
Name
Gender
Birth date
Names, addresses of parents or guardians
Dates of admission
Placement upon discharge
Policies and procedures to update:
Grievance: add board member contact information in the event the complaint is pertaining to the ED.
Incident reporting: Update this sentence, "Interviews of all involved parties will be conducted to ensure the accuracy of the report,
prior to submission, except reports made to the Child Abuse Hotline to not interfere with the investigation process.
Behavior Management, were prohibited discipline is noted: Add
- (K) Removing or limiting the use of a mobility aid or other assistive device for the purpose of controlling a child in care's
behavior.
Discipline: recommend combing the Discipline and Behavior management policies and procedures.
- Note: (K) above is included in the discipline P&P.
Form revised 3/12/2025 Page 23 of 26
Transportation: Add information related to the following:
- (A) Each vehicle used to transport a child in care must be: (i) Properly registered.
- A statement regarding (E) The child-caring agency must take reasonable steps to ensure safety when using off-road
vehicles.
- That the fire extinguisher is "properly secured".
Searches: Add information related to the following:
- (E) The staff member must then pat the clothing of the child in care using only enough contact to conduct an appropriate
search;
- (G) If the child in care refuses to comply, the executive director or designee must be notified immediately and be
responsible to resolve the matter;
- (H) All searches must be documented in writing.
- (f) If the child in care refuses to comply with a requirement of the search, the program must follow established policies to
determine if the child in care can be refused admission to or discharged from the program.
- (g) Information regarding any personal or room searches and protocols for confiscation of contraband items, including the
notification of law enforcement if illegal contraband is discovered. This information will include the procedures and
rationales of the child-caring agency for any program-initiated room or body search.
Hazards: Add
- (b) Direct supervision by staff must be provided for any child in care who does not have the ability to adjust and control
water temperature.
- (c) Each light fixture must have a protective cover unless it is designed to be used without one.
Personnel: Some requirements are referenced in the "Employee Training Manual" document, but missing all requirements set
forth in this rule. The agency shall either update this manual or create a new Personnel Policy and Procedure to capture all
requirements set forth in OAR

excerpt:
419-400-0120.
Privacy:
- Add "audio or video recording: to the sentence where it states, "Youth photos will not be used without a signed media
consent form by the ODHS Caseworker / legal guardian."
Form revised 3/12/2025 Page 24 of 26
- Update the "Calls & Visitation Policy" where it states, "All calls will be made in a public area, there is no guarantee of
privacy." This is in conflict with OAR

excerpt:
419-400-0090(1)(b) The child in care's right to privacy.
- Recommend updating the title or opening sentence that includes privacy, disclosure of camera use, and youth private
communication; or see recommendation below.
Audio Video Monitoring:
- Recommend removing this section from the Privacy policy and procedure document and create a stand-alone for this topic,
which can refer to the privacy policy and procedure.
- Add a statement of: all employees, volunteers, parents or guardians, and children in care must be informed about the
intended use and locations of the equipment
Health Services, "Medical Care": add information related to the following:
(2) Medical history. Within 30 days of a child in care being placed with a residential care agency, the residential care
agency must obtain available medical history and other health-related information on the child in care, including:
(a) Significant findings of the most current physical examination;
(b) The child in care's current immunizations, history of surgical procedures and significant health issues or injuries, and
past or present communicable diseases;
(c) Any known allergies;
(d) Dental, vision, hearing, and behavioral health; and
(e) Physician or qualified medical professional's orders, including those related to medications, if any.
(3) Health Services. The residential care agency must provide or arrange for the following health services, as applicable:
(a) Medical exams.
(b) Information on maintaining reproductive health and birth control.
(c) Prenatal care.
(d) Well-baby care.
(e) Fetal alcohol syndrome.
(f) Accessing child and infant health insurance programs.
(g) Screening for breast and other common cancers.
(h) Provide all necessary feminine hygiene products.
(i) Access to birth control, vaccinations, and information about preventing sexually transmitted diseases.
(j) Age-appropriate consultation is provided regarding nutrition, pregnancy prevention, prevention of HIV and AIDS and
general information about the prevention and treatment of sexually transmitted illnesses.
Form revised 3/12/2025 Page 25 of 26
Medications:
- Self-administration - add that the physician approval must be in writing.
- Documentation to include: (d) what to do if there is a charting documentation error, if a medication is refused, if a
medication is missed, or any other type of medication error that results in a medication not being administered as
prescribed.
- Storage - add information regarding being stored behind at least two locking mechanisms.
- (a) Prescription medications that are unused and medications that are expired or recalled may not be maintained with
current medication and must be disposed of as described in agency disposal policy.
- Medication Administration Record (MAR) form: dates and times, method of administration; and space to record any
possible adverse reactions to a medication.
- Add the medication record detail to the Medication policy and procedure, to match the MAR form.


state: OR

facility_name: Calo Programs Missouri, Inc., d.b.a. Embark Date of site visit: 04/15/2025 Behavioral Health - Bend

summary: Unannounced - 3 findings

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Residential Care
Licensee: Program Design Concepts, dba New Leaf Academy
Executive Director: Deveney Marshall Date of Unannounced: May 22, 2023
Board Chairperson: Craig Christiansen Licensing Coordinator: Robin DuVal
Other Regulatory or Accrediting Agencies: COGNIA accredited, Student Exchange and Visitor Program (SEVS) approved, certified by California
Dept. of Education to provide special education services.
Purpose: Per OAR 419-400-0240 (1)(b) Children’s Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Findings Comments
Unannounced Site Visit 10-13-2022 Further Action
Needed
Case Management 413-215-0681(3)(f) Incident Reporting Yes☐ No The agency recently changed to an electronic system for
Incident Report documentation which allows individual
Incident Reports were filed separately from each youths file. The documentation and tracking per youth.
agency shall ensure Incident Reports must be individualized by each
youth and retained in each youth file.  This licensor will provide technical assistance to ensure
all incident reporting documentation requirements in this
1)Incident reports were individualized by youth when an incident new electronic system are being met.
involved more than one youth. No further corrective action needed.
2)Incident reports were filed together, and not in each youth’s file. The
agency shall provide a systematic procedure to prevent recurrences.
This is a repeat finding.
1 |P ag e
Form Rev. 01/23/2023
New Findings from Site Visit Corrective Action
OAR 419-470-0020(2)(c) All areas of buildings where children in care are present must be Corrective Action: The agency shall ensure these areas are
kept clean and in good repair. corrected and institute a prevention method to reduce future
OAR 419-470-0020(2)(h)(A) Buildings must be ventilated by natural or mechanical means occurrences.
and must be free of excessive heat, condensation, and obnoxious odors.
The following was observed during the walk-thru.
 The concrete near the front door is cracked and raised exposing sharp areas creating
a trip/fall hazard.
 The downstairs bathroom ceiling and wall had black substance, possibly be mold,
which is also a health concern.
 The downstairs bathroom ventilation fan cover has build-up, which could impact the
effectiveness of ventilation from showers.
Interview Summary
Three youth were individually interviewed, ages 14, 15, and 13, ranging from 3-13 months in the program. They described how the program is
helping them. All reported the food is amazing since the new chef started December 2022, they’re well fed, and the chef works closely with the
nutritionist. They reported getting their medications as prescribed, the therapists are great, and there’s staff that are trusting. Family contact is
better with therapy and when it’s mediated, and they have regular contact in therapy sessions, private calls, and in-person. School is reported as
good, and they get help when needed, but one youth reports not liking the change to “online” version of school. With the lower census, it’s been
good to form closer relationships with peers, but it’s also challenging to be with the same group every day. There’s some drama among peers and
can feel toxic at times. Staff try to redirect, but some insert their personal opinions, side with one youth over another, or let it slide. If a youth gets
in trouble, they report there’s different levels of consequences such as therapeutic focus paperwork or restrictions ranging from no TV or movie
time, not going to the store or an outing, or restriction from interacting with another peer (like time out from peer to peer). One youth described
the process when/if a youth is on safety.* On-site activities and outings were described, however a desire was expressed for more or different
outings.**
They report the agency does well at implementing natural consequences, works well with families, personal development, building family
relationship, and having great therapists. The agency could improve on reducing the amount of down time in the evenings, which was referred to
as “My Time”*** and described as sitting in the living room with staff present for “silent” time, not able to speak to other peers while doing quiet
activities. When asked if they could change anything, it was reported the desire to reduce and/or change “My Time”, improve staff’s abilities on
dealing with youth and peer-to-peer behaviors, and to integrate technology for skill-building to prepare for the “real world” and create opportunities
for work or volunteering.
This licensor followed up on the below areas:
*Further information obtained regarding a youth on “safety” to confirm it meets current licensing rule requirements.
**The activity schedule for April, May, and June was provided to this licensor demonstrating regular activities and outing opportunities.
***My Time. The Program Director shared that youth concerns were expressed over a month ago and with youth input, changes were implemented
approximately mid-April and documentation of this was provided.
2 |P ag e
Form Rev. 01/23/2023
Other notable info: In addition to the full-time RN during the week, a new LPN nurse was recently hired for weekend coverage.
Observations
The Executive Director accompanied this licensor for the walk-thru which consisted of the dorm rooms, bedrooms, living rooms, medication
room, dining hall, kitchen, and therapists’ office area. The environment was welcoming, in good condition and clean, except areas noted above.
Food was observed in the various refrigerators, freezers, and pantry. Bedrooms and dorm rooms were relatively clean with beds made and had
individualized décor.
Corrective Actions and Timeframes: Please submit the following to verify compliance.
Within 45 days of receipt of this report, New Leaf Academy must submit a letter of verification indicating the agency is in compliance with the specific
rules cited above and describing how compliance will be maintained going forward. Along with the letter of verification, the agency must submit any
and all specific documentation requested in the body of this report. The letter of verification and any additional requested documents can be emailed
directly to robin.m.duval@odhsoha.oregon.gov.
Licensing Coordinator’s Signature: ________________________ Date: _6_/2__/2_0_2_3_ ___________
Manager Review: ______________________________________ Date: _6_-_2_-2_0__2_3_ _________
3 | P a g e
Form Rev. 01/23/2023

agency_name: Calo Programs of Missouri, Inc. dba Embark Behavioral Health (EBH)

program_type: (RC) Residential Care Programs

report_type: Unannounced

view_code: RC

facility_type: Residential Care

licensing_coordinator: Robin DuVal

purpose:
Per OAR 419-400-0240 (1)(b) Children's Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Findings Comments
Unannounced Site Visit 10-13-2022 Further Action
Needed
Case Management 413-215-0681(3)(f) Incident Reporting Yes[ ] No The agency recently changed to an electronic system for
Incident Report documentation which allows individual
Incident Reports were filed separately from each youths file. The documentation and tracking per youth.
agency shall ensure Incident Reports must be individualized by each
youth and retained in each youth file. - This licensor will provide technical assistance to ensure
all incident reporting documentation requirements in this
1)Incident reports were individualized by youth when an incident new electronic system are being met.
involved more than one youth. No further corrective action needed.
2)Incident reports were filed together, and not in each youth's file. The
agency shall provide a systematic procedure to prevent recurrences.
This is a repeat finding.

New Findings from Site Visit Corrective Action
OAR 419-470-0020(2)(c) All areas of buildings where children in care are present must be Corrective Action: The agency shall ensure these areas are
kept clean and in good repair. corrected and institute a prevention method to reduce future
OAR 419-470-0020(2)(h)(A) Buildings must be ventilated by natural or mechanical means occurrences.
and must be free of excessive heat, condensation, and obnoxious odors.
The following was observed during the walk-thru.
- The concrete near the front door is cracked and raised exposing sharp areas creating
a trip/fall hazard.
- The downstairs bathroom ceiling and wall had black substance, possibly be mold,
which is also a health concern.
- The downstairs bathroom ventilation fan cover has build-up, which could impact the
effectiveness of ventilation from showers.
Interview Summary
Three youth were individually interviewed, ages 14, 15, and 13, ranging from 3-13 months in the program. They described how the program is
helping them. All reported the food is amazing since the new chef started December 2022, they're well fed, and the chef works closely with the
nutritionist. They reported getting their medications as prescribed, the therapists are great, and there's staff that are trusting. Family contact is
better with therapy and when it's mediated, and they have regular contact in therapy sessions, private calls, and in-person. School is reported as
good, and they get help when needed, but one youth reports not liking the change to "online" version of school. With the lower census, it's been
good to form closer relationships with peers, but it's also challenging to be with the same group every day. There's some drama among peers and
can feel toxic at times. Staff try to redirect, but some insert their personal opinions, side with one youth over another, or let it slide. If a youth gets
in trouble, they report there's different levels of consequences such as therapeutic focus paperwork or restrictions ranging from no TV or movie
time, not going to the store or an outing, or restriction from interacting with another peer (like time out from peer to peer). One youth described
the process when/if a youth is on safety.* On-site activities and outings were described, however a desire was expressed for more or different
outings.**
They report the agency does well at implementing natural consequences, works well with families, personal development, building family
relationship, and having great therapists. The agency could improve on reducing the amount of down time in the evenings, which was referred to
as "My Time"*** and described as sitting in the living room with staff present for "silent" time, not able to speak to other peers while doing quiet
activities. When asked if they could change anything, it was reported the desire to reduce and/or change "My Time", improve staff's abilities on
dealing with youth and peer-to-peer behaviors, and to integrate technology for skill-building to prepare for the "real world" and create opportunities
for work or volunteering.
This licensor followed up on the below areas:
*Further information obtained regarding a youth on "safety" to confirm it meets current licensing rule requirements.
**The activity schedule for April, May, and June was provided to this licensor demonstrating regular activities and outing opportunities.
***My Time. The Program Director shared that youth concerns were expressed over a month ago and with youth input, changes were implemented
approximately mid-April and documentation of this was provided.

Other notable info: In addition to the full-time RN during the week, a new LPN nurse was recently hired for weekend coverage.
Observations
The Executive Director accompanied this licensor for the walk-thru which consisted of the dorm rooms, bedrooms, living rooms, medication
room, dining hall, kitchen, and therapists' office area. The environment was welcoming, in good condition and clean, except areas noted above.
Food was observed in the various refrigerators, freezers, and pantry. Bedrooms and dorm rooms were relatively clean with beds made and had
individualized décor.


summary: Unannounced - 27 findings

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Residential Care
Licensee: Calo Programs Missouri, Inc., d.b.a. Embark Behavioral Health Date of Unannounced: May 13, 2024
Executive Director: Deveney Marshall Licensing Coordinator: Robin DuVal
Program Director: Amber Hailey
Other Regulatory or Accrediting Agencies: Joint Commission Accreditation
Purpose: Per OAR 419-400-0240 (1)(b) Children’s Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Findings Comments
License Renewal Site Visit 11/06-07/2023 Further Action
Needed
Supplemental Information Provided by CCA Yes☐ No✓ All policies and procedures were updated
All required policies and procedures as identified in the “Umbrella Rules” pursuant to each OAR. There’s no further
corrective action needed at this time.
Upon review of the following policies and procedures, there are minor to moderate
edits needed.
Corrective Action: The agency shall update the following policies and procedures
pursuant to each OAR and submit for review.
• Conflict of interest in OAR 419-400-0070
• Children Rights in OAR 419-400-0090(1)
• Grievance Procedures in OAR 419-400-0090(2)
• Mandatory Abuse Reporting in OAR 400-0110(2)(a)
• Incident reporting in OAR 419-400-0110(2)(b)
• Personnel in OAR 419-400-0120
• Privacy in OAR 419-400-0130
• Suicide Prevention in OAR 419-400-0150(4)
• Discipline and behavior management in OAR 419-400-0150
• Transportation in OAR 419-400-0200(1)
• Searches in OAR 419-400-0200(2)
• Hazards in OAR 419-400-0200(4)
Supplemental Information Provided by CCA Yes☐ No✓ All policies and procedures were updated
All required policies and procedures as identified in “Agency Type Specific Rules” pursuant to this OAR. There’s no further
corrective action needed at this time.
The agency shall update the following policy and procedure pursuant to the OAR and
submit for review.
• Medications in OAR 419-470-0110
Form Rev. 11/14/2023 P age 1 | 6
Residential Care Safety 419-470-0080(5)(a) Evacuation drill occurs monthly under Yes☐ No✓ Records were reviewed, and this requirement
varying conditions, is retained 2 years and contains: was met. There’s no further corrective action
(A) identify of person conducting drill needed at this time.
(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
Documentation of evacuation drills were inconsistent.
Corrective Action: The agency shall ensure the evacuation drill log form includes all
required elements noted in (A-H); ensure that evacuation drills occur monthly and are
appropriately documented.
Medication 419-470-0100(7)(a) Prescription medications that are unused and Yes☐ No✓ Medications were observed, and this finding
medications that are expired or recalled may not be maintained with current has been corrected. There’s no further
medication and must be disposed of as described in agency disposal policy. corrective action needed at this time.
Several bubble pack medications were observed to be unsealed, however there were
still pills tucked back in the bubble and/or taped back in. The medication record did
not provide a reasoning for any anomalies. Medications that have been popped out of
their bubble packs and subsequently not administered to a child in care must not be
placed back in the original container.
This concern was brought to the attention of the Executive Director and the Nurse and
immediately began investigating.
Corrective Action:
• The agency shall ensure staff are retrained and following procedures to dispose of
medications when a medication is refused, missed or any other type of medication
error that results in a medication not being administered as prescribed and to follow
the agency’s disposal policy.
• The agency shall ensure management oversight occurs regularly to ensure proper
procedures are followed.
Form Rev. 11/14/2023 P age 2 | 6
Medication 419-470-0100(10) Written record of the administration of medication Yes✓ No Blanks were observed on the Medication
includes: Administration Records (MAR) with no
(a) name corresponding notation. During the review,
(b) description this was discussed with the program RN and
(c) dates and times they will increase their weekly audit to 3-4
(d) missed doses times weekly.
(e) medication disposed
(f) method of administration Corrective action: The agency shall ensure
(g) ID of person administering medication errors, or anomalies in
(h) possible adverse reactions documentation, are documented by adding a
(i) medication taken outside facility notation to the MAR.
Medications that were not administered, refused, missed or any other type of This is a repeat violation.
medication error must be documented. Refer to (7)(c) above.
Corrective Action:
• The agency shall ensure medication errors, or anomalies in documentation, are
documented by adding a notation to the medication administration record.
• The agency shall ensure staff are retrained and following procedures for proper
documentation.
• The agency shall ensure management oversight occurs regularly to ensure proper
procedures are followed.
New Employee Orientation – Umbrella Requirements (30 days) 419-400-0120(4) Yes☐ No✓ Records were reviewed, and this requirement
(c) Suicide prevention and intervention was met. There’s no further corrective action
needed at this time.
The agency shall ensure that all new employees (under Calo Programs Missouri Inc.)
complete this training within 30 days of hire, regardless of their prior employment.
New Employee Orientation – Residential 419-470-0120(1)(e) Training on the Yes☐ No✓ Records were reviewed, and this requirement
agency’s policy on suicide prevention and suicide risk assessment tool. (Prior to was met. There’s no further corrective action
working alone and within 30 days) needed at this time.
The agency shall ensure that all new employees (under Calo Programs Missouri Inc.)
complete this training within 30 days of hire, regardless of their prior employment.
Consents 419-470-0160(1)(f) Impose a dress code Yes☐ No✓ Records were reviewed, and this requirement
was met. There’s no further corrective action
The agency shall ensure consent to impose a dress code is obtained from the child in needed at this time.
care’s parent/guardian and properly documented.
Disclosures 419-470-0160(2) Parent/guardian has acknowledged in writing: Yes☐ No✓ Records were reviewed, and this requirement
(b) Statement of Rights of Children and Parents/Guardians was met. There’s no further corrective action
needed at this time.
The agency shall ensure this disclosure is provided and properly documented
indicating that the parent/guardian has acknowledged.
Form Rev. 11/14/2023 P age 3 | 6
Disclosures 419-470-0160(2) Parent/guardian has acknowledged in writing: Yes☐ No✓ Records were reviewed, and this requirement
(c) Any policies and procedures upon request was met. There’s no further corrective action
needed at this time.
The agency shall ensure this disclosure is provided and properly documented
indicating that the parent/guardian has acknowledged.
Information about Children in Care 419-400-0190(1) Summary sheet contains the Yes☐ No✓ Records were reviewed, and this requirement
following: (a)The name, gender, date of birth, religious preference, and previous was met. There’s no further corrective action
address. needed at this time.
The agency shall ensure an entry is noted for religious preference.
While on-site, the agency discussed ways to incorporate that into their electronic
system in the demographic page.
Information about Children in Care 419-400-0190(1) Summary sheet contains the Yes☐ No✓ Records were reviewed, and this requirement
following: (b) Name and location of previous and current school was met. There’s no further corrective action
needed at this time.
• The agency shall ensure this information is obtained and documented.
• While on-site, the agency discussed ways to incorporate that into their
electronic system in the demographic page.
Information about Children in Care 419-400-0190(1) Summary sheet contains the Yes☐ No✓ Records were reviewed, and this requirement
following: (d) Legal custody was met. There’s no further corrective action
needed at this time.
The agency shall ensure an entry is noted for legal custody.
• While on-site, the agency discussed ways to incorporate that into their electronic
system in the demographic page.
Case Management 419-470-0170(3)(c) Discharge planning evaluations and Yes☐ No✓ Records were reviewed, and this requirement
decisions are documented. was met. There’s no further corrective action
needed at this time.
The agency shall ensure discharge planning evaluations, decisions, etc. are captured
and documented.
Records Relating to Restraint & Involuntary Seclusion 419-400-0180(13)(e) Each Yes☐ No✓ Records were reviewed, and this requirement
child caring agency shall provide notice regarding how to access the quarterly reports was met. There’s no further corrective action
to the parents or guardians of children in care in the program. The child caring agency needed at this time.
shall provide the notice upon the child in care’s admission and at least two times each
year thereafter.
This requirement is not met in its entirety. The agency shall update the notice and
submit for review.
Form Rev. 11/14/2023 P age 4 | 6
Records Relating to Restraint & Involuntary Seclusion 419-400-0190(1) Yes☐ No✓ Records were reviewed, and this requirement
Information provided to children in care relating to Restraint & Involuntary Seclusion was met. There’s no further corrective action
needed at this time.
This requirement is not met in its entirety. The agency shall update the notice and
submit for review.
Financial Records 419-470-0170(4) Records contain date, amount, source, purpose, Yes☐ No✓ Records were reviewed, and this requirement
signatures. was met. There’s no further corrective action
needed at this time.
A small amount of cash was discovered after a child’s admission process, and it was
placed in a baggie labeled with the child’s name and stored in the office.
Corrective Action:
• The agency shall create a financial record log to document any monies belonging to
a child in care. The form must include all elements notes in this rule. Note: Typically,
the program does not allow cash, however a log is required in the event
Comment: The agency has a process for in-program earnings for each child in care
which translates into money on a debit card that’s specific to each child to use on
store outings. The agency provided documentation outlining how the debit card
system works and how it’s tracked.
Comments
While on-site, this licensor and the Program Registered Nurse (RN) who oversees all medication policies, procedures, practices, etc. discussed options regarding
their practice of securely storing unused medications that were being held to return to the guardian. It was decided that this practice will stop, and the stored
medications at the time of this review will be destroyed utilizing the disposal procedures, and the guardians will be notified. Going forward, any unused medications
will be timely destroyed in accordance with disposal procedures.
Action: The RN will update policies and procedures and update all other intake paperwork referring to the practice,
New Findings from Site Visit
None
Form Rev. 11/14/2023 P age 5 | 6
Interview Summary
Two youth were individually interviewed, both ages 13, who had been in the program approximately 22 and 83 days. Both reported that staff are trusting, the
food and chef are good, school is going ok, and they get their medications as prescribed. They feel generally safe, Activities in the program and outings were
described. Due to some other youth’s behaviors, it can be challenging day-to-day to tolerate, but the staff make efforts to separate in groups when possible.
They report having regular contact with approved people outside the program, such as family, and have privacy unless it’s in their plan to be monitored for safety
reasons. When asked to describe “monitoring”, they said a staff person sits on the stairs while youth are in the downstairs living room to monitor but not actively
listening. They report the program does well at keeping a routine and schedule and accommodating each youth’s needs. The program could improve on having
more staff, especially during times when 1-2 other youth are dysregulated. This would provide more ability to separate youth from youth who are dysregulated,
so the other youth aren’t triggered.
Observations
This program has a home-like environment in one building consisting of two dorm-like wings with the dining room in between. An adjacent building houses the
therapists’ offices with along with a milieu space. Youth bedrooms, dorm rooms, bathrooms, living rooms, kitchen, dining room, and the medication room were
observed to be clean, odor-free, and in good condition. A variety of food was observed in appropriate food storage areas. Staff were observed interacting with
youth, as well as other administrative staff, and staff were welcoming. The outside grounds are maintained with areas of green grass, pavement, and gravel
areas for outside activities.
Corrective Actions and Timeframes: Please submit the following to verify compliance.
Within 45 days of receipt of this report Calo Programs Missouri, Inc. must submit a letter of verification indicating the agency is in compliance
with the specific rules cited above and describing how compliance will be maintained going forward. Along with the letter of verification, the agency
must submit any and all specific documentation requested in the body of this report. The letter of verification and any additional requested
documents are to be emailed directly to Robin DuVal at robin.m.duval@odhsoha.oregon.gov.
Licensing Coordinator’s Signature: ________________________ Date: _8_/1_2_/_2_0_2_4___________
8-12-2024
Manager Review: ______________________________________ Date: __________________
Form Rev. 11/14/2023 P age 6 | 6

program_director: Amber Hailey

other_regulatory_agencies: Joint Commission Accreditation

purpose:
Per OAR 419-400-0240 (1)(b) Children's Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Findings Comments
License Renewal Site Visit 11/06-07/2023 Further Action
Needed
Supplemental Information Provided by CCA Yes[ ] No✓ All policies and procedures were updated
All required policies and procedures as identified in the "Umbrella Rules" pursuant to each OAR. There's no further
corrective action needed at this time.
Upon review of the following policies and procedures, there are minor to moderate
edits needed.
Corrective Action: The agency shall update the following policies and procedures
pursuant to each OAR and submit for review.
- Conflict of interest in OAR 419-400-0070
- Children Rights in OAR 419-400-0090(1)
- Grievance Procedures in OAR 419-400-0090(2)
- Mandatory Abuse Reporting in OAR 400-0110(2)(a)
- Incident reporting in OAR 419-400-0110(2)(b)
- Personnel in OAR 419-400-0120
- Privacy in OAR 419-400-0130
- Suicide Prevention in OAR 419-400-0150(4)
- Discipline and behavior management in OAR 419-400-0150
- Transportation in OAR 419-400-0200(1)
- Searches in OAR 419-400-0200(2)
- Hazards in OAR 419-400-0200(4)
Supplemental Information Provided by CCA Yes[ ] No✓ All policies and procedures were updated
All required policies and procedures as identified in "Agency Type Specific Rules" pursuant to this OAR. There's no further
corrective action needed at this time.
The agency shall update the following policy and procedure pursuant to the OAR and
submit for review.
- Medications in OAR 419-470-0110

Residential Care Safety 419-470-0080(5)(a) Evacuation drill occurs monthly under Yes[ ] No✓ Records were reviewed, and this requirement
varying conditions, is retained 2 years and contains: was met. There's no further corrective action
(A) identify of person conducting drill needed at this time.
(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
Documentation of evacuation drills were inconsistent.
Corrective Action: The agency shall ensure the evacuation drill log form includes all
required elements noted in (A-H); ensure that evacuation drills occur monthly and are
appropriately documented.
Medication 419-470-0100(7)(a) Prescription medications that are unused and Yes[ ] No✓ Medications were observed, and this finding
medications that are expired or recalled may not be maintained with current has been corrected. There's no further
medication and must be disposed of as described in agency disposal policy. corrective action needed at this time.
Several bubble pack medications were observed to be unsealed, however there were
still pills tucked back in the bubble and/or taped back in. The medication record did
not provide a reasoning for any anomalies. Medications that have been popped out of
their bubble packs and subsequently not administered to a child in care must not be
placed back in the original container.
This concern was brought to the attention of the Executive Director and the Nurse and
immediately began investigating.
Corrective Action:
- The agency shall ensure staff are retrained and following procedures to dispose of
medications when a medication is refused, missed or any other type of medication
error that results in a medication not being administered as prescribed and to follow
the agency's disposal policy.
- The agency shall ensure management oversight occurs regularly to ensure proper
procedures are followed.

Medication 419-470-0100(10) Written record of the administration of medication Yes✓ No Blanks were observed on the Medication
includes: Administration Records (MAR) with no
(a) name corresponding notation. During the review,
(b) description this was discussed with the program RN and
(c) dates and times they will increase their weekly audit to 3-4
(d) missed doses times weekly.
(e) medication disposed
(f) method of administration Corrective action: The agency shall ensure
(g) ID of person administering medication errors, or anomalies in
(h) possible adverse reactions documentation, are documented by adding a
(i) medication taken outside facility notation to the MAR.
Medications that were not administered, refused, missed or any other type of This is a repeat violation.
medication error must be documented. Refer to (7)(c) above.
Corrective Action:
- The agency shall ensure medication errors, or anomalies in documentation, are
documented by adding a notation to the medication administration record.
- The agency shall ensure staff are retrained and following procedures for proper
documentation.
- The agency shall ensure management oversight occurs regularly to ensure proper
procedures are followed.
New Employee Orientation - Umbrella Requirements (30 days) 419-400-0120(4) Yes[ ] No✓ Records were reviewed, and this requirement
(c) Suicide prevention and intervention was met. There's no further corrective action
needed at this time.
The agency shall ensure that all new employees (under Calo Programs Missouri Inc.)
complete this training within 30 days of hire, regardless of their prior employment.
New Employee Orientation - Residential 419-470-0120(1)(e) Training on the Yes[ ] No✓ Records were reviewed, and this requirement
agency's policy on suicide prevention and suicide risk assessment tool. (Prior to was met. There's no further corrective action
working alone and within 30 days) needed at this time.
The agency shall ensure that all new employees (under Calo Programs Missouri Inc.)
complete this training within 30 days of hire, regardless of their prior employment.
Consents 419-470-0160(1)(f) Impose a dress code Yes[ ] No✓ Records were reviewed, and this requirement
was met. There's no further corrective action
The agency shall ensure consent to impose a dress code is obtained from the child in needed at this time.
care's parent/guardian and properly documented.
Disclosures 419-470-0160(2) Parent/guardian has acknowledged in writing: Yes[ ] No✓ Records were reviewed, and this requirement
(b) Statement of Rights of Children and Parents/Guardians was met. There's no further corrective action
needed at this time.
The agency shall ensure this disclosure is provided and properly documented
indicating that the parent/guardian has acknowledged.

Disclosures 419-470-0160(2) Parent/guardian has acknowledged in writing: Yes[ ] No✓ Records were reviewed, and this requirement
(c) Any policies and procedures upon request was met. There's no further corrective action
needed at this time.
The agency shall ensure this disclosure is provided and properly documented
indicating that the parent/guardian has acknowledged.
Information about Children in Care 419-400-0190(1) Summary sheet contains the Yes[ ] No✓ Records were reviewed, and this requirement
following: (a)The name, gender, date of birth, religious preference, and previous was met. There's no further corrective action
address. needed at this time.
The agency shall ensure an entry is noted for religious preference.
While on-site, the agency discussed ways to incorporate that into their electronic
system in the demographic page.
Information about Children in Care 419-400-0190(1) Summary sheet contains the Yes[ ] No✓ Records were reviewed, and this requirement
following: (b) Name and location of previous and current school was met. There's no further corrective action
needed at this time.
- The agency shall ensure this information is obtained and documented.
- While on-site, the agency discussed ways to incorporate that into their
electronic system in the demographic page.
Information about Children in Care 419-400-0190(1) Summary sheet contains the Yes[ ] No✓ Records were reviewed, and this requirement
following: (d) Legal custody was met. There's no further corrective action
needed at this time.
The agency shall ensure an entry is noted for legal custody.
- While on-site, the agency discussed ways to incorporate that into their electronic
system in the demographic page.
Case Management 419-470-0170(3)(c) Discharge planning evaluations and Yes[ ] No✓ Records were reviewed, and this requirement
decisions are documented. was met. There's no further corrective action
needed at this time.
The agency shall ensure discharge planning evaluations, decisions, etc. are captured
and documented.
Records Relating to Restraint & Involuntary Seclusion 419-400-0180(13)(e) Each Yes[ ] No✓ Records were reviewed, and this requirement
child caring agency shall provide notice regarding how to access the quarterly reports was met. There's no further corrective action
to the parents or guardians of children in care in the program. The child caring agency needed at this time.
shall provide the notice upon the child in care's admission and at least two times each
year thereafter.
This requirement is not met in its entirety. The agency shall update the notice and
submit for review.

Records Relating to Restraint & Involuntary Seclusion 419-400-0190(1) Yes[ ] No✓ Records were reviewed, and this requirement
Information provided to children in care relating to Restraint & Involuntary Seclusion was met. There's no further corrective action
needed at this time.
This requirement is not met in its entirety. The agency shall update the notice and
submit for review.
Financial Records 419-470-0170(4) Records contain date, amount, source, purpose, Yes[ ] No✓ Records were reviewed, and this requirement
signatures. was met. There's no further corrective action
needed at this time.
A small amount of cash was discovered after a child's admission process, and it was
placed in a baggie labeled with the child's name and stored in the office.
Corrective Action:
- The agency shall create a financial record log to document any monies belonging to
a child in care. The form must include all elements notes in this rule. Note: Typically,
the program does not allow cash, however a log is required in the event
Comment: The agency has a process for in-program earnings for each child in care
which translates into money on a debit card that's specific to each child to use on
store outings. The agency provided documentation outlining how the debit card
system works and how it's tracked.
Comments
While on-site, this licensor and the Program Registered Nurse (RN) who oversees all medication policies, procedures, practices, etc. discussed options regarding
their practice of securely storing unused medications that were being held to return to the guardian. It was decided that this practice will stop, and the stored
medications at the time of this review will be destroyed utilizing the disposal procedures, and the guardians will be notified. Going forward, any unused medications
will be timely destroyed in accordance with disposal procedures.
Action: The RN will update policies and procedures and update all other intake paperwork referring to the practice,
New Findings from Site Visit
None

Interview Summary
Two youth were individually interviewed, both ages 13, who had been in the program approximately 22 and 83 days. Both reported that staff are trusting, the
food and chef are good, school is going ok, and they get their medications as prescribed. They feel generally safe, Activities in the program and outings were
described. Due to some other youth's behaviors, it can be challenging day-to-day to tolerate, but the staff make efforts to separate in groups when possible.
They report having regular contact with approved people outside the program, such as family, and have privacy unless it's in their plan to be monitored for safety
reasons. When asked to describe "monitoring", they said a staff person sits on the stairs while youth are in the downstairs living room to monitor but not actively
listening. They report the program does well at keeping a routine and schedule and accommodating each youth's needs. The program could improve on having
more staff, especially during times when 1-2 other youth are dysregulated. This would provide more ability to separate youth from youth who are dysregulated,
so the other youth aren't triggered.
Observations
This program has a home-like environment in one building consisting of two dorm-like wings with the dining room in between. An adjacent building houses the
therapists' offices with along with a milieu space. Youth bedrooms, dorm rooms, bathrooms, living rooms, kitchen, dining room, and the medication room were
observed to be clean, odor-free, and in good condition. A variety of food was observed in appropriate food storage areas. Staff were observed interacting with
youth, as well as other administrative staff, and staff were welcoming. The outside grounds are maintained with areas of green grass, pavement, and gravel
areas for outside activities.

excerpt:
419-400-0070
- Children Rights in OAR

excerpt:
419-400-0150
- Transportation in OAR

excerpt:
419-470-0110
Residential Care Safety