summary: Unannounced - 2 findings

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Licensee: Parrott Creek Child & Family Srvs
Executive Director: Simon Fulford
Program Director(s): Neil Davies
Date of Unannounced: 10/24/2022
Licensing Coordinator: Jeff Minden and Aubrey Kelly
Other Regulatory or Accrediting Agencies: Oregon Youth Authority (OYA), Oregon Department of Human Services (ODHS)
Purpose: Per OAR 413-215-0101 (1) (b) Children’s Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Comments
2022 License Renewal Report 09-12-2022 Findings
Further Action
Needed
413-215-0541(3)(a) Yes☐ No Drill logs were reviewed, and monthly drills had been completed as required since the
An unannounced evacuation drill must be held licensing review in early September.
monthly under varying conditions to simulate
the unusual conditions that occur in the event
of fire.
Evacuation and fire drills were not conducted
on a monthly basis, and nearly a year’s worth
of drills was not logged. The program has
been consistent in conducting them for the
last few months.
The program is still within the 45-day timeframe to address the outstanding findings
from the previous site review.
1
(rev. 07/21/2022)
New Findings from Site Visit Comments
413-215-0511 (2)(b) A hole was observed in the wall of a room used for youth to use who are feeling ill during the school day The
All areas of buildings where children in care hole was several inches in diameter and located in the wall of a room off of the classroom area that youth use
are present must be kept clean and in good when feeling ill during school times
repair. Major appliances and heating,
ventilation, plumbing, and electrical systems
must be functional and in good repair.
Interview Summary
2 youth were interviewed as a part of the unannounced visit. Both youth reported feeling safe in the program and liking the program. Neither youth had been
at any other programs previously. Both you reported getting along well with peers and having staff they could go to if they needed something. Both youth
reported having frequent contact with family and that the food was good, although one youth did wish there was more variety in the casseroles. Neither youth
reported witnessing any holds or concerning incidents by staff. Both youth were aware of their discharge plans and timelines. One youth wished that they
didn’t have to group at med pass time but understood the need for it so medications could be passed in an orderly manner. The other youth wished for more
activities and a better basketball court.
Observations
A tour of the facility was completed. The facility was clean and in good repair, except for the previously noted hole. Youth bedrooms were relatively organized
and clean, especially given that daily cleaning time was not until later in the day.
Corrective Actions and Timeframes:
Please submit the following to verify compliance.
Within 45 days of receipt of this report Parrott Creek Child and Family Svcs 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,
2
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 Jeffrey.E.Minden@dhsoha.state.or.us.
Licensing Coordinator’s Signature: ________________________ Date: _1_1_-_0_2_-2__0_2_2_ ________
Manager Review: ______________________________________ Date: _1_0_-_2_7_-_2_0_2_2_ _______
3

licensee: Parrott Creek Child & Family Srvs

executive_director: Simon Fulford

program_director: Neil Davies

licensing_coordinator: Jeff Minden and Aubrey Kelly

purpose:
Per OAR 413-215-0101 (1) (b) Children's Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Comments
2022 License Renewal Report 09-12-2022 Findings
Further Action
Needed
413-215-0541(3)(a) Yes[ ] No Drill logs were reviewed, and monthly drills had been completed as required since the
An unannounced evacuation drill must be held licensing review in early September.
monthly under varying conditions to simulate
the unusual conditions that occur in the event
of fire.
Evacuation and fire drills were not conducted
on a monthly basis, and nearly a year's worth
of drills was not logged. The program has
been consistent in conducting them for the
last few months.
The program is still within the 45-day timeframe to address the outstanding findings
from the previous site review.
1

New Findings from Site Visit Comments
413-215-0511 (2)(b) A hole was observed in the wall of a room used for youth to use who are feeling ill during the school day The
All areas of buildings where children in care hole was several inches in diameter and located in the wall of a room off of the classroom area that youth use
are present must be kept clean and in good when feeling ill during school times
repair. Major appliances and heating,
ventilation, plumbing, and electrical systems
must be functional and in good repair.
Interview Summary
2 youth were interviewed as a part of the unannounced visit. Both youth reported feeling safe in the program and liking the program. Neither youth had been
at any other programs previously. Both you reported getting along well with peers and having staff they could go to if they needed something. Both youth
reported having frequent contact with family and that the food was good, although one youth did wish there was more variety in the casseroles. Neither youth
reported witnessing any holds or concerning incidents by staff. Both youth were aware of their discharge plans and timelines. One youth wished that they
didn't have to group at med pass time but understood the need for it so medications could be passed in an orderly manner. The other youth wished for more
activities and a better basketball court.
Observations
A tour of the facility was completed. The facility was clean and in good repair, except for the previously noted hole. Youth bedrooms were relatively organized
and clean, especially given that daily cleaning time was not until later in the day.


state: OR

facility_name: New Era House

summary: Unannounced - 7 findings

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Licensee: Parrott Creek Child and Family Services
Executive Director: Simon Fulford
Date of Unannounced: 10/23/2023
Licensing Coordinator: Jeff Minden, Aubrey Kelly
Other Regulatory or Accrediting Agencies: Oregon Youth Authority (OYA)
Purpose: Per OAR 419-400-0240 (1)(b) Children’s Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Comments
License Renewal Site Visit Findings
October 2022 Further Action
Needed
419-470-0080 Yes☐ No✓ Fire Marshal inspection was completed and provided to licensing for the new temporary
Safety location of services prior to moving.
A residential care agency must meet all of the
following requirements related to safety:
(1) Fire safety. Prior to licensure and every
two years upon license renewal, the program
must be assessed and approved by the State
Fire Marshall or designee.
Fire Marshal inspection had not been
completed at time of last review
Written policies for compliance with Interstate Yes☐ No✓ The program has added policies for compliance with the Interstate Compact of the
Compact of the placement of children and the Placement of Children and the Indian Child Welfare Act
Indian Child Welfare Act were not submitted
1| P age
Form Rev. 01/23/2023
413-215-0541 Safety Yes☐ No✓ The program has been conducting regular fire drills
(5) Evacuation drills.
(a) An unannounced evacuation drill must be
held monthly under varying conditions to
simulate the unusual conditions that occur in
the event of fire.
Evacuation and fire drills were not conducted
on a monthly basis and nearly a year’s worth
of drills were not logged.
419-470-0120 Staff Training Yes☐ No✓ The program has been completing New Employee Orientation within 30 days of hire
(1) Staff of the residential care agency must be
provided with orientation training prior to
working alone with a child in care and must be
completed within 30 days of hire.
New Employee orientation trainings in 4 out of
5 reviewed files were not completed within 30
days of hire
419-470-0160 Consents, Disclosures, and Yes☐ No✓ The program has added consent documentation for the Reasonable and Prudent Parent
Authorizations Standard to the intake packet.
(1) Consents. For each child in care in
placement with a residential care agency, the
residential care agency must ensure that a
parent or legal guardian signs a consent that
authorizes the residential care agency to
undertake each of the following: ---
(g) To apply the reasonable and prudent
parent standard to determine whether the
child in care is allowed to participate in age-
appropriate or developmentally appropriate
activities including extracurricular, enrichment,
cultural, and social activities.
Consent for reasonable and prudent parent
standard was only located in 1 out of 5
reviewed files
419-470-0170 Information About Children Yes☐ No✓ The summary sheet now includes a section for religious preference.
in Care
(1) Case files of children in care. For each
child in care a residential care agency accepts
for placement, the residential care agency
must maintain an individual record that
includes a summary sheet containing all of the
following information:
2| P age
Form Rev. 01/23/2023
(a) The name, gender, date of birth, religious
preference, and previous address of the child
in care.
Summary Sheet did not include information
about religious preference
419-470-0170 Information About Children Yes☐ No✓ Client files were reviewed, and Assessments were completed within 45 days.
in Care ---
(2) Service planning. ---
(d) Assessment. A comprehensive
assessment must be completed within the first
45 days of placement.
One reviewed file indicated an assessment
was completed on day 52. Assessments are
required to be completed within 45 days.
New Findings from Site Visit Comments
OAR 419-400-0200(4)(a) A child caring During the site walkthrough it was noted that Parrott Creek had installed several foaming hand
agency must protect children in its care sanitizer dispensers throughout the facility, including in client areas. It was noted that the
from hazardous materials dispensers were easily opened and contained plastic containers with liquid hand sanitizer containing
67% ethanol alcohol.
Parrott Creek sent photos confirming the dispensers had been removed within a few hours of the
visit.
Interview Summary
One youth was interviewed as a part of the site visit. He’s been here about 9 months. This is not where he wants to be but appreciates the
warm food, nice bed and nice home. They teach DBT and it has helped him a lot. It has helped him reflect on other people’s feelings and has
learned about distress tolerance. When he first came here, he got into arguments with the other clients and ran away for 1 night. He believes
he’s grown a lot here and has become a better person. He’s from Albany and has frequent visits. Another client is discharging today, so he says
he’s now the “OG” of the clients. They get phone calls during the week and on the weekend. The food is good, his favorites are nachos and
quesadillas. He’s currently working on his GED. No one has put their hands on him since being at the program and he now gets along with the
other clients. His favorite staff is Payton, she’s positive and has a brighter perspective on things. They had 1 staff who worked here who was
“creepy and weird”. After the interview licensing did follow up with the program about the staff member mentioned by the youth. Management
confirmed that there had been a staff who had exhibited some behaviors towards other staff that were as described by the youth, and that staff
was let go. Management reported that there were no concerns about any of this staff’s behaviors being directed towards youth.
One staff member was also interviewed. Staff reported having been with Parrott Creek for approximately 4.5 years. The staff member reported
getting along well with other staff and that her manager is supportive and they feel comfortable reaching out for support. Staff reported that they
do not like all the mag lock doors at the current temporary location, and that they wish the program had more youth and more staff.
3| P age
Form Rev. 01/23/2023
Observations
A walk through of the program was completed as a part of the review. Parrott Creek is currently building a new facility at their normal location,
and for the duration of the construction the program has temporarily relocated to the former Robinswood site owned by Youth Villages. The
program estimates that they will be at this site until sometime in 2025, and the transition back will be dependent on ensuring that the client’s
schooling is not interrupted due to the school district change. The facility was clean and organized. Management noted that the transition has
been good overall, and youth having their own spaces has helped reduce incidents; however, staff are not fans of all the doors that need
unlocking. The youth also have access to an indoor basketball court which they reportedly really enjoy.
Corrective Actions and Timeframes:
Only 1 corrective action was identified during the site visit, and Licensing has already verified that it has been corrected. No further corrective
actions are required by the program.
Licensing Coordinator’s Signature: ________________________ Date: ___________________
Manager Review: ______________________________________ Date: _1_0_-_3_0_-_2_3_2_3_ _______
4| P age
Form Rev. 01/23/2023

agency_name: Parrott Creek Child and Family Services (PCCFS)

program_name: New Era House

program_type: (RC) Residential Care Programs

report_type: Unannounced

view_code: RC

licensee: Parrott Creek Child and Family Services

licensing_coordinator: Jeff Minden, Aubrey Kelly

other_regulatory_agencies: Oregon Youth Authority (OYA)

purpose:
Per OAR 419-400-0240 (1)(b) Children's Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Comments
License Renewal Site Visit Findings
October 2022 Further Action
Needed
419-470-0080 Yes[ ] No✓ Fire Marshal inspection was completed and provided to licensing for the new temporary
Safety location of services prior to moving.
A residential care agency must meet all of the
following requirements related to safety:
(1) Fire safety. Prior to licensure and every
two years upon license renewal, the program
must be assessed and approved by the State
Fire Marshall or designee.
Fire Marshal inspection had not been
completed at time of last review
Written policies for compliance with Interstate Yes[ ] No✓ The program has added policies for compliance with the Interstate Compact of the
Compact of the placement of children and the Placement of Children and the Indian Child Welfare Act
Indian Child Welfare Act were not submitted

413-215-0541 Safety Yes[ ] No✓ The program has been conducting regular fire drills
(5) Evacuation drills.
(a) An unannounced evacuation drill must be
held monthly under varying conditions to
simulate the unusual conditions that occur in
the event of fire.
Evacuation and fire drills were not conducted
on a monthly basis and nearly a year's worth
of drills were not logged.
419-470-0120 Staff Training Yes[ ] No✓ The program has been completing New Employee Orientation within 30 days of hire
(1) Staff of the residential care agency must be
provided with orientation training prior to
working alone with a child in care and must be
completed within 30 days of hire.
New Employee orientation trainings in 4 out of
5 reviewed files were not completed within 30
days of hire
419-470-0160 Consents, Disclosures, and Yes[ ] No✓ The program has added consent documentation for the Reasonable and Prudent Parent
Authorizations Standard to the intake packet.
(1) Consents. For each child in care in
placement with a residential care agency, the
residential care agency must ensure that a
parent or legal guardian signs a consent that
authorizes the residential care agency to
undertake each of the following: ---
(g) To apply the reasonable and prudent
parent standard to determine whether the
child in care is allowed to participate in age-
appropriate or developmentally appropriate
activities including extracurricular, enrichment,
cultural, and social activities.
Consent for reasonable and prudent parent
standard was only located in 1 out of 5
reviewed files
419-470-0170 Information About Children Yes[ ] No✓ The summary sheet now includes a section for religious preference.
in Care
(1) Case files of children in care. For each
child in care a residential care agency accepts
for placement, the residential care agency
must maintain an individual record that
includes a summary sheet containing all of the
following information:

(a) The name, gender, date of birth, religious
preference, and previous address of the child
in care.
Summary Sheet did not include information
about religious preference
419-470-0170 Information About Children Yes[ ] No✓ Client files were reviewed, and Assessments were completed within 45 days.
in Care ---
(2) Service planning. ---
(d) Assessment. A comprehensive
assessment must be completed within the first
45 days of placement.
One reviewed file indicated an assessment
was completed on day 52. Assessments are
required to be completed within 45 days.
New Findings from Site Visit Comments
OAR 419-400-0200(4)(a) A child caring During the site walkthrough it was noted that Parrott Creek had installed several foaming hand
agency must protect children in its care sanitizer dispensers throughout the facility, including in client areas. It was noted that the
from hazardous materials dispensers were easily opened and contained plastic containers with liquid hand sanitizer containing
67% ethanol alcohol.
Parrott Creek sent photos confirming the dispensers had been removed within a few hours of the
visit.
Interview Summary
One youth was interviewed as a part of the site visit. He's been here about 9 months. This is not where he wants to be but appreciates the
warm food, nice bed and nice home. They teach DBT and it has helped him a lot. It has helped him reflect on other people's feelings and has
learned about distress tolerance. When he first came here, he got into arguments with the other clients and ran away for 1 night. He believes
he's grown a lot here and has become a better person. He's from Albany and has frequent visits. Another client is discharging today, so he says
he's now the "OG" of the clients. They get phone calls during the week and on the weekend. The food is good, his favorites are nachos and
quesadillas. He's currently working on his GED. No one has put their hands on him since being at the program and he now gets along with the
other clients. His favorite staff is Payton, she's positive and has a brighter perspective on things. They had 1 staff who worked here who was
"creepy and weird". After the interview licensing did follow up with the program about the staff member mentioned by the youth. Management
confirmed that there had been a staff who had exhibited some behaviors towards other staff that were as described by the youth, and that staff
was let go. Management reported that there were no concerns about any of this staff's behaviors being directed towards youth.
One staff member was also interviewed. Staff reported having been with Parrott Creek for approximately 4.5 years. The staff member reported
getting along well with other staff and that her manager is supportive and they feel comfortable reaching out for support. Staff reported that they
do not like all the mag lock doors at the current temporary location, and that they wish the program had more youth and more staff.

Observations
A walk through of the program was completed as a part of the review. Parrott Creek is currently building a new facility at their normal location,
and for the duration of the construction the program has temporarily relocated to the former Robinswood site owned by Youth Villages. The
program estimates that they will be at this site until sometime in 2025, and the transition back will be dependent on ensuring that the client's
schooling is not interrupted due to the school district change. The facility was clean and organized. Management noted that the transition has
been good overall, and youth having their own spaces has helped reduce incidents; however, staff are not fans of all the doors that need
unlocking. The youth also have access to an indoor basketball court which they reportedly really enjoy.

excerpt:
419-400-0200(4)(a) A child caring During the site walkthrough it was noted that Parrott Creek had installed several foaming hand
agency must protect children in its care sanitizer dispensers throughout the facility, including in client areas. It was noted that the
from hazardous materials dispensers were easily opened and contained plastic containers with liquid hand sanitizer containing
67% ethanol alcohol.
Parrott Creek sent photos confirming the dispensers had been removed within a few hours of the
visit.
OAR


summary: Unannounced - 3 findings

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Residential Care
Licensee: Parrot Creek Child and Family Services
Executive Director: Simon Folford
Program Director(s): Leah Lamb
Date of Unannounced: 4/9/2024
Licensing Coordinator: Jeff Minden
Other Regulatory or Accrediting Agencies: Oregon Youth Authority (OYA)
Purpose: Per OAR 419-400-0240 (1)(b) Children’s Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Comments
Unannounced Site Visit 10/23/2023 Findings
Further Action
Needed
OAR 419-400-0200 Yes☐ No✓ The hand sanitizer dispensers were no longer in the facility during this walk through.
(4)(a) A child caring agency must protect
children in its care from hazardous materials
• During the site walkthrough it was
noted that Parrott Creek had installed
several foaming hand sanitizer
dispensers throughout the facility,
including in client areas. It was noted
that the dispensers were easily
opened and contained plastic
containers with liquid hand sanitizer
containing 67% ethanol alcohol.
Parrott Creek sent photos confirming the
dispensers had been removed within a few
hours of the visit.
Form Rev. 11/14/2023 P age 1 | 4
Room and Space Requirements Yes☐ No✓ Licensing rules have updated since this finding and window exceptions are no longer
Bedrooms 419-470-0030 (3) required as long as they are functioning as designed and approved during the fire marshal
(d) Be an outside room, with a window that inspection.
operates as designed. If the window is
modified from its original design, the fire
marshal must approve the modification and
indicate the room still meets applicable
Oregon Fire Code.
• An exception request was granted for
the 2020-2022 licensing period for the
windows to be secure in The Ranch
facility.
CORRECTIVE ACTION: Submit new
exception request for licensing period 2022-
2024 for windows to continue to remain fixed.
New Findings from Site Visit Comments
OAR 419-400-0200 During the facility walkthrough a bottle of spray cleaner had been left in one of the day
(4)(a) A child caring agency must rooms.
protect children in its care from
hazardous materials.
Form Rev. 11/14/2023 P age 2 | 4
Interview Summary
2 youth and 1 staff were interviewed as a part of the site visit. One youth had been with Parrott Creek for approximately 18 months
and the other for approximately 6 months. Both reported liking the program and feeling safe. Both youth reported that staff are
friendly and helpful, and both named Skyler as a preferred staff for helping work through things. One youth also stated that Staff
Hayden was good for getting advice from. One youth appreciated that the program had been working with their dental provider to
schedule some appointments that they needed. Both youth reported liking the food. One youth reported wishing there were more
activities to do, but did appreciate the access to the weight room and the ability to go on outings. Both youth reported having plenty
of access to make phone calls to family. One youth stated they wished there was more equipment in the weightroom so they had
more variety.
The interviewed staff reported that they really enjoy working for Parrott Creek. Staff reported that they recently received their
Certified Alcohol and Drug Counselor (CADC) certification and are working on becoming a Qualified Mental Health Professional
(QMHP) and that the program has been very supportive of their ongoing training. Staff reported that management is very
supportive and open, and the reason they continue to work for Parrott Creek. Staff reported that they felt the initial training could
have been more extensive, however they reported that recently management has done a good job of increasing training and
building a supportive work culture. Staff reported appreciating that they felt like management allowed for mistakes to happen as
long as they were learned from.
Observations
A walkthrough of the facility was conducted as a part of the site review. The youth bedrooms were clean, and each youth had
decorated their doors and rooms with art, posters, and lighting. The bathrooms appeared clean and well maintained, without any
unpleasant odors. Common areas also appeared in good repair. It was noted that there were a couple holes in the walls in the
weight room that the program reported were being reported to the facility maintenance for fixing.
In discussion with Program Manager Leah Lamb, she reported that things were going well in the program’s temporary location in
Lake Oswego. Parrott Creek is still working on fundraising for construction of a new facility at the program’s original site, and the
outcome of that would determine when the clients would move back to the Oregon City location, either January or July.
Construction is reportedly progressing at the Oregon City location.
Form Rev. 11/14/2023 P age 3 | 4
Corrective Actions and Timeframes:
Please submit the following to verify compliance.
Within 45 days of receipt of this report Parrot Creek Child and Family Services must submit a letter of verification indicating the agency is in
compliance with the specific rules cited above and describing how compliance will be maintained going forward. Along with the letter of verification,
the agency must submit any and all specific documentation requested in the body of this report. The letter of verification and any additional
requested documents can be emailed directly to Jeff Minden Jeffrey.E.Minden@odhsoha.oregon.gov.
Licensing Coordinator’s Signature: ________________________ Date: _4_/_2_3_/2_0_2__4__________
Manager Review: ______________________________________ Date: _4_-2_3_-_2_0_2_4__________
Form Rev. 11/14/2023 P age 4 | 4

facility_type: Residential Care

licensee: Parrot Creek Child and Family Services

executive_director: Simon Folford

program_director: Leah Lamb

licensing_coordinator: Jeff Minden

purpose:
Per OAR 419-400-0240 (1)(b) Children's Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Comments
Unannounced Site Visit 10/23/2023 Findings
Further Action
Needed
OAR 419-400-0200 Yes[ ] No✓ The hand sanitizer dispensers were no longer in the facility during this walk through.
(4)(a) A child caring agency must protect
children in its care from hazardous materials
- During the site walkthrough it was
noted that Parrott Creek had installed
several foaming hand sanitizer
dispensers throughout the facility,
including in client areas. It was noted
that the dispensers were easily
opened and contained plastic
containers with liquid hand sanitizer
containing 67% ethanol alcohol.
Parrott Creek sent photos confirming the
dispensers had been removed within a few
hours of the visit.

Room and Space Requirements Yes[ ] No✓ Licensing rules have updated since this finding and window exceptions are no longer
Bedrooms 419-470-0030 (3) required as long as they are functioning as designed and approved during the fire marshal
(d) Be an outside room, with a window that inspection.
operates as designed. If the window is
modified from its original design, the fire
marshal must approve the modification and
indicate the room still meets applicable
Oregon Fire Code.
- An exception request was granted for
the 2020-2022 licensing period for the
windows to be secure in The Ranch
facility.
CORRECTIVE ACTION: Submit new
exception request for licensing period 2022-
2024 for windows to continue to remain fixed.
New Findings from Site Visit Comments
OAR 419-400-0200 During the facility walkthrough a bottle of spray cleaner had been left in one of the day
(4)(a) A child caring agency must rooms.
protect children in its care from
hazardous materials.

Interview Summary
2 youth and 1 staff were interviewed as a part of the site visit. One youth had been with Parrott Creek for approximately 18 months
and the other for approximately 6 months. Both reported liking the program and feeling safe. Both youth reported that staff are
friendly and helpful, and both named Skyler as a preferred staff for helping work through things. One youth also stated that Staff
Hayden was good for getting advice from. One youth appreciated that the program had been working with their dental provider to
schedule some appointments that they needed. Both youth reported liking the food. One youth reported wishing there were more
activities to do, but did appreciate the access to the weight room and the ability to go on outings. Both youth reported having plenty
of access to make phone calls to family. One youth stated they wished there was more equipment in the weightroom so they had
more variety.
The interviewed staff reported that they really enjoy working for Parrott Creek. Staff reported that they recently received their
Certified Alcohol and Drug Counselor (CADC) certification and are working on becoming a Qualified Mental Health Professional
(QMHP) and that the program has been very supportive of their ongoing training. Staff reported that management is very
supportive and open, and the reason they continue to work for Parrott Creek. Staff reported that they felt the initial training could
have been more extensive, however they reported that recently management has done a good job of increasing training and
building a supportive work culture. Staff reported appreciating that they felt like management allowed for mistakes to happen as
long as they were learned from.
Observations
A walkthrough of the facility was conducted as a part of the site review. The youth bedrooms were clean, and each youth had
decorated their doors and rooms with art, posters, and lighting. The bathrooms appeared clean and well maintained, without any
unpleasant odors. Common areas also appeared in good repair. It was noted that there were a couple holes in the walls in the
weight room that the program reported were being reported to the facility maintenance for fixing.
In discussion with Program Manager Leah Lamb, she reported that things were going well in the program's temporary location in
Lake Oswego. Parrott Creek is still working on fundraising for construction of a new facility at the program's original site, and the
outcome of that would determine when the clients would move back to the Oregon City location, either January or July.
Construction is reportedly progressing at the Oregon City location.

excerpt:
419-400-0200 During the facility walkthrough a bottle of spray cleaner had been left in one of the day
(4)(a) A child caring agency must rooms.
protect children in its care from
hazardous materials.
OAR


summary: License Renewals - 11 findings

raw_content:
Licensed Child Caring Agency Site Visit Report
Residential Care
Licensee: Parrott Creek Children and Family Svs Date of site visit: 10/08/2024
Executive Director: Simon Fulford Licensing Coordinator: Jeff Minden, Irvin Minten
Board Chairperson: Glen Wachter
Other Regulatory or Accrediting Agencies: Oregon Youth Authority
Program Compliance: The program was found to be compliant or will be compliant with OAR 419-400-0005 to 419-400-0310, Licensing Umbrella
Rules, and OAR 419-470-0010 to 419-470-0180, Licensing Residential Care Agencies Rules. Personnel records were reviewed and compliance
with required background checks was documented for employees in all programs.
Program Description(s): long term residential treatment program for adolescent boys with a focus on developing sustainable and prosocial
behaviors and skills that help them reach their full potential.
Program type and services: Residential
Capacity and Age Range: 21, males ages 13-18
Funding sources: Oregon Youth Authority
Contracts and sources for referrals: BRS and OYA
Average length of stay: 9-14 months
Average daily population served: 16
Number of children served annually: 54
Use of seclusion or restraint: The program utilizes restraints with CPI as their training program.
P age 1 | 17
Form Rev. 1/2/2024
Interviews, Observations: A tour was conducted as a part of the licensing site review. The program is currently occupying a leased property in
Lake Oswego while a completely new set of buildings are being built at their permanent Oregon City location. The facility was clean and in good
repair. Bedrooms were well furnished, decorated, and clean. Bathrooms were also very clean. Common spaces were uncluttered and functional.
Irvin Minten randomly selected and individually interviewed 3 youth enrolled in the program and 2 staff who worked at the program.
During interviews with the 3 youth, each of the youth described the program as being a good program and all stated the program was teaching them
skills to better manage and regulate their behaviors and emotions. Each of the youth also stated they felt safe in the program both during the day
and at night and each of the youth liked that they had individual bedrooms. Each of the youth also reported they believed staff in the program were
adequately trained to effectively assist them in meeting their needs and addressing their issues. One of the youth stated when you do something
wrong, program staff will give you “an opportunity to be honest,” as they did not want youth to feel like they had to “lie.” Another youth stated that
program staff were “cool” since they played cards and basketball with them. Each of the youth also described the food served at the program as
being pretty good to good, and all stated they could have a second helping of food, if they were still hungry. In addition, each of the youth denied
ever being treated badly by program staff, and all denied ever being placed in a restraint or in seclusion by program staff. Each of the youth also
stated they were able to call their parents or approved loved ones at least twice a week. Also, each youth was aware of their discharge plan and
stated they participated in their treatment planning. Finally, when asked if they would change anything, 2 youth stated they wished some of the staff
would play basketball with them more or talk with them more throughout the day, and one of the youth stated he wished he could still call his
girlfriend. One of the youth stated they would change nothing about the program.
During individual interview with the 2-program staff, both stated they enjoyed working for the agency, that the culture of the agency was both
supportive and positive, and both stated they enjoyed working with the youth and seeing most of the youth make positive changes in their
lives. Both staff also described an agency culture which allowed for staff of all levels to provide input into decision making, to suggest and make
changes to staff processes if they believed the change in process could make things better, as well as a culture which supported any and all
questions by staff. Both staff also described the training provided by the program as good, that the training provided assisted them in effectively
doing their job, and that if they wanted to learn more about a topic, their supervisor would most likely support their continued learning and do all they
could to see that they received the training. Also, each of the staff was able to effectively describe the program’s suicide prevention protocol, and
they also stated that if they had a question, there was always someone available to ask. Finally, when asked if they would change anything to make
the agency and the work they do better, one staff could not think of anything and the other stated they wished that the turnover of line staff would
slow down, as it took a great deal of energy to hire and effectively train new staff.
Program Strengths: From the Program: Parrott Creek uses a mindfulness bases model paired with Collaborative Problem solving that allows us to
create safe and trusting relationships with you. This allows us to engage the youth in being a part of the solution and teaches them long term
internal skills.
Program Challenges: From the program: We are in a temporary location while our new facility is being built. This has been a challenge for the
youth and staff to get used to the physical space.
Changes that have occurred in the last 2 years: Moved into a temporary location.
P age 2 | 17
Form Rev. 1/2/2024
Lawsuits: None
Grievances and complaints filed in the last two years: None
Corrective Actions and Timeframes: Please submit the following to verify compliance.
Within 45 days of receipt of this report (insert name of agency) must submit a letter of verification indicating the agency is in compliance with the
specific rules cited above and describing how compliance will be maintained going forward. Along with the letter of verification, the agency must
submit any and all specific documentation requested in the body of this report. The letter of verification and any additional requested documents can
be emailed directly to (Licensing Coordinator and email address).
Recommendations: The program is providing documentation to clients about reporting wrongful restraint, however they are not currently
documenting in the client file that this is occurring. It is recommended that they add documentation around wrongful restraint reporting to the client
file.
Exceptions: None
Changes in License: Licensed location changed as a part of the temporary site change.
Summary of Review
Program and Services
Yes No N/A Corrective Actions/Comments
419-400-0020 (2)
Program and services are in scope of license X
Governance of the Agency
Yes No N/A Corrective Actions/Comments
419-400-0040
(1)(a) Minimum of 5 board members X
(2)(f) Formally evaluate the exec. Director’s
X
performance annually
(2)(g) Approves annual budget X
(2)(h) Obtain and review an annual
independent financial review or audit of X
financial records.
(2)(k) Written quality improvement program
(2)(l) Meeting minutes X
Executive Director or Program Director
Yes No N/A Corrective Actions/Comments
419-400-0040
P age 3 | 17
Form Rev. 1/2/2024
(3)(a) knowledge of requirements for
providing care and treatment appropriate to X
programs
(3)(g) Approval from BCU X
Installation and Use of Video Equipment
Used to Monitor or Record Children in
Yes No N/A Corrective Actions/Comments
Care
419-400-0145
(1) If a child-caring agency installs video
equipment to monitor or record a child in
The program has a video monitoring policy. However, they are currently not
care, all employees, volunteers, parents or
X notifying guardians or children in care of the intended use and locations of the
guardians, and children in care must be
equipment.
informed about the intended use and
locations of the equipment.
Discipline, Behavior Management, and
Suicide Prevention Yes No N/A Corrective Actions/Comments
419-400-0150
(3) Agency uses appropriate and positive
methods of behavior management and
X
nationally recognized non-violent crisis
intervention
(3)(b)(C) Agency does not use chemical and
mechanical restraint (excluding medically X
necessary devices/prescriptions)
(3)(c) Agency uses appropriate time-out
rooms (adequate space, heat, light and
ventilation and is not capable of locking) and X Program does not utilize a time-out space
documents use in child’s record when
applicable
(3)(e) Agency uses seclusion
X Program does not utilize seclusion
appropriately/consistent with policy
(4) Agency has adequate plan in place to
X
respond to suicidal behavior/warning signs
Contractors (if applicable)
Yes No N/A Corrective Actions/Comments
419-400-0120(6)
(a) Agency ensures the contractor meets the
requirements of this rule and Chapter 413 X Program does not use contractors
division 215
(b)(B) Contract includes the following:
(i) Services provided
(ii) Contractor fees
(iii) Disclosure of information from contractor
X Program does not use contractors
to agency
(iv) Lines of authority
(v) Adherence to rules, including background
check
P age 4 | 17
Form Rev. 1/2/2024
(vi) Any liability of the agency for acts of the
contractor, rights of indemnity and limitations
on liability
Restraints and Involuntary Seclusion
Yes No N/A Corrective Actions/Comments
419-400-0180
(13)(d) Each child caring agency that
submits a report under this section shall
make its quarterly report available to the Program is not providing notice to guardians about how to access the quarterly
X
public upon request at the Child Caring reports.
Agency’s main office and on the child caring
agency’s website if applicable.
Supplemental Information Provided by
Yes No N/A Corrective Actions/Comments
CCA
Documents as indicated on the form titled
X
“Renewal Licensing Required Documents”
Documents as indicated on form titled
“Required Financial Documents and X
Information”
All required policies and procedures as
X
identified in the “Umbrella Rules”
All required policies and procedures as
X
identified in “Agency Type Specific Rules”
Physical Plant
Yes No N/A Corrective Actions/Comments
419-400-0090(3)(a) Foster Rights Posted (if
X Agency does not house youth in DHS custody. All youth are in OYA custody
children in DHS custody)
419-400-0100(1) Sufficient safe space,
X
equipment, and office equipment
419-400-0230(12) License is posted in
X
common area at each facility
419-470-0020(2)(a) &(c) Buildings are
X
smoke free, clean and in good repair
419-470-0020 (2)(d) Rooms are free of
X
harmful drafts, odors, and excessive noise
419-470-0020 (2)(e) Rooms are adequate in
X
size and arrangement
419-470-0020 (2)(f) System provides a
continuous supply of hot and cold water to X
taps located throughout the facility
419-470-0020 (2)(h) Building is well
ventilated and room temperature is within a X
normal comfort range
419-470-0030 (1) All parts of the facility
X
ensure the safety of children
Room and Space Requirements Yes No N/A Corrective Actions/Comments
P age 5 | 17
Form Rev. 1/2/2024
419-470-0030
(2) There is a separate living room or lounge X
area – 15 SF minimum per child
(5) There is a separate dining room with X
capacity for ½ of children in care and 15 SF
per child in care
(7) Laundry is separate from living, kitchen, X
and dining areas
(8) Separate storage areas are provided for X
food, kitchen supplies, utensils, clean linens,
soiled linens and clothing, cleaning supplies
and equip, poisons, chemicals, outdoor
recreational and maintenance equipment.
(Hazardous materials are properly labeled, in
original container and locked)
(9) Outdoor activity area is protected from X
vehicles and other hazards and of a size and
availability appropriate to the age and needs
of children in care
(11) Time-out rooms: Rooms used for time X
out or quiet time must have adequate space,
heat, light and ventilation and must not be
capable of locking.
Room and Space Requirements
Bedrooms Yes No N/A Corrective Actions/Comments
419-470-0030(3)
(a) Adequate furnishings and personal items X
(b) Separate from rooms used for dining,
X
living, laundry, kitchen, and storage
(c) Meet Oregon Fire Code Requirements Fire Marshall visit has been scheduled but was not completed by time of this
X report. The program must send a copy of the fire inspection documentation to
Licensing when inspection is complete.
(d) Be an outside room, with a window that
operates as designed. If the window is
modified from its original design, the fire
X
marshal must approve the modification and
indicate this room still meets applicable
Oregon Fire Code.
(d) Ceiling at least 90 inches X
(e) Minimum 60 SF per occupant X
(f) No more than 25 if dorm style X Program does not have dorm style rooms
(g) Permanently wired fixtures X
(h) Window covering X
Room and Space Requirements
Yes No N/A Corrective Actions/Comments
Bathrooms
P age 6 | 17
Form Rev. 1/2/2024
419-470-0030(4)
(a)(A)&(B) 1:8 ratio for toilets and sinks X
(a)(D) Hot and cold running water, soap, and
X
approved hand drying options
(a)(E) 1:10 ratio for shower or bathtub X
(a)(E) Individual privacy X
(a)(F) Window covering X
(a)(G) Permanently wired fixtures X
(a)(H) Adequate ventilation X
(b)&(c) Wooden racks on floors are
prohibited and impervious shower mats are
X Wooden Racks and Shower Mats are not in use.
disinfected & dried daily be in good condition
and free of mold
Room and Space Requirements
Kitchen Yes No N/A Corrective Actions/Comments
419-470-0030(6)
(a) Used exclusively for storage, food
preparation, dishwashing, and activities
X
related to eating and food preparation
activities
(b) Walls, floors are easily cleanable X
(c) Equipment and utensils are easily
X
cleanable, durable, nontoxic, and kept clean
(e) Equipment is easy to clean beneath,
X
between and behind
Furnishings and Personal Items
Yes No N/A Corrective Actions/Comments
419-470-0040
(1) There is a bed with frame, X
(1)(b) clean mattress in good condition,
X
with a minimum thickness of five inches
(1)(c) a pillow in good condition X
(1)(d) a private dresser, closet, or similar
storage area for personal belongings that X
is readily accessible
(2) Linens are in good repair. There is a
waterproof mattress cover or mattress.
X
Linens are appropriate and towels and
washcloths are provided
(3) Bedding is changed weekly or when
X
soiled
(4)&(5) Personal hygiene supplies and
X
appropriate clothing are provided
Food Services
Yes No N/A Corrective Actions/Comments
419-470-0070
P age 7 | 17
Form Rev. 1/2/2024
(1)(a) Meals are arranged daily, consistent
with normal mealtimes that occur during the
X
hours of operation and provide snacks
between mealtimes
(1)(b) Menus are prepared in advance in
accordance with USDA guidelines, provide a
X
variety of foods and are adjusted for
seasonal changes including snacks
(1)(b) Menus are kept for at least 6 months X
(1)(c) Drinking water is freely available X
(2)(a) Food is stored, prepared & served in a
X
sanitary manner
(2)(c) & (d) Food products are obtained from
commercial suppliers (exception of fruits &
vegetables), unpasteurized juice is X
prohibited, and only Grade A pasteurized
and fortified milk in appropriate container.
Residential Care Safety
Yes No N/A Corrective Actions/Comments
419-470-0080
(2) Written emergency plan that includes X
(a) Identifying the types of emergencies most
likely to happen where the residential care X
agency is located
(b) Identifying a place to meet for each type
X
of emergency identified
(c) Identifying an alternate shelter if
X
necessary
(d) Ensuring access to necessary
X
medications or medical equipment
(e) How to help each child in care recover
X
after a disaster
(3) Telephone numbers for local police, fire
department, poison control, after hours
medical advice and other appropriate X
emergency numbers must be posted near all
telephones.
(4) Operative flashlights sufficient in number
X
are readily available to staff
(5)(a) Evacuation drill occurs monthly under
varying conditions, is retained 2 years and
contains:
(A) identify of person conducting drill
X No evacuation drill was conducted in June 2024.
(B) date & time
(C) notification method
(D) staff participating
(E) # of children & staff evacuated
P age 8 | 17
Form Rev. 1/2/2024
(F) special conditions simulated
(G) problems encountered
(H) time to complete
Umbrella Safety
Yes No N/A Corrective Actions/Comments
419-400-0200
(5)(b) Vehicle has insurance policy, is smoke X
free, safe operating condition, and has first
aid kit and fire extinguisher 2-A:10-BC
(1)(b)(A) Each vehicle used to transport a X
child in care must be: properly registered,
covered by an insurance policy in full force
and effect, maintained in safe operating
condition, and smoke-free.
(3) If a child-caring agency has a swimming X Program does not have a swimming pool
pool on the premises that is accessible to
children in care or if a child-caring agency
plans to have children in care engage in
swimming, the child-caring agency must
have and adhere to policies and procedures
that address, at a minimum, providing
disclosures and obtaining consents,
assessing swimming ability of children in
care, and ensuring the safety of pool access.
(4)(a) The program protects children from X
potentially harmful items and materials.
(4)(b) Direct supervision of children who do X
not have the ability to adjust and control
water temperature
(4)(c) Light fixtures have protective covers X
unless designed to be used without one
Medication
Yes No N/A Corrective Actions/Comments
419-470-0100
(3)&(7)(e) Medications have a prescription
and are stored in the original container with X
prescription label
(4)&(5) Herbal supplements and remedies,
medical treatments, special diets, physical
therapy, physical aides or limitations have a
written order signed by a physician or
qualified medical professional. A written X
order, signed by a physician or qualified
medical professional, is also required before
a restriction on diet or physical activity is
imposed.
(7)(c) Medications are inaccessible to
X
children and stored behind at least two
P age 9 | 17
Form Rev. 1/2/2024
locking mechanisms. This does not apply to
Naloxone.
(8) Medications are disposed in accordance
X
with state and federal law
(9) Written record of the disposal of
medications is maintained and includes:
(a) description and amount
(b) name X
(c) reason
(d) method
(e) staff & witness signature
(10) Written record of the administration of
medication includes:
(a) name
(b) description
(c) dates and times
(d) missed doses X
(e) medication disposed
(f) method of administration
(g) ID of person administering
(h) possible adverse reactions
(i) medication taken outside facility
Extracurricular, Enrichment, Cultural &
Social Activities Yes No N/A Corrective Actions/Comments
419-470-0110
(2) Children have ongoing opportunities to X
participate in at least one age-appropriate or
developmentally appropriate activity
Minimum Staffing Requirements
Yes No N/A Corrective Actions/Comments
419-470-0130
(1)&(2) Supervision is adequate for the type X
of program, location, age and type of
children, ability of supervisor to respond,
electronic back-up systems.
Minimum ratios are maintained:
Under 30 months of age: 1:4
30 months to ˃ 6 years or non-ambulatory:
1:6
Ages 6 and older: 1:7
Overnight (staff awake)
1:10
(4)(a) When one staff on duty, there is X Staff Ratios require 2 or more staff at all times.
additional staff immediately available with
max response time of 30 minutes
P age 10 | 17
Form Rev. 1/2/2024
(5) There is at least one on-site employee X
authorized to apply the reasonable and
prudent parent standard
Sleeping Arrangements
Yes No N/A Corrective Actions/Comments
419-470-0140
(1) Children are in separate bedrooms than X Clients are in individual bedrooms.
adults, unless parent and child, or there is
written approval from guardian/parent and
licensing coordinator
(2) There is adequate supervision of children X
when sleeping
(3) When assigning bedrooms a residential X Clients are in individual bedrooms.
care agency must consider all of the
following:
(a) Chronological age
(b) Developmental age
(c) Gender identity
(d) Personal history, including medical,
mental health, behavioral health, and past
adverse experiences including any physical
or sexual abuse
Personnel Files
Yes No N/A Corrective Actions/Comments
419-400-0120
Staff Name/Position X
(3)(g) Date of Hire X
(3)(a) record of education, training, and
X
previous employment
(1)(b) & (3)(b) reference checks completed
X 2 Reviewed files did not contain reference checks
and documented
(1)(a) & (3)(c) Background check completed
X
and documented
(3)(d) Annual performance evaluations X
(3)(f) Record of personnel actions X
(3)(g) Termination date, reason for
X
termination
(3)(h) Current job description (1)(c)
Employee meets minimum qualifications X
stated in current job description
New Employee Orientation – Umbrella
Requirements (30 days) Yes No N/A Corrective Actions/Comments
419-400-0120(4)
(a) Agency policies and procedures X
(b) Ethical and professional guidelines X
P age 11 | 17
Form Rev. 1/2/2024
One reviewed file did not show that the suicide prevention training had been
(c) Suicide prevention and intervention X
completed
(d) Attributes of population served X
(e) & (5)(a) to (c) Mandatory reporting that
includes:
(a) legal definition of child abuse in ORS
418.257 and 419B.005 X
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to
the employee
(f) Privacy laws X
(g) Emergency procedures X One reviewed file did not show that the Emergency Procedures had been reviewed.
New Employee Orientation
Residential (Prior to working alone and
Yes No N/A Corrective Actions/Comments
within 30 days)
419-470-0120(1)
(a) Discipline and behavior management
including de-escalation, crisis prevention,
positive behavior management, and X
disciplinary techniques that are non-punitive
in nature
(b) CPR and First Aid sufficient to retain a
X
current certification
(c) Universal precautions and hygiene X
(d) Application of the reasonable and None of the reviewed files showed that Reasonable and Prudent Parent Standard
X
prudent parent standard training had been completed
(e) Training on the agency’s policy on
One reviewed file did not show that the suicide prevention training had been
suicide prevention and suicide risk X
completed
assessment tool
Crisis Intervention Training Standards
and Certification Yes No N/A Corrective Actions/Comments
419-400-0160(4) (as applicable)
(a)Complete a minimum of 12 hours of initial
training in person from a certified instructor,
including but not limited to a minimum of six
Two reviewed files did not include documentation of completing crisis and restraint
hours of training focused on positive
X training. The one file that did have confirmation did not include the number of
behavior support, nonviolent crisis
hours of training
intervention and other methods of
nonphysical intervention to support children
in care during a crisis
(d) Receive a certificate that states:
Two files did not have a certificate. The other file did contain a certificate however
(A) The dates during which the certification X
it did not have all of the required information.
is current
P age 12 | 17
Form Rev. 1/2/2024
(B) The type of restraint which the individual
is certified to perform if applicable
(C) The type of training the individual is
certified to conduct if applicable
(D) Any special endorsements earned by the
individual
(E) The level of training
(F) The name of the certified instructor who
conducted the training and administered the
assessment of proficiency.
(e) A certification issued:
(A) Must be personal to the individual
certified by the training provider X
(B) May be valid for no more than two years
with recertification
Ongoing Training Yes No N/A Corrective Actions/Comments
419-470-0070(2)(b) Employees who handle
food served to children have a valid food X
handler’s card
419-400-0200 (1) Employees transporting
children have: current driver’s license,
Two of the reviewed files did not contain information about driver’s licenses. All
insurance, trained in emergency procedures X
reviewed files did include insurance information.
and behavior management, and training for
15+ passenger vans if applicable)
419-470-0120 (2)(a) Environmental
X
emergencies
419-470-0120 (2)(b) Universal Precautions X
419-470-0120 (2)(c) Discipline and Behavior
X
Management
419-470-0120 (2)(d) Agency’s policy on None of the reviewed files showed completion of annual suicide prevention
X
suicide prevention and risk assessment tool training.
419-470-0120 (3) Staff providing direct care
must maintain current CPR/First Aid X
certification
419-470-0120 (4) Designated staff
authorized to apply reasonable and prudent
X
parent standard are trained in application of
the standard
419-400-0120(5) Mandatory reporting
(annually) that includes:
X
(a) legal definition of child abuse in ORS
418.257 and 419B.005
P age 13 | 17
Form Rev. 1/2/2024
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to
the employee
419-400-0160(4)(b) Receive continuing
education (as applicable on crisis
X
intervention training) from a certified
instructor on an annual basis
Comments:
Children’s Records Yes No N/A Corrective Actions/Comments
Health Services
419-470-0090
(2) Medical history obtained within 30 days
(significant findings, current immunizations,
history of surgical procedures-health issues- X
injuries, allergies, dental, vision, hearing,
behavioral health, and physician orders)
(4)(a) to (f) Medical exams (3 in first year of
life, 2,4,6,9,14) X All reviewed youth files were for clients over the age of 14.
(g) Have a physical examination within the
first 60 days after admission of a child in
care. Documentation of a physical X
examination having occurred within the
calendar year will meet this requirement.
Consents
Yes No N/A Corrective Actions/Comments
419-470-0160(1)
(a) Provide routine and emergency medical
X
care
(b) Use the discipline and behavior
X
management system
(c) Use restraint or seclusion (if applicable).
Must specify the reasons for the intervention X
and how staff are trained and supervised
(d) Restrict contact with persons outside of
X
the agency
P age 14 | 17
Form Rev. 1/2/2024
(e) Allow access as defined in 419-400-0230
X
& 0240
(f) Impose a dress code X
(g) Apply the reasonable and prudent parent
X
standard
Disclosures
419-470-0160(2) Yes No N/A Corrective Actions/Comments
Parent/guardian has acknowledged in writing:
(a) Information regarding personal or room
searches and protocols for confiscation of X
contraband
(b) Statement of Rights of Children and
X
Parents/Guardians
(c) Any policies and procedures upon request X
Authorizations
Yes No N/A Corrective Actions/Comments
419-470-0160(3)
(a) Disclose or exchange information with
X
others
(b) Child specific visitors X
(c) Visitation resources are pre-approved X
(d) Activity specific authorizations are pre-
approved to allow children to participate in
potentially hazardous activities, including but X
not limited to using motorized yard
equipment, swimming, and horseback riding.
Information about Children in Care
419-400-0190(1) Yes No N/A Corrective Actions/Comments
Summary sheet contains the following:
(a)The name, gender, date of birth, religious
X
preference, and previous address
(b) Name and location of previous and
X
current school
(c) Date of admission X
(d) Legal custody X
(e) The name, address, and telephone
number of:
(A) The child in care's parents.
(B) The child in care's legal guardian, if
different than the parents, and a copy of
X
the document that provides for his or her
authority over the child in care.
(C) Other persons significant to child
(D) Other professionals to be involved in
service planning (if applicable)
Service Planning Yes No N/A Corrective Actions/Comments
P age 15 | 17
Form Rev. 1/2/2024
419-470-0170(2)
(b) Intake document is completed the date
child accepted into care (emergency X
placement 48 hours)
(d) Assessment is completed within 30 days
and contains relevant historical info., current
behavioral observations, identified need for X
services, and how agency will provide
services
(e) (A)&(B) Service plan within 60 days
(parent, guardian and child actively involved).
Describes how child’s issues will be X
addressed, anticipated outcomes, and
reviewed by child and guardian/parent.
(e)(C)&(D) Service plan is reviewed quarterly
and revised when information indicates other X
services should be provided
Case Management
Yes No N/A Corrective Actions/Comments
419-470-0170(3)
(a) Services are documented, progress
X
toward achieving goals is tracked
(c) Discharge summary must include:
(A)Current medications
(B)Name of the physician or qualified medical
professional who prescribed each medication
(C)Any outstanding medical or other
appointments X
(D)Summary of the child’s participation in the
program and progress achieved
(E)Results of evaluations
(F)Recommendations regarding services
(G)Discharge destination
(e) Follow up services X
(f) Incident Reports X
Records Relating to Restraint &
Yes No N/A Corrective Actions/Comments
Involuntary Seclusion
419-400-0180 (12) Records X
419-400-0180(13)(e) Each child caring
agency shall provide notice regarding how to
access the quarterly reports to the parents or
guardians of children in care in the program. X
The child caring agency shall provide the
notice upon the child in care’s admission and
at least two times each year thereafter.
P age 16 | 17
Form Rev. 1/2/2024
419-400-0190(1) Information provided to
children in care relating to Restraint & X
Involuntary Seclusion
Financial Records
Yes No N/A Corrective Actions/Comments
419-470-0170(4)
Records contain date, amount, source,
X
purpose, signatures
Personal Possessions Records
Yes No N/A Corrective Actions/Comments
419-470-0170 (5)
Individual written inventory of all personal
possessions is maintained and updated as X
needed
Records and Documentation
Yes No N/A Corrective Actions/Comments
419-400-0140
(1) Stored safely X
(2) Permanent, legible, dated, and signed X
(3)&(4) Uniform in organization, readily
identifiable and accessible, current, and
X
complete, containing all required info. No
eraser tape or white out.
(7) Permanent registry for each child
includes:
Name
Gender
X
Birth date
Names, addresses of parents or guardians
Dates of admission
Placement upon discharge
Comments:
Licensing Coordinator’s Signature: ________________________ Date: ____1_0_-_1_1_-2__0_2_4______
Manager Review: ______________________________________ Date: _____1_0_-_1_1_-_2_0_2_4____
P age 17 | 17
Form Rev. 1/2/2024

report_type: License Renewals

board_chairperson: Glen Wachter

licensing_coordinator: Jeff Minden, Irvin Minten

other_regulatory_agencies: Oregon Youth Authority

program_services: Residential

capacity_age_range: 21, males ages 13-18

funding_sources: Oregon Youth Authority

contracts_and_referrals: BRS and OYA

average_length_of_stay: 9-14 months

interviews_observations:
A tour was conducted as a part of the licensing site review. The program is currently occupying a leased property in
Lake Oswego while a completely new set of buildings are being built at their permanent Oregon City location. The facility was clean and in good
repair. Bedrooms were well furnished, decorated, and clean. Bathrooms were also very clean. Common spaces were uncluttered and functional.
Irvin Minten randomly selected and individually interviewed 3 youth enrolled in the program and 2 staff who worked at the program.
During interviews with the 3 youth, each of the youth described the program as being a good program and all stated the program was teaching them
skills to better manage and regulate their behaviors and emotions. Each of the youth also stated they felt safe in the program both during the day
and at night and each of the youth liked that they had individual bedrooms. Each of the youth also reported they believed staff in the program were
adequately trained to effectively assist them in meeting their needs and addressing their issues. One of the youth stated when you do something
wrong, program staff will give you "an opportunity to be honest," as they did not want youth to feel like they had to "lie." Another youth stated that
program staff were "cool" since they played cards and basketball with them. Each of the youth also described the food served at the program as
being pretty good to good, and all stated they could have a second helping of food, if they were still hungry. In addition, each of the youth denied
ever being treated badly by program staff, and all denied ever being placed in a restraint or in seclusion by program staff. Each of the youth also
stated they were able to call their parents or approved loved ones at least twice a week. Also, each youth was aware of their discharge plan and
stated they participated in their treatment planning. Finally, when asked if they would change anything, 2 youth stated they wished some of the staff
would play basketball with them more or talk with them more throughout the day, and one of the youth stated he wished he could still call his
girlfriend. One of the youth stated they would change nothing about the program.
During individual interview with the 2-program staff, both stated they enjoyed working for the agency, that the culture of the agency was both
supportive and positive, and both stated they enjoyed working with the youth and seeing most of the youth make positive changes in their
lives. Both staff also described an agency culture which allowed for staff of all levels to provide input into decision making, to suggest and make
changes to staff processes if they believed the change in process could make things better, as well as a culture which supported any and all
questions by staff. Both staff also described the training provided by the program as good, that the training provided assisted them in effectively
doing their job, and that if they wanted to learn more about a topic, their supervisor would most likely support their continued learning and do all they
could to see that they received the training. Also, each of the staff was able to effectively describe the program's suicide prevention protocol, and
they also stated that if they had a question, there was always someone available to ask. Finally, when asked if they would change anything to make
the agency and the work they do better, one staff could not think of anything and the other stated they wished that the turnover of line staff would
slow down, as it took a great deal of energy to hire and effectively train new staff.

excerpt:
(1) If a child-caring agency installs video
equipment to monitor or record a child in
care, all employees, volunteers, parents or
guardians, and children in care must be
informed about the intended use and
locations of the equipment. The program has a video monitoring policy. However, they are currently not
notifying guardians or children in care of the intended use and locations of the
equipment.

excerpt:
(13)(d) Each child caring agency that
submits a report 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. Program is not providing notice to guardians about how to access the quarterly
reports.

excerpt:
(c) Meet Oregon Fire Code Requirements Fire Marshall visit has been scheduled but was not completed by time of this
report. The program must send a copy of the fire inspection documentation to
Licensing when inspection is complete.

excerpt:
(5)(a) Evacuation drill occurs monthly under
varying conditions, is retained 2 years and
contains:
(A) identify of person conducting drill
(B) date & time
(C) notification method
(D) staff participating
(E) # of children & staff evacuated No evacuation drill was conducted in June 2024.

excerpt:
(1)(b) & (3)(b) reference checks completed
and documented 2 Reviewed files did not contain reference checks

excerpt:
(c) Suicide prevention and intervention One reviewed file did not show that the suicide prevention training had been
completed

excerpt: (g) Emergency procedures One reviewed file did not show that the Emergency Procedures had been reviewed.

excerpt:
(d) Application of the reasonable and
prudent parent standard None of the reviewed files showed that Reasonable and Prudent Parent Standard
training had been completed

excerpt:
(e) Training on the agency’s policy on
suicide prevention and suicide risk
assessment tool One reviewed file did not show that the suicide prevention training had been
completed

excerpt:
(a)Complete a minimum of 12 hours of initial
training in person from a certified instructor,
including but not limited to a minimum of six
hours of training focused on positive
behavior support, nonviolent crisis
intervention and other methods of
nonphysical intervention to support children
in care during a crisis Two reviewed files did not include documentation of completing crisis and restraint
training. The one file that did have confirmation did not include the number of
hours of training

excerpt:
(d) Receive a certificate that states:
(A) The dates during which the certification
is current Two files did not have a certificate. The other file did contain a certificate however
it did not have all of the required information.