summary: Unannounced - 7 findings

raw_content:
Licensed Child Caring Agency Site Visit Report
Residential Care - Unannounced
Licensee: J Bar J Youth Services – The Boys Ranch and J5 Date of site visit: May 13, 2025
Executive Director: Stephanie Alvstad Licensing Coordinator: Aubrey Kelly
Program Director: Bruce Waldrup (The Boys Ranch) &
Reilly Carson (J5)
Other regulatory or accrediting agencies: ODHS, COA & Oregon Youth Authority
Purpose: Per OAR 419-400-0240 (1)(b) Children’s Care Licensing is required to perform at least one unannounced site visit a year
where children in care reside.
Previous findings Repeat Comments
Unannounced Site Visit – 9/24/2024 findings
further action
needed
New Employee Orientation Residential (Prior to
working alone and within 30 days)
419-470-0120(1)
(c) Universal precautions and hygiene
Several staff personnel files were reviewed and there
Boys Ranch – There was no documentation in two staff was documentation showing that staff completed
No
files to indicate that training on universal precautions universal precautions and hygiene within 30 days of
and hygiene was completed with 30 days of hire. hire.
• At the time of the unannounced site visits, CCLP
had not yet received the corrective action plan
from J Bar J following their two year licensing
Form Rev. 3/12/2025 P a g e 1 | 6
Previous findings Repeat Comments
Unannounced Site Visit – 9/24/2024 findings
further action
needed
renewal review. The corrective actions were not
reviewed during these visits.
Ongoing Training
419-470-0120 (2)(c) Discipline and Behavior
Management
Boys Ranch and J5 – There was no documentation
Several staff personnel files were reviewed and there
verifying staff completed ongoing training on discipline
was documentation showing that staff completed
and behavior management. No
ongoing training on discipline and behavior
management.
• At the time of the unannounced site visits, CCLP
had not yet received the corrective action plan
from J Bar J following their two year licensing
renewal review. The corrective actions were not
reviewed during these visits.
Ongoing Training
419-470-0120 (2)(d) Agency’s policy on suicide
prevention and risk assessment tool
Boys Ranch and J5 – There was no documentation
Several staff personnel files were reviewed and there
verifying staff completed ongoing training on agency’s
was documentation showing that staff completed
policy on suicide prevention and risk assessment tool. No
ongoing training on the agency’s policy on suicide
prevention and risk assessment tool.
• At the time of the unannounced site visits, CCLP
had not yet received the corrective action plan
from J Bar J following their two year licensing
renewal review. The corrective actions were not
reviewed during these visits.
Form Rev. 3/12/2025 P a g e 2 | 6
Previous findings Repeat Comments
Unannounced Site Visit – 9/24/2024 findings
further action
needed
Ongoing Training 419-400-0120(5) Mandatory
reporting (annually) that includes:
(a) legal definition of child abuse in ORS 418.257 and
419B.005
(b) legal responsibility to immediately report
© legal responsibility to report is personal to the
employee
Several staff personnel files were reviewed and there
Boys Ranch and J5 – There was no documentation No was documentation showing that staff completed
verifying staff completed ongoing training on mandatory ongoing training on mandatory reporting.
reporting abuse policy.
• At the time of the unannounced site visits, CCLP
had not yet received the corrective action plan
from J Bar J following their two year licensing
renewal review. The corrective actions were not
reviewed during these visits.
Health Services 419-470-0090
2) Medical history obtained within 30 days (significant
findings, current immunizations, history of surgical
procedures-health issues-injuries, allergies, dental,
vision, hearing, behavioral health, and physician orders)
Several client files were reviewed and there was
No
Boys Ranch and J5 – There was a lack of documentation of the client’s medical history.
documentation regarding the medical history of clients.
• At the time of the unannounced site visits, CCLP
had not yet received the corrective action plan
from J Bar J following their two year licensing
Form Rev. 3/12/2025 P a g e 3 | 6
Previous findings Repeat Comments
Unannounced Site Visit – 9/24/2024 findings
further action
needed
renewal review. The corrective actions were not
reviewed during these visits.
Authorizations 419-470-0160(3)(d) Activity specific
authorizations are pre-approved to allow children to
participate in potentially hazardous activities, including
but not limited to using motorized yard equipment,
swimming, and horseback riding.
Boys Ranch and J5 – Client files did not contain activity Several client files were reviewed and the files
No
specific authorizations. contained activity specific authorizations.
• At the time of the unannounced site visits, CCLP
had not yet received the corrective action plan
from J Bar J following their two year licensing
renewal review. The corrective actions were not
reviewed during these visits.
Information about Children in Care
419-400-0190(1)
Summary sheet contains the following:
(b) Name and location of previous and current school
Boys Ranch and J5 – Client files did not contain the
Several client files were reviewed and the files
name and location of the previous school and current
No contained the name and location of previous and
school.
current school.
• At the time of the unannounced site visits, CCLP
had not yet received the corrective action plan
from J Bar J following their two year licensing
renewal review. The corrective actions were not
reviewed during these visits.
Form Rev. 3/12/2025 P a g e 4 | 6
New findings from site visit Comments
None
Interview summary
Boys Ranch – Client #1 – They are 16 years old and have been here for one year. They came from detention. They like it here
and appreciates the opportunity to focus on what each resident needs to do. They get along with staff. The food is not luxury, but
they get enough to eat. They get snacks, and water is always available. They have gone on home visits. They have the
opportunity to make phone calls to family every day. They feel safe here, and no one has put their hands on them. If they could
change anything about the program, it would be that staff communicate with each other more, and there is more consistency with
staff.
Client # 2 – They are 18 years old and have been here for four months. They were previously at J5. The boy’s ranch is similar to
J5, but they feel like there is more freedom at the ranch. They feel like it was a good transition going from J5 to the ranch. They
feel safe here. The staff are cool, though they can be nitpicky. They get along with the other residents, though some are mean.
Staff intervene when residents are mean. The food is amazing; they work in the kitchen. The food is authentic. No one has put
their hands on them. They have visits on Saturdays and phone calls every day.
J5 – Client # 1 – They are 15 years old and been here for one and a half months. They were previously in the program but was
sent to detention for two months for not engaging. They feel like they can learn what they need to do, and they know they need to
be here. They expect to be here for 60-90 days and then go to a residential program, such as the boys Boy’s Ranch. They feel
safe here, and no one has put their hands on them. The food is pretty good; last night they had chicken parmesan for dinner. They
get along with the other clients. Staff do their job. They get phone calls to family four times a week. Six hour offsite visits can be
earned, but they have not had any offsite visits yet. They don’t like that when one resident is acting out, it affects everyone else.
Form Rev. 3/12/2025 P a g e 5 | 6
Observations
Boys Ranch – The program currently has a total of 28 residents. The program was very clean and in good repair. The campus has
a new greenhouse, which was sponsored by the local Rotary club. The program will be building a pole shed for storage for the
vocational program. The program has started getting the grounds ready for the annual horse show this summer.
J5 – The program currently has 11 residents. The program was very clean and in good repair. Residents were in school. The
second pod is currently empty as the program doesn’t have the staff to open the pod. The program focuses on restorative justice.
Safety, security, supervision and structure are the key points in the program. The program receives meals from the Boy’s Ranch.
Corrective actions and timeframes: Please submit the following to verify compliance.
Within 45 days of receipt of this report J Bar J Youth Services – Boys Ranch and J5 must submit a letter of verification indicating
the agency is in compliance with the specific rules cited above and describing how compliance will be maintained going forward.
Along with the letter of verification, the agency must submit any and all specific documentation requested in the body of this report.
The letter of verification and any additional requested documents can be emailed directly to Aubrey Kelly at
Aubrey.J.Kelly@odhsoha.oregon.gov.
5-29-2025 5-28-2025
Aubrey Kelly Harry Gilmore
Licensing Coordinator's signature Manager Review
Form Rev. 3/12/2025 P a g e 6 | 6

facility_type: Residential Care - Unannounced

licensee: J Bar J Youth Services - The Boys Ranch and J5 Date of site visit: May 13, 2025

other_regulatory_agencies: ODHS, COA & Oregon Youth Authority

purpose:
Per OAR 419-400-0240 (1)(b) Children's Care Licensing is required to perform at least one unannounced site visit a year
where children in care reside.
Previous findings Repeat Comments
Unannounced Site Visit - 9/24/2024 findings
further action
needed
New Employee Orientation Residential (Prior to
working alone and within 30 days)
419-470-0120(1)
(c) Universal precautions and hygiene
Several staff personnel files were reviewed and there
Boys Ranch - There was no documentation in two staff was documentation showing that staff completed
No
files to indicate that training on universal precautions universal precautions and hygiene within 30 days of
and hygiene was completed with 30 days of hire. hire.
- At the time of the unannounced site visits, CCLP
had not yet received the corrective action plan
from J Bar J following their two year licensing

Previous findings Repeat Comments
Unannounced Site Visit - 9/24/2024 findings
further action
needed
renewal review. The corrective actions were not
reviewed during these visits.
Ongoing Training
419-470-0120 (2)(c) Discipline and Behavior
Management
Boys Ranch and J5 - There was no documentation
Several staff personnel files were reviewed and there
verifying staff completed ongoing training on discipline
was documentation showing that staff completed
and behavior management. No
ongoing training on discipline and behavior
management.
- At the time of the unannounced site visits, CCLP
had not yet received the corrective action plan
from J Bar J following their two year licensing
renewal review. The corrective actions were not
reviewed during these visits.
Ongoing Training
419-470-0120 (2)(d) Agency's policy on suicide
prevention and risk assessment tool
Boys Ranch and J5 - There was no documentation
Several staff personnel files were reviewed and there
verifying staff completed ongoing training on agency's
was documentation showing that staff completed
policy on suicide prevention and risk assessment tool. No
ongoing training on the agency's policy on suicide
prevention and risk assessment tool.
- At the time of the unannounced site visits, CCLP
had not yet received the corrective action plan
from J Bar J following their two year licensing
renewal review. The corrective actions were not
reviewed during these visits.

Previous findings Repeat Comments
Unannounced Site Visit - 9/24/2024 findings
further action
needed
Ongoing Training 419-400-0120(5) Mandatory
reporting (annually) that includes:
(a) legal definition of child abuse in ORS 418.257 and
419B.005
(b) legal responsibility to immediately report
© legal responsibility to report is personal to the
employee
Several staff personnel files were reviewed and there
Boys Ranch and J5 - There was no documentation No was documentation showing that staff completed
verifying staff completed ongoing training on mandatory ongoing training on mandatory reporting.
reporting abuse policy.
- At the time of the unannounced site visits, CCLP
had not yet received the corrective action plan
from J Bar J following their two year licensing
renewal review. The corrective actions were not
reviewed during these visits.
Health Services 419-470-0090
2) Medical history obtained within 30 days (significant
findings, current immunizations, history of surgical
procedures-health issues-injuries, allergies, dental,
vision, hearing, behavioral health, and physician orders)
Several client files were reviewed and there was
No
Boys Ranch and J5 - There was a lack of documentation of the client's medical history.
documentation regarding the medical history of clients.
- At the time of the unannounced site visits, CCLP
had not yet received the corrective action plan
from J Bar J following their two year licensing

Previous findings Repeat Comments
Unannounced Site Visit - 9/24/2024 findings
further action
needed
renewal review. The corrective actions were not
reviewed during these visits.
Authorizations 419-470-0160(3)(d) Activity specific
authorizations are pre-approved to allow children to
participate in potentially hazardous activities, including
but not limited to using motorized yard equipment,
swimming, and horseback riding.
Boys Ranch and J5 - Client files did not contain activity Several client files were reviewed and the files
No
specific authorizations. contained activity specific authorizations.
- At the time of the unannounced site visits, CCLP
had not yet received the corrective action plan
from J Bar J following their two year licensing
renewal review. The corrective actions were not
reviewed during these visits.
Information about Children in Care
419-400-0190(1)
Summary sheet contains the following:
(b) Name and location of previous and current school
Boys Ranch and J5 - Client files did not contain the
Several client files were reviewed and the files
name and location of the previous school and current
No contained the name and location of previous and
school.
current school.
- At the time of the unannounced site visits, CCLP
had not yet received the corrective action plan
from J Bar J following their two year licensing
renewal review. The corrective actions were not
reviewed during these visits.

New findings from site visit Comments
None
Interview summary
Boys Ranch - Client #1 - They are 16 years old and have been here for one year. They came from detention. They like it here
and appreciates the opportunity to focus on what each resident needs to do. They get along with staff. The food is not luxury, but
they get enough to eat. They get snacks, and water is always available. They have gone on home visits. They have the
opportunity to make phone calls to family every day. They feel safe here, and no one has put their hands on them. If they could
change anything about the program, it would be that staff communicate with each other more, and there is more consistency with
staff.
Client # 2 - They are 18 years old and have been here for four months. They were previously at J5. The boy's ranch is similar to
J5, but they feel like there is more freedom at the ranch. They feel like it was a good transition going from J5 to the ranch. They
feel safe here. The staff are cool, though they can be nitpicky. They get along with the other residents, though some are mean.
Staff intervene when residents are mean. The food is amazing; they work in the kitchen. The food is authentic. No one has put
their hands on them. They have visits on Saturdays and phone calls every day.
J5 - Client # 1 - They are 15 years old and been here for one and a half months. They were previously in the program but was
sent to detention for two months for not engaging. They feel like they can learn what they need to do, and they know they need to
be here. They expect to be here for 60-90 days and then go to a residential program, such as the boys Boy's Ranch. They feel
safe here, and no one has put their hands on them. The food is pretty good; last night they had chicken parmesan for dinner. They
get along with the other clients. Staff do their job. They get phone calls to family four times a week. Six hour offsite visits can be
earned, but they have not had any offsite visits yet. They don't like that when one resident is acting out, it affects everyone else.

Observations
Boys Ranch - The program currently has a total of 28 residents. The program was very clean and in good repair. The campus has
a new greenhouse, which was sponsored by the local Rotary club. The program will be building a pole shed for storage for the
vocational program. The program has started getting the grounds ready for the annual horse show this summer.
J5 - The program currently has 11 residents. The program was very clean and in good repair. Residents were in school. The
second pod is currently empty as the program doesn't have the staff to open the pod. The program focuses on restorative justice.
Safety, security, supervision and structure are the key points in the program. The program receives meals from the Boy's Ranch.

excerpt:
419-400-0190(1)
Summary sheet contains the following:
(b) Name and location of previous and current school
Boys Ranch and J5 - Client files did not contain the
Several client files were reviewed and the files
name and location of the previous school and current
No contained the name and location of previous and
school.
current school.
- At the time of the unannounced site visits, CCLP
had not yet received the corrective action plan
from J Bar J following their two year licensing
renewal review. The corrective actions were not
reviewed during these visits.
New findings from site visit Comments
None
None


state: OR

facility_name: Jackson County Juvenile Department - Barrier 2 Bridges

summary: Unannounced - 3 findings

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Licensee: Jackson County Barriers 2 Bridges
Executive Director: Eric Guyer
Program Director(s): Joe Ferguson
Date of Unannounced: 10/19/2021
Licensing Coordinator: Todd Cooley
Other Regulatory or Accrediting Agencies: OYA
Purpose: Per OAR 413-215-0101 (1) (b) Children’s Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Comments
Findings
Further Action
Needed
Safety 413-215-0541 Yes No☐  (2019 Site Review) Only six months of fire drills were presented and they
(3)(a) Evacuation drill occurs monthly contained minimal information.
2020 Unannounced – Since the last review drills were not conducted in May
and September 2020, yet some of the months they are conducting more than
one drill and average one a month. The completed drills are significantly
improved and contain all of the necessary information. Continue to ensure
monthly drills are conducted and documented.
 2021 Unannounced – Since last unannounced there was no documentation
of evacuation drills for November 2020 and January 2021. It was noted the
drills were likely conducted, but not documented. (REPEAT FINDING)
New Employee Orientation – Umbrella Yes☐ No  (2019 Site Review) There was no documentation of nearly all the new employee
Requirements (30 days) orientation training. One staff had documentation of emergency procedures
413-215-0061(4) training but received it over four months after being hired.
1
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 200115)
2020 Unannounced – Program has provided their updated new employee
training curriculum which is very extensive and covers all licensing
requirements and much more.
 2021 Unannounced – A new employee’s file was reviewed and it contained
all of the appropriate new employee orientation training.
Health Services 413-215-0546 Yes☐ No  (2019 Site Review) The reviewed youth files did not contain any documentation of
(2)(e) Documentation of age appropriate age appropriate instruction.
instruction
2020 Unannounced – Barriers 2 Bridges provides ongoing education in sex
education, health and wellness that is age appropriate. Consent for this
education is signed upon entry to the program, although specific
documentation of the group education is not contained in individual youth
files.
 2021 Unannounced – B2B has documentation in youth files of this
requirement. They had an outside person providing regular health/sex
education classes for the clients, but that service had been interrupted
during this Covid pandemic. Youth continue to receive basic education and
questions answered at intake as part of the medical screening.
New Findings from Site Visit Comments
No new observed findings
Interview Summary
Two youth were interviewed during the course of the unannounced review. The first youth has been at the program for about one month. Stated the program
has a lot of structure and is ran very well. Youth said they connect with a lot of the staff which makes them feel safe and able to talk to them about any issue
or concerns they may have. They stated the food was decent and they had gotten used to it because it was the same food they ate in while in detention.
They received plenty to eat and snacks were always available, but they never got hungry at B2B. Youth said school and classes were set up really good.
They are currently a little bit ahead in school credits due to being in the program. Youth was aware of their service and transition plans, stating they and their
mom were involved in the process. They get phone calls pretty much whenever they want if someone else isn’t currently using the phone. They play a lot of
volleyball, basketball, and can work out with small weights. Outside of the program they have been mountain biking, fishing and have been to local parks.
They could not think of anything they would change about the program and said staff really connect with the youth.
The second youth has been at B2B for approximately 7 months and plan to transition home sometime in the next month. They said they feel safe and are
comfortable talking with the staff from various shifts. Youth also said the food was decent and they received plenty to eat. Phone calls can be made during
2
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 200115)
free time and there are no restrictions on how many they can make. Youth stated family was involved in service and transition planning and they have been
doing 4-8 hour home visits leading up to discharge. They don’t like math and need to make up some credits in that area, but are ahead in other areas. They
have opportunity for solo and group recreation every day. For outings they have been to the park, Crater Lake, movies and on Wednesday they have
mountain biking with Bo (unknown spelling). They could not think of anything the program or staff need to improve on and noted staff were really good at
talking to youth when they were upset, sad or escalated.
Observations
Overall, the program was clean and in good repair. One toilet was not operational, and a work ticket had already been submitted to maintenance. The rooms
were in a reasonable condition consistent with a typical teenager. It was noted due to Covid there were not as many community activities being conducted. It
should also be noted B2B under normal conditions has an exceptional track record of providing youth a wide variety of activities from fishing, mountain biking,
gold panning, etc. There were no complaints from youth about the “reduced” activities and outings.
Corrective Actions and Timeframes:
Please submit the following to verify compliance.
Within 45 days of receipt of this report Jackson County Barriers 2 Bridges 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@dhsoha.state.or.us or sent by regular mail to the following
address:
Department of Human Services
Children’s Care Licensing Program
Attn: Robin DuVal
201 High St. SE Suite 500
Salem, OR 97301
Licensing Coordinator’s Signature: ________________________ Date: _____1__1_-_1_-_2_0_2_1__ ___
10-29-2021
Manager Review: ______________________________________ Date: __________________
3
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 200115)

agency_name: Jackson County Juvenile Department (JCJD)

program_type: (RC) Residential Care Programs

report_type: Unannounced

view_code: RC

licensee: Jackson County Barriers 2 Bridges

executive_director: Eric Guyer

program_director: Joe Ferguson

licensing_coordinator: Todd Cooley

other_regulatory_agencies: OYA

purpose:
Per OAR 413-215-0101 (1) (b) Children's Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Comments
Findings
Further Action
Needed
Safety 413-215-0541 Yes No[ ] - (2019 Site Review) Only six months of fire drills were presented and they
(3)(a) Evacuation drill occurs monthly contained minimal information.
2020 Unannounced - Since the last review drills were not conducted in May
and September 2020, yet some of the months they are conducting more than
one drill and average one a month. The completed drills are significantly
improved and contain all of the necessary information. Continue to ensure
monthly drills are conducted and documented.
- 2021 Unannounced - Since last unannounced there was no documentation
of evacuation drills for November 2020 and January 2021. It was noted the
drills were likely conducted, but not documented. (REPEAT FINDING)
New Employee Orientation - Umbrella Yes[ ] No - (2019 Site Review) There was no documentation of nearly all the new employee
Requirements (30 days) orientation training. One staff had documentation of emergency procedures
413-215-0061(4) training but received it over four months after being hired.
1

2020 Unannounced - Program has provided their updated new employee
training curriculum which is very extensive and covers all licensing
requirements and much more.
- 2021 Unannounced - A new employee's file was reviewed and it contained
all of the appropriate new employee orientation training.
Health Services 413-215-0546 Yes[ ] No - (2019 Site Review) The reviewed youth files did not contain any documentation of
(2)(e) Documentation of age appropriate age appropriate instruction.
instruction
2020 Unannounced - Barriers 2 Bridges provides ongoing education in sex
education, health and wellness that is age appropriate. Consent for this
education is signed upon entry to the program, although specific
documentation of the group education is not contained in individual youth
files.
- 2021 Unannounced - B2B has documentation in youth files of this
requirement. They had an outside person providing regular health/sex
education classes for the clients, but that service had been interrupted
during this Covid pandemic. Youth continue to receive basic education and
questions answered at intake as part of the medical screening.
New Findings from Site Visit Comments
No new observed findings
Interview Summary
Two youth were interviewed during the course of the unannounced review. The first youth has been at the program for about one month. Stated the program
has a lot of structure and is ran very well. Youth said they connect with a lot of the staff which makes them feel safe and able to talk to them about any issue
or concerns they may have. They stated the food was decent and they had gotten used to it because it was the same food they ate in while in detention.
They received plenty to eat and snacks were always available, but they never got hungry at B2B. Youth said school and classes were set up really good.
They are currently a little bit ahead in school credits due to being in the program. Youth was aware of their service and transition plans, stating they and their
mom were involved in the process. They get phone calls pretty much whenever they want if someone else isn't currently using the phone. They play a lot of
volleyball, basketball, and can work out with small weights. Outside of the program they have been mountain biking, fishing and have been to local parks.
They could not think of anything they would change about the program and said staff really connect with the youth.
The second youth has been at B2B for approximately 7 months and plan to transition home sometime in the next month. They said they feel safe and are
comfortable talking with the staff from various shifts. Youth also said the food was decent and they received plenty to eat. Phone calls can be made during
2

free time and there are no restrictions on how many they can make. Youth stated family was involved in service and transition planning and they have been
doing 4-8 hour home visits leading up to discharge. They don't like math and need to make up some credits in that area, but are ahead in other areas. They
have opportunity for solo and group recreation every day. For outings they have been to the park, Crater Lake, movies and on Wednesday they have
mountain biking with Bo (unknown spelling). They could not think of anything the program or staff need to improve on and noted staff were really good at
talking to youth when they were upset, sad or escalated.
Observations
Overall, the program was clean and in good repair. One toilet was not operational, and a work ticket had already been submitted to maintenance. The rooms
were in a reasonable condition consistent with a typical teenager. It was noted due to Covid there were not as many community activities being conducted. It
should also be noted B2B under normal conditions has an exceptional track record of providing youth a wide variety of activities from fishing, mountain biking,
gold panning, etc. There were no complaints from youth about the "reduced" activities and outings.

new_findings: No new observed findings

excerpt:
413-215-0546 Yes[ ] No - (2019 Site Review) The reviewed youth files did not contain any documentation of
(2)(e) Documentation of age appropriate age appropriate instruction.
instruction
2020 Unannounced - Barriers 2 Bridges provides ongoing education in sex
education, health and wellness that is age appropriate. Consent for this
education is signed upon entry to the program, although specific
documentation of the group education is not contained in individual youth
files.
- 2021 Unannounced - B2B has documentation in youth files of this
requirement. They had an outside person providing regular health/sex
education classes for the clients, but that service had been interrupted
during this Covid pandemic. Youth continue to receive basic education and
questions answered at intake as part of the medical screening.
New Findings from Site Visit Comments
No new observed findings
No new observed findings


summary: License Renewals - 26 findings

raw_content:
Licensed Child Caring Agency Site Visit Report
Residential Care
Licensee: Jackson County Juvenile Barriers 2 Bridges (B2B)
Executive Director: Eric Guyer Date of site visit: December 1, 2021
Program Manager: Megan McUne Licensing Coordinator: Robin DuVal, assisted by Todd Cooley
County Commissioner Chair: Rick Dyer
Other Regulatory or Accrediting Agencies: Oregon Youth Authority and Oregon Health Authority
Program Compliance: The program was found to be compliant or will be compliant with OAR 413-215-0001 to 413-215-0131, Licensing Umbrella
Rules, and OAR 413-215-0501 to 413-215-0586, Licensing Residential Care Agencies Rules. Personnel records were reviewed and compliance with
required background checks was documented for employees in all programs.
Program Description(s): 15 bed residential program serving adjudicated male youth ages 12-18 years of age. Barriers 2 Bridges (B2B) is a voluntary
program in which youth and their families agree to enter when a youth has emotional and/or behavioral problems which cannot be adequately
assessed while at home. B2B determines the level of the youth’s need for services, develops, and implements an individual case plan, and provides
rehabilitative services to further stabilize the behavior for successful transition back into the community.
Program type and services: BRS level 5 Intensive Residential. Provides BRS group and individual services, education, mental health, and addictions
treatment.
Capacity and Age Range: 15, ages 10-20
Funding sources: Jackson County General Fund and Medicaid BRS
Contracts and sources for referrals:
Contracts: Lynn Greene LPC – Mental health counseling
Referrals: Jackson County Community Justice – Juvenile Department
Average length of stay: 6 months
(rev. 03/25/2021)
Average daily population served: 8
Number of children served annually: 27
Use of seclusion or restraint: No. However, staff is trained in CPI with restraints that can be utilized in the event of an emergency.
Interviews: During the review, this licensor spoke with the Program Director, Program Supervisor, multiple staff and two youth.
Youth felt safe at the program and feels the program is helping them. They have regular contact with people on their approved contact list and time
isn’t restricted. Youth feel comfortable talking to any number of staff across shifts. The food doesn’t taste the best but they have regular meals and
snacks. Youth know that management is working on improving food quality. Youth report giving input on their treatment plans and feel listened to.
Neither youth report any issues with getting medications as prescribed. School is going well and they prefer the smaller setting. Youth report the
program does well at working with people and is family oriented. The least favorite aspect of the program is the food.
Two interviewed staff described the types and frequency of training at time of hire and ongoing. They have regular staff meetings, have daily contact
with their immediate supervisor, and management is responsible to concerns made by staff. Both report staffing has been challenging, and they have
been working extra shifts to cover, however the program is working on hiring. The food quality could improve as well as having better and more
nutritious breakfast food. Neither staff physically intervene since the program changed to a policy of no hands on. Staff reported the program does
well at integrating youth into society (out in the “real world”) and providing structure, individual and group therapy, and incentives to children they
serve. One staff was fully aware of the requirements of mandatory abuse reporting, while the other was unclear in their knowledge. This licensor
provided training during the interview and followed up with the Program Manager.
Observations: During the review, the walkthrough consisted of the youth bedrooms, common areas, bathrooms, classroom, and recreation room.
The program was clean and in good repair.
Program Strengths, directly quoted by the agency:
Barriers to Bridges program has many strengths. We are a program that is able to serve youth that are local to our community, meaning families can
and are involved in youths treatment. We ensure our youth get lots of practice in their skills by taking them in to the community for various activities
and outings like, mountain bike riding, hiking, recreation at local parks, photography, movies, facility shopping (taking them to help buy items we need
for the program), and other various outings and activities. Covid prevented some of this but we worked hard to find activities and areas that limited
their exposure. We also have a great education program that is very individualized and helps students not only get caught up on credit, start or finish
their GED, and others begin online college courses all while learning and practicing new skills to help them be successful once back in public school.
We also have an on-site MH and A&D counselor who provides services to our youth while they are with us but also once they leave creating a
continuum of care that has shown to be effective at keepings kids engaged in these much-needed services once they graduate or leave B2B.
Further, Barriers to Bridges values relationships with youth, with staff investing time and effort in to building rapport and individualized goals that reflect
the youths input and goals. We work closely with families and probation officers, as well as community members to build a strong support network
outside of B2B for our youth when they leave.
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B2B has also begun to shift our focus to a restorative model working closely with Resolve, a local agency that trains and helps others implement this
philosophy into their work.
We have an incentive program that motivates youth to do well so that they can use earned points to purchase fun items out of the "green hwy store"
and reward youth with Resident of the Week as well as Room of the Week. B2B works hard to build on strengths and use positive reinforcement
while holding youth accountable in a more restorative way.
Our staff also have worked hard at improving their group facilitation skills and provide groups with engagement and reflection that builds skills and
creates a common language.
Program Challenges, directly quoted by the agency:
As with most residential programs, consistency among the staff members when enforcing rules and using consequences and discipline is an area
that we continually work to improve on. Another challenge that B2B struggles with is being as individualized for each youth as we would like. Our
youth come with a wide range of skills, and individualizing groups is a challenge that staff work hard to address through individual counseling. We
are also, like most, working to be creative in our recruitment for new staff so that we can have a fully trained full-time staff as well as a full on-call list
to draw from heading into the new year
Changes that have occurred in the last 2 years, directly quoted by the agency:
Megan McUne was hired as program manager, and we have a new detention manager that works closely with her to ensure the "upstairs" is running
smoothly. We have begun to implement Restorative Justice practices throughout the facility, and to build a new behavior management system
(accountability system) to replace the "point system" that is currently in use.
We also were raised to "intensive BRS" and will begin the process of being designated a QRTP (Quality Residential Treatment Program).
Lawsuits, directly quoted by the agency: None
Grievances and complaints filed in the last two years, directly quoted by the agency: No formal grievances filed during review period.
Summary of Review
Program and Services
Yes No N/A
413-215-0011(2)
Program and services are in scope of license X
Governance of the Agency
Yes No N/A
413-215-0021
(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
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(2)(h) Obtain and review an annual X
independent financial review or audit of
financial records.
(2)(k) Written quality improvement program X
(2)(l) Meeting minutes X
Executive Director or Program Director
Yes No N/A
413-215-0021
(3)(a) knowledge of requirements for X
providing care and treatment appropriate to
programs
(3)(g) Approval from BCU X
Discipline, Behavior Management, and
Yes No N/A
Suicide Prevention 413-215-0076
(3) Agency uses appropriate and positive
methods of behavior management and
X
nationally recognized non-violent crisis
intervention
(3)(b)(C) Agency does not use chemical and
mechanical restraint (excluding medically X
necessary devices/prescriptions)
(3)(c) Agency uses appropriate time-out
rooms (adequate space, heat, light and
ventilation and is not capable of locking) and X
documents use in child’s record when
applicable
(3)(e) Agency uses seclusion
X
appropriately/consistent with policy
(4) Agency has adequate plan in place to
X
respond to suicidal behavior/warning signs
Contractors (if applicable)
Yes No N/A
413-215-0061(6)
(a) Agency ensures the contractor meets the
requirements of this rule and Chapter 413 X
division 215
(b)(B) Contract includes the following:
(i) Services provided
(ii) Contractor fees
(iii) Disclosure of information from contractor
to agency
(iv) Lines of authority X
(v) Adherence to rules, including background
check
(vi) Any liability of the agency for acts of the
contractor, rights of indemnity and limitations
on liability
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Supplemental Information Provided by
Yes No N/A Comments
CCA
Documents as indicated on the form titled Certificate of Occupancy will be submitted once obtained.
X
“Renewal Licensing Required Documents”
Documents as indicated on form titled
“Required Financial Documents and X
Information”
All required policies and procedures as The agency will submit the following policies and procedures
identified in the “Umbrella Rules” for review:
 Conflict of Interest
X
 Grievances
 Personnel
All required policies and procedures as The agency will review all medication policy and procedures
identified in “Agency Type Specific Rules” to ensure all licensing requirements are met and submit for
X review.
Update Referral Policy to reflect correct ages served.
SB710 Requirements: Policy and
Procedures; notifications to guardian and X
children in care.
Physical Plant Corrective Action
Yes No N/A Corrective Actions
Completed
413-215-0046(3)(a) Foster Rights Posted (if X
children in DHS custody)
413-215-0051(1) Sufficient safe space, X
equipment, and office equipment
413-215-0091(12) License is posted in X
common area at each facility
413-215-0001(5)(d), 0516(4(a)(I) & 0521(1) X
Adequate furnishings and personal items
413-215-0511(2)(a) &(c) Buildings are X
smoke free, clean and in good repair
413-215-0511(2)(d) Rooms are free of X Corrective Action: The bathrooms were odorous of urine.
harmful drafts, odors, and excessive noise The agency shall ensure bathrooms are clean and free from
413-215-0511(2)(e) Rooms are adequate in X
odor.
size and arrangement
413-215-0511(2)(f) System provides a X
continuous supply of hot and cold water to
taps located throughout the facility
Corrective Action: Shower/bathroom ventilation. The
413-215-0511(2)(h) Building is well X
agency shall inspect the effectiveness of the bathroom
ventilated and room temperature is within a
normal comfort range
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413-215-0516(1) All parts of the facility X ventilation. The bathroom was observed following a shower
ensure the safety of children and water was dripping from the ceiling and doorway.
Room and Space Requirements
Yes No N/A Comments
Bedrooms 413-215-0516(3)
(a) Adequate furnishings and personal items X
(b) Separate from rooms used for dining, X
living, laundry, kitchen, and storage
(c) Outside room with window allowing X Comment: Approved exception on file.
egress from building
(d) Ceiling at least 90 inches X
(e) Minimum 60 SF per bed X
(f) No more than 25 if dorm style X
(g) Permanently wired fixtures X
Comment: Window covering is frosted glass.
(h) Window covering X
(i) Beds are 3 feet apart and maintained to X
ensure safety
Room and Space Requirements Corrective Action
Yes No N/A Corrective Action
Bathrooms 413-215-0516(4) Completed
(a)(A)&(B) 1:8 ratio for toilets and sinks X
(a)(D) Hot and cold running water, soap, and X
approved hand drying options
(a)(E) 1:10 ratio for shower or bathtub X
(a)(E) Individual privacy X
(a)(F) Window covering X
(a)(G) Permanently wired fixtures X
(a)(H) Adequate ventilation X
Corrective Action: The agency shall inspect the
effectiveness of the bathroom ventilation and repair as
(b)&(c) Wooden racks on floors are X
needed. The bathroom was observed following a shower and
prohibited and impervious shower mats are
condensation/water was dripping from the ceiling and
disinfected & dried daily
doorway.
Room and Space Requirements
Yes No N/A Comments
Kitchen 413-215-0516(6)
(a) Used exclusively for storage, food X
preparation, dish washing and activities Comments:
related to eating  All meals are prepared at the County Jail and
(b) Walls, floors are easily cleanable X brought over for youth, as well as from other outside
(c) Equipment and utensils are easily X vendors.
cleanable, durable, nontoxic, and kept clean
(e) Equipment is easy to clean beneath, X
between and behind
Room and Space Requirements
Yes No N/A
413-215-0516
(2) There is a separate living room or lounge X
area – 15 SF minimum per child
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(5) There is a separate dining room with X
capacity for ½ of children in care and 15 SF
per child in care
(7) Laundry is separate from living areas, X
kitchen and dining
(8) Separate storage areas are provided for X
food, kitchen supplies, utensils, clean linens,
soiled linens and clothing, cleaning supplies
and equip, poisons, chemicals, outdoor
recreational and maintenance equipment
(9) Outdoor activity area is protected from X
vehicles and other hazards and of a size and
availability appropriate to the age and needs
of children in care
(11) & 413-215-0076(3)(c)(C)Time out rooms X
have adequate space, heat, light and
ventilation and is not capable of locking
Furnishings and Personal Items
Yes No N/A
413-215-0521
(1) There is a bed with frame, clean mattress X
and pillow and personal storage (dresser,
closet)
(2) Linens are in good repair. There is a X
waterproof mattress cover or mattress.
Linens are appropriate and towels and
washcloths are provided
(3) Bedding is changed weekly or when X
soiled
(4)&(5) Personal hygiene supplies and X
appropriate clothing are provided
Food Services
Yes No N/A
413-215-0536(1)&(2)
(1)(a) Meals are arranged daily, consistent X
with normal mealtimes that occur during the
hours of operation
(1)(b) Menus are prepared in advance in X
accordance with USDA guidelines, provide a
variety of foods and are adjusted for
seasonal changes.
(1)(b) Menus are kept for at least 6 months X
(1)(c) Drinking water is freely available X
(2)(a) Food is stored, prepared & served in a X
sanitary manner
(2)(c) & (d) Food products are obtained from X
commercial suppliers (exception of fruits &
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vegetables), unpasteurized juice is
prohibited, and only Grade A pasteurized
and fortified milk in appropriate container.
Safety Corrective Action
Yes No N/A Corrective Actions
413-215-0541 Completed
(2)(a) Written emergency plan X
(2)(b) Telephone numbers for local police X
and fire are posted near all telephones
(2)(c) Operative flashlights sufficient in X
number are readily available to staff
(3)(a) Evacuation drill occurs monthly under X Corrective Action: Evacuation Drill logs are missing
varying conditions, is retained 2 yrs and required elements; therefore, the information was not
contains; captured. The agency shall utilize and implement an
(A) identify of person conducting drill evacuation drill log which identifies each area of information
(B) date & time required, complete each area, and retain the documentation
(C) notification method for 2 years. This is a repeat violation from 2019.
(D) staff participating
(E) # of children & staff evacuated
(F) special conditions simulated
(G) problems encountered
(H) time to complete
Safety – Transportation
Yes No N/A
413-215-0541
(5)(b) Vehicle has insurance policy, is smoke X
free, safe operating condition, and has first
aid kit and fire extinguisher 2-A:10-BC
Medication Corrective Action
Yes No N/A Corrective Actions
413-215-0551 Completed
(3)&(7)(e) Medications have a prescription X
and are stored in the original container with
prescription label
(4)&(5) Herbal supplements and remedies, X
medical treatments, special diets, physical
therapy, physical aides or limitations have a
written order signed by a physician or
qualified medical professional.
(7)(c) Medications are inaccessible to X Corrective Actions:
children
(8) Medications are disposed in accordance X  The agency shall review policy and procedure to
with state and federal law ensure medication disposals are occurring in
(9) Written record of the disposal of X accordance with state and federal law.
medications is maintained and includes:
(a) description and amount  The agency shall ensure all unused medication are
(b) name documented capturing all required elements (a-e).
(c) reason
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(d) method The written disposal record shall be thoroughly
(e) staff & witness signature completed and maintained.
(10) Written record of the administration of X
medication includes:  Possible adverse reactions (side effects) for each
(a) name medication must be included on or with the youths
(b) description medication record. During the course of the review,
(c) dates and times the nurse added them to the current youths records.
(d) missed doses The agency shall ensure policy and procedures are
(e) medication disposed updated, implemented, and trained to staff.
(f) method of administration
(g) ID of person administering  The medication administration records had some
(h) possible adverse reactions blanks. The agency shall ensure the written
(i) medication taken outside facility medication administration are filled out accurately
without blanks. An explanation must be documented
for any missed medications.
Extracurricular, Enrichment, Cultural &
Social Activities Yes No N/A
413-215-0554
(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
413-215-0561
(1)&(2) Supervision is adequate for the type X
of program, location, age and type of
children, ability of supervisor to respond,
electronic back-up systems.
Minimum ratios are maintained:
Under 30 months of age: 1:4
30 months to ˃ 6 yrs or non-ambulatory: 1:6
Ages 6 and older: 1:7
Overnight (staff awake)
1:10
(4)(a) When one staff on duty, there is X
additional staff immediately available with
max response time of 30 minutes
(5) There is at least one on-site employee X
authorized to apply the reasonable and
prudent parent standard
Separation of Residents
Yes No N/A
413-215-0566
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(1) Children are in separate bedrooms than X
adults, unless parent and child, or there is
written approval from guardian/parent and
licensing coordinator
(2) There is adequate supervision of children X
if both males and females are served by the
program
Personnel Files
Yes No N/A
413-215-0061
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
and documented
(1)(a) & (3)(c) Background check completed
X
and documented
(3)(d) Annual performance evaluations X
(3)(f) Record of personnel actions X
(3)(g) Termination date, reason for
X
termination
(3)(h) Current job description (1)(c)
Employee meets minimum qualifications X
stated in current job description
New Employee Orientation – Umbrella
Corrective Action
Requirements (30 days) Yes No N/A Corrective Actions
Completed
413-215-0061(4)
(a) Agency policies and procedures X Corrective Action: The agency has a detailed orientation
(b) Ethical and professional guidelines X training checklist; however, documentation confirming
completion was inconsistent or altogether missing. The
(c) Organizational lines of authority X
agency shall implement a system to ensure training occurs
(d) Attributes of population served X
as scheduled and is documented appropriately. This is a
(e) & (5)(a) to (c) Mandatory reporting that
repeat violation from 2019.
includes:
(a) legal definition of child abuse ORS
X
419B.005, Oregon Laws 2016, chapter 106,
section 36
(b) legal responsibility to immediately report
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(c) legal responsibility to report is personal to
the employee
(f) Privacy laws X
(g) Emergency procedures X
New Employee Orientation – Residential
Corrective Action
(30 days) Yes No N/A Corrective Actions
Completed
413-215-0556
(1)(a) Discipline and behavior management
Corrective Action: The agency has a detailed orientation
including de-escalation, crisis prevention,
training checklist; however, documentation confirming
positive behavior management, and X completion was inconsistent or altogether missing. The
disciplinary techniques that are non-punitive
agency shall implement a system to ensure training occurs
in nature
as scheduled and is documented appropriately. This is a
(1)(b) Restraint and seclusion (if applicable) X repeat violation from 2019.
Ongoing Training Yes No N/A
413-215-0536(2)(b) Employees who handle X
food served to children have a valid food
handler’s card
413-215-0541(5)(a) Employees transporting
children have: current driver’s license,
insurance, trained in emergency procedures X
and behavior management, and training for
15+ passenger vans if applicable)
413-215-0556(2)(a) Environmental
X
emergencies
413-215-0556(2)(b) Universal Precautions X
413-215-0556(2)(c) Discipline and Behavior
X
Management
413-215-0556(3) Staff providing direct care
must maintain current CPR/First Aid X
certification
413-215-0556(4) Designated staff authorized
to apply reasonable and prudent parent
X
standard are trained in application of the
standard
413-215-0061(5) Mandatory reporting
(annually) that includes:
(a) legal definition of child abuse ORS
X
419B.005, Oregon Laws 2016, chapter 106,
section 36
(b) legal responsibility to immediately report
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(c) legal responsibility to report is personal to
the employee
Children’s Records Corrective Action
Yes No N/A Corrective Actions
Completed
Health Services
413-215-0546
(2) Medical history obtained within 30 days
(significant findings, current immunizations,
history of surgical procedures-health issues- X
injuries, allergies, dental, vision, hearing,
behavioral health, and physician orders)
(2)(e) Documentation of age appropriate Corrective Action:
instruction – pregnancy prevention, nutrition, The reviewed youth files did not contain any documentation
prevention of HIV & AIDS, and prevention X of age-appropriate instruction. The agency shall ensure this
and treatment of sexually transmitted instruction is provided and documented in each youth file.
disease This is a repeat violation from 2019.
(4)(a) to (f) Medical exams (3 in first year of
life, 2,4,6,9,14) X
Consents
Yes No N/A
413-215-0576(1)
(a) Provide routine and emergency medical
X
care
(b) Use the discipline and behavior
X
management system
(c) Use restraint or seclusion (if applicable).
Must specify the reasons for the intervention X
and how staff are trained and supervised
(d) Restrict contact with persons outside of
X
the agency
(e) Allow access as defined in 413-215-0091
X
& 0101
(f) Impose a dress code X
(g) Apply the reasonable and prudent parent
X
standard
Disclosures
Corrective Action
413-215-0576(2) Parent/guardian has Yes No N/A Corrective Actions
Completed
acknowledged in writing:
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(a) Information regarding personal or room
searches and protocols for confiscation of X
contraband Corrective Actions:
(b) Statement of Rights of Children and  The agency shall ensure disclosure (b) is included in
X
Parents/Guardians its entirety in the program handbook.
(c) Any policies and procedures upon  The agency shall ensure disclosure (c) is included in
X
request the disclosures.
Authorizations
Yes No N/A
413-215-0576(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
413-215-0581(1) Summary sheet contains Yes No N/A
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
413-215-0581(2)
(b) Intake document is completed the date
child accepted into care (emergency X
placement 48 hours)
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(d) Assessment is completed within 30 days
and contains relevant historical info., current
behavioral observations, identified need for X
services, and how agency will provide
services
(e) (A)&(B) Service plan within 60 days
(parent, guardian and child actively
involved). Describes how child’s issues will X
be addressed, anticipated outcomes and
reviewed by child and guardian/parent.
(e)(C)&(D) Service plan is reviewed quarterly
and revised when information indicates other X
services should be provided
Case Management
Yes No N/A
413-215-0581(3)
(a) Services are documented, progress
X
toward achieving goals is tracked
(b)-(d) discharge planning and instructions X
(f) Incident Reports X
Financial Records
Yes No N/A
413-215-0581(4)
Records contain date, amount, source,
X
purpose, signatures
Personal Possessions Records
Yes No N/A
413-215-0581(5)
Individual written inventory of all personal
possessions is maintained and updated as X
needed
Records and Documentation Corrective Action
Yes No N/A Corrective Actions
413-215-0071 Completed
(1) Stored safely X
(2) Permanent, legible, dated, and signed X
Corrective Actions:
(3)&(4) Uniform in organization, readily
 Personnel, youth records and medication records are
identifiable and accessible, current, and
X incomplete missing required elements noted above.
complete, containing all required info. No
 Personnel training records were not easily
eraser tape or white out.
identifiable or accessible.
(7) Permanent registry for each child
includes:
Name X
Gender
Birth date
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Names, addresses of parents or guardians
Dates of admission
Placement upon discharge
Corrective Actions and Timeframes: Please submit the following to verify compliance.
Within 45 days of receipt of this report Jackson County Juvenile B2B 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, ROBIN.M.DuVal@dhsoha.state.or.us.
Recommendations:
 Provide a refresher training to all staff regarding mandatory abuse reporting requirements. One of two interviewed staff was either unaware
or unclear about mandatory abuse reporting requirements.
 Ensure youth and guardian statement of rights in the Handbook and all other referenced documents include all requirements per OAR 413-
215-0046(1)(a-j).
Exceptions: Bedroom window egress exception on file.
Changes in License: No changes to the license.
12/29/2021
Licensing Coordinator’s Signature: ________________________ Date: ___________________
Manager Review: ______________________________________ Date: _1_2_-_2_9_-_2_0_2_1_ _______
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report_type: License Renewals

facility_type: Residential Care

program_description:
15 bed residential program serving adjudicated male youth ages 12-18 years of age. Barriers 2 Bridges (B2B) is a voluntary
program in which youth and their families agree to enter when a youth has emotional and/or behavioral problems which cannot be adequately
assessed while at home. B2B determines the level of the youth's need for services, develops, and implements an individual case plan, and provides
rehabilitative services to further stabilize the behavior for successful transition back into the community.

contracts_and_referrals:
Contracts: Lynn Greene LPC - Mental health counseling
Referrals: Jackson County Community Justice - Juvenile Department

average_length_of_stay: 6 months

use_of_seclusion_or_restraint: No. However, staff is trained in CPI with restraints that can be utilized in the event of an emergency. Interviews: During the review, this licensor spoke with the Program Director, Program Supervisor, multiple staff and two youth. Youth felt safe at the program and feels the program is helping them. They have regular contact with people on their approved contact list and time isn't restricted. Youth feel comfortable talking to any number of staff across shifts. The food doesn't taste the best but they have regular meals and snacks. Youth know that management is working on improving food quality. Youth report giving input on their treatment plans and feel listened to. Neither youth report any issues with getting medications as prescribed. School is going well and they prefer the smaller setting. Youth report the program does well at working with people and is family oriented. The least favorite aspect of the program is the food. Two interviewed staff described the types and frequency of training at time of hire and ongoing. They have regular staff meetings, have daily contact with their immediate supervisor, and management is responsible to concerns made by staff. Both report staffing has been challenging, and they have been working extra shifts to cover, however the program is working on hiring. The food quality could improve as well as having better and more nutritious breakfast food. Neither staff physically intervene since the program changed to a policy of no hands on. Staff reported the program does well at integrating youth into society (out in the "real world") and providing structure, individual and group therapy, and incentives to children they serve. One staff was fully aware of the requirements of mandatory abuse reporting, while the other was unclear in their knowledge. This licensor provided training during the interview and followed up with the Program Manager. Observations: During the review, the walkthrough consisted of the youth bedrooms, common areas, bathrooms, classroom, and recreation room. The program was clean and in good repair.

recommendations:
Provide a refresher training to all staff regarding mandatory abuse reporting requirements. One of two interviewed staff was either unaware
or unclear about mandatory abuse reporting requirements.
- Ensure youth and guardian statement of rights in the Handbook and all other referenced documents include all requirements per OAR 413-
215-0046(1)(a-j).

changes_in_license:
No changes to the license.
12/29/2021

excerpt:
Documents as indicated on the form titled
“Renewal Licensing Required Documents” Certificate of Occupancy will be submitted once obtained.

excerpt:
All required policies and procedures as
identified in the “Umbrella Rules” The agency will submit the following policies and procedures
for review:
 Conflict of Interest
 Grievances
 Personnel

excerpt:
All required policies and procedures as
identified in “Agency Type Specific Rules” The agency will review all medication policy and procedures
to ensure all licensing requirements are met and submit for
review.
Update Referral Policy to reflect correct ages served.

excerpt:
Foster Rights Posted (if
children in DHS custody) Corrective Action: The bathrooms were odorous of urine.
The agency shall ensure bathrooms are clean and free from
odor.
Corrective Action: Shower/bathroom ventilation. The
agency shall inspect the effectiveness of the bathroom

excerpt:
Rooms are free of
harmful drafts, odors, and excessive noise

excerpt:
Building is well
ventilated and room temperature is within a
normal comfort range

excerpt:
(c) Outside room with window allowing
egress from building

excerpt:
(a)(A)&(B) 1:8 ratio for toilets and sinks Corrective Action: The agency shall inspect the
effectiveness of the bathroom ventilation and repair as
needed. The bathroom was observed following a shower and
condensation/water was dripping from the ceiling and
doorway.

excerpt: (a)(H) Adequate ventilation

excerpt:
(2)(a) Written emergency plan Corrective Action: Evacuation Drill logs are missing
required elements; therefore, the information was not
captured. The agency shall utilize and implement an
evacuation drill log which identifies each area of information
required, complete each area, and retain the documentation
for 2 years. This is a repeat violation from 2019.

excerpt:
(3)(a) Evacuation drill occurs monthly under
varying conditions, is retained 2 yrs and
contains;
(A) identify of person conducting drill
(B) date & time
(C) notification method
(D) staff participating
(E) # of children & staff evacuated
(F) special conditions simulated
(G) problems encountered
(H) time to complete

excerpt:
(8) Medications are disposed in accordance
with state and federal law

excerpt:
(9) Written record of the disposal of
medications is maintained and includes:
(a) description and amount
(b) name
(c) reason

excerpt:
(10) Written record of the administration of
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

excerpt: (a) Agency policies and procedures

excerpt: (b) Ethical and professional guidelines

excerpt: (c) Organizational lines of authority

excerpt: (d) Attributes of population served

excerpt:
(e) & (5)(a) to (c) Mandatory reporting that
includes:
(a) legal definition of child abuse ORS
419B.005, Oregon Laws 2016, chapter 106,
section 36
(b) legal responsibility to immediately report

excerpt: (f) Privacy laws

excerpt: (g) Emergency procedures

excerpt:
(1)(a) Discipline and behavior management
including de-escalation, crisis prevention,
positive behavior management, and
disciplinary techniques that are non-punitive
in nature Corrective Action: The agency has a detailed orientation
training checklist; however, documentation confirming
completion was inconsistent or altogether missing. The
agency shall implement a system to ensure training occurs
as scheduled and is documented appropriately. This is a
repeat violation from 2019.

excerpt:
(1)(b) Restraint and seclusion (if applicable) Corrective Action:
The reviewed youth files did not contain any documentation
of age-appropriate instruction. The agency shall ensure this
instruction is provided and documented in each youth file.
This is a repeat violation from 2019.

excerpt:
(b) Statement of Rights of Children and
Parents/Guardians

excerpt:
(c) Any policies and procedures upon
request

excerpt:
(3)&(4) Uniform in organization, readily
identifiable and accessible, current, and
complete, containing all required info. No
eraser tape or white out.


summary: Unannounced - 8 findings

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Residential Care
Licensee: Jackson County Juvenile Dept. Barriers 2 Bridges (B2B)
Executive Director: Eric Guyer Date of Unannounced: April 4, 2023
Deputy Director: Joe Furguson Licensing Coordinator: Robin DuVal
Program Director: Megan McUne
Other Regulatory or Accrediting Agencies: Oregon Youth Authority and Oregon Health Authority
Purpose: Per OAR 419-400-0240 (1)(b) Children’s Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Repeat Findings
Previous Findings
Further Action Comments
Unannounced Site Visit 04/20/2022
Needed
419-470-0080 (3)(a) Evacuation drill occurs monthly under varying Yes☐ No Evacuation drill logs for the last two months were reviewed,
conditions, is retained 2 yrs and contains; and all required elements are completed.
(A) identify of person conducting drill  No further corrective action needed.
(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
Corrective Action: Evacuation Drill logs are missing required
elements; therefore, the information was not captured. The agency
shall utilize and implement an evacuation drill log which identifies each
area of information required, complete each area, and retain the
documentation for 2 years. This is a repeat violation from 2019,
2021, and 2022.
Page 1 of 4
Form Rev. 01/23/2023
419-470-0100 (8) (9) Written record of the disposal of medications Yes☐ No Medication disposal logs were reviewed, and all required
is maintained and includes: elements are completed.
(a) description and amount  No further corrective action needed.
(b) name
(c) reason
(d) method
(e) staff & witness signature
Corrective Actions: The agency shall ensure all unused medication
are documented capturing all required elements (a-e). The written
disposal record shall be thoroughly completed and maintained. This is
a repeat violation from 2022.
419-470-0100 (8) (10) Written record of the administration of Yes☐ No Medication records were reviewed, and all required elements
medication includes: are completed and are without blanks. Possible adverse
(a) name reactions were documented for each child in care.
(b) description  No further corrective action needed.
(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
Corrective Actions: Possible adverse reactions (side effects) for each
medication must be included on or with the youths medication record.
During the course of the review, the nurse added them to the current
youths records. The agency shall ensure policy and procedures are
updated, implemented, and trained to staff. This is a repeat violation
from 2021 and 2022.
The medication administration records had some blanks. The agency
shall ensure the written medication administration are filled out
accurately without blanks. An explanation must be documented for any
missed medications. This is a repeat violation from 2021 and 2022.
419-470-0090 (2)(e) Documentation of age- appropriate instruction Yes☐ No Children in care records were reviewed and contained
– pregnancy prevention, nutrition, prevention of HIV & AIDS, and documentation of age-appropriate instruction.
prevention and treatment of sexually transmitted disease.  No further corrective action needed.
Corrective Action: The reviewed youth files did not contain any
documentation of age-appropriate instruction. The agency shall ensure
this instruction is provided and documented in each youth file. This is a
repeat violation from 2019, 2021 and 2022.
Page 2 of 4
419-400-0140 (3)&(4) Uniform in organization, readily identifiable Yes☐ No Personnel records, including training records, were observed
and accessible, current, and complete, containing all required and are accessible within the program managers office.
info. No eraser tape or white out.  No further corrective action needed.
Corrective Actions: Personnel training records were not easily
identifiable or accessible.
419-470-0030 (6)(c) Kitchen: All equipment and utensils used for food Yes No☐ The “servery” room was observed in need of a deep clean,
service, including plastic ware and food-contact surfaces, must be i.e. toaster oven, microwaves, walls, floor, refrigerator, etc.
easily cleanable, durable, nontoxic, and nonabsorbent, and must be This is a repeat violation from 2022.
maintained in a clean and sanitary condition.
Corrective Action: The agency shall ensure that a scheduled
Food preparing appliances in the “servery” room were observed in need deep-clean routinely occurs as well as maintaining daily
of a deep clean, i.e., toaster oven. The agency shall ensure all cleanliness.
equipment used for food service be maintained in a clean and sanitary
condition.
New Findings from Site Visit Comments
OAR 419-470-0020(2)(c): All areas of buildings where children in care Bathroom/shower rooms: The following was observed.
are present must be kept clean and in good repair. Major appliances
and heating, ventilation, plumbing, and electrical systems must be  Standing water, due to a leak, on the bathroom floor of each shower
functional and in good repair. threshold. The floor where the water sits looked discolored and raised.
- This is a slip hazard and injury risk to the children in care.
OAR 419-470-0030(4)(c) Bathrooms: When impervious shower mats - It’s unclear if children in care are using their bath towel to also use on the
are used, they must be disinfected and dried at least once per day. wet floor, and if so, is unhygienic.
 Toilet plumbing issues; clogging and/or overflowing.
 Ceiling vent holes are clogged with built-up debris that could impact the
effectiveness of adequate ventilation.
 A shower floor mat (inside the shower) was wet and appeared dirty or
moldy.
Corrective Action: The agency shall ensure the above are remedied and
maintained in good working order and free from risk going forward.
Page 3 of 4
Interview Summary
While reviewing the medications and new medication cart, the nurse joined me and shared all the areas of improvement and compliance, including all the
features of the new medication cart.
Two youth were interviewed, ages 16 and 15, and have been in the program approximately 5 months and 1.5 months, respectfully. Both reported feeling safe,
that the program is helping them and that staff are trusting. Program expectations are communicated at intake and are reinforced by youth following their peers.
They receive their medications as prescribed without issues. School is good, and they get extra help when needed. One youth reported that the food trays are
good, while the other reported the food is not always appealing. However, the program does its best by providing seasonings and the “snack shack”, and both
report getting enough food. Numerous outings occur, such as going to the gym, parks, hikes, bowling, soccer, football, and going on drives. Activities inside the
program include basketball, gaming, card games, puzzles, reading. Regular phone contact with approved individuals occurs without restrictions, and there are
options to have a private phone call, depending on their service plan. One youth stated the program does well at being supportive to youth and the other stated
that everything is good and well-rounded. One youth stated the program could do better at mixing up the routine outings.
Observations
Manager Megan accompanied this licensor for the walk-through of the program, which included youth bedrooms, common areas, bathrooms, and the classroom.
Most areas were clean, well-kept, and without foul odor, except areas noted above in findings. New bedframes have been installed and are working well. The
program recently purchased a locking medication cart with drawers for better use and organization which staff are happy about. The hand drying blowers in the
bathroom are still working out well.
Comments
The following areas were discussed with the manager, with follow-up after the review from this licensor.
 Critical event notifications within one business day.
 Incident reports: resolved system capability to email completed incident reports.
 Youth phone calls ensuring privacy.
Corrective Actions and Timeframes: Please submit the following to verify compliance.
Within 45 days of receipt of this report Jackson County Juvenile Department Barriers 2 Bridges (B2) 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: _4_/1_7_/_2_0_2_3_ __________
Manager Review: ______________________________________ Date: _4_-1_7_-_2_0_2_3_ _________
Page 4 of 4

program_director: Megan McUne

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.
Repeat Findings
Previous Findings
Further Action Comments
Unannounced Site Visit 04/20/2022
Needed
419-470-0080 (3)(a) Evacuation drill occurs monthly under varying Yes[ ] No Evacuation drill logs for the last two months were reviewed,
conditions, is retained 2 yrs and contains; and all required elements are completed.
(A) identify of person conducting drill - No further corrective action needed.
(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
Corrective Action: Evacuation Drill logs are missing required
elements; therefore, the information was not captured. The agency
shall utilize and implement an evacuation drill log which identifies each
area of information required, complete each area, and retain the
documentation for 2 years. This is a repeat violation from 2019,
2021, and 2022.
Page 1 of 4

419-470-0100 (8) (9) Written record of the disposal of medications Yes[ ] No Medication disposal logs were reviewed, and all required
is maintained and includes: elements are completed.
(a) description and amount - No further corrective action needed.
(b) name
(c) reason
(d) method
(e) staff & witness signature
Corrective Actions: The agency shall ensure all unused medication
are documented capturing all required elements (a-e). The written
disposal record shall be thoroughly completed and maintained. This is
a repeat violation from 2022.
419-470-0100 (8) (10) Written record of the administration of Yes[ ] No Medication records were reviewed, and all required elements
medication includes: are completed and are without blanks. Possible adverse
(a) name reactions were documented for each child in care.
(b) description - No further corrective action needed.
(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
Corrective Actions: Possible adverse reactions (side effects) for each
medication must be included on or with the youths medication record.
During the course of the review, the nurse added them to the current
youths records. The agency shall ensure policy and procedures are
updated, implemented, and trained to staff. This is a repeat violation
from 2021 and 2022.
The medication administration records had some blanks. The agency
shall ensure the written medication administration are filled out
accurately without blanks. An explanation must be documented for any
missed medications. This is a repeat violation from 2021 and 2022.
419-470-0090 (2)(e) Documentation of age- appropriate instruction Yes[ ] No Children in care records were reviewed and contained
- pregnancy prevention, nutrition, prevention of HIV & AIDS, and documentation of age-appropriate instruction.
prevention and treatment of sexually transmitted disease. - No further corrective action needed.
Corrective Action: The reviewed youth files did not contain any
documentation of age-appropriate instruction. The agency shall ensure
this instruction is provided and documented in each youth file. This is a
repeat violation from 2019, 2021 and 2022.
Page 2 of 4
419-400-0140 (3)&(4) Uniform in organization, readily identifiable Yes[ ] No Personnel records, including training records, were observed
and accessible, current, and complete, containing all required and are accessible within the program managers office.
info. No eraser tape or white out. - No further corrective action needed.
Corrective Actions: Personnel training records were not easily
identifiable or accessible.
419-470-0030 (6)(c) Kitchen: All equipment and utensils used for food Yes No[ ] The "servery" room was observed in need of a deep clean,
service, including plastic ware and food-contact surfaces, must be i.e. toaster oven, microwaves, walls, floor, refrigerator, etc.
easily cleanable, durable, nontoxic, and nonabsorbent, and must be This is a repeat violation from 2022.
maintained in a clean and sanitary condition.
Corrective Action: The agency shall ensure that a scheduled
Food preparing appliances in the "servery" room were observed in need deep-clean routinely occurs as well as maintaining daily
of a deep clean, i.e., toaster oven. The agency shall ensure all cleanliness.
equipment used for food service be maintained in a clean and sanitary
condition.
New Findings from Site Visit Comments
OAR 419-470-0020(2)(c): All areas of buildings where children in care Bathroom/shower rooms: The following was observed.
are present must be kept clean and in good repair. Major appliances
and heating, ventilation, plumbing, and electrical systems must be - Standing water, due to a leak, on the bathroom floor of each shower
functional and in good repair. threshold. The floor where the water sits looked discolored and raised.
- This is a slip hazard and injury risk to the children in care.
OAR 419-470-0030(4)(c) Bathrooms: When impervious shower mats - It's unclear if children in care are using their bath towel to also use on the
are used, they must be disinfected and dried at least once per day. wet floor, and if so, is unhygienic.
- Toilet plumbing issues; clogging and/or overflowing.
- Ceiling vent holes are clogged with built-up debris that could impact the
effectiveness of adequate ventilation.
- A shower floor mat (inside the shower) was wet and appeared dirty or
moldy.
Corrective Action: The agency shall ensure the above are remedied and
maintained in good working order and free from risk going forward.
Page 3 of 4
Interview Summary
While reviewing the medications and new medication cart, the nurse joined me and shared all the areas of improvement and compliance, including all the
features of the new medication cart.
Two youth were interviewed, ages 16 and 15, and have been in the program approximately 5 months and 1.5 months, respectfully. Both reported feeling safe,
that the program is helping them and that staff are trusting. Program expectations are communicated at intake and are reinforced by youth following their peers.
They receive their medications as prescribed without issues. School is good, and they get extra help when needed. One youth reported that the food trays are
good, while the other reported the food is not always appealing. However, the program does its best by providing seasonings and the "snack shack", and both
report getting enough food. Numerous outings occur, such as going to the gym, parks, hikes, bowling, soccer, football, and going on drives. Activities inside the
program include basketball, gaming, card games, puzzles, reading. Regular phone contact with approved individuals occurs without restrictions, and there are
options to have a private phone call, depending on their service plan. One youth stated the program does well at being supportive to youth and the other stated
that everything is good and well-rounded. One youth stated the program could do better at mixing up the routine outings.
Observations
Manager Megan accompanied this licensor for the walk-through of the program, which included youth bedrooms, common areas, bathrooms, and the classroom.
Most areas were clean, well-kept, and without foul odor, except areas noted above in findings. New bedframes have been installed and are working well. The
program recently purchased a locking medication cart with drawers for better use and organization which staff are happy about. The hand drying blowers in the
bathroom are still working out well.
Comments
The following areas were discussed with the manager, with follow-up after the review from this licensor.
- Critical event notifications within one business day.
- Incident reports: resolved system capability to email completed incident reports.
- Youth phone calls ensuring privacy.

excerpt:
419-470-0030(4)(c) Bathrooms: When impervious shower mats - It's unclear if children in care are using their bath towel to also use on the
are used, they must be disinfected and dried at least once per day. wet floor, and if so, is unhygienic.
- Toilet plumbing issues; clogging and/or overflowing.
- Ceiling vent holes are clogged with built-up debris that could impact the
effectiveness of adequate ventilation.
- A shower floor mat (inside the shower) was wet and appeared dirty or
moldy.
Corrective Action: The agency shall ensure the above are remedied and
maintained in good working order and free from risk going forward.
Page 3 of 4
OAR


summary: Unannounced - 3 findings

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Residential Care
Licensee: Jackson County Juvenile Department – Barrier 2 Bridges
Executive Director: Kiki Parker-Rose Licensing Coordinator: Robin DuVal
Deputy Director: Bobby Divine Date of Unannounced: April 2, 2025
Program Manager: Megan McUne
Other Regulatory or Accrediting Agencies: Oregon Health Authority
Purpose: Per OAR 419-400-0240 (1)(b) Children’s Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Findings Comments
Unannounced Site Visit – 06/24/2024 Further Action Needed
Medication 419-470-0100(10) Written record of the administration of Yes☐ No✓ Medication administration records were
medication includes: reviewed, and this requirement was met.
(a) name There’s no further corrective action needed at
(b) description this time.
(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
Medication administration records (MARs) were observed, and there continues
to be lack of corresponding documentation when a medication was not
administered. However, to note, when this licensor asked two staff what the
process is when a medication is not administered, they were able to verbally
describe the correct procedure. This is a repeat violation.
Corrective Action: The agency shall provide an administrative oversight plan
that details how ongoing compliance will occur. In the plan, state who will be
directly responsible to ensure ongoing compliance.
Form Rev. 11/14/2023 P age 1 | 3
New Findings from Site Visit Corrective Actions
419-470-0020 Physical Plant Requirements Bathrooms observations:
(2) A residential care agency must meet all of the following • Paint at the top of the door jams is peeling and hanging down.
requirements: • Both toilet bowls had a discoloration, unknown of the cause.
(c) All areas of buildings where children in care are present must be • One bathroom was a bit odorous.
kept clean and in good repair.
Corrective Action: The agency shall assess these areas and submit findings
including plans to remedy.
419-400-0090(1)(a)(B)(b) Children’s right to privacy during phone Privacy during phone calls usually happens within the phone booth, where staff have
calls. eyes on youth, however another youth damaged the phone so it’s not working
properly.
Corrective Action: The agency shall establish an interim plan to ensure youth have
privacy during phone calls; and communicate that process to ensure the practice is
consistent among staff.
Interview Summary
During my visit, I interacted with the case manager, deputy director, other youth in the milieu and two staff. Two youth were individually interviewed ages 16 and
17 with stays in the program for 5 and 2 months respectively. Both reported that this is their first program, feel safe here, and they described ways the program
is helping them. Activities and outings were described and both report that school is going well, working on credit recovery and school completion courses. They
have regular contact with people on their approved contact list and time isn’t restricted, although limited depending on how many other youth have calls and the
schedule that day. Privacy during phone calls usually happens within the phone booth, where staff have eyes on youth, however another youth damaged the
phone so its not working. The staff that they have a better rapport with are trusting and they show care and concern. They give input in their treatment plan and
feel listened to. They shared that the case manager and therapist are “amazing”. At times, it can feel like staff are not treating youth equally as if the same rules
don’t apply to all; however, they understand how each youth could have an individualized plan or need a different approach. Despite this, the youth said they’ve
learned to reframe those thoughts and stay focused on their goals and success. Neither youth report any issues getting their medications as prescribed. They
report the program does well at assisting in their education, helping youth with mental and physical health, and transitioning into jobs. If there was something
they could change about the program, it would be more staff to have different groups going to different activities, and better food.
Note: All meals are prepared at the County Jail and brought over to the youth. The program continues to make efforts in improving food satisfaction and has
seasonings and sauces available to enhance the flavor. Other food options are available to supplement, only after the youth eat 50% of their tray.
Form Rev. 11/14/2023 P age 2 | 3
Observations
The construction of the new corner office and the adjacent reconfiguring of a youth bedroom wall and door has been completed. The milieu was clean, tidy, odor
free, and comfortable temperature. The kitchen room was tidy and clean including the refrigerator and the sink has been replaced with a new 3-compartment
sink. Youth bedrooms had varying levels of cleanliness/messiness typical for this age range, some more tidy than others, some with extra piles of clothes on
the floor; however, there were no odors or evidence of unhygienic conditions. The program has a weekly schedule for bedroom cleaning. Refer to new findings
above regarding the bathrooms. A dinner tray was observed which included a main dish, salad, veggie, fruit and a pastry for dessert.
Corrective Actions and Timeframes:
Please submit the following to verify compliance. Within 45 days of receipt of this report Jackson County Juvenile Dept. Barriers 2 Bridges 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 at
robin.m.duval@odhsoha.oregon.gov.
Licensing Coordinator’s Signature: ________________________ Date: _4_/1_7_/_2_0_2_5___________
Manager Review: ______________________________________ Date: _4_/1_7_/_2_0_2_5__________
Form Rev. 11/14/2023 P age 3 | 3

licensee: Jackson County Juvenile Department - Barrier 2 Bridges

other_regulatory_agencies: Oregon Health Authority

purpose:
Per OAR 419-400-0240 (1)(b) Children's Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Findings Comments
Unannounced Site Visit - 06/24/2024 Further Action Needed
Medication 419-470-0100(10) Written record of the administration of Yes[ ] No✓ Medication administration records were
medication includes: reviewed, and this requirement was met.
(a) name There's no further corrective action needed at
(b) description this time.
(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
Medication administration records (MARs) were observed, and there continues
to be lack of corresponding documentation when a medication was not
administered. However, to note, when this licensor asked two staff what the
process is when a medication is not administered, they were able to verbally
describe the correct procedure. This is a repeat violation.
Corrective Action: The agency shall provide an administrative oversight plan
that details how ongoing compliance will occur. In the plan, state who will be
directly responsible to ensure ongoing compliance.

New Findings from Site Visit Corrective Actions
419-470-0020 Physical Plant Requirements Bathrooms observations:
(2) A residential care agency must meet all of the following - Paint at the top of the door jams is peeling and hanging down.
requirements: - Both toilet bowls had a discoloration, unknown of the cause.
(c) All areas of buildings where children in care are present must be - One bathroom was a bit odorous.
kept clean and in good repair.
Corrective Action: The agency shall assess these areas and submit findings
including plans to remedy.
419-400-0090(1)(a)(B)(b) Children's right to privacy during phone Privacy during phone calls usually happens within the phone booth, where staff have
calls. eyes on youth, however another youth damaged the phone so it's not working
properly.
Corrective Action: The agency shall establish an interim plan to ensure youth have
privacy during phone calls; and communicate that process to ensure the practice is
consistent among staff.
Interview Summary
During my visit, I interacted with the case manager, deputy director, other youth in the milieu and two staff. Two youth were individually interviewed ages 16 and
17 with stays in the program for 5 and 2 months respectively. Both reported that this is their first program, feel safe here, and they described ways the program
is helping them. Activities and outings were described and both report that school is going well, working on credit recovery and school completion courses. They
have regular contact with people on their approved contact list and time isn't restricted, although limited depending on how many other youth have calls and the
schedule that day. Privacy during phone calls usually happens within the phone booth, where staff have eyes on youth, however another youth damaged the
phone so its not working. The staff that they have a better rapport with are trusting and they show care and concern. They give input in their treatment plan and
feel listened to. They shared that the case manager and therapist are "amazing". At times, it can feel like staff are not treating youth equally as if the same rules
don't apply to all; however, they understand how each youth could have an individualized plan or need a different approach. Despite this, the youth said they've
learned to reframe those thoughts and stay focused on their goals and success. Neither youth report any issues getting their medications as prescribed. They
report the program does well at assisting in their education, helping youth with mental and physical health, and transitioning into jobs. If there was something
they could change about the program, it would be more staff to have different groups going to different activities, and better food.
Note: All meals are prepared at the County Jail and brought over to the youth. The program continues to make efforts in improving food satisfaction and has
seasonings and sauces available to enhance the flavor. Other food options are available to supplement, only after the youth eat 50% of their tray.

Observations
The construction of the new corner office and the adjacent reconfiguring of a youth bedroom wall and door has been completed. The milieu was clean, tidy, odor
free, and comfortable temperature. The kitchen room was tidy and clean including the refrigerator and the sink has been replaced with a new 3-compartment
sink. Youth bedrooms had varying levels of cleanliness/messiness typical for this age range, some more tidy than others, some with extra piles of clothes on
the floor; however, there were no odors or evidence of unhygienic conditions. The program has a weekly schedule for bedroom cleaning. Refer to new findings
above regarding the bathrooms. A dinner tray was observed which included a main dish, salad, veggie, fruit and a pastry for dessert.