summary: Visit conducted on 1-28-25. Visit covered 8 main areas/topics. No compliance issues identified.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM:     Noank Community Support Services (Church Hill House)

TIME OF VISIT (FROM - TO):  	11:15 am- 12:00 pm                   DATE: 1-28-25

AGENCY PERSONNEL WHO PARTICIPATED: Program Director, Director of Quality Assurance

List of Areas / Topics covered during visit:

•	Discussed current census (5) and the licensed bed capacity is 5. One resident in detention.

•	Discussed current staffing levels and staff vacancies. Discussed coverage for all shifts. Met with new Program Director.

•	During the visit, one resident was at school and three present. Met with youths in their rooms with PD.

•	Discussed recent AWOLs, 911 calls and Exceptional Circumstances.

•	Clinical programming, resident participation. Will refill restorative justice coach position.

•	Discussed overall milieu, interactions between the residents, efforts to resolve issues and discharge planning.

•	Discussed resident's education status and recreation outside the house.

•	Inspection of the Church Hill House physical plant was completed and discussed. Replacement part for dishwasher on order.  Washing machine repair order made.  Currently using a laundry mat and Gray Farm's washer. Broken blinds being replaced during the visit.

•	During the past quarter licensing responded to one incident and completed one incident response note. The incident occurred on 11-17-24 and involved inappropriate responses by former staff in regard to resident behaviors.

Corrective Actions implemented as a result of previous visit:

•	Not applicable

Areas of regulatory non-compliance identified during this visit:

•	Not applicable

Please submit a regulation compliance plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The Regulation Compliance Plan must be submitted to the attention of the undersigned at the address listed above. No Regulation Compliance Plan is required for this Licensing visit.

James Funaro  				Date:    1/31/25
Regulatory Consultant

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM
Cc: File, Program Director and Director of Quality Assurance|


state: CT

facility_name: NOANK Community Support Services / Church Hill

summary: Visit conducted on 11-6-24. Visit covered 8 main areas/topics. No compliance issues identified.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM:     Noank Community Support Services (Church Hill House)

TIME OF VISIT (FROM - TO):  	12:00 am- 12:50 pm                   DATE: 11-6-24

AGENCY PERSONNEL WHO PARTICIPATED:
Job Title
Program Director, Director of Quality Assurance

List of Areas / Topics covered during visit:

•	Discussed current census (4) and the licensed bed capacity is 5.

•	Discussed current staffing levels and staff vacancies.

•	During the visit three residents were at school and one was present.  Met with youth in her room with PD.

•	Discussed AWOLs and 911 calls.

•	Clinical programming for residents discussed as well as resident participation.

•	Discussed overall milieu and interactions between the residents as well as a recent discharge to a TGH.

•	Discussed recreation. New activity board installed in the kitchen. Discussed incentive program for the residents.

•	Inspection of the Church Hill House physical plant was completed and discussed. Serve Pro was recently on site to clean up a plumbing issue in the basement. A work order submitted to repair a closet door.  No safety concerns were observed in the home.

.

Corrective Actions implemented as a result of previous visit:

•	Not applicable

Areas of regulatory non-compliance identified during this visit:

•	Not applicable

Please submit a regulation compliance plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The Regulation Compliance Plan must be submitted to the attention of the undersigned at the address listed above. No Regulation Compliance Plan is required for this Licensing visit.

James Funaro  				Date:    11/12/24
Regulatory Consultant

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM
Cc: File, Program Director and Director of Quality Assurance|


summary: Visit conducted on 7-24-24. Visit covered 9 main areas/topics. No compliance issues identified.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM:     Noank Community Support Services (Church Hill House)

TIME OF VISIT (FROM - TO):  	11:00 am- 12:00 pm                   DATE: 7-24-24

AGENCY PERSONNEL WHO PARTICIPATED:
Job Title
Program Manager

List of Areas / Topics covered during visit:

•	Discussed current census (5) and the licensed bed capacity is 5.

•	Discussed current staffing levels. Vacancies for direct care staff on all shifts and two supervisor positions.

•	During the visit three residents were in their rooms, one at a medical appointment and this regulatory consultant conversed with one of the residents in the kitchen.

•	Discussed AWOLs 911 calls and pending discharge planning.

•	Clinical programming for residents discussed. Life skills, Risking Connections and Restorative Justice approach.

•	Discussed overall milieu and interactions between the residents.

•	Discussed the increase in recreation. Going to the beach, movies, and parks.  The girls enjoy rock painting.

•	Inspection of the Church Hill House physical plant was completed and discussed. The kitchen renovation has been completed.  A new generator for the house is being installed as well as new emergency lighting.

•	Creating a new activity board with menu in the kitchen.

Corrective Actions implemented as a result of previous visit:

•	Not applicable

Areas of regulatory non-compliance identified during this visit:

•	Not applicable

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

James Funaro
Regulatory Consultant                                   Date: 7-26-24

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM
Cc: Program Director|


summary: Visit conducted on 5-10-24. Visit covered 8 main areas/topics. No compliance issues identified.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM:     Noank Community Support Services (Church Hill House)

TIME OF VISIT (FROM - TO):  	10:30 am- 11:30 am                   DATE: 5-10-24

AGENCY PERSONNEL WHO PARTICIPATED:
Job Title
Quality Assurance Director and Director of Residential Services

List of Areas / Topics covered during visit:

•	Discussed current census (4) and the licensed bed capacity is 4.

•	Discussed current staffing levels. Three vacant RA positions.

•	During the visit two residents in their rooms.  One at school and one with her assigned DCF SW.

•	Discussed recent discharges, AWOLs and calls to 911.

•	Clinical programming for residents discussed. Risking Connections Coordinator started working with the clients.

•	Discussed recent SIU investigations.  Three pending.

•	Inspection of the Church Hill House physical plant was completed. No safety concerns or regulatory violations observed.  Kitchen renovation near completion.

•	Two incident response notes completed this quarter.

Corrective Actions implemented as a result of previous visit:

•	Not applicable

Areas of regulatory non-compliance identified during this visit:

•	Not applicable

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

James Funaro
Regulatory Consultant                                   Date: 5-13-24

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM
Cc: Program Director|


summary: Visit conducted on 2-16-24. Visit covered 8 main areas/topics. No compliance issues identified.

raw_content:
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM:     Noank Community Support Services (Church Hill House)

TIME OF VISIT (FROM - TO):  	12:35 pm- 1:30 pm                   DATE: 2-16-24

AGENCY PERSONNEL WHO PARTICIPATED:
Job Title
Program Director

List of Areas / Topics covered during visit:

•	Discussed current census (3) and the licensed bed capacity is 4.

•	Discussed current staffing levels. Two vacant RA positions and one supervisor position.

•	Observed two residents in the milieu.  One resident in her bedroom and remained there.

•	Discussed recent discharge, AWOLs and calls to 911.

•	Clinical programming for residents discussed. Discussed efforts to engage residents in treatment.

•	Discussed staff training.

•	Inspection of the Church Hill House physical plant was completed with the program director. No safety concerns or regulatory violations observed.

•	Discussed upcoming kitchen renovation.

Corrective Actions implemented as a result of previous visit:

•	Not applicable

Areas of regulatory non-compliance identified during this visit:

•	Not applicable

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

James Funaro
Regulatory Consultant                                   Date: 2-20-24

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM
Cc: Program Director
      Executive Director|


raw_content:
December 4, 2023

Ms. Regina Moller
Executive Director
Noank Community Support Services
479 Gold Star Highway
Groton, CT  06340

Re: Relicensing inspection –License #CCF-167
Regulatory Consultants: James Funaro, Penny Woodward

Dear Ms. Moller,

On November 14-15, 2023, a biennial re-licensing inspection was conducted at the Church Hill House Star Program, located at 105 Church Hill Rd, Ledyard, CT. This inspection was conducted to determine the compliance of this program with the DCF Regulations for Operation of Child-Caring Agencies and Facilities 17a-145-48 through 17a-145-124. Additionally, a review was conducted on 11-14-23 by DCF Nurse Consultant Errolee Miller, RN to determine the program’s compliance with the DCF Medication Administration Guidelines and the DCF Nursing Standards. A full standard of compliance was issued. A copy of the nursing site visit summary report is included with this report.

Listed below are the areas of regulatory non-compliance which were identified during the re-licensing inspection. Please review the areas identified and submit a service development plan (SDP) to address each area of noncompliance utilizing the SDP template included with this report. The service development plan must be submitted to the assigned Regulatory Consultant within 30 days of receipt of this emailed report.

Also included in this report are recommendations.  Recommendations are meant to highlight areas that are not currently areas of non-compliance, but may become non-compliant if actions are not taken, or, highlight areas for improvement. Recommendations do not require the submission of a service development plan.

The areas of regulatory noncompliance are as follows:

17a-145-86	Instructions in Safety Procedures. Supervision
•	In 2023, no fire drills were completed on 2nd and 3rd shift for the Third Quarter; no fire drills were completed on 1st and 2nd shift for the Second Quarter; no fire drills completed for any shift for the First Quarter.
•	In 2022, no fire drills were completed on 1st and 3rd shift for the 4th Quarter; no fire drills completed on 1st and 3rd shift for the Third Quarter.  There were 6 drills that were completed in 2022, with no dates listed for any of the drills completed in order to correspond to a particular quarter.

Section 17a-145-96. Discharge of child
•	Two closed records did not contain documentation that identified person(s) that took legal custody of clients when discharge from the program.

Section 17a-145-78. Recreational facilities
•	Shift change notes were reviewed and there was no documentation to support that the program was providing recreational activities, for clients in the community on a consistent basis. Director Greene was interviewed and confirmed that due to high-risk behaviors of clients the program had not been scheduling community activities on a regular basis.

Section 17a-145-98. Case records. Reports. Confidentiality
•	One file did not contain a placement agreement.

Recommendation: No recommendations made in this report.

Once the Licensing Unit has reviewed and accepted the service development plan and has determined that your agency is in compliance with the regulations, a decision on the issuance of a regular twenty-four month license for the program will be made.  Until DCF makes this decision, the current license will remain in effect. Should you have any questions or comments regarding the contents of this report please do not hesitate to contact me at (860) 937-7551.

Sincerely,

James Funaro
_____________________________
James Funaro
DCF Regulatory Consultant

Copy: file
          Executive Director|

report_type: unstructured


summary: Visit conducted on 8-17-23. Visit covered 7 main areas/topics. Found 1 compliance issues.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM:     Noank Community Support Services (Church Hill
House)

TIME OF VISIT (FROM - TO):  	10:45am- 12:00pm                   DATE: 8-17-23

AGENCY PERSONNEL WHO PARTICIPATED:
Job Title
Program Director

List of Areas / Topics covered during visit:

•	Discussed current census (3) and the licensed bed capacity is 4.

•	Discussed current staffing levels. Currently two contracted staff will become full time Noank staff members.

•	No residents in milieu at the time of the visit. Overall milieu discussed and staff has been implementing Circle Forward with the residents daily.

•	Clinical programming for residents discussed. Clinician running individual and group sessions with the residents.

•	Discussed change in supervisory coverage.  Supervisors now cover during the week and weekend with overlap on Wednesday.

•	Upcoming relicensing inspection discussed.

•	Inspection of the Church Hill House physical plant was completed with the program director.

Corrective Actions implemented as a result of previous visit:

•	Not applicable

Areas of regulatory non-compliance identified during this visit:

Section 17a-145-74: Lavatory facilities: There appeared to be mold forming on the second floor bathroom ceiling.

Section 17a-145-73. Sleeping accommodations:  Screen missing from second floor bedroom window.

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

James Funaro
Regulatory Consultant                                   Date: 8-30-23

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM
Cc: Program Director|

description: Section 17a-145-73.


summary: Found 2 compliance issues.

raw_content:
DCF-3034
1/2013 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM: NOANK/ Church Hill Program

TIME OF VISIT: (FROM–TO): 10:30 am to 11:45am   DATE: 5/11/23

AGENCY PERSONNEL WHO PARTICIPATED:
Name	Job Title
                                  N/A	                   Program Director

Areas / Topics covered during visit:
The Department of Children and Families conducted a scheduled quarterly inspection visit at the Church Hill Program on May 11, 2023. Topics covered during the quarterly visit included current census, program staffing and training, physical plant inspection, milieu issues and medication administration system.

Physical plant: A walkthrough of the physical plant was conducted with the program director and areas of improvements were addressed with the program.

Corrections implemented as a result of previous visit:
N/A

Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning)
N/A

Areas of regulatory non-compliance identified during this visit:
Section 17a-145-63: Chief administrative officer. Upon review of program information, ongoing and pervasive behavioral issues of residents at the facility has caused the milieu to become unstable on a regular basis.

Section 17a-145-73: Sleeping accommodations: Upon inspection of the facility, bedroom four's walls contained dirt and scuff marks and they need to be addressed.

Section 17a-145-74: Lavatory facilities. Upon inspection of the first-floor bathroom, a wall tile was missing and it needs to be addressed.

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Penny Woodward, LCSW_                       June 10, 2023
Regulatory Consultant                                   Date

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

regulation: Chief administrative officer.

facility_name: NOANK/ Church Hill Program


summary: Found 2 compliance issues.

raw_content:
DCF-3034
1/2013 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM: NOANK/ Church Hill Program

TIME OF VISIT: (FROM–TO): 12:00 pm to 1:30pm   DATE: 1/24/23

AGENCY PERSONNEL WHO PARTICIPATED:
Name	Job Title
N/A	                   Program Director

Areas / Topics covered during visit:
The Department of Children and Families conducted a scheduled quarterly inspection visit at the Church Hill Program on January 24, 2023. Topics covered during the quarterly visit included current census, program staffing and training, physical plant inspection, milieu services and medication administration system.

Physical plant: A walkthrough of the physical plant with the program director was conducted; a citation was identified and discussed with the director.

Corrections implemented as a result of previous visit:
N/A

Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning)
N/A

Areas of regulatory non-compliance identified during this visit:
Section 17a-145-63: Chief administrative officer. Upon reviewing of staffing information, it was confirmed that the program's staffing level remains low and does not meet regulatory standards.

Section 17a-145-63: Chief administrative officer. Upon review of training information, it was found that not all staff had been fully trained in Risking Connections.

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Penny Woodward, LCSW                      March 1, 2023
Regulatory Consultant                                   Date

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|


raw_content:
The plan of correction should include specific goals, objectives, and steps that effectively reflect the issues described above. Please submit this plan to the undersigned by the close of business on March 1st, 2023. We hope to continue an ongoing dialogue with you as you work on the plan of correction. If you have any questions, please feel free to contact Diane Rosell, via email at diane.rosell@ct.gov

Area Needing Attention Noank Plan of Correction Completion Date Title/Person Responsible to Monitor Plan

Management, Staffing and Training:
1.	Submit a plan to ensure adequate supervision, communication, and training of staff.
2.	Submit a plan to hire and retain staff.
3.	Submit consistent schedules for milieu programming and interventions.
4.	Submit a plan ensure that staff with medication certification are on every shift.

1.Submit a plan and timeframe to renovate/repair the first-floor bathroom, closets, and kitchen cabinets.

A.	All staff receive supervision from their supervisor bi-weekly bias. A schedule for Supervision is kept on file.
**See attached Supervision form (1A).
B.	A clinical meeting takes place on weekly basis that includes the Nurse, Psychiatrist, Program Director, and Clinical Director to review each client’s clinical needs.
**See attached Clinical Team Meeting form (1B).
C.	The Program Director will lead weekly staff meetings to review all clinical, nursing and milieu information/needs of each client in the program. The meeting will also include topics to discuss of business items, quality assurance, and trainings.
**See attached Staff Meeting form, Minutes and Sign in sheet (1C).
D.	Once a month staff will receive a training given by the nurse to review previous and new medical information, for example, Epi Pen training.
**See attached Nurse Training form (1D).
E.	January 1, 2023, the agency formed an Orientation Committee to overhaul the agency’s new employee onboarding and orientation process in an effort to retain staff at a higher rate. Orientation will now take place once a month for all new hires to attend as one group. New hires will receive all required program trainings during this onboarding process and will not be allowed to work any scheduled shifts in their programs until trainings are complete. Any current employee who has not completed all the required trainings will attend the appropriate training during the orientation. The first orientation using the new onboarding process is taking place March 1, 2023.
**See attached Orientation Committee meeting minutes and the new hire orientation power point presentation attached (1E, 1E.2, 1E.3).

Completion Date
A.	2/1/2023
B.	2/1/2023
C.	2/1/2023
D.	2/1/2023
3/10/2023

A.	Use of indeed advertising for vacant positions, including highlighting the agency’s generous benefits package that includes 4 weeks starting paid vacation and matching 401k’s.
B.	The HR Coordinator and Director of Residential Services will be attending a local job fair in Uncasville in the end of March.
C.	January 1, 2023, the agency formed an Orientation Committee to overhaul the agency’s new employee onboarding and orientation process to retain staff at a higher rate. Orientation will now take place once a month for all new hires to attend as one group. New hires will receive all required program trainings during this onboarding process and will not be allowed to work any scheduled shifts in their programs until trainings are complete. Any current employee who has not completed all the required trainings will attend the appropriate training during the orientation. The first orientation using the new onboarding process is taking place March 1, 2023.
**See attached Orientation Committee meeting minutes and the new hire orientation power point presentation attached (2C).

Completion Date
A.	2/1/2023
B.	3/31/2023
C.	3/1/2023

A.	Each month the staff team works collaboratively with the clients in a house meeting to develop a monthly calendar of activities, for both in and out of the house.
**See attached schedules of events for February 2023 (3A).
B.	The program Supervisors will be responsible for working with clients and managing to work out all aspects of the activities from facilitating group to funding.

A.	A weekly schedule is created to ensure that there is a medication administration staff on each shift. The Program Director and Supervisor are responsible for creating and implementing a weekly med schedule and signing up staff for medication administration training.
**See attached copy of the week of Medication Administration schedule (4A).
New staff will be signed up and trained in medication administration within the first three months of their employment.

A.	Upstairs and downstairs bathroom has been renovated (new shower, vanity, and toilet).
B.	New closet doors have been ordered and will be installed in the 4 bedrooms.
C.	A grant to purchase new Kitchen cabinets and counter tops has been submitted and the agency is awaiting results of the grant request. NCSS will update status as soon the results come in.

Completion Date
A.	2/1/2023
2/1/2023

A.	A weekly schedule is created to ensure that there is a medication administration staff on each shift. The Program Director and Supervisor are responsible for creating and implementing a weekly med schedule and signing up staff for medication administration training.
**See attached copy of the week of Medication Administration schedule (4A).
New staff will be signed up and trained in medication administration within the first three months of their employment.

Completion Date
A.	2/1/2023
2/1/2023

Physical plant:
A.	Upstairs and downstairs bathroom has been renovated (new shower, vanity, and toilet).
B.	New closet doors have been ordered and will be installed in the 4 bedrooms.
C.	A grant to purchase new Kitchen cabinets and counter tops has been submitted and the agency is awaiting results of the grant request. NCSS will update status as soon the results come in.

Completion Date
A.	1/3/2023
B.	4/1/2023
TBD|


summary: Found 3 compliance issues.

raw_content:
DCF-3034
1/2013 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM: NOANK/ Church Hill Program

TIME OF VISIT: (FROM–TO): 10:45am to 12:30pm   DATE: 10/21/22

AGENCY PERSONNEL WHO PARTICIPATED:
Name 	Job Title
N/A  Program Director

Areas / Topics covered during visit:
The Department of Children and Families conducted a scheduled quarterly inspection visit at the  Church Hill Program on October 21, 2022. Topics covered during the quarterly visit included program staffing and training, physical plant inspection, milieu services and medication administration system.

Physical plant: A walkthrough of the physical plant with the program director was conducted; deficiencies were identified and discussed with the director.

Corrections implemented as a result of previous visit:
N/A

Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning)
N/A

Areas of regulatory non-compliance identified during this visit:
Section 17a-145-63: Chief administrative officer. Upon reviewing of staffing information, it was confirmed that the program's staffing level for each shift continue not to meet regulatory requirements.

Section 17a-145-63: Chief administrative officer. Upon review of training information, it was found that all staff had not been trained in TCI, Risking Connections and Restorative Approach.

Section 17a-145-74: Lavatory facilities. Upon inspection of the facility, the second-floor bathroom was in disrepair and it needs to be addressed.

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Penny Woodward, LCSW                       November 21, 2022
Regulatory Consultant                                             Date

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

regulation: Lavatory facilities.


summary: Found 2 compliance issues.

raw_content:
DCF-3034
1/2013 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM: NOANK/ Church Hill Program

TIME OF VISIT: (FROM–TO):  11:30am to 12:30pm DATE: 7/7/22

AGENCY PERSONNEL WHO PARTICIPATED:
Name	Job Title
                                  N/A	                Program Director
                                  N/A	                      Director

Areas / Topics covered during visit:
The Department of Children and Families attended a meeting and conducted a physical plant inspection at the Church Hill Program on July 7, 2022. Topics covered during the meeting included administrative changes at the shelter, program staffing and training, the client population, milieu services and medication administration system.

Physical plant: During the quarterly visit a walkthrough of the physical plant was conducted with the shelter's program director. Please see citations that are listed below in the area of regulatory non-compliance section.

Corrections implemented as a result of previous visit:
N/A

Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning)
N/A

Areas of regulatory non-compliance identified during this visit:
Section 17a-145-63: Chief administrative Officer. Upon review of training information, it was found that all staff had not been trained in TCI, Risking Connections and Restorative Approach.

Section 17a-145-63: Chief administrative Officer. Upon review of staffing information, it was found that the staffing levels at the shelter was not meeting regulatory requirements.

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Penny Woodward, LCSW                       August 2, 2022
Regulatory Consultant                                   Date

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

regulation: Chief administrative Officer.

personnel:
N/A	                Program Director
N/A	                      Director


summary: Found 1 compliance issues.

raw_content:
DCF-3034
1/2013 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM: NOANK/ Church Hill Program

TIME OF VISIT: (FROM–TO):  Morning to Afternoon     DATE: 5/3/22

AGENCY PERSONNEL WHO PARTICIPATED:
Name	Job Title
                                  N/A
                Program Director

Areas / Topics covered during visit:
The Department of Children and Families conducted a scheduled quarterly inspection visit at the  Church Hill Program on May 3, 2022. Topics covered during the quarterly visit included program staffing and training, physical plant inspection, milieu services and medication administration system.

Physical plant: A walkthrough of the physical plant with the program director was conducted; deficiencies were identified and discussed with the director.

Corrections implemented as a result of previous visit:
N/A

Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning)
N/A

Areas of regulatory non-compliance identified during this visit:
Section 17a-145-63: Chief administrative Officer. Upon review of training information, it was found that all staff had not been trained in TCI, Risking Connections and Restorative Approach.

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Penny Woodward, LCSW_                       May 3 , 2022
Regulatory Consultant                                   Date

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|


facility_name: NOANK Community Support Services / Clift House /TS

summary: Visit covered 7 main areas/topics. No compliance issues identified.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM:     Noank Community Support Services (Clift House Shelter)

TIME OF VISIT (FROM - TO) 11:00-11:45 am                   DATE: 3-12-26

AGENCY PERSONNEL WHO PARTICIPATED:
Job Title
Program Director

List of Areas / Topics covered during visit:

•	Discussed current census 4 and the licensed bed capacity is 12.

•	Discussed current staffing levels and shift coverage. Current vacancies on third shift and second shift.

•	All four residents observed with their teacher doing educational programming and preparing for lunch.

•	Inspection of the Clift House physical plant. No concerns and no current physical plant projects.

•	No AWOLs, 911 calls or Exceptional Circumstances. The residents are reportedly well behaved.

•	Discussed the increase in the length of stay for the residents due to vetting of sponsors.

•	Discussed clinical programming. The program clinician has been able to incorporate some family sessions.

Corrective Actions implemented as a result of previous visit:

•	Not applicable

Areas of regulatory non-compliance identified during this visit:

•	Not applicable

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above. NA

James Funaro
Regulatory Consultant                                   Date: 3-16-26

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM
Cc: Program Director|


summary: Visit conducted on 11-5-25. Visit covered 8 main areas/topics. No compliance issues identified.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM:     Noank Community Support Services (Clift House Shelter)

TIME OF VISIT (FROM - TO):  10:30-11:15 am                   DATE: 11-5-25

AGENCY PERSONNEL WHO PARTICIPATED:
Job Title
Program Director

List of Areas / Topics covered during visit:

•	Discussed current census (3 males) and the licensed bed capacity is 12.

•	Discussed current staffing levels and shift coverages. Current vacancies on third shift and second shift.

•	The three residents observed with their teacher doing educational programming.

•	Inspection of the Clift House physical plant. No concerns and no current physical plant projects.

•	No AWOLs, 911 calls or Exceptional Circumstances.

•	Discussed the increase in the length of stay for the residents.

•	Discussed clinical programming. Cooperative overall.

•	The residents go into the community for recreational activities.

Corrective Actions implemented as a result of previous visit:

•	Not applicable

Areas of regulatory non-compliance identified during this visit:

•	Not applicable

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above. NA

James Funaro
Regulatory Consultant                                   Date: 11-6-25

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM
Cc: Program Director|


summary: Visit conducted on 7-22-25. Visit covered 7 main areas/topics. No compliance issues identified.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM:     Noank Community Support Services (Clift House Shelter)

TIME OF VISIT (FROM - TO):  1:00 1:35pm                   DATE: 7-22-25

AGENCY PERSONNEL WHO PARTICIPATED:
Job Title
Program Director

List of Areas / Topics covered during visit:

•	Discussed current census (3) and the licensed bed capacity is 12.

•	Discussed current staffing levels and shift coverages. Current vacancies on third shift.

•	The three residents observed in the kitchen with staff.

•	Inspection of the Clift House physical plant. Overall, very clean and no safety concerns observed.

•	No AWOLs, 911 calls or Exceptional Circumstances.

•	Discussed recent communication with Office of Refugee Resettlement (ORR). ORR no longer visiting regularly.

•	Discussed clinical programming. Lengths of stay have been increasing.

Corrective Actions implemented as a result of previous visit:

•	Not applicable

Areas of regulatory non-compliance identified during this visit:

•	Not applicable

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above. NA

James Funaro
Regulatory Consultant                                   Date: 7-22-25

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM
Cc: Program Director|


summary: Visit conducted on 5-8-25. Visit covered 7 main areas/topics. No compliance issues identified.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM:     Noank Community Support Services (Clift House Shelter)

TIME OF VISIT (FROM - TO):  1:15 1:45pm                   DATE: 5-8-25

AGENCY PERSONNEL WHO PARTICIPATED:
Job Title
Program Director and Director of Quality Assurance

List of Areas / Topics covered during visit:

•	Discussed current census (4) and the licensed bed capacity is 12.

•	Discussed current staffing levels and shift coverages.

•	Observed residents who were heading into the community with staff.

•	Inspection of the Clift House physical plant. Overall, very clean and no safety concerns observed.  Installing three split units AC/Heat on the first floor at the time of the visit.

•	No AWOLs, 911 calls and Exceptional Circumstances.

•	Discussed recent communication with Office of Refugee Resettlement (ORR).

•	Discussed clinical programming and as a result of increased lengths of stay, there has been increased time for individual and group/family work.

Corrective Actions implemented as a result of previous visit:

•	Not applicable

Areas of regulatory non-compliance identified during this visit:

•	Not applicable

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above. NA

James Funaro
Regulatory Consultant                                   Date: 5-9-25

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM
Cc: Program Director, Director of Quality Assurance|


summary: Visit conducted on 1-28-25. Visit covered 7 main areas/topics. No compliance issues identified.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM:     Noank Community Support Services (Clift House Shelter)

TIME OF VISIT (FROM - TO):  1:15 2:00pm                   DATE: 1-28-25

AGENCY PERSONNEL WHO PARTICIPATED:
Job Title
Program Director and Director of Quality Assurance

List of Areas / Topics covered during visit:

•	Discussed current census (1) and the licensed bed capacity is 12.

•	Discussed current staffing levels.

•	Observed resident engaging in educational programming with staff.

•	Inspection of the Clift House physical plant. The physical plant was clean and in excellent repair with no health or safety concerns noted. New furnace venting being completed from basement through the chimney.

•	No AWOLs, 911 calls and Exceptional Circumstances.

•	Discussed recent communication with Office of Refugee Resettlement (ORR)

•	Discussed recent DCF relicensing process.

Corrective Actions implemented as a result of previous visit:

•	Not applicable

Areas of regulatory non-compliance identified during this visit:

•	Not applicable

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above. NA

James Funaro
Regulatory Consultant                                   Date: 1-31-25

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM
Cc: Program Director, Director of Quality Assurance|


raw_content:
January 13, 2025

Regina Moller
Executive Director
Noank Community Support Services
479 Gold Star Highway
Groton, CT  06340

Re: Relicensing inspection –License #CCF-156 (Amended Report Letter)
Regulatory Consultants: James Funaro, Theresa Bohara and Pat Hughes

Dear Ms. Moller,

On December 10-12, 2024, a biennial re-licensing inspection was conducted at the Clift House Shelter located at 193 High Street, Mystic, CT. This inspection was conducted to determine the compliance of this program with the DCF Regulations for Operation of Child-Caring Agencies and Facilities 17a-145-48 through 17a-145-124. Additionally, a review was conducted on 12-10-24 by DCF Nurse Consultant Errolee Miller, RN to determine the program’s compliance with the DCF Medication Administration Guidelines and the DCF Nursing Standards. A full standard of compliance was issued.

During the inspection no areas of regulatory non-compliance were identified. Enclosed you will find a renewal license for the residential program.  I thank you and your staff for the cooperation extended to me during the relicensing process.

If you have any questions, please do not hesitate to contact me at (860) 209-3136.

Sincerely,

James Funaro
_____________________________
James Funaro
DCF Regulatory Consultant

Copy: file
          Executive Director|


summary: Visit conducted on 7-24-24. Visit covered 8 main areas/topics. No compliance issues identified.

raw_content:
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM:     Noank Community Support Services (Clift House Shelter)

TIME OF VISIT (FROM - TO):  1:15 2:00pm                   DATE: 7-24-24

AGENCY PERSONNEL WHO PARTICIPATED:
Job Title
Clift House Shelter Director

List of Areas / Topics covered during visit:

•	Discussed current census (5) and the licensed bed capacity is 12. Discussed overall milieu.

•	Discussed current staffing levels.  Two vacant positions for 32-hour direct care staff, one cook and one recreation coordinator.

•	Observed residents engaging in educational programming.

•	Inspection of the Clift House physical plant. The physical plant was clean and in excellent repair with no health or safety concerns noted.

•	No AWOL or 911 calls.

•	Discussed recreation for the residents.  Trips to the YMCA, beach, bowling and parks.

•	A biannual Federal audit taking place at the time of the visit.  Discussed scheduling for the DCF relicensing inspection this fall.

Corrective Actions implemented as a result of previous visit:

•	Not applicable

Areas of regulatory non-compliance identified during this visit:

•	Not applicable

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

James Funaro
Regulatory Consultant                                   Date: 7-26-24

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM
Cc: Marina Nieto-Marquez, Program Director, Noank Community Support Services|


summary: Visit conducted on 5-10-24. Visit covered 7 main areas/topics. No compliance issues identified.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM:     Noank Community Support Services (Clift House Shelter)

TIME OF VISIT (FROM - TO):  12:15 1:00pm                   DATE: 5-10-24

AGENCY PERSONNEL WHO PARTICIPATED:
Job Title
Clift House Shelter Director, Director of Quality Assurance

List of Areas / Topics covered during visit:

•	Discussed current census (4) and the licensed bed capacity is 12.

•	Discussed current staffing levels and hiring.  Three vacant positions for direct care staff, one cook and one recreation coordinator.

•	Observed residents eating lunch. Current residents discussed.

•	Inspection of the Clift House physical plant. The physical plant was clean and in excellent repair with no health or safety concerns noted.

•	No AWOL or 911 calls.

•	Discussed clinical services for the clients.

•	Discussed staff training.

Corrective Actions implemented as a result of previous visit:

•	Not applicable

Areas of regulatory non-compliance identified during this visit:

•	Not applicable

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

James Funaro
Regulatory Consultant                                   Date: 5-13-24

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM
Cc: Marina Nieto-Marquez, Program Director, Noank Community Support Services|


summary: Visit conducted on 2-16-24. Visit covered 9 main areas/topics. No compliance issues identified.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM:     Noank Community Support Services (Clift House Shelter)

TIME OF VISIT (FROM - TO):  11:15- 12:15pm                   DATE: 2-16-24

AGENCY PERSONNEL WHO PARTICIPATED:
Job Title
Clift House Shelter Director

List of Areas / Topics covered during visit:

•	Completed six-month personnel file review.

•	Discussed current census (3) and the licensed bed capacity is 12.

•	Discussed current staffing levels and hiring.  Two vacant positions for direct care staff.

•	During January there were nine intakes and nine discharges.

•	Observed residents participating in on site educational programming.

•	Inspection of the Clift House physical plant. The physical plant was immaculately clean and in excellent condition with no health or safety concerns noted.

•	Discussed initial training for new staff and refresher training for existing staff.

•	Discussed clinical services for the clients.

Corrective Actions implemented as a result of previous visit:

•	Not applicable

Areas of regulatory non-compliance identified during this visit:

•	Not applicable

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

James Funaro
Regulatory Consultant                                   Date: 2-20-24

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM
Cc: Marina Nieto-Marquez, Program Director, Noank Community Support Services|


summary: Visit conducted on 11-20-23. Visit covered 7 main areas/topics. No compliance issues identified.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM:     Noank Community Support Services (Clift House Shelter)

TIME OF VISIT (FROM - TO):  11:55- 12:45pm                   DATE: 11-20-23

AGENCY PERSONNEL WHO PARTICIPATED:
Job Title
Clift House Shelter Director

List of Areas / Topics covered during visit:

•	Discussed current census (8) and the licensed bed capacity is 12.

•	Discussed current staffing levels and hiring.  Three vacant positions for direct care staff. There were four recent direct care staff hired.

•	During the last quarter there were 41 admissions and 33 discharges.

•	Observed residents participating in on site educational programming and then eating lunch.

•	During this quarter there were no calls to 911, no restraints an no hospitalizations.

•	Inspection of the Clift House physical plant both inside and the outside grounds.  The physical plant was clean and in excellent condition with no health or safety concerns noted.

•	Staff receiving TCI a refresher in November, CPR and First Aid completed in October for new hires.

Corrective Actions implemented as a result of previous visit:

•	Not applicable

Areas of regulatory non-compliance identified during this visit:

•	Not applicable

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

James Funaro
Regulatory Consultant                                   Date: 11-21-23

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM
Cc: Marina Nieto-Marquez, Program Director, Noank Community Support Services|


summary: Visit conducted on 8-28-23. Visit covered 6 main areas/topics. No compliance issues identified.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

 NAME OF FACILITY / PROGRAM:     Noank Community Support Services (Clift House Shelter)

 TIME OF VISIT (FROM - TO):  10:45am- 12:00pm                   DATE: 8-28-23

 AGENCY PERSONNEL WHO PARTICIPATED:
Job Title
Clift House Shelter Director

List of Areas / Topics covered during visit:

•	Discussed current census (6) and the licensed bed capacity is 12.

•	Discussed current staffing levels and hiring.  Two vacant positions for a floater and 2nd shift direct care staff.

•	During the last quarter there were 28 admissions and 24 discharges.

•	Observed residents participating in on site educational programming. No concerns reported or observed with the current milieu.

•	Clinical programming for residents discussed.

•	Inspection of the Clift House physical plant both inside and the outside grounds.  The physical plant was clean and well maintained with no health or safety concerns noted.

Corrective Actions implemented as a result of previous visit:

•	Not applicable

Areas of regulatory non-compliance identified during this visit:

•	Not applicable

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

James Funaro
Regulatory Consultant                                   Date: 8-29-23

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM
Cc: Marina Nieto-Marquez, Program Director, Noank Community Support Services|


summary: Visit conducted on June 5, 2023. Found 1 compliance issues.

raw_content:
DCF-3034
1/2013 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM: NOANK/Clift House Shelter Program

 TIME OF VISIT (FROM - TO): 11:30am to 12:30pm                     DATE: June 5, 2023

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Title
Program Director

Areas / Topics covered during visit:
The program census was three males and four females and the shelter's licensed bed capacity remains at twelve. The program reported that there were three employee vacancies and the agency expects to fill open positions soon. Topics covered during the quarterly visit included new admissions, discharges, staffing and training, physical plant maintenance, milieu services and medication administration system.

Corrections implemented as a result of previous visit:
N/A

Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning)
N/A

Areas of regulatory non-compliance identified during this visit:
Section 17a-145-63: Chief administrative officer. Upon inspection of the physical plant, the right side of the roof continues to be in disrepair and it needs to be addressed.

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Penny Woodward, LCSW                                June 28, 2023
Regulatory Consultant                                         Date

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

facility_name: NOANK/Clift House Shelter Program


raw_content:
March 15, 2023

NOANK Community Support Services

Re: Bi-annual licensing inspection for the Clift House Shelter Program located in Mystic, CT. Regulatory Consultants: Penny Woodward and Tom Cuchara.

On 3/1/23 and 3/2/23, a bi-annual re-licensing inspection was conducted at the Clift House Program to determine compliance with Regulations for Operation of Child-Caring Agencies and Facilities 17a-145-48 through 17a-145-98, as well as the DCF Guidelines for the Administration of Medication by certified staff.

DCF has determined that the program is in compliance with all applicable regulatory provisions except those itemized below. Please review areas identified and submit a service development plan to address each area.

The plan must be submitted within 30 days of receipt of this letter and should identify: 1. Steps to be taken to correct the non-compliance. 2. The date correction(s) will be completed.  The areas of non-compliance are as follows:

Section 17a-145-61: Written policies and procedures.
(Evidence) Upon review of agency manual, the child abuse and neglect policy did not include a time frame for reporting suspected abuse to the Department. Please refer to the State of Connecticut Summary of Reporting Laws for additional information.

(Evidence) Upon review of agency manual, the resident drug screening policy did not address action taken by the program if a client refuses to submit to drug testing.

Section 17a-145-63: Chief administrative officer.
(Evidence) Upon inspection of the house's exterior, the roof contained an excessive amount of green moss that could potentially cause damage to the surface and it needs to be addressed. The side and back of the building contained chipping paint and it needs to be addressed.

(Evidence) Upon inspection of the garage, the back left side of the building contained an excessive amount of chipping paint and it needs to be addressed.

(Evidence) Upon inspection of the physical plant, the back hallway wall (near stairs) contained a large repair patch and it needs to be addressed.

Section 17a-145-64: Personnel policies and procedures.
(Evidence) Upon review of personnel records, one file contained documentation that the employee had been hired before the CT State Police Check Result had been received.

Section 17a-145-73: Sleeping accommodations.
(Evidence) Upon inspection of the physical plant, bedroom one contained a damaged floor tile and it needs to be addressed. Bedroom two contained a wall (near bed) that had a small hole and it needs to be addressed. The doorless closet contains exposed mental hinges and they need to be removed. Bedroom five contained a window that was missing a screen and it needs to be addressed.

Section 17a-145-86: Instruction in safety procedures.
(Evidence) Upon inspection of fire drill documentation, no second shift or third shift drills were conducted in the 4th quarter of 2021.

Section 17a-145-94: Written treatment plan.
(Evidence) Upon review of case records, two files did not have treatment plan documentation as required by regulations.

Once a finding is made that your agency has satisfactorily addressed the regulatory compliance issues, and all required supplementary materials have been received, the Department of Children and Families will be prepared to issue a regular license. Failure to submit a plan of correction or successfully implement a plan will result in the refusal to renew the license.

Sincerely,

Penny Woodward, LCSW
Regulatory Consultant
Department of Children and Families
505 Hudson Street
Hartford, CT. 06016|


summary: Visit conducted on October 25, 2022. Found 2 compliance issues.

raw_content:
DCF-3034
1/2013 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

  NAME OF FACILITY / PROGRAM: NOANK/Clift House Shelter Program

 TIME OF VISIT (FROM - TO): 11:30am to 1:00pm                     DATE: October 25, 2022

 AGENCY PERSONNEL WHO PARTICIPATED:

Name	Job Title
N/A	                       Program Director  N/A	                       Agency Executive Director

Areas / Topics covered during visit:
The Department of Children and Families conducted a scheduled quarterly inspection visit at the Clift House Shelter Program on October 25, 2022.  Topics covered during the quarterly visit included staffing and training, physical plant inspection, and medication administration system.

Physical plant: A walkthrough of the facility was conducted with the director; areas of improvement were identified and discussed with the program representative.

Corrections implemented as a result of previous visit:
N/A

Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning)
N/A

Areas of regulatory non-compliance identified during this visit:
Section 17a-145-63: Chief administrative officer. Upon review of training information, it was found that all staff had not been trained in Risking Connections and Restorative Approach.

Section 17a-145-63: Chief administrative officer. Upon inspection of the physical plant, the right side of the roof continues to be in disrepair and it needs to be addressed.

Section 17a-145-93: Medical, dental and nursing care: Upon review of the medication administration system, it was confirmed that the nurse was not conducting face to face visits when completing nursing assessments.

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Penny Woodward, LCSW                          November  30, 2022
Regulatory Consultant                                         Date

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

visit_date: October 25, 2022


summary: Visit conducted on August 4, 2022. Found 2 compliance issues.

raw_content:
DCF-3034
1/2013 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

  NAME OF FACILITY / PROGRAM: NOANK/Clift House Shelter Program

 TIME OF VISIT (FROM - TO): 11:30am to 1:00pm                     DATE: August 4, 2022

 AGENCY PERSONNEL WHO PARTICIPATED:

Name	Job Title
N/A	                       Program Director

Areas / Topics covered during visit:
The Department of Children and Families conducted a scheduled quarterly inspection visit at the Clift House Shelter Program on August 4, 2022.  Topics covered during the quarterly visit included staffing and training, physical plant inspection, and medication administration system.

Physical plant: A walkthrough of the facility was conducted with the director; areas of improvement were identified and discussed with the program representative.

Corrections implemented as a result of previous visit:
N/A

Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning)
N/A

Areas of regulatory non-compliance identified during this visit:
Section 17a-145-63: Chief administrative officer. Upon review of training information, it was found that all staff had not been trained in Risking Connections and Restorative Approach.

Section 17a-145-63: Chief administrative officer. Upon inspection of the physical plant, the right side of the roof remains in disrepair and it needs to be repaired.

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Penny Woodward, LCSW                          August 22, 2022
Regulatory Consultant                                   Date

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

visit_date: August 4, 2022

personnel: N/A	                       Program Director


summary: Visit conducted on May 13, 2022. Found 1 compliance issues.

raw_content:
DCF-3034
1/2013 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

  NAME OF FACILITY / PROGRAM: NOANK/Clift House Shelter Program

 TIME OF VISIT (FROM - TO): 11:30am to 1:00pm                     DATE: May 13, 2022

 AGENCY PERSONNEL WHO PARTICIPATED:

Name	Job Title
N/A	                       Program Director

Areas / Topics covered during visit:
The Department of Children and Families conducted a scheduled quarterly inspection visit at the Clift House Shelter Program on May 13, 2022.  Topics covered during the quarterly visit included staffing and training, physical plant inspection, and medication administration system.

Physical plant: A walkthrough of the facility was conducted with the director; areas of improvement were identified and discussed with the program representative. One of the bedrooms contained a ripped window screen and it needs to be repaired or replaced. The roof had a moss issue and it needs to be addressed.

Corrections implemented as a result of previous visit:
N/A

Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning)
N/A

Areas of regulatory non-compliance identified during this visit:
Section 17a-145-63: Chief administrative officer. Upon review of training information, it was found that all staff had not been trained in Risking Connections and Restorative Approach.

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Penny Woodward, LCSW                          June 17, 2022
Regulatory Consultant                                   Date

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|


facility_name: Noank CSS, Inc/Gray Farm Shelter

summary: Visit conducted on 1-12-26. Visit covered 8 main areas/topics. No compliance issues identified.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

 NAME OF FACILITY / PROGRAM:     Noank Community Support Services (Gray Farm Shelter)

TIME OF VISIT (FROM - TO):  10:30 am- 11:15 am                   DATE: 1-12-26

AGENCY PERSONNEL WHO PARTICIPATED:
Job Title: Director of Residential Care and Restorative Coach

List of Areas / Topics covered during visit:

•	Discussed current census (3) and the licensed bed capacity is 5.

•	Met with new Restorative Coach.

•	Discussed recent Exceptional Circumstances.

•	Two residents at home.  Met with resident OF in the kitchen area.  Resident SMR was in a meeting and JR was on a family visit.

•	Discussed staffing and coverages.

•	Discussed clinical support and grief curriculum to support the residents.

•	Discussed educational plans for the residents.

•	Physical plant inspection completed.  No safety issues noted. Bedroom 5 just repainted. New vehicle on order.

Corrective Actions implemented as a result of previous visit:

•	Not applicable

Areas of regulatory non-compliance identified during this visit:

•	Not applicable

Please submit a regulation compliance plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The Regulation Compliance Plan must be submitted to the attention of the undersigned at the address listed above. No Regulation Compliance Plan is required for this Licensing visit.

James Funaro  				Date:    1/15/26
Regulatory Consultant

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM
Cc: File, Program Director and Director of Quality Assurance|


summary: Visit conducted on 7-8-25. Visit covered 7 main areas/topics. No compliance issues identified.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

 NAME OF FACILITY / PROGRAM:     Noank Community Support Services (Gray Farm Shelter)

TIME OF VISIT (FROM - TO):  11:15 am- 12:15 pm                   DATE: 7-8-25

AGENCY PERSONNEL WHO PARTICIPATED:
Job Title: New Director and Director of Residential Care

List of Areas / Topics covered during visit:

•	Discussed current census (5) and the licensed bed capacity is 5.

•	Met with new Director and discussed her vision for the program.

•	Discussed ongoing search for vacant supervisor positions.

•	Five residents at home.  Met residents in the living room, dining room and bedroom areas with the director.

•	Discussed efforts to curb marijuana use.

•	Discussed recent report made to the Careline and subsequent investigation.

•	Physical plant inspection completed.  No safety issues noted.  Recent wall damage in AA's room and a work order to repair has been made.

Corrective Actions implemented as a result of previous visit:

•	Not applicable

Areas of regulatory non-compliance identified during this visit:

•	Not applicable

Please submit a regulation compliance plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The Regulation Compliance Plan must be submitted to the attention of the undersigned at the address listed above. No Regulation Compliance Plan is required for this Licensing visit.

James Funaro  				Date:    7/10/25
Regulatory Consultant

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM
Cc: File, Program Director and Director of Quality Assurance|


summary: Visit conducted on 6-5-25. Visit covered 7 main areas/topics. No compliance issues identified.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

 NAME OF FACILITY / PROGRAM:     Noank Community Support Services (Gray Farm Shelter)

TIME OF VISIT (FROM - TO):  11:00 am- 11:45 am                   DATE: 6-5-25

AGENCY PERSONNEL WHO PARTICIPATED:
Job Title: Director and Nurse

List of Areas / Topics covered during visit:

•	Discussed current census (5) and the licensed bed capacity is 5.

•	Discussed soon to be vacant Restorative Coach position and plans to fill it. Also plans to fill the Director position which will be vacant as of 7/3/25.

•	Three residents at home, one at school and one hospitalized.  Met residents with the Director in the upstairs bedroom area.

•	Discussed the milieu and current discharge planning with the Department's assigned workers.

•	Discussed cooperation with attending school and behavior challenges displayed by the residents.

•	Discussed SIU investigations and recent Exceptional Circumstances.

•	Physical plant inspection completed.  No safety issues noted.  A gas shut off will be installed for the gas stove soon. The stove will be inspected this coming Wednesday.

Corrective Actions implemented as a result of previous visit:

•	Not applicable

Areas of regulatory non-compliance identified during this visit:

•	Not applicable

Please submit a regulation compliance plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The Regulation Compliance Plan must be submitted to the attention of the undersigned at the address listed above. No Regulation Compliance Plan is required for this Licensing visit.

James Funaro  				Date:    6/6/25
Regulatory Consultant

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM
Cc: File, Program Director and Director of Quality Assurance|


summary: Visit conducted on 5-22-25. Visit covered 6 main areas/topics. No compliance issues identified.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

 NAME OF FACILITY / PROGRAM:     Noank Community Support Services (Gray Farm Shelter)

TIME OF VISIT (FROM - TO):  11:00 am- 12:00pm                   DATE: 5-22-25

AGENCY PERSONNEL WHO PARTICIPATED:
Job Title: Restorative Justice Coach, nurse and clinician

List of Areas / Topics covered during visit:

•	Discussed current census (5) and the licensed bed capacity is 5.

•	Discussed current staffing levels and staff coverages.

•	Three residents at school and two in the home at the time of the visit.

•	Discussed the overall milieu and cooperation with education.

•	Discussed current discharge planning with the Department.

•	Physical plant inspection completed.  No safety issues noted.  A gas shut off will be installed for the gas stove.  This plan discussed with the gas provider and accessible to staff only.

Corrective Actions implemented as a result of previous visit:

•	Not applicable

Areas of regulatory non-compliance identified during this visit:

•	Not applicable

Please submit a regulation compliance plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The Regulation Compliance Plan must be submitted to the attention of the undersigned at the address listed above. No Regulation Compliance Plan is required for this Licensing visit.

James Funaro  				Date:    5/23/25
Regulatory Consultant

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM
Cc: File, Program Director and Director of Quality Assurance|


raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

 NAME OF FACILITY / PROGRAM:     Noank Community Support Services (Gray Farm Shelter)

TIME OF VISIT (FROM - TO):  11:10 am- 12:00pm                   DATE: 5-8-25

AGENCY PERSONNEL WHO PARTICIPATED:
Job Title: Director of Quality Assurance and Restorative Justice Coach

List of Areas / Topics covered during visit:

•	Discussed current census (5) and the licensed bed capacity is 5.

•	Discussed current staffing levels and staff coverage.

•	Two residents at school, one leaving for school and two in the home at the time of the visit. Met with resident TR prior to her leaving for school.

•	Discussed AWOLs, 911 calls and exceptional circumstances.

•	Discussed clinical programming and cooperation with Restorative Justice Coach.

•	Discussed overall milieu, cooperation with school and incentives.

•	Physical plant inspection completed with the Director of Quality Assurance. One window screen is being replaced.  Overall, the rooms were clean. TR cleaning her room at the time of the visit. Ample amounts of food in the upstairs and downstairs fridge/freezer as well as snacks in the kitchen and basement storage area.

•	During the past quarter licensing responded to one incident and completed one incident response note. The incident occurred on 3-12-25 and involved an investigation completed by SIU.

Corrective Actions implemented as a result of previous visit:

•	Not applicable

Areas of regulatory non-compliance identified during this visit:

•	Not applicable

Please submit a regulation compliance plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The Regulation Compliance Plan must be submitted to the attention of the undersigned at the address listed above. No Regulation Compliance Plan is required for this Licensing visit.

James Funaro  				Date:    5/9/25
Regulatory Consultant

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM
Cc: File, Program Director and Director of Quality Assurance|


raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

 NAME OF FACILITY / PROGRAM:     Noank Community Support Services (Gray Farm Shelter)

TIME OF VISIT (FROM - TO):  12:15 pm- 1:15pm                   DATE: 1-28-25

AGENCY PERSONNEL WHO PARTICIPATED:
Job Title: Program Director and Director of Quality Assurance, Clinician

List of Areas / Topics covered during visit:

•	Discussed current census (5) and the licensed bed capacity is 5.

•	Discussed current staffing levels, staff coverage, staff vacancies and creating a per diem pool.

•	Three residents in the home during the visit. Met with the residents in the bedrooms with the PD.

•	Discussed AWOLs, 911 calls and exceptional circumstances.

•	Discussed clinical programming. Clinician reported residents are cooperating. New restorative justice coach hired and in place.

•	Discussed overall milieu and behaviors. Efforts to resolve behavior concerns. Discussed recreation outside the home.

•	Physical plant inspection completed with the program director. Bedroom # 1 new window installation completed. Staff office door repaired to prevent resident entry. Bedroom #3 door was damaged and being replaced (replacement door on site). Cameras to be installed in the basement area where recreation and clinical programming takes place. Requested immediate action by maintenance to fix resident graffiti in bedroom #4.

Corrective Actions implemented as a result of previous visit:

•	Not applicable

Areas of regulatory non-compliance identified during this visit:

•	Not applicable

Please submit a regulation compliance plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The Regulation Compliance Plan must be submitted to the attention of the undersigned at the address listed above. No Regulation Compliance Plan is required for this Licensing visit.

James Funaro  				Date:    1/31/25
Regulatory Consultant

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM
Cc: File, Program Director and Director of Quality Assurance|


summary: Visit conducted on 11-6-24. Visit covered 7 main areas/topics. Found 2 compliance issues.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

 NAME OF FACILITY / PROGRAM:     Noank Community Support Services (Gray Farm TGH)

TIME OF VISIT (FROM - TO):  11:15 am- 12:15pm                   DATE: 11-6-24

AGENCY PERSONNEL WHO PARTICIPATED:
Job Title
Program Director and Director of Quality Assurance

List of Areas / Topics covered during visit:

•	Discussed current census (4) and the licensed bed capacity is 5.

•	Discussed current staffing levels, staff coverage and staff vacancies.

•	Two residents in the home during the visit. Met with the residents in the bedroom with the PD.

•	Discussed AWOLs, 911 calls and exceptional circumstances.

•	Discussed clinical programming and cooperation with individual and group therapies.

•	Discussed overall milieu and discussed incentive programming.

•	Physical plant inspection completed with the program director. Bedroom # 1 suffered significant damage from a resident and is in the process of being repaired.

Corrective Actions implemented as a result of previous visit:

•	Not applicable

Areas of regulatory non-compliance identified during this visit:

Section 17a-145-74: Lavatory facilities: Overall the bathrooms were not clean and one had graffiti on the wall.

Section 17a-145-73. Sleeping accommodations:  Bedroom #4 had food and crumbs on the floor. Bedroom # 3 had writing on the wall.  All four bedrooms in use had clothes strewn about on the floor and were unkempt.

Please submit a regulation compliance plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The Regulation Compliance Plan must be submitted to the attention of the undersigned at the address listed above. No Regulation Compliance Plan is required for this Licensing visit.

James Funaro  				Date:    11/12/24
Regulatory Consultant

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM
Cc: File, Program Director and Director of Quality Assurance|

description: Section 17a-145-73.

area_type: Sleeping accommodations


summary: Visit conducted on 7-24-24. Visit covered 7 main areas/topics. No compliance issues identified.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM:     Noank Community Support Services (Gray Farm Star)

 TIME OF VISIT (FROM - TO):  12:15 pm- 1:00pm                   DATE: 7-24-24

AGENCY PERSONNEL WHO PARTICIPATED:
Job Title
Director of Residential Services

List of Areas / Topics covered during visit:

•	Discussed current census (4) and the licensed bed capacity is 5.

•	Discussed current staffing levels. One opening for direct care staff on each shift.

•	One resident in the milieu, with staff, who talked to this regulatory consultant.  The other three were in their bedroom, with staff checking on them.

•	Discussed recent 911 calls and AWOL's.

•	Inspection of the Gray Farm House physical plant. No health or safety concerns noted. Parking area has been renovated. Painting being done on the ceiling in the dining area.

•	Discussed clinical programming and overall cooperation with the program and house rules.

•	Discussed recent discharge and the overall milieu and how the residents interact with each other.

Corrective Actions implemented as a result of previous visit:

•	Not applicable

Areas of regulatory non-compliance identified during this visit:

•	Not applicable

James Funaro
Regulatory Consultant                                   Date: 7-26-24

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM
Cc: Program Director|


summary: Visit conducted on 5-10-24. Visit covered 6 main areas/topics. No compliance issues identified.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM:     Noank Community Support Services (Gray Farm Star)

 TIME OF VISIT (FROM - TO):  11:35am- 12:20pm                   DATE: 5-10-24

AGENCY PERSONNEL WHO PARTICIPATED:
Job Title
Director and Quality Assurance Director

List of Areas / Topics covered during visit:

•	Discussed current census (4) and the licensed bed capacity is 4.

•	Discussed current staffing levels. 4 RA vacancies.

•	Three residents at school and one in her bedroom. Discussed current milieu and discharge plans.

•	Discussed recent 911 calls and AWOLs.

•	Inspection of the Gray Farm House physical plant. No health or safety concerns noted. Parking area being renovated. Walls being repaired and painted after recent damage caused in a bedroom. Kitchen ceiling recently repainted. New sofas in the living room.  New washer and dryer in the laundry area.

•	Discussed clinical programming.

Corrective Actions implemented as a result of previous visit:

•	Not applicable

Areas of regulatory non-compliance identified during this visit:

•	Not applicable

James Funaro
Regulatory Consultant                                   Date: 5-13-24

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM
Cc: Program Director|


summary: Visit conducted on 1-4-24. Visit covered 5 main areas/topics. No compliance issues identified.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM:     Noank Community Support Services (Gray Farm Star)

 TIME OF VISIT (FROM - TO):  1:30pm- 2:00pm                   DATE: 1-4-24

AGENCY PERSONNEL WHO PARTICIPATED:
Job Title
Gray Farm House Star Director
Noank Community Support Services Nurse

List of Areas / Topics covered during visit:

•	Discussed current census (3) and the licensed bed capacity is 4.

•	Discussed current staffing levels, coverage and vacancies.

•	No residents observed.  Two at school and one at a medical appointment.

•	House projects discussed.  Painting and bathroom renovation.

•	Inspection of the Gray Farm House physical plant. No health or safety concerns noted.

Corrective Actions implemented as a result of previous visit:

•	Not applicable

Areas of regulatory non-compliance identified during this visit:

•	Not applicable

James Funaro
Regulatory Consultant                                   Date: 1-5-24

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM
Cc: Program Director
      Executive Director|


raw_content:
December 8, 2023

Regina Moller
Executive Director
Noank Community Support Services
479 Gold Star Highway
Groton, CT  06340

Re: Relicensing inspection –License #CCF-177
Regulatory Consultants: James Funaro, Theresa Bohara

Dear Ms. Moller,

On December 5-6, 2023, a biennial re-licensing inspection was conducted at the Gray Farm Star Program, located at 10 Gray Farm Rd, Ledyard, CT. This inspection was conducted to determine the compliance of this program with the DCF Regulations for Operation of Child-Caring Agencies and Facilities 17a-145-48 through 17a-145-124. Additionally, a review was conducted on 11-30-23 by DCF Nurse Consultant Errolee Miller, RN to determine the program’s compliance with the DCF Medication Administration Guidelines and the DCF Nursing Standards. A full standard of compliance was issued. A copy of the nursing site visit summary report is included with this report.

Listed below are the areas of regulatory non-compliance which were identified during the re-licensing inspection. Please review the areas identified and submit a service development plan (SDP) to address each area of noncompliance utilizing the SDP template included with this report. The service development plan must be submitted to the assigned Regulatory Consultant within 30 days of receipt of this emailed report.

Also included in this report are recommendations.  Recommendations are meant to highlight areas that are not currently areas of non-compliance, but may become non-compliant if actions are not taken, or, highlight areas for improvement. Recommendations do not require the submission of a service development plan.

The areas of regulatory noncompliance are as follows:

17a-145-86	Instructions in Safety Procedures. Supervision
•	In 2022, Quarter 4 is missing fire drills for 1st and 3rd shift. In 2023, Quarter 1 is missing fire drills for 2nd and 3rd shift, and Quarter 2 is missing fire drills for 2nd and 3rd shift.

Section 17a-145-96. Discharge of child
•	Two closed records did not contain documentation that identified person(s) that took legal custody of clients when discharged from the program.

Section 17a-145-64. Personnel policies and procedures
•	One personnel file did not have a date of a physical exam or date of TB test (and result) prior to hire.

Recommendation: No recommendations made in this report.

Once the Licensing Unit has reviewed and accepted the service development plan and has determined that your agency is in compliance with the regulations, a decision on the issuance of a regular twenty-four month license for the program will be made.  Until DCF makes this decision, the current license will remain in effect. Should you have any questions or comments regarding the contents of this report please do not hesitate to contact me at (860) 209-3136.

Sincerely,

James Funaro
_____________________________
James Funaro
DCF Regulatory Consultant

Copy: file
          Executive Director|


facility_name: Waterford Country School - ITTC

summary: Visit conducted on __3-17-26______. Visit covered 7 main areas/topics. Implemented 1 corrective actions.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

  NAME OF FACILITY / PROGRAM: ____WCS - ITTC__________________________________

 TIME OF VISIT (FROM - TO):       __________________________         DATE:__3-17-26______

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:
JH - Supervisor
BF _ Director

List of Areas / Topics covered during visit:

•	Census - 3
•	Staff hiring continues. The current plan is to have new staff in place by early/mid April and to increase the LBC to full census.
•	Bedrooms were clean and well organized. It was suggested to have residents use make up in the designated areas in the basement in order to maintain cleanliness.
•	Bathrooms were clean.
•	 All 3 residents were at school at the time of the visit.
•	Review of the record kept on the unit. Currently treatment plans are kept in the clinician's office in another building. It was suggested that a copy of the treatment plan be kept on the unit so that staff are aware of the goals and objectives and can provide assistance in achieving the goals.
•	Provisional license to be issued.

Corrective Actions implemented as a result of previous visit: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Areas of regulatory non-compliance identified during this visit:

Please submit a service development plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The service development plan must be submitted to the attention of the undersigned at the address listed above.
    Terri Bohara                                               3-18-26
______________________________            _________________
Regulatory Consultant                                   Date

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

personnel:
JH - Supervisor
BF _ Director