summary: Unannounced - 06/30/2022

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Licensee: Albertina Kerr Sub-Acute (AKC)
Executive Director: Miki Herman
Date of Unannounced: June 30, 2022
Licensing Coordinator: Conducted Review - Todd Cooley (Assigned Coordinator Aubrey Kelly)
Other Regulatory or Accrediting Agencies: OHA
Purpose: Per OAR 413-215-0101 (1) (b) Children’s Care Licensing is required to perform at least one unannounced site visit a year where
cPhirledvreionu isn F cianrdein rgess ide. Repeat Comments
Findings
Further Action
Needed
Personnel Files 413-215-0061 Yes☐ No License renewal was on 2/22/2022. Given the short amount of time since the previous
(3)(d) Annual performance evaluation review it is recommended to verify status of annual reviews at next unannounced and
license renewal.
New Employee Orientation – Residential (30 Yes No☐ Multiple staff files were reviewed of individuals hired in March, April and May of 2022.
days) 413-215-0556 There were no training records available showing CPS training had been conducted within
(1)(a) Discipline and behavior management 30 days of hire.
New Employee Orientation – Residential (30 Yes No☐ Multiple staff files were reviewed of individuals hired in March, April and May of 2022. CPI
days) 413-215-0556 training was consistently being completed between 45-55 days from hire date and outside
(1)(b) Restraint and Seclusion of the 30 day requirement.
New Findings from Site Visit Comments
No new findings were observed during this
unannounced visit.
1
(rev. 200115)
Interview Summary
During the unannounced visit only two clients were interviewed, and all others declined the opportunity. The first client had been at AKC about three weeks
and said overall things were going well. They said there could definitely be more staff, but only elaborated to say it would give clients more opportunity for
individual activities or 1:1 time when needed. They said they have felt safe and comfortable during their time at the program and have multiple staff members
they can talk to if they have any issues or concerns. Although school is out for the summer, client stated they still have daily education groups that mainly
consist of watching a documentary. They are currently watching one on penguins that is pretty interesting, but others can be boring. Client said they get
plenty of recreation and outdoor activity time throughout the day, each day. When asked about the food their response was it was “suspicious” in a
joking/sarcastic way. They were not a big fan of the food but did say the mac-n-cheese was really good. Client stated they were never hungry, alternatives
such as bean and cheese burritos or PB&J sandwiches are offered, as well as snacks being available all the time. When asked what they thought could be
improved at the program, client just referred back to additional staffing and maybe night staff paying more attention (refer to notes in observations). When
asked about things they thought the program did well the client responded saying the staff are all pretty moderate. By moderate they explained staff knew
there were times to be a bit lenient and times to be a bit stricter and did a good job of balancing that. Client was unaware of a discharge date but anticipated
going to a residential program following their time at AKC.
The second client had been at AKC approximately two weeks. They stated they have never been in any other programs and were just there as a respite from
their family (dad). They only had a few more days and were to be discharged prior to the holiday back to their family. Client said staff have made them feel
safe and they are comfortable talking to staff about concerns if they have them. Client had the same response about education that school was out, but they
still had to watch documentaries every day. Client felt outdoor recreation time was pretty limited and stated they only got 15-20 minutes. They also said
because a lot of their peers would mess around it would take a lot of time to get outside and then they would only get maybe 10 minutes outside. Client
reported being pescatarian and stated most all of the options were pretty terrible and the meat alternatives were always soaked in soy sauce making
everything very salty. The client did say they receive a lot of food and for them this was a slight issue coming from a home in which food was not always
available they felt they had to finish everything as to not waste. They always had snacks available and alternative meals. Client stated they opted for the
bean and cheese burrito on many occasions due to the quality of the food. Client said the program overall was pretty good. They said staff could at times be
better at intervening sooner with other clients. They relayed stories of a particular peer who frequently engaged others to antagonize them, and staff would
allow this to occur for some time before separating or trying to redirect. Client also mentioned being very passionate about playing instruments and was
frustrated the policy only allowed for one-on-one instrument time and they couldn’t share their music with the pod or their peers, even if all of the peers were in
agreement on wanting to listen. There were no other concerns noted by the client.
Observations
A walkthrough of the program showed all areas were clean and in good repair. There were no items of concern with the facility.
During a youth interview there was a concern of night staff paying more attention. This was regarding client information being accidentally released to youth in
the program. It was reported clients woke up to papers in their bedroom doors, it was believed staff intended to provide youth with blank or scrap paper for
art/projects that day. When youth looked at the papers it was discovered it had a discharged clients personally identifying information on it to include items
like contact lists. A grievance report was filed and follow-up by licensing is currently being conducted with management to get further information on the
incident and action taken.
2
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 200115)
Corrective Actions and Timeframes:
Please submit the following to verify compliance.
Within 45 days of receipt of this report Albertina Kerr Sub-Acute must submit a letter of verification indicating the agency is in compliance with the
specific rules cited above and describing how compliance will be maintained going forward. Along with the letter of verification, the agency must
submit any and all specific documentation requested in the body of this report. The letter of verification and any additional requested documents can
be emailed directly to Aubrey Kelly, AUBREY.J.KELLY@dhsoha.state.or.us or sent by regular mail to the following address:
Department of Human Services
Children’s Care Licensing Program
Attn: Aubrey Kelly
201 High St. SE Suite 500
Salem, OR 97301
Licensing Coordinator’s Signature: ________________________ Date: ___7_-_2_0_-2_0_2_2_ ________
Manager Review: ______________________________________ Date: _ _ _7_-1_3_-_2_0_2_2_ _______
3
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 200115)

licensee: Albertina Kerr Sub-Acute (AKC)

executive_director: Miki Herman

purpose:
Per OAR 413-215-0101 (1) (b) Children's Care Licensing is required to perform at least one unannounced site visit a year where
cPhirledvreionu isn F cianrdein rgess ide. Repeat Comments
Findings
Further Action
Needed
Personnel Files 413-215-0061 Yes[ ] No License renewal was on 2/22/2022. Given the short amount of time since the previous
(3)(d) Annual performance evaluation review it is recommended to verify status of annual reviews at next unannounced and
license renewal.
New Employee Orientation - Residential (30 Yes No[ ] Multiple staff files were reviewed of individuals hired in March, April and May of 2022.
days) 413-215-0556 There were no training records available showing CPS training had been conducted within
(1)(a) Discipline and behavior management 30 days of hire.
New Employee Orientation - Residential (30 Yes No[ ] Multiple staff files were reviewed of individuals hired in March, April and May of 2022. CPI
days) 413-215-0556 training was consistently being completed between 45-55 days from hire date and outside
(1)(b) Restraint and Seclusion of the 30 day requirement.
New Findings from Site Visit Comments
No new findings were observed during this
unannounced visit.
1

Interview Summary
During the unannounced visit only two clients were interviewed, and all others declined the opportunity. The first client had been at AKC about three weeks
and said overall things were going well. They said there could definitely be more staff, but only elaborated to say it would give clients more opportunity for
individual activities or 1:1 time when needed. They said they have felt safe and comfortable during their time at the program and have multiple staff members
they can talk to if they have any issues or concerns. Although school is out for the summer, client stated they still have daily education groups that mainly
consist of watching a documentary. They are currently watching one on penguins that is pretty interesting, but others can be boring. Client said they get
plenty of recreation and outdoor activity time throughout the day, each day. When asked about the food their response was it was "suspicious" in a
joking/sarcastic way. They were not a big fan of the food but did say the mac-n-cheese was really good. Client stated they were never hungry, alternatives
such as bean and cheese burritos or PB&J sandwiches are offered, as well as snacks being available all the time. When asked what they thought could be
improved at the program, client just referred back to additional staffing and maybe night staff paying more attention (refer to notes in observations). When
asked about things they thought the program did well the client responded saying the staff are all pretty moderate. By moderate they explained staff knew
there were times to be a bit lenient and times to be a bit stricter and did a good job of balancing that. Client was unaware of a discharge date but anticipated
going to a residential program following their time at AKC.
The second client had been at AKC approximately two weeks. They stated they have never been in any other programs and were just there as a respite from
their family (dad). They only had a few more days and were to be discharged prior to the holiday back to their family. Client said staff have made them feel
safe and they are comfortable talking to staff about concerns if they have them. Client had the same response about education that school was out, but they
still had to watch documentaries every day. Client felt outdoor recreation time was pretty limited and stated they only got 15-20 minutes. They also said
because a lot of their peers would mess around it would take a lot of time to get outside and then they would only get maybe 10 minutes outside. Client
reported being pescatarian and stated most all of the options were pretty terrible and the meat alternatives were always soaked in soy sauce making
everything very salty. The client did say they receive a lot of food and for them this was a slight issue coming from a home in which food was not always
available they felt they had to finish everything as to not waste. They always had snacks available and alternative meals. Client stated they opted for the
bean and cheese burrito on many occasions due to the quality of the food. Client said the program overall was pretty good. They said staff could at times be
better at intervening sooner with other clients. They relayed stories of a particular peer who frequently engaged others to antagonize them, and staff would
allow this to occur for some time before separating or trying to redirect. Client also mentioned being very passionate about playing instruments and was
frustrated the policy only allowed for one-on-one instrument time and they couldn't share their music with the pod or their peers, even if all of the peers were in
agreement on wanting to listen. There were no other concerns noted by the client.
Observations
A walkthrough of the program showed all areas were clean and in good repair. There were no items of concern with the facility.
During a youth interview there was a concern of night staff paying more attention. This was regarding client information being accidentally released to youth in
the program. It was reported clients woke up to papers in their bedroom doors, it was believed staff intended to provide youth with blank or scrap paper for
art/projects that day. When youth looked at the papers it was discovered it had a discharged clients personally identifying information on it to include items
like contact lists. A grievance report was filed and follow-up by licensing is currently being conducted with management to get further information on the
incident and action taken.
2


state: OR

facility_name: Albertina Kerr - Subacute

summary: Unannounced - 4 findings

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Residential Care
Licensee: Albertina Kerr Sub-Acute (AKC)
Executive Director: Derrick Perry
Program Director(s): Owen Gibson, Stephanie Scovil, Dr. Naomi Fishman
Date of Unannounced: 5.11.2023
Licensing Coordinator: Jorge Pelinski & Aubrey Kelly
Other Regulatory or Accrediting Agencies: OHA
Purpose: Per OAR 419-400-0240 (1)(b) Children’s Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Comments
Unannounced Site Visit 06-30-2022 Findings
Further Action
Needed
New Employee Orientation – Residential YesNo☐ New Employee Orientation – Residential (30 days) 413-215-0556
(30 days) 413-215-0556 (1)(a) Discipline and behavior management
(1)(a) Discipline and behavior management • Of the files reviewed, Behavior Management Training was not consistently
found to be completed within the 30-day Licensing Rule requirement.
Multiple staff files were reviewed of individuals (REPEAT FINDING)
hired in March, April and May of 2022. There • Amended. This report has been amended on 5.23.2023 to show that Behavior
were no training records available showing Management Training was not found to be completed within the 30-day Licensing
Behavior Management Training had been Rule requirement and not CPS (Collaborative Problem Solving) as indicated in the
conducted within 30 days of hire. previous report.
New Employee Orientation – Residential YesNo☐ New Employee Orientation – Residential (30 days) 413-215-0556
(30 days) 413-215-0556 (1)(b) Restraint and Seclusion
(1)(b) Restraint and Seclusion • Of the files reviewed, the OIS Training was not consistently found to be
completed within the 30-day Licensing Rule requirement.
Multiple staff files were reviewed of individuals (REPEAT FINDING)
hired in March, April and May of 2022. OIS • Amended. The report has been amended on 5.31.2023. OAR 413-215-0556 was
training was consistently being completed eliminated as part of a recent rule update. Therefore, this finding is no longer
1 | Pa g e
Form Rev. 01/23/2023
between 45-55 days from hire date and applicable because the rule has been deleted. Restraint and seclusion training is
outside of the 30-day requirement. part of Behavior Management Training which is covered in the citation above.
New Findings from Site Visit Comments
N/A No new findings were found during site visit.
Interview Summary
Youth from the program were interviewed (2 youth) at the unannounced site inspection. Both youths are 16 years old and new to the program. The
following information was obtained from the youth interviews:
• Both youths stated that they felt safe in the program.
• One youth stated they wish they had more activities to do; to manage their time better.
• Both youths stated things were going well in general at the programs.
• Both youths described the staff as supportive and kind. One youth described the staff as “Amazing!” Both youths stated that in general, they get
along with their peers.
• Both youths reported that they see a therapist regularly.
• Both youths have goals that they are working towards.
• Both youths confirmed they receive enough food to eat and have plenty of snacks in between meals.
Observations
Staff and youth were observed at the programs during the inspection. The youth that were at the programs appeared to be at ease and
comfortable in the environments. All areas of the programs (inside and outside) where youth had access were observed to be well kept
and in good repair. Program Manager (Benjamin Treckman) stated that new vanities will be eventually installed in all 4 of the youth bathrooms. Medication
was observed to be in locked medication carts in locked rooms which were inaccessible to the youth.
2 | Pa g e
Form Rev. 01/23/2023
Corrective Actions and Timeframes:
Please submit the following to verify compliance.
Within 45 days of receipt of this report Agency Name must submit a letter of verification indicating the agency is in compliance with the specific
rules cited above and describing how compliance will be maintained going forward. Along with the letter of verification, the agency must submit any,
and all specific documentation requested in the body of this report. The letter of verification and any additional requested documents can be emailed
directly to Jorge Pelinski, Licensing Coordinator email address: jorge.l.pelinski@odhsoha.oregon.gov
5-31-2023
Licensing Coordinator’s Signature: ________________________ Date: ___________________
Manager Review: ______________________________________ Date: _5_-_3_1_-2__0_2_3_________
3 | Pa g e
Form Rev. 01/23/2023

agency_name: Albertina Kerr Centers for Children (AKCC)

program_type: (RC) Residential Care Programs

report_type: Unannounced

view_code: RC

facility_type: Residential Care

executive_director: Derrick Perry

licensing_coordinator: Jorge Pelinski & Aubrey Kelly

other_regulatory_agencies: OHA

purpose:
Per OAR 419-400-0240 (1)(b) Children's Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Comments
Unannounced Site Visit 06-30-2022 Findings
Further Action
Needed
New Employee Orientation - Residential YesNo[ ] New Employee Orientation - Residential (30 days) 413-215-0556
(30 days) 413-215-0556 (1)(a) Discipline and behavior management
(1)(a) Discipline and behavior management - Of the files reviewed, Behavior Management Training was not consistently
found to be completed within the 30-day Licensing Rule requirement.
Multiple staff files were reviewed of individuals (REPEAT FINDING)
hired in March, April and May of 2022. There - Amended. This report has been amended on 5.23.2023 to show that Behavior
were no training records available showing Management Training was not found to be completed within the 30-day Licensing
Behavior Management Training had been Rule requirement and not CPS (Collaborative Problem Solving) as indicated in the
conducted within 30 days of hire. previous report.
New Employee Orientation - Residential YesNo[ ] New Employee Orientation - Residential (30 days) 413-215-0556
(30 days) 413-215-0556 (1)(b) Restraint and Seclusion
(1)(b) Restraint and Seclusion - Of the files reviewed, the OIS Training was not consistently found to be
completed within the 30-day Licensing Rule requirement.
Multiple staff files were reviewed of individuals (REPEAT FINDING)
hired in March, April and May of 2022. OIS - Amended. The report has been amended on 5.31.2023. OAR 413-215-0556 was
training was consistently being completed eliminated as part of a recent rule update. Therefore, this finding is no longer

between 45-55 days from hire date and applicable because the rule has been deleted. Restraint and seclusion training is
outside of the 30-day requirement. part of Behavior Management Training which is covered in the citation above.
New Findings from Site Visit Comments
N/A No new findings were found during site visit.
Interview Summary
Youth from the program were interviewed (2 youth) at the unannounced site inspection. Both youths are 16 years old and new to the program. The
following information was obtained from the youth interviews:
- Both youths stated that they felt safe in the program.
- One youth stated they wish they had more activities to do; to manage their time better.
- Both youths stated things were going well in general at the programs.
- Both youths described the staff as supportive and kind. One youth described the staff as "Amazing!" Both youths stated that in general, they get
along with their peers.
- Both youths reported that they see a therapist regularly.
- Both youths have goals that they are working towards.
- Both youths confirmed they receive enough food to eat and have plenty of snacks in between meals.
Observations
Staff and youth were observed at the programs during the inspection. The youth that were at the programs appeared to be at ease and
comfortable in the environments. All areas of the programs (inside and outside) where youth had access were observed to be well kept
and in good repair. Program Manager (Benjamin Treckman) stated that new vanities will be eventually installed in all 4 of the youth bathrooms. Medication
was observed to be in locked medication carts in locked rooms which were inaccessible to the youth.

excerpt:
413-215-0556 was
training was consistently being completed eliminated as part of a recent rule update. Therefore, this finding is no longer
between 45-55 days from hire date and applicable because the rule has been deleted. Restraint and seclusion training is
outside of the 30-day requirement. part of Behavior Management Training which is covered in the citation above.
New Findings from Site Visit Comments
N/A No new findings were found during site visit.
N/A No new findings were found during site visit.


summary: Unannounced - 12 findings

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Residential Care
Licensee: Albertina Kerr – Subacute
Executive Director: Allison Stark
Program Director(s): Derrick Perry
Date of Unannounced: 8.21.2024
Licensing Coordinator: Jorge Pelinski & Harry Gilmore
Other Regulatory or Accrediting Agencies: OHA
Purpose: Per OAR 419-400-0240 (1)(b) Children’s Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Comments
License Renewal Site Visit 01/24/2024 Findings
Further Action
Needed
Supplemental Information Provided by Yes☐ No✓ The agency submitted in their Plan of Correction policy revisions that meet OAR
CCA requirements. There is nothing further required regarding this finding.
All required policies and procedures as
identified in the “Umbrella Rules”
419-400-0150Licensing Umbrella Rules:
Discipline, Behavior Management & Training,
and Suicide Prevention (Excluding Adoption
Agencies)
(4) Suicide Prevention. The policy must
include the following:
(c) Emergency protocol and contacts;
(d) Training requirements for staff,
including…..suicide risk assessment tool
training;
Form Rev. 11/14/2023 P age 1 | 8
• The policy wasn’t sufficient with
details regarding emergency protocol
and contacts. Licensing spoke with
management during the review about
what is needed to bring the policy into
compliance and sent an email with
this information after the review.
• The policy did not include
requirements for staff regarding
suicide risk assessment tool training.
Physical Plant Yes☐ No✓ Pictures submitted to licensing coordinator verifying repairs have been completed. No
419-470-0020(2)(a) &(c) Buildings are smoke further action needed regarding this finding.
free, clean and in good repair
• The key switch for the gate/door that
leads to the outside gated
recreational area needs to be rewired
due to a short in the wiring. Program
Leadership stated an outside
contractor will be coming to fix the
lock.
Corrective Action: Agency will fix the gate
lock. Agency will submit a copy of the repair
receipt as part of their corrective action plan.
Residential Care Safety 419-470-0080 Yes☐ No✓ In the Correction Action Plan, administrative oversight was identified to ensure fire drills
(5)(a) Evacuation drill occurs monthly under occur monthly. During site visit on 8.21.2024, all files reviewed showed monthly fire drills
varying conditions, is retained 2 years and completed. No further follow up needed.
contains:
(A) identify of person conducting drill
(B) date & time
(C) notification method
(D) staff participating
(E) # of children & staff evacuated
(F) special conditions simulated
(G) problems encountered
(H) time to complete
• Agency was missing an evacuation
drill for September 2023.
Corrective Action: Agency must ensure that
evacuation drills are conducted monthly.
Form Rev. 11/14/2023 P age 2 | 8
New Employee Orientation – Umbrella Yes✓ No☐ In the Correction Action Plan, administrative oversight was identified to ensure the required
Requirements (30 days) 419-400-0120(4) orientation occurs within 30 days of hire for staff. During site visit on 8.21.2024, one file
(d) Attributes of population served was found not having this training completed within the 30-day requirement.
• Documentation of this training was Repeat Finding:
found in all files reviewed. One file
was found not having this training Corrective Action:
completed within the 30-day • Agency will ensure Attributes of population served training is provided and
requirement. documented within 30 days of hire for new employees.
Corrective Action: Agency will ensure
Attributes of population served training is
provided and documented within 30 days of
hire for new employees.
New Employee Orientation – Umbrella Yes✓ No☐ In the Correction Action Plan, administrative oversight was identified to ensure the required
Requirements (30 days) 419-400-0120(4) training occurs within 30 days of hire for staff. During site visit on 8.21.2024, one file
(e) & (5)(a) to (c) Mandatory reporting that reviewed was found not having this training completed within the 30-day requirement.
includes:
(a) legal definition of child abuse in ORS Repeat Finding:
418.257 and 419B.005
(b) legal responsibility to immediately report Corrective Action:
(c) legal responsibility to report is personal to • Agency will ensure Mandatory Reporting training is provided and
the employee documented within 30 days of hire for new employees.
• Documentation of this training was
found in all files reviewed. One file
reviewed was found not having this
training completed within the 30-day
requirement.
Corrective Action: Agency will ensure
Mandatory Reporting training is provided and
documented within 30 days of hire for new
employees.
New Employee Orientation – Umbrella Yes☐ No✓ In the Correction Action Plan, administrative oversight was identified to ensure the required
Requirements (30 days) 419-400-0120(4) training occurs within 30 days of hire for staff. During site visit on 8.21.2024, all files
(g) Emergency procedures reviewed showed the training requirements were within the 30 days. No further follow up
needed.
• Documentation of this training was
found in all files reviewed. One file
was found not having this training
completed within the 30-day
requirement.
Corrective Action: Agency will ensure
Emergency procedures training is provided
Form Rev. 11/14/2023 P age 3 | 8
and documented within 30 days of hire for
new employees.
New Employee Orientation Residential Yes☐ No✓ In the Correction Action Plan, administrative oversight was identified to ensure the required
(Prior to working alone and within 30 days) training occurs within 30 days of hire for staff. During site visit on 8.21.2024, all files
419-470-0120(1) reviewed showed the training requirements were within the 30 days. No further follow up
(a)Discipline and behavior management needed.
including de-escalation, crisis prevention,
positive behavior management, and
disciplinary techniques that are non-punitive in
nature
• Documentation of this training was
found in all files reviewed. One file
was found not having this training
completed within the 30-day
requirement. (Repeat Finding)
Corrective Action: Agency will ensure
discipline and behavior management training
is provided and documented within 30 days of
hire for new employees.
New Employee Orientation Residential Yes☐ No✓ In the Correction Action Plan, administrative oversight was identified to ensure the required
(Prior to working alone and within 30 days) training occurs within 30 days of hire for staff. During site visit on 8.21.2024, all files
419-470-0120(1) reviewed showed the training requirements were within the 30 days. No further follow up
(b) CPR and First Aid sufficient to retain a needed.
current certification
• Documentation of this training was
found in all files reviewed. One file
was found not having this training
completed within the 30-day
requirement.
Corrective Action: Agency will complete
CPR and First Aid staff training and document
it within 30 days of hire for new employees
Crisis Intervention Training Standards and Yes☐ No✓ In the Correction Action Plan, administrative oversight was identified to ensure the required
Certification 419-400-0160(4) (as applicable) training occurs within 30 days of hire for staff. During site visit on 8.21.2024, all files
(a)Complete a minimum of 12 hours of initial reviewed showed the training requirements were within the 30 days. No further follow up
training in person from a certified instructor, needed.
including but not limited to a minimum of six
hours of training focused on positive behavior
support, nonviolent crisis intervention and
other methods of nonphysical intervention to
support children in care during a crisis
Form Rev. 11/14/2023 P age 4 | 8
• Documentation of this training was
found in all files reviewed. One file
was found not having this training
completed within the 30-day
requirement.
Corrective Action: Agency will ensure the 12
hours of initial training are completed and
documented within 30 days of hire for new
employees
Records Relating to Restraint & Yes☐ No✓ Due to SB710, restraint reports are required. Albertina Kerr revised initial admission
Involuntary Seclusion paperwork to include verification that parents received information about how to access the
419-400-0180(13)(e) Each child caring program’s restraint reports. Licensing rules require this information to be provided at
agency shall provide notice regarding how to intake and two times thereafter within the year. Agency submitted documents on 8.22.2024
access the quarterly reports to the parents or regarding how parents/guardians can access the quarterly reports relating to restraint &
guardians of children in care in the program. involuntary seclusion. The program is in compliance.
The child caring agency shall provide the
notice upon the child in care’s admission and
at least two times each year thereafter.
• The agency does not have a process
for providing access to quarterly
reports for parents or guardians of
children.
Corrective Action: Agency will create a
process for providing access to quarterly
reports for parents and guardians of children
in care in the program. The child caring
agency shall provide notice to guardians of
how to access reports upon the child in care’s
admission and at least two times each year
thereafter.
Records Relating to Restraint & Yes☐ No✓ Agency created a process for providing information to children in care relating to suspected
Involuntary Seclusion inappropriate use of restraint & seclusion. Agency is in compliance with rule relating to SB
419-400-0190(1) Information provided to 710.
children in care relating to Restraint &
Involuntary Seclusion
• The agency is creating a process for
providing information to children in
care relating to suspected
inappropriate use of restraint &
seclusion.
Form Rev. 11/14/2023 P age 5 | 8
Corrective Action: Agency will create and
implement a process for providing information
to children in care relating to suspected
inappropriate use of restraint & seclusion.
Licensing provided an example for the
agency.
New Findings from Site Visit Comments
419-400-0100 Licensing Manager and Licensing Coordinator reviewed the programs Room Search Logs. Two out of six
Licensing Umbrella Rules: Resources room searches were not completed according to the log. The program has retrained their staff on the proper
Required methods of searching rooms and are making efforts toward making sure searches are happening more
reliably, even though they have missed a couple searches.
(2) A child-caring agency must employ or
contract for a sufficient number of Corrective Action:
competent and qualified employees to
perform the functions regulated by these Program will ensure youth room checks are completed per program policy and procedures. During
rules and to provide adequate care, safety, the unannounced review, the program was encouraged to review policy and procedures regarding
protection, and supervision of the children in
Room Searches and to evaluate if their needs to be changes made to the current policy.
care and families the child-caring agency
serves.
Form Rev. 11/14/2023 P age 6 | 8
Interview Summary
Two youths were interviewed at the unannounced site inspection.
• Both youths stated things were going well at the programs.
• When asked what the youth appreciated most about the program the youth stated: “Appreciate the staff.” “Good relationships.” “I get to
decorate my room.” I get to have a clock in my room.” “Staff are nice.” “Everyone is pretty cool.”
• One youth talked about being involved in skills groups, education group, and other kinds of groups.
• When asked about recreation or fun things to do in the program, youths stated, “going to the gym, making bracelets, sand art, drawing,
painting, crochet, coloring, making crafts, listening to music, and going outside.” One youth stated that they would like to have more
activities to do as they feel there is more down time than they would like.
• Both youths confirmed they receive enough food to eat, snacks are provided and as well as fruit.
• Both youths stated they can make phone calls and have privacy when making phone calls.
• Both youths stated they are provided sufficient hygiene products by the program.
• All the youth stated they had someone at the program they could talk to if they felt uncomfortable or needed anything.
• When asked if they could change anything about the program, one youth stated they wished they could have more visits. The other
youth interviewed stated that they would want the food to be better overall.
• When asked about feeling safe in the program, both youths feel safe at the program. One youth felt that not all staff are great at dealing
with youth behaviors; but still feels safe in the program.
Observations
Staff and youth were observed at the program during the inspection. The youth that were at the program appeared to be at ease and
comfortable in the environment. All areas of the program (inside and outside) where youth had access were observed to be well kept, clean and
mostly in good repair. It was observed that the vinyl is cracked around the drain in the kitchen. Also, three rooms in the Northwest Wing where
youth reside were observed to be cluttered. The program does have a weekly structured room cleaning time. Medication was observed to be in
locked medication carts in locked rooms which were inaccessible to the youth. The agency now has six beds for DHS youth that integrate with
the other youth in the Subacute Program. These youth are housed on the Northwest Unit. The licensing supervisor & licensing coordinator were
able to look at the Room Check Logs. It was observed that checks are being completed; but that a few checks were not completed during shifts.
The program is retraining their staff on proper methods of searching youth’s rooms and they are making efforts towards making sure they
happen more reliably.
Form Rev. 11/14/2023 P age 7 | 8
Corrective Actions and Timeframes:
Please submit the following to verify compliance.
Within 45 days of receipt of this report Albertina Kerr must submit a letter of verification indicating the agency is in compliance with the specific
rules cited above and describing how compliance will be maintained going forward. Along with the letter of verification, the agency must submit any
and all specific documentation requested in the body of this report. The letter of verification and any additional requested documents can be emailed
directly to Jorge Pelinski at Jorge.L.Pelinski@odhsoha.oregon.gov.
Licensing Coordinator’s Signature: ________________________ Date: ____9_-_9_-_2_0_2_4________
Manager Review: ______________________________________ Date: __________________
Form Rev. 11/14/2023 P age 8 | 8

licensee: Albertina Kerr - Subacute

executive_director: Allison Stark

program_director: Derrick Perry

licensing_coordinator: Jorge Pelinski & Harry Gilmore

purpose:
Per OAR 419-400-0240 (1)(b) Children's Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Comments
License Renewal Site Visit 01/24/2024 Findings
Further Action
Needed
Supplemental Information Provided by Yes[ ] No✓ The agency submitted in their Plan of Correction policy revisions that meet OAR
CCA requirements. There is nothing further required regarding this finding.
All required policies and procedures as
identified in the "Umbrella Rules"
419-400-0150Licensing Umbrella Rules:
Discipline, Behavior Management & Training,
and Suicide Prevention (Excluding Adoption
Agencies)
(4) Suicide Prevention. The policy must
include the following:
(c) Emergency protocol and contacts;
(d) Training requirements for staff,
including…..suicide risk assessment tool
training;

- The policy wasn't sufficient with
details regarding emergency protocol
and contacts. Licensing spoke with
management during the review about
what is needed to bring the policy into
compliance and sent an email with
this information after the review.
- The policy did not include
requirements for staff regarding
suicide risk assessment tool training.
Physical Plant Yes[ ] No✓ Pictures submitted to licensing coordinator verifying repairs have been completed. No
419-470-0020(2)(a) &(c) Buildings are smoke further action needed regarding this finding.
free, clean and in good repair
- The key switch for the gate/door that
leads to the outside gated
recreational area needs to be rewired
due to a short in the wiring. Program
Leadership stated an outside
contractor will be coming to fix the
lock.
Corrective Action: Agency will fix the gate
lock. Agency will submit a copy of the repair
receipt as part of their corrective action plan.
Residential Care Safety 419-470-0080 Yes[ ] No✓ In the Correction Action Plan, administrative oversight was identified to ensure fire drills
(5)(a) Evacuation drill occurs monthly under occur monthly. During site visit on 8.21.2024, all files reviewed showed monthly fire drills
varying conditions, is retained 2 years and completed. No further follow up needed.
contains:
(A) identify of person conducting drill
(B) date & time
(C) notification method
(D) staff participating
(E) # of children & staff evacuated
(F) special conditions simulated
(G) problems encountered
(H) time to complete
- Agency was missing an evacuation
drill for September 2023.
Corrective Action: Agency must ensure that
evacuation drills are conducted monthly.

New Employee Orientation - Umbrella Yes✓ No[ ] In the Correction Action Plan, administrative oversight was identified to ensure the required
Requirements (30 days) 419-400-0120(4) orientation occurs within 30 days of hire for staff. During site visit on 8.21.2024, one file
(d) Attributes of population served was found not having this training completed within the 30-day requirement.
- Documentation of this training was Repeat Finding:
found in all files reviewed. One file
was found not having this training Corrective Action:
completed within the 30-day - Agency will ensure Attributes of population served training is provided and
requirement. documented within 30 days of hire for new employees.
Corrective Action: Agency will ensure
Attributes of population served training is
provided and documented within 30 days of
hire for new employees.
New Employee Orientation - Umbrella Yes✓ No[ ] In the Correction Action Plan, administrative oversight was identified to ensure the required
Requirements (30 days) 419-400-0120(4) training occurs within 30 days of hire for staff. During site visit on 8.21.2024, one file
(e) & (5)(a) to (c) Mandatory reporting that reviewed was found not having this training completed within the 30-day requirement.
includes:
(a) legal definition of child abuse in ORS Repeat Finding:
418.257 and 419B.005
(b) legal responsibility to immediately report Corrective Action:
(c) legal responsibility to report is personal to - Agency will ensure Mandatory Reporting training is provided and
the employee documented within 30 days of hire for new employees.
- Documentation of this training was
found in all files reviewed. One file
reviewed was found not having this
training completed within the 30-day
requirement.
Corrective Action: Agency will ensure
Mandatory Reporting training is provided and
documented within 30 days of hire for new
employees.
New Employee Orientation - Umbrella Yes[ ] No✓ In the Correction Action Plan, administrative oversight was identified to ensure the required
Requirements (30 days) 419-400-0120(4) training occurs within 30 days of hire for staff. During site visit on 8.21.2024, all files
(g) Emergency procedures reviewed showed the training requirements were within the 30 days. No further follow up
needed.
- Documentation of this training was
found in all files reviewed. One file
was found not having this training
completed within the 30-day
requirement.
Corrective Action: Agency will ensure
Emergency procedures training is provided

and documented within 30 days of hire for
new employees.
New Employee Orientation Residential Yes[ ] No✓ In the Correction Action Plan, administrative oversight was identified to ensure the required
(Prior to working alone and within 30 days) training occurs within 30 days of hire for staff. During site visit on 8.21.2024, all files
419-470-0120(1) reviewed showed the training requirements were within the 30 days. No further follow up
(a)Discipline and behavior management needed.
including de-escalation, crisis prevention,
positive behavior management, and
disciplinary techniques that are non-punitive in
nature
- Documentation of this training was
found in all files reviewed. One file
was found not having this training
completed within the 30-day
requirement. (Repeat Finding)
Corrective Action: Agency will ensure
discipline and behavior management training
is provided and documented within 30 days of
hire for new employees.
New Employee Orientation Residential Yes[ ] No✓ In the Correction Action Plan, administrative oversight was identified to ensure the required
(Prior to working alone and within 30 days) training occurs within 30 days of hire for staff. During site visit on 8.21.2024, all files
419-470-0120(1) reviewed showed the training requirements were within the 30 days. No further follow up
(b) CPR and First Aid sufficient to retain a needed.
current certification
- Documentation of this training was
found in all files reviewed. One file
was found not having this training
completed within the 30-day
requirement.
Corrective Action: Agency will complete
CPR and First Aid staff training and document
it within 30 days of hire for new employees
Crisis Intervention Training Standards and Yes[ ] No✓ In the Correction Action Plan, administrative oversight was identified to ensure the required
Certification 419-400-0160(4) (as applicable) training occurs within 30 days of hire for staff. During site visit on 8.21.2024, all files
(a)Complete a minimum of 12 hours of initial reviewed showed the training requirements were within the 30 days. No further follow up
training in person from a certified instructor, needed.
including but not limited to a minimum of six
hours of training focused on positive behavior
support, nonviolent crisis intervention and
other methods of nonphysical intervention to
support children in care during a crisis

- Documentation of this training was
found in all files reviewed. One file
was found not having this training
completed within the 30-day
requirement.
Corrective Action: Agency will ensure the 12
hours of initial training are completed and
documented within 30 days of hire for new
employees
Records Relating to Restraint & Yes[ ] No✓ Due to SB710, restraint reports are required. Albertina Kerr revised initial admission
Involuntary Seclusion paperwork to include verification that parents received information about how to access the
419-400-0180(13)(e) Each child caring program's restraint reports. Licensing rules require this information to be provided at
agency shall provide notice regarding how to intake and two times thereafter within the year. Agency submitted documents on 8.22.2024
access the quarterly reports to the parents or regarding how parents/guardians can access the quarterly reports relating to restraint &
guardians of children in care in the program. involuntary seclusion. The program is in compliance.
The child caring agency shall provide the
notice upon the child in care's admission and
at least two times each year thereafter.
- The agency does not have a process
for providing access to quarterly
reports for parents or guardians of
children.
Corrective Action: Agency will create a
process for providing access to quarterly
reports for parents and guardians of children
in care in the program. The child caring
agency shall provide notice to guardians of
how to access reports upon the child in care's
admission and at least two times each year
thereafter.
Records Relating to Restraint & Yes[ ] No✓ Agency created a process for providing information to children in care relating to suspected
Involuntary Seclusion inappropriate use of restraint & seclusion. Agency is in compliance with rule relating to SB
419-400-0190(1) Information provided to 710.
children in care relating to Restraint &
Involuntary Seclusion
- The agency is creating a process for
providing information to children in
care relating to suspected
inappropriate use of restraint &
seclusion.

Corrective Action: Agency will create and
implement a process for providing information
to children in care relating to suspected
inappropriate use of restraint & seclusion.
Licensing provided an example for the
agency.
New Findings from Site Visit Comments
419-400-0100 Licensing Manager and Licensing Coordinator reviewed the programs Room Search Logs. Two out of six
Licensing Umbrella Rules: Resources room searches were not completed according to the log. The program has retrained their staff on the proper
Required methods of searching rooms and are making efforts toward making sure searches are happening more
reliably, even though they have missed a couple searches.
(2) A child-caring agency must employ or
contract for a sufficient number of Corrective Action:
competent and qualified employees to
perform the functions regulated by these Program will ensure youth room checks are completed per program policy and procedures. During
rules and to provide adequate care, safety, the unannounced review, the program was encouraged to review policy and procedures regarding
protection, and supervision of the children in
Room Searches and to evaluate if their needs to be changes made to the current policy.
care and families the child-caring agency
serves.

Interview Summary
Two youths were interviewed at the unannounced site inspection.
- Both youths stated things were going well at the programs.
- When asked what the youth appreciated most about the program the youth stated: "Appreciate the staff." "Good relationships." "I get to
decorate my room." I get to have a clock in my room." "Staff are nice." "Everyone is pretty cool."
- One youth talked about being involved in skills groups, education group, and other kinds of groups.
- When asked about recreation or fun things to do in the program, youths stated, "going to the gym, making bracelets, sand art, drawing,
painting, crochet, coloring, making crafts, listening to music, and going outside." One youth stated that they would like to have more
activities to do as they feel there is more down time than they would like.
- Both youths confirmed they receive enough food to eat, snacks are provided and as well as fruit.
- Both youths stated they can make phone calls and have privacy when making phone calls.
- Both youths stated they are provided sufficient hygiene products by the program.
- All the youth stated they had someone at the program they could talk to if they felt uncomfortable or needed anything.
- When asked if they could change anything about the program, one youth stated they wished they could have more visits. The other
youth interviewed stated that they would want the food to be better overall.
- When asked about feeling safe in the program, both youths feel safe at the program. One youth felt that not all staff are great at dealing
with youth behaviors; but still feels safe in the program.
Observations
Staff and youth were observed at the program during the inspection. The youth that were at the program appeared to be at ease and
comfortable in the environment. All areas of the program (inside and outside) where youth had access were observed to be well kept, clean and
mostly in good repair. It was observed that the vinyl is cracked around the drain in the kitchen. Also, three rooms in the Northwest Wing where
youth reside were observed to be cluttered. The program does have a weekly structured room cleaning time. Medication was observed to be in
locked medication carts in locked rooms which were inaccessible to the youth. The agency now has six beds for DHS youth that integrate with
the other youth in the Subacute Program. These youth are housed on the Northwest Unit. The licensing supervisor & licensing coordinator were
able to look at the Room Check Logs. It was observed that checks are being completed; but that a few checks were not completed during shifts.
The program is retraining their staff on proper methods of searching youth's rooms and they are making efforts towards making sure they
happen more reliably.


facility_name: Boys and Girls Aid Society of Oregon

summary: License Renewals - 02/02/2022

raw_content:
Licensed Child Caring Agency Site Visit Report
Residential Care
Licensee: Boys and Girls Aid Society of Oregon
Date of site visit: February 2-4, 2022
Board Chairperson: Fergal Donoher
President and CEO: Suzan Huntington
Program Director: Nicole Laliberte
Program Coordinator: Jennifer Benson
Licensing Coordinator: Tom Heidt with Holly Ivey and Irvin Minten
Other regulatory or accrediting agencies:
Oregon Department of Human Services
Program Compliance: The program was found to be compliant or will be compliant with:
OAR 413-215-0001 to 0136 Licensing Umbrella rules and
OAR 413-215-0501 to 0586 Licensing Residential Care Agencies
Personnel records were reviewed and compliance with required background checks was documented for employees
in all programs.
(rev. 03/25/2021)
Program Description:
Children served in the program are between the ages of 4-10. All the children are in the custody of DHS and the
majority of referrals have been boys ages 7-9. Most of the clients exhibit debilitating psychosocial, emotional, and
behavioral disorders. Weekly skills training services include 6-7 hours of Behavioral Rehabilitation Services and ten
hours of educational support. Youth in the program engage in at least one social, extracurricular, cultural, or
physical recreational activity per day and at least one activity per week must be in the community. Children engage
in the 3-5-7 model. This model assists children in grieving losses, formulating self-identity, establishing trust and
security through healthy attachments, and building relationships with the intent of being able to join or rejoin families
on a permanent basis. CPI’s Non-violent Crisis Intervention model is utilized for de-escalation, crisis prevention,
and as a last resort, restraint. Seclusion is not used. Despite the extreme issues of children served by the Nest, the
program has been able to move the vast majority of their clients to permanent placements.
Program type and services:
Residential Care
Capacity (size and ages):
The Nest has the capacity to serve four youth ages 4-10.
Funding and referral sources:
Oregon Department of Human Services - Child Welfare.
Average length of stay:
Approximately one year.
Average daily population served:
The Nest typically serves between 2-3 children on a daily basis.
Number of children served annually:
Six.
2
Use of seclusion or restraint:
CPI’s Non-violent Crisis Intervention model is utilized.
Interviews, Observations:
I met several staff and interviewed one while getting a tour of the facility. She felt that things were going well. She
feels well trained and supported. She showed me how the new window opening control devices operated. I asked
how SB710 has impacted the program. She is a CPI instructor and welcomed the legislation as she feels restraints
should be closely monitored. Boys and Girls Aid was already meeting the majority of the new requirements so she
feels it has had a minimal impact. I thought that was a fantastic answer.
There is currently just one child at the Nest. He was at school during the site review, but I previously interviewed
him. He has been in the program since May and will be transitioning into the little nest within the next month. He
said he likes the program and the staff. He didn’t mention any concerns about the program. He knows his new
foster parents and already refers to their place as home.
Program Strengths:
 The Nest admits children who have suffered extreme trauma and holds onto them through very difficult times as
the children work through their issues.
 Staff are very compassionate, relationship based, and planful with the kids.
 Staff frequently take the kids on outings.
 Most of the children served by the program are much better able to regulate their emotions and are able to
transition into permanency.
Program Challenges:
It is always a challenge to recruit and retain staff who can consistently work with children who have severe
behavioral issues.
3
Changes that have occurred in the last 2 years:
 COVID has made everything more difficult and has significantly impacted the program. Other parts of the system
have been unable to meet the needs of their clients in a timely manner and it has exasperated staffing issues.
 The Program Administrator retired and an agency decision to manage leadership differently created general
changes and adjustments for staff who were already feeling a bit overwhelmed.
Lawsuits:
None.
Grievances and complaints filed in the last two years:
There was a grievance filed by staff in March of 2021 regarding what they felt was an unsupportive and unsafe
environment. The issues were investigated and did result in a public apology, personnel actions, staffing changes,
program restructuring, and an agency wide training on harassment. A report was provided to the Licensing
Coordinator.
Corrective Actions and Timeframes:
The Nest residential program has no corrective actions. The program was found to be out of compliance with
conducting monthly evacuation drills during an unannounced visit on November 8, 2021. I believe the agency has
put safeguards in place to prevent this from happening again and the program has been in compliance with this rule
since Licensing’s last visit, but the Fire Marshal did note that, “Failure to adhere to drills requirements may result in a
citation upon the next inspection.”
Recommendations:
None.
4
Exceptions:
The agency was previously provided an exception to not carry a fire extinguisher in their vehicle and this exception
was approved to be continued until the agency’s next Licensing renewal.
Changes in License:
None.
Summary of Review
Program and Services Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0011(2) Completed
Program and services are in scope of license
X
Governance of the Agency Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0021 Completed
(1)(a) Minimum of 5 board members X
(2)(f) Formally evaluate the exec. Director’s
X
performance annually
(2)(g) Approves annual budget X
(2)(h) Obtain and review an annual
independent financial review or audit of X
financial records.
(2)(k) Written quality improvement program X
(2)(l) Meeting minutes X
Executive Director or Program Director Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0021 Completed
(3)(a) knowledge of requirements for
providing care and treatment appropriate to X
programs
(3)(g) Approval from BCU X
Discipline, Behavior Management, and Corrective Action
Yes No N/A Corrective Actions/Comments
Suicide Prevention 413-215-0076 Completed
(3) Agency uses appropriate and positive
methods of behavior management and
X
nationally recognized non-violent crisis
intervention
(3)(b)(C) Agency does not use chemical and
mechanical restraint (excluding medically X
necessary devices/prescriptions)
5
(3)(c) Agency uses appropriate time-out
rooms (adequate space, heat, light and
ventilation and is not capable of locking) and X
documents use in child’s record when
applicable
(3)(e) Agency uses seclusion
X
appropriately/consistent with policy
(4) Agency has adequate plan in place to
X
respond to suicidal behavior/warning signs
Contractors (if applicable) Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0061(6) Completed
(a) Agency ensures the contractor meets the
requirements of this rule and Chapter 413 X
division 215
(b)(B) Contract includes the following:
(i) Services provided
(ii) Contractor fees
(iii) Disclosure of information from contractor
to agency
(iv) Lines of authority X
(v) Adherence to rules, including background
check
(vi) Any liability of the agency for acts of the
contractor, rights of indemnity and limitations
on liability
Supplemental Information Provided by Corrective Action
Yes No N/A Corrective Actions/Comments
CCA Completed
Documents as indicated on the form titled
X
“Renewal Licensing Required Documents”
Documents as indicated on form titled
“Required Financial Documents and X
Information”
All required policies and procedures as
X
identified in the “Umbrella Rules”
All required policies and procedures as
X
identified in “Agency Type Specific Rules”
Physical Plant Corrective Action
Yes No N/A Corrective Actions/Comments
Completed
413-215-0046(3)(a) Foster Rights Posted (if
X
children in DHS custody)
413-215-0051(1) Sufficient safe space,
X
equipment, and office equipment
413-215-0091(12) License is posted in
X
common area at each facility
6
413-215-0001(5)(d), 0516(4(a)(I) & 0521(1)
X
Adequate furnishings and personal items
413-215-0511(2)(a) &(c) Buildings are
X
smoke free, clean and in good repair
413-215-0511(2)(d) Rooms are free of
X
harmful drafts, odors, and excessive noise
413-215-0511(2)(e) Rooms are adequate in
X
size and arrangement
413-215-0511(2)(f) System provides a
continuous supply of hot and cold water to X
taps located throughout the facility
413-215-0511(2)(h) Building is well
ventilated and room temperature is within a X
normal comfort range
413-215-0516(1) All parts of the facility
X
ensure the safety of children
Room and Space Requirements Corrective Action
Yes No N/A Corrective Actions/Comments
Bedrooms 413-215-0516(3) Completed
(a) Adequate furnishings and personal items X
(b) Separate from rooms used for dining,
X
living, laundry, kitchen, and storage
(c) Outside room with window allowing
X
egress from building
(d) Ceiling at least 90 inches X
(e) Minimum 60 SF per bed X
(f) No more than 25 if dorm style X
(g) Permanently wired fixtures X
(h) Window covering X
(i) Beds are 3 feet apart and maintained to
X
ensure safety
Room and Space Requirements Corrective Action
Yes No N/A Corrective Actions/Comments
Bathrooms 413-215-0516(4) Completed
(a)(A)&(B) 1:8 ratio for toilets and sinks X
(a)(D) Hot and cold running water, soap, and
X
approved hand drying options
(a)(E) 1:10 ratio for shower or bathtub X
(a)(E) Individual privacy X
(a)(F) Window covering X
(a)(G) Permanently wired fixtures X
(a)(H) Adequate ventilation X
(b)&(c) Wooden racks on floors are
prohibited and impervious shower mats are X
disinfected & dried daily
7
Room and Space Requirements Corrective Action
Yes No N/A Corrective Actions/Comments
Kitchen 413-215-0516(6) Completed
(a) Used exclusively for storage, food
preparation, dish washing and activities X
related to eating
(b) Walls, floors are easily cleanable X
(c) Equipment and utensils are easily
X
cleanable, durable, nontoxic, and kept clean
(e) Equipment is easy to clean beneath,
X
between and behind
Room and Space Requirements Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0516 Completed
(2) There is a separate living room or lounge
X
area – 15 SF minimum per child
(5) There is a separate dining room with
capacity for ½ of children in care and 15 SF X
per child in care
(7) Laundry is separate from living areas,
X
kitchen and dining
(8) Separate storage areas are provided for
food, kitchen supplies, utensils, clean linens,
soiled linens and clothing, cleaning supplies X
and equip, poisons, chemicals, outdoor
recreational and maintenance equipment
(9) Outdoor activity area is protected from
vehicles and other hazards and of a size and
X
availability appropriate to the age and needs
of children in care
(11) & 413-215-0076(3)(c)(C)Time out rooms
have adequate space, heat, light and X
ventilation and is not capable of locking
Furnishings and Personal Items Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0521 Completed
(1) There is a bed with frame, clean mattress
and pillow and personal storage (dresser, X
closet)
(2) Linens are in good repair. There is a
waterproof mattress cover or mattress.
X
Linens are appropriate and towels and
washcloths are provided
(3) Bedding is changed weekly or when
X
soiled
(4)&(5) Personal hygiene supplies and
X
appropriate clothing are provided
8
Food Services Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0536(1)&(2) Completed
(1)(a) Meals are arranged daily, consistent
with normal mealtimes that occur during the X
hours of operation
(1)(b) Menus are prepared in advance in
accordance with USDA guidelines, provide a
X
variety of foods and are adjusted for
seasonal changes.
(1)(b) Menus are kept for at least 6 months X
(1)(c) Drinking water is freely available X
(2)(a) Food is stored, prepared & served in a
X
sanitary manner
(2)(c) & (d) Food products are obtained from
commercial suppliers (exception of fruits &
vegetables), unpasteurized juice is X
prohibited, and only Grade A pasteurized
and fortified milk in appropriate container.
Safety Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0541 Completed
(2)(a) Written emergency plan X
(2)(b) Telephone numbers for local police
X
and fire are posted near all telephones
(2)(c) Operative flashlights sufficient in
X
number are readily available to staff
(3)(a) Evacuation drill occurs monthly under
varying conditions, is retained 2 years and See note under corrective actions
contains;
(A) identify of person conducting drill
(B) date & time
(C) notification method X
(D) staff participating
(E) # of children & staff evacuated
(F) special conditions simulated
(G) problems encountered
(H) time to complete
Safety – Transportation Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0541 Completed
(5)(b) Vehicle has insurance policy, is smoke
Exception was approved for the program to not carry a fire
free, safe operating condition, and has first X
extinguisher in their vehicle.
aid kit and fire extinguisher 2-A:10-BC
9
Medication Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0551 Completed
(3)&(7)(e) Medications have a prescription
and are stored in the original container with X
prescription label
(4)&(5) Herbal supplements and remedies,
medical treatments, special diets, physical
therapy, physical aides or limitations have a X
written order signed by a physician or
qualified medical professional.
(7)(c) Medications are inaccessible to
X
children
(8) Medications are disposed in accordance
X
with state and federal law
(9) Written record of the disposal of
medications is maintained and includes:
(a) description and amount
(b) name X
(c) reason
(d) method
(e) staff & witness signature
(10) Written record of the administration of
medication includes:
(a) name
(b) description
(c) dates and times
(d) missed doses X
(e) medication disposed
(f) method of administration
(g) ID of person administering
(h) possible adverse reactions
(i) medication taken outside facility
Extracurricular, Enrichment, Cultural &
Corrective Action
Social Activities Yes No N/A Corrective Actions/Comments
Completed
413-215-0554
(2) Children have ongoing opportunities to
participate in at least one age-appropriate or X
developmentally appropriate activity
Minimum Staffing Requirements Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0561 Completed
(1)&(2) Supervision is adequate for the type
of program, location, age and type of
children, ability of supervisor to respond, X
electronic back-up systems.
10
Minimum ratios are maintained:
Under 30 months of age: 1:4
30 months to ˃ 6 yrs or non-ambulatory: 1:6
Ages 6 and older: 1:7
Overnight (staff awake)
1:10
(4)(a) When one staff on duty, there is
additional staff immediately available with X
max response time of 30 minutes
(5) There is at least one on-site employee
authorized to apply the reasonable and X
prudent parent standard
Separation of Residents Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0566 Completed
(1) Children are in separate bedrooms than
adults, unless parent and child, or there is
X
written approval from guardian/parent and
licensing coordinator
(2) There is adequate supervision of children
if both males and females are served by the X
program
Personnel Files Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0061 Completed
Staff Name/Position X
(3)(g) Date of Hire X
(3)(a) record of education, training and
X
previous employment
(1)(b) & (3)(b) reference checks completed
X
and documented
(1)(a) & (3)(c) Background check completed
X
and documented
(3)(d) Annual performance evaluations X
(3)(f) Record of personnel actions X
(3)(g) Termination date, reason for
X
termination
(3)(h) Current job description (1)(c)
Employee meets minimum qualifications X
stated in current job description
11
New Employee Orientation – Umbrella
Corrective Action
Requirements (30 days) Yes No N/A Corrective Actions/Comments
Completed
413-215-0061(4)
(a) Agency policies and procedures X
(b) Ethical and professional guidelines X
(c) Organizational lines of authority X
(d) Attributes of population served X
(e) & (5)(a) to (c) Mandatory reporting that
includes:
(a) legal definition of child abuse ORS
419B.005, Oregon Laws 2016, chapter 106,
X
section 36
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to
the employee
(f) Privacy laws X
(g) Emergency procedures X
New Employee Orientation – Residential
Corrective Action
(30 days) Yes No N/A Corrective Actions/Comments
Completed
413-215-0556
(1)(a) Discipline and behavior management
including de-escalation, crisis prevention,
positive behavior management, and X
disciplinary techniques that are non-punitive
in nature
(1)(b) Restraint and seclusion (if applicable) X
Ongoing Training Corrective Action
Yes No N/A Corrective Actions/Comments
Completed
413-215-0536(2)(b) Employees who handle
food served to children have a valid food X
handler’s card
413-215-0541(5)(a) Employees transporting
children have: current driver’s license,
insurance, trained in emergency procedures X
and behavior management, and training for
15+ passenger vans if applicable)
413-215-0556(2)(a) Environmental
X
emergencies
413-215-0556(2)(b) Universal Precautions X
413-215-0556(2)(c) Discipline and Behavior
X
Management
12
413-215-0556(3) Staff providing direct care
must maintain current CPR/First Aid
certification
413-215-0556(4) Designated staff authorized
to apply reasonable and prudent parent
X
standard are trained in application of the
standard
413-215-0061(5) Mandatory reporting
(annually) that includes:
(a) legal definition of child abuse ORS
419B.005, Oregon Laws 2016, chapter 106,
X
section 36
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to
the employee
Comments:
Children’s Records Corrective Action
Yes No N/A Corrective Actions/Comments
Completed
Health Services
413-215-0546
(2) Medical history obtained within 30 days
(significant findings, current immunizations,
history of surgical procedures-health issues- X
injuries, allergies, dental, vision, hearing,
behavioral health, and physician orders)
(2)(e) Documentation of age appropriate
instruction – pregnancy prevention, nutrition,
prevention of HIV & AIDS, and prevention X
and treatment of sexually transmitted
disease
(4)(a) to (f) Medical exams (3 in first year of
life, 2,4,6,9,14) X
13
Consents Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0576(1) Completed
(a) Provide routine and emergency medical
X
care
(b) Use the discipline and behavior
X
management system
(c) Use restraint or seclusion (if applicable).
Must specify the reasons for the intervention X
and how staff are trained and supervised
(d) Restrict contact with persons outside of
X
the agency
(e) Allow access as defined in 413-215-0091
X
& 0101
(f) Impose a dress code X
(g) Apply the reasonable and prudent parent
X
standard
Disclosures
Corrective Action
413-215-0576(2) Parent/guardian has Yes No N/A Corrective Actions/Comments
Completed
acknowledged in writing:
(a) Information regarding personal or room
searches and protocols for confiscation of X
contraband
(b) Statement of Rights of Children and
X
Parents/Guardians
(c) Any policies and procedures upon
X
request
Authorizations Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0576(3) Completed
(a) Disclose or exchange information with
X
others
(b) Child specific visitors X
(c) Visitation resources are pre-approved X
(d) Activity specific authorizations are pre-
approved to allow children to participate in
potentially hazardous activities, including but X
not limited to using motorized yard
equipment, swimming, and horseback riding.
14
Information about Children in Care
Corrective Action
413-215-0581(1) Summary sheet contains Yes No N/A Corrective Actions/Comments
Completed
the following:
(a)The name, gender, date of birth, religious
X
preference, and previous address
(b) Name and location of previous and
X
current school
(c) Date of admission X
(d) Legal custody X
(e) The name, address, and telephone
number of:
(A) The child in care's parents.
(B) The child in care's legal guardian, if
different than the parents, and a copy of
X
the document that provides for his or her
authority over the child in care.
(C) Other persons significant to child
(D) Other professionals to be involved in
service planning (if applicable)
Service Planning Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0581(2) Completed
(b) Intake document is completed the date
child accepted into care (emergency X
placement 48 hours)
(d) Assessment is completed within 30 days
and contains relevant historical info., current
X
behavioral observations, identified need for
services, & how agency will provide services
(e) (A)&(B) Service plan within 60 days
(parent, guardian and child actively
involved). Describes how child’s issues will X
be addressed, anticipated outcomes and
reviewed by child and guardian/parent.
(e)(C)&(D) Service plan is reviewed quarterly
and revised when information indicates other X
services should be provided
Case Management Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0581(3) Completed
(a) Services are documented, progress
X
toward achieving goals is tracked
(b)-(d) discharge planning and instructions X
(f) Incident Reports X
15
Financial Records Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0581(4) Completed
Records contain date, amount, source,
X
purpose, signatures
Personal Possessions Records Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0581(5) Completed
Individual written inventory of all personal
possessions is maintained and updated as X
needed
Records and Documentation Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0071 Completed
(1) Stored safely X
(2) Permanent, legible, dated, and signed X
(3)&(4) Uniform in organization, readily
identifiable and accessible, current, and
X
complete, containing all required info. No
eraser tape or white out.
(7) Permanent registry for each child
includes:
Name
Gender
X
Birth date
Names, addresses of parents or guardians
Dates of admission
Placement upon discharge
Comments:
Licensing Coordinator’s Signature: __________________________________ Date: __2_/1__1_/_2_0_2_2_ __________
Manager Review: __________________________________ Date: _ _ 2_-2_5_-2_0_2_2 _____________
16

agency_name: Boys & Girls Aid (BGAID)

report_type: License Renewals

licensee: Boys and Girls Aid Society of Oregon

visit_date: February 2-4, 2022

other_regulatory_agencies: Oregon Department of Human Services

program_description:
Children served in the program are between the ages of 4-10. All the children are in the custody of DHS and the
majority of referrals have been boys ages 7-9. Most of the clients exhibit debilitating psychosocial, emotional, and
behavioral disorders. Weekly skills training services include 6-7 hours of Behavioral Rehabilitation Services and ten
hours of educational support. Youth in the program engage in at least one social, extracurricular, cultural, or
physical recreational activity per day and at least one activity per week must be in the community. Children engage
in the 3-5-7 model. This model assists children in grieving losses, formulating self-identity, establishing trust and
security through healthy attachments, and building relationships with the intent of being able to join or rejoin families
on a permanent basis. CPI's Non-violent Crisis Intervention model is utilized for de-escalation, crisis prevention,
and as a last resort, restraint. Seclusion is not used. Despite the extreme issues of children served by the Nest, the
program has been able to move the vast majority of their clients to permanent placements.

average_length_of_stay: Approximately one year.

number_of_children_served_annually: Six. 2

use_of_seclusion_or_restraint: CPI's Non-violent Crisis Intervention model is utilized.

interviews_observations:
I met several staff and interviewed one while getting a tour of the facility. She felt that things were going well. She
feels well trained and supported. She showed me how the new window opening control devices operated. I asked
how SB710 has impacted the program. She is a CPI instructor and welcomed the legislation as she feels restraints
should be closely monitored. Boys and Girls Aid was already meeting the majority of the new requirements so she
feels it has had a minimal impact. I thought that was a fantastic answer.
There is currently just one child at the Nest. He was at school during the site review, but I previously interviewed
him. He has been in the program since May and will be transitioning into the little nest within the next month. He
said he likes the program and the staff. He didn't mention any concerns about the program. He knows his new
foster parents and already refers to their place as home.

program_strengths:
The Nest admits children who have suffered extreme trauma and holds onto them through very difficult times as
the children work through their issues.
- Staff are very compassionate, relationship based, and planful with the kids.
- Staff frequently take the kids on outings.
- Most of the children served by the program are much better able to regulate their emotions and are able to
transition into permanency.

changes_in_last_two_years:
COVID has made everything more difficult and has significantly impacted the program. Other parts of the system
have been unable to meet the needs of their clients in a timely manner and it has exasperated staffing issues.
- The Program Administrator retired and an agency decision to manage leadership differently created general
changes and adjustments for staff who were already feeling a bit overwhelmed.

lawsuits: None.

recommendations:
None.
4

exceptions:
The agency was previously provided an exception to not carry a fire extinguisher in their vehicle and this exception
was approved to be continued until the agency's next Licensing renewal.

changes_in_license: None.