state: OR

facility_name: Anisa's Place

summary: License Renewals - 9 findings

raw_content:
Licensed Child Caring Agency Site Visit Report
Residential Care
Licensee: A Village for One – Anisa’s Place Date of site visit: March 15, 2021
Executive Director: Cassie Trahan Licensing Coordinator: Aubrey Kelly
Other Regulatory or Accrediting Agencies: Child welfare
Program Compliance: The program was found to be compliant or will be compliant with OAR 413-215-0001 to 413-215-0131, Licensing Umbrella
Rules, and OAR 413-215-0501 to 413-215-0586, Licensing Residential Care Agencies Rules. Personnel records were reviewed and compliance
with required background checks was documented for employees in all programs.
Program Description(s): A Village for One – Anisa’s Place is a residential program serving clients who are identified as Commercially Sexually
Exploited Children (CSEC). The program uses a phase system. The program places a great emphasis on providing a nurturing, safe and trauma-
informed milieu that allows for healing and growth.
Program type and services: individual mental health counseling, drug and alcohol counseling, group mental health counseling, family counseling,
education services, social and community activities, access to medical, dental, and vision care, skills training and job search/career development.
Capacity and age-range: Ages 12-17; capacity of 7.
Funding sources: Child welfare contracts
Contracts and sources for referrals: Child welfare
Average daily population served: 3
Use of seclusion or restraint: Restraint – Mandt.System, Seclusion – n/a.
Interviews, Observations:
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 08/13/2020)
Client #1: She’s been at the program since September 4, 2020. She hates it here, the other kids are loud and annoying. Staff step in when that
happens. Staff are supportive, Cassie is her favorite staff. The food is gross but can be good. She’s making Rotel dip tonight, staff makes most of
the meals but the clients help make dinner. She’s been at several other programs. She feels safe at the program sometimes, she does not feel safe
when staff get too close to her. She has been in restraints since being at the program. She has run several times from the program. School is good,
she likes learning.
Client #2: She feels safe at the program, admission was almost 3 weeks ago. She’s been at several other programs. She hasn’t run since she’s
been here. Her favorite staff are Arielle, Cassie and Taylor, they are cool and easy to approach. There are no staff she doesn’t like. The food is
good, she’s helping cook dinner tonight. She likes school, she is appreciative she gets to do school at her pace. She has not been any restraints. A
change she would like to make is doing equine therapy every week, as opposed to every other week as they do now. She currently identifies as a
vampire wolf demon and appreciates the program respects that.
Staff #1: She has been employed at the program since it opened. She likes working here. Her supervisor is approachable and she feels like she can
call or text her supervisor at any time. During orientation, staff received training on Trust-Based Relational Intervention (TBIR), trauma informed
care, The Mandt behavior intervention system, de-escalation techniques, CSEC. They regularly go over Mandt, trauma informed care and crisis
intervention.
Program Strengths: Diversity of activities, such as equine therapy every other week. The program works hard at keeping clients in the program for
as long as they need it. The program has managed several crises since opening, to include a worldwide pandemic, wildfires, an ice storm and a
flood in the program. The program does a lot of activities with the clients. Many of the staff are highly educated.
Program Challenges: Staffing has been a challenge as well as maintaining clients in the program who often runaway.
Changes that have occurred in the last 2 years: n/a
Lawsuits: None
Grievances and complaints filed in the last two years: None
Corrective Actions and Timeframes: Please submit the following to verify compliance.
Within 45 days of receipt of this report A Village for One – Anisa’s Place must submit a letter of verification indicating the agency is in compliance
with the specific rules cited above and describing how compliance will be maintained going forward. Along with the letter of verification, the agency
must submit any and all specific documentation requested in the body of this report. The letter of verification and any additional requested
documents can be emailed directly to (Licensing Coordinator and email address) or sent by regular mail to the following address:
2
Department of Human Services, Children’s Care Licensing Program
Attn: Aubrey Kelly
201 High St SE, Suite 500
Salem, OR 97301
Recommendations: None
Exceptions: None
Changes in License: None
Summary of Review
Program and Services Corrective Action
Yes No N/A Corrective Actions
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
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 X
independent financial review or audit of
financial records.
(2)(k) Written quality improvement program X
(2)(l) Meeting minutes X
Executive Director or Program Director Corrective Action
Yes No N/A Corrective Actions
413-215-0021 Completed
(3)(a) knowledge of requirements for X
providing care and treatment appropriate to
programs
(3)(g) Approval from BCU X
Discipline, Behavior Management, and Corrective Action
Yes No N/A 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)
(3)(c) Agency uses appropriate time-out
X
rooms (adequate space, heat, light and
3
ventilation and is not capable of locking) and
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
Physical Plant Corrective Action
Yes No N/A Corrective Actions
Completed
413-215-0046(3)(a) Foster Rights Posted (if X
children in DHS custody)
413-215-0051(1) Sufficient safe space, X
equipment, and office equipment
413-215-0091(12) License is posted in X
common area at each facility
413-215-0001(5)(d), 0516(4(a)(I) & 0521(1) X
Adequate furnishings and personal items
413-215-0511(2)(a) &(c) Buildings are X Two bedrooms were very messy and had items all over the
smoke free, clean and in good repair floor. The program shall ensure all rooms are clean. This is a
413-215-0511(2)(d) Rooms are free of X repeat finding from December 2020.
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 X
continuous supply of hot and cold water to
taps located throughout the facility
413-215-0511(2)(h) Building is well X
ventilated and room temperature is within a
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
Bedrooms 413-215-0516(3) Completed
(a) Adequate furnishings and personal items X
(b) Separate from rooms used for dining,
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
4
(i) Beds are 3 feet apart and maintained to X
ensure safety
Room and Space Requirements Corrective Action
Yes No N/A Corrective Actions
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 X
prohibited and impervious shower mats are
disinfected & dried daily
Room and Space Requirements Corrective Action
Yes No N/A Corrective Actions
Kitchen 413-215-0516(6) Completed
(a) Used exclusively for storage, food X
preparation, dish washing and activities
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
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 X
capacity for ½ of children in care and 15 SF
per child in care
(7) Laundry is separate from living areas, X
kitchen and dining
(8) Separate storage areas are provided for X
food, kitchen supplies, utensils, clean linens,
soiled linens and clothing, cleaning supplies
and equip, poisons, chemicals, outdoor
recreational and maintenance equipment
(9) Outdoor activity area is protected from X
vehicles and other hazards and of a size and
availability appropriate to the age and needs
of children in care
5
(11) & 413-215-0076(3)(c)(C)Time out rooms X
have adequate space, heat, light and
ventilation and is not capable of locking
Furnishings and Personal Items Corrective Action
Yes No N/A Corrective Actions
413-215-0521 Completed
(1) There is a bed with frame, clean mattress X
and pillow and personal storage (dresser,
closet)
(2) Linens are in good repair. There is a X
waterproof mattress cover or mattress.
Linens are appropriate and towels and
washcloths are provided
(3) Bedding is changed weekly or when X
soiled
(4)&(5) Personal hygiene supplies and X
appropriate clothing are provided
Food Services Corrective Action
Yes No N/A Corrective Actions
413-215-0536(1)&(2) Completed
(1)(a) Meals are arranged daily, consistent X
with normal mealtimes that occur during the
hours of operation
(1)(b) Menus are prepared in advance in X
accordance with USDA guidelines, provide a
variety of foods and are adjusted for
seasonal changes.
(1)(b) Menus are kept for at least 6 months X
(1)(c) Drinking water is freely available X
(2)(a) Food is stored, prepared & served in a X
sanitary manner
(2)(c) & (d) Food products are obtained from X
commercial suppliers (exception of fruits &
vegetables), unpasteurized juice is
prohibited, and only Grade A pasteurized
and fortified milk in appropriate container.
Safety Corrective Action
Yes No N/A Corrective Actions
413-215-0541 Completed
(2)(a) Written emergency plan X
(2)(b) Telephone numbers for local police X
and fire are posted near all telephones
(2)(c) Operative flashlights sufficient in X
number are readily available to staff
(3)(a) Evacuation drill occurs monthly X The program completed one evacuation drill since opening in
under varying conditions, is retained 2 September 2020. The program shall ensure evacuation drills
yrs and contains; are completed on a monthly basis.
6
(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
Safety – Transportation Corrective Action
Yes No N/A Corrective Actions
413-215-0541 Completed
(5)(b) Vehicle has insurance policy, is smoke X
free, safe operating condition, and has first
aid kit and fire extinguisher 2-A:10-BC
Medication Corrective Action
Yes No N/A Corrective Actions
413-215-0551 Completed
(3)&(7)(e) Medications have a prescription X
and are stored in the original container with
prescription label
(4)&(5) Herbal supplements and remedies, X
medical treatments, special diets, physical
therapy, physical aides or limitations have a
written order signed by a physician or
qualified medical professional.
(7)(c) Medications are inaccessible to X
children
(8) Medications are disposed in accordance X
with state and federal law
(9) Written record of the disposal of X
medications is maintained and includes:
(a) description and amount
(b) name
(c) reason
(d) method
(e) staff & witness signature
(10) Written record of the administration of X
medication includes:
(a) name
(b) description
(c) dates and times
(d) missed doses
(e) medication disposed
(f) method of administration
(g) ID of person administering
(h) possible adverse reactions
(i) medication taken outside facility
7
Extracurricular, Enrichment, Cultural &
Corrective Action
Social Activities Yes No N/A Corrective Actions
Completed
413-215-0554
(2) Children have ongoing opportunities to X
participate in at least one age-appropriate or
developmentally appropriate activity
Minimum Staffing Requirements Corrective Action
Yes No N/A Corrective Actions
413-215-0561 Completed
(1)&(2) Supervision is adequate for the type X
of program, location, age and type of
children, ability of supervisor to respond,
electronic back-up systems.
Minimum ratios are maintained:
Under 30 months of age: 1:4
30 months to ˃ 6 yrs or non-ambulatory: 1:6
Ages 6 and older: 1:7
Overnight (staff awake)
1:10
(4)(a) When one staff on duty, there is X
additional staff immediately available with
max response time of 30 minutes
(5) There is at least one on-site employee X
authorized to apply the reasonable and
prudent parent standard
Separation of Residents Corrective Action
Yes No N/A Corrective Actions
413-215-0566 Completed
(1) Children are in separate bedrooms than X
adults, unless parent and child, or there is
written approval from guardian/parent and
licensing coordinator
(2) There is adequate supervision of children X
if both males and females are served by the
program
8
Personnel Files Corrective Action
Yes No N/A Corrective Actions
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) Staff personnel files did not contain a current job description.
Employee meets minimum qualifications X The program shall ensure there is a current job description in
stated in current job description each staff’s personnel file.
New Employee Orientation – Umbrella
Corrective Action
Requirements (30 days) Yes No N/A Corrective Actions
Completed
413-215-0061(4)
(a) Agency policies and procedures X
(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,
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
Completed
413-215-0556
(1)(a) Discipline and behavior management
including de-escalation, crisis prevention, X
positive behavior management, and
9
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
Completed
413-215-0536(2)(b) Employees who handle X
food served to children have a valid food
handler’s card
413-215-0541(5)(a) Employees transporting
children have: current driver’s license,
insurance, trained in emergency procedures X
and behavior management, and training for
15+ passenger vans if applicable)
413-215-0556(2)(a) Environmental
X
emergencies
413-215-0556(2)(b) Universal Precautions X
413-215-0556(2)(c) Discipline and Behavior
X
Management
413-215-0556(3) Staff providing direct care
must maintain current CPR/First Aid X
certification
413-215-0556(4) Designated staff authorized
to apply reasonable and prudent parent
X
standard are trained in application of the
standard
413-215-0061(5) Mandatory reporting
(annually) that includes:
(a) legal definition of child abuse ORS
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
Contractors (if applicable) Corrective Action
Yes No N/A Corrective Actions
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 X
(ii) Contractor fees
10
(iii) Disclosure of information from contractor
to agency
(iv) Lines of authority
(v) Adherence to rules, including background
check
(vi) Any liability of the agency for acts of the
contractor, rights of indemnity and limitations
on liability
Children’s Records Corrective Action
Yes No N/A Corrective Actions
Completed
Health Services
413-215-0546
(2) Medical history obtained within 30 days
(significant findings, current immunizations,
history of surgical procedures-health issues- X
injuries, allergies, dental, vision, hearing,
behavioral health, and physician orders)
(2)(e) Documentation of age appropriate
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
Consents Corrective Action
Yes No N/A Corrective Actions
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
Client files did not contain all the required consents signed by
(d) Restrict contact with persons outside
X the legal guardian. The program shall ensure all required
of the agency
11
(e) Allow access as defined in 413-215- consents are signed by the legal guardian and placed in
X
0091 & 0101 each client’s file.
(f) Impose a dress code X
(g) Apply the reasonable and prudent
X
parent standard
Disclosures
Corrective Action
413-215-0576(2) Parent/guardian has Yes No N/A Corrective Actions
Completed
acknowledged in writing:
(a) Information regarding personal or
room searches and protocols for X
Client files did not contain all the required disclosures signed
confiscation of contraband
by the legal guardian. The program shall ensure all required
(b) Statement of Rights of Children and
X disclosures are signed by the legal guardian and placed in
Parents/Guardians
each client’s file.
(c) Any policies and procedures upon
X
request
Authorizations Corrective Action
Yes No N/A Corrective Actions
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 Client files did not contain all the required authorizations
signed by the legal guardian. The program shall ensure all
(d) Activity specific authorizations are
required authorizations are signed by the legal guardian and
pre-approved to allow children to
placed in each client’s file.
participate in potentially hazardous
X
activities, including but not limited to
using motorized yard equipment,
swimming, and horseback riding.
Information about Children in Care
Corrective Action
413-215-0581(1) Summary sheet contains Yes No N/A Corrective Actions
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. X
(B) The child in care's legal guardian, if
different than the parents, and a copy of
12
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
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
behavioral observations, identified need for X
services, and how agency will provide
services
(e) (A)&(B) Service plan within 60 days
(parent, guardian and child actively
involved). Describes how child’s issues will X
be addressed, anticipated outcomes and
reviewed by child and guardian/parent.
(e)(C)&(D) Service plan is reviewed quarterly
and revised when information indicates other X
services should be provided
Case Management Corrective Action
Yes No N/A Corrective Actions
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
Financial Records Corrective Action
Yes No N/A Corrective Actions
413-215-0581(4) Completed
Records contain date, amount, source,
X
purpose, signatures
Personal Possessions Records Corrective Action
Yes No N/A Corrective Actions
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
413-215-0071 Completed
(1) Stored safely X
13
(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
03-22-2021
Licensing Coordinator’s Signature: ________________________ Date: ___________________
03-22-2021
Manager Review: ______________________________________ Date: __________________
14

agency_name: A Village for One (AVFO)

program_name: Anisa's Place

program_type: (RC) Residential Care Programs

report_type: License Renewals

view_code: RC

facility_type: Residential Care

licensee: A Village for One - Anisa's Place Date of site visit: March 15, 2021

licensing_coordinator: Aubrey Kelly

other_regulatory_agencies: Child welfare

program_description:
A Village for One - Anisa's Place is a residential program serving clients who are identified as Commercially Sexually
Exploited Children (CSEC). The program uses a phase system. The program places a great emphasis on providing a nurturing, safe and trauma-
informed milieu that allows for healing and growth.

capacity_age_range: Ages 12-17; capacity of 7.

funding_sources: Child welfare contracts

contracts_and_referrals: Child welfare

use_of_seclusion_or_restraint: Restraint - Mandt.System, Seclusion - n/a.

interviews_observations:
Client #1: She's been at the program since September 4, 2020. She hates it here, the other kids are loud and annoying. Staff step in when that
happens. Staff are supportive, Cassie is her favorite staff. The food is gross but can be good. She's making Rotel dip tonight, staff makes most of
the meals but the clients help make dinner. She's been at several other programs. She feels safe at the program sometimes, she does not feel safe
when staff get too close to her. She has been in restraints since being at the program. She has run several times from the program. School is good,
she likes learning.
Client #2: She feels safe at the program, admission was almost 3 weeks ago. She's been at several other programs. She hasn't run since she's
been here. Her favorite staff are Arielle, Cassie and Taylor, they are cool and easy to approach. There are no staff she doesn't like. The food is
good, she's helping cook dinner tonight. She likes school, she is appreciative she gets to do school at her pace. She has not been any restraints. A
change she would like to make is doing equine therapy every week, as opposed to every other week as they do now. She currently identifies as a
vampire wolf demon and appreciates the program respects that.
Staff #1: She has been employed at the program since it opened. She likes working here. Her supervisor is approachable and she feels like she can
call or text her supervisor at any time. During orientation, staff received training on Trust-Based Relational Intervention (TBIR), trauma informed
care, The Mandt behavior intervention system, de-escalation techniques, CSEC. They regularly go over Mandt, trauma informed care and crisis
intervention.

excerpt:
&(c) Buildings are
smoke free, clean and in good repair

excerpt:
(3)(a) Evacuation drill occurs monthly
under varying conditions, is retained 2
yrs and contains;

excerpt:
(3)(h) Current job description (1)(c)
Employee meets minimum qualifications
stated in current job description Client files did not contain all the required consents signed by
the legal guardian. The program shall ensure all required

excerpt:
(d) Restrict contact with persons outside
of the agency

excerpt:
(e) Allow access as defined in 413-215-
0091 & 0101 consents are signed by the legal guardian and placed in
each client’s file.

excerpt: (f) Impose a dress code

excerpt:
(g) Apply the reasonable and prudent
parent standard

excerpt:
(a) Information regarding personal or
room searches and protocols for
confiscation of contraband Client files did not contain all the required disclosures signed
by the legal guardian. The program shall ensure all required
disclosures are signed by the legal guardian and placed in
each client’s file.

excerpt:
(d) Activity specific authorizations are
pre-approved to allow children to
participate in potentially hazardous
activities, including but not limited to
using motorized yard equipment,
swimming, and horseback riding.


summary: Unannounced - 9 findings

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Licensee: A Village for One
Executive Director: Cassie Trahan
Date of Unannounced: 11.16.2021
Licensing Coordinator: Aubrey Kelly
Other Regulatory or Accrediting Agencies: Child Welfare
Purpose: Per OAR 413-215-0101 (1) (b) Children’s Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings: Repeat Comments
6-Mth Review 03-15-2021 Findings
Further Action
Needed
413-215-0511(2)(a) &(c) Buildings are Yes☐ No The buildings were clean and in good repairs.
smoke free, clean and in good repair:
“Two bedrooms were very messy and had
items all over the floor. The program shall
ensure all rooms are clean. This is a
repeat finding from December 2020.”
413-215-0541(3)(a) Evacuation drill Yes No☐ The program did not complete an evacuation drill in June 2021. The program shall ensure
occurs monthly under varying an evacuation drill is completed on a monthly basis and documented accurately.
conditions, is retained 2 yrs. and
contains;
(A) identify of person conducting drill
(B) date & time
(C) notification method
(D) staff participating
(E) # of children & staff evacuated
(F) special conditions simulated
(G) problems encountered
1
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 200115)
(H) time to complete
“The program completed one evacuation
drill since opening in September 2020.
The program shall ensure evacuation
drills are completed on a monthly basis.”
413-215-0061(3)(h) Current job Yes☐ No Current job descriptions were reviewed for two current staff.
description (1)(c) Employee meets
minimum qualifications stated in
current job description: “Staff personnel
files did not contain a current job
description. The program shall ensure
there is a current job description in each
staff’s personnel file.”
413-215-0576(1) (d) Restrict contact Yes☐ No The consent is contained in the THP Program Rules document, which is signed by the
with persons outside of the agency: legal guardian.
“Client files did not contain all the required
consents signed by the legal guardian.
The program shall ensure all required
consents are signed by the legal guardian
and placed in each client’s file.”
413-215-0576(1) (e) Allow access as Yes No☐ Client files did not contain the required consent. The program shall ensure all required
defined in 413-215-0091 & 0101: “Client consents are signed by the legal guardian and placed in each client’s file.
files did not contain all the required
consents signed by the legal guardian.
The program shall ensure all required
consents are signed by the legal guardian
and placed in each client’s file.
413-215-0576(1) (f) Impose a dress Yes☐ No The consent is contained in the THP Program Rules document, which is signed by the
code: “Client files did not contain all the legal guardian.
required consents signed by the legal
guardian. The program shall ensure all
required consents are signed by the legal
guardian and placed in each client’s file.”
413-215-0576(1) (g) Apply the Yes☐ No The consent is contained in the Waiver for Higher Risk Activities form, which is signed by
reasonable and prudent parent the legal guardian.
standard: “Client files did not contain all
the required consents signed by the legal
guardian. The program shall ensure all
required consents are signed by the legal
guardian and placed in each client’s file.”
2
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 200115)
413-215-0576(3) (d) Activity specific Yes☐ No The consent is contained in the Waiver for Higher risk Activities form, which is signed by
authorizations are pre-approved to the legal guardian.
allow children to participate in
potentially hazardous activities,
including but not limited to using
motorized yard equipment, swimming,
and horseback riding: “Client files did
not contain all the required authorizations
signed by the legal guardian. The
program shall ensure all required
authorizations are signed by the legal
guardian and placed in each client’s file.”
New Findings from Site Visit Comments
None
Interview Summary
Client #1: They have been here for 1 year and several months. They don’t like it here, doesn’t like 15 minute checks after they self harm. They
have been in multiple programs throughout Oregon. They wish they had an allowance here. They don’t like the food, doesn’t like that the
program repeats the same meals over and over. They have a lot of quesadillas for lunch. When it’s not meal time, they are only allowed fruits
and veggies, they also have designated snack time several times a day. They want more than fruit and veggies. They have outings every other
week. Staff can do better, they need trauma informed skills. They don’t like when staff uses the term self-harm. They like one specific staff who
is caring, she listens, she’s warm hearted, not a pushover. Everyone in the house is vaccinated. Staff took the covid signs down around the
house. They were restrained after an altercation with a peer. The rules could be more clear, kids are disrespectful and staff don’t do anything
about it.
Client #2: They have been here for 7 months. They have been in multiple programs throughout Oregon. They have no favorite staff. There is
lots of “bullshit” right now at the program, girls are being rude. They feel that staff are giving them attitude. They feel they are bullied by other
clients. The food is good, clients help make the menus. They have been restrained one time at the program. They speak to their family as often
as they want. They don’t feel safe here because there is a lot of drama, other clients are talking behind her back and are being rude to her.
There is no discharge plan yet. They want a better MP3 player than what they have.
3
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 200115)
Observations
There are currently five clients in the program. The program was in good physical condition.
Corrective Actions and Timeframes:
Please submit the following to verify compliance.
Within 45 days of receipt of this report A Village for One 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: _1_2_/_1_3_/2_0__2_1_ ________
Manager Review: ______________________________________ Date: _1_2_-9_-_2_0_2_1_ _________
4
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 200115)

report_type: Unannounced

licensee: A Village for One

executive_director: Cassie Trahan

other_regulatory_agencies: Child Welfare

purpose:
Per OAR 413-215-0101 (1) (b) Children's Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings: Repeat Comments
6-Mth Review 03-15-2021 Findings
Further Action
Needed
413-215-0511(2)(a) &(c) Buildings are Yes[ ] No The buildings were clean and in good repairs.
smoke free, clean and in good repair:
"Two bedrooms were very messy and had
items all over the floor. The program shall
ensure all rooms are clean. This is a
repeat finding from December 2020."
413-215-0541(3)(a) Evacuation drill Yes No[ ] The program did not complete an evacuation drill in June 2021. The program shall ensure
occurs monthly under varying an evacuation drill is completed on a monthly basis and documented accurately.
conditions, is retained 2 yrs. and
contains;
(A) identify of person conducting drill
(B) date & time
(C) notification method
(D) staff participating
(E) # of children & staff evacuated
(F) special conditions simulated
(G) problems encountered
1

(H) time to complete
"The program completed one evacuation
drill since opening in September 2020.
The program shall ensure evacuation
drills are completed on a monthly basis."
413-215-0061(3)(h) Current job Yes[ ] No Current job descriptions were reviewed for two current staff.
description (1)(c) Employee meets
minimum qualifications stated in
current job description: "Staff personnel
files did not contain a current job
description. The program shall ensure
there is a current job description in each
staff's personnel file."
413-215-0576(1) (d) Restrict contact Yes[ ] No The consent is contained in the THP Program Rules document, which is signed by the
with persons outside of the agency: legal guardian.
"Client files did not contain all the required
consents signed by the legal guardian.
The program shall ensure all required
consents are signed by the legal guardian
and placed in each client's file."
413-215-0576(1) (e) Allow access as Yes No[ ] Client files did not contain the required consent. The program shall ensure all required
defined in 413-215-0091 & 0101: "Client consents are signed by the legal guardian and placed in each client's file.
files did not contain all the required
consents signed by the legal guardian.
The program shall ensure all required
consents are signed by the legal guardian
and placed in each client's file.
413-215-0576(1) (f) Impose a dress Yes[ ] No The consent is contained in the THP Program Rules document, which is signed by the
code: "Client files did not contain all the legal guardian.
required consents signed by the legal
guardian. The program shall ensure all
required consents are signed by the legal
guardian and placed in each client's file."
413-215-0576(1) (g) Apply the Yes[ ] No The consent is contained in the Waiver for Higher Risk Activities form, which is signed by
reasonable and prudent parent the legal guardian.
standard: "Client files did not contain all
the required consents signed by the legal
guardian. The program shall ensure all
required consents are signed by the legal
guardian and placed in each client's file."
2

413-215-0576(3) (d) Activity specific Yes[ ] No The consent is contained in the Waiver for Higher risk Activities form, which is signed by
authorizations are pre-approved to the legal guardian.
allow children to participate in
potentially hazardous activities,
including but not limited to using
motorized yard equipment, swimming,
and horseback riding: "Client files did
not contain all the required authorizations
signed by the legal guardian. The
program shall ensure all required
authorizations are signed by the legal
guardian and placed in each client's file."
New Findings from Site Visit Comments
None
Interview Summary
Client #1: They have been here for 1 year and several months. They don't like it here, doesn't like 15 minute checks after they self harm. They
have been in multiple programs throughout Oregon. They wish they had an allowance here. They don't like the food, doesn't like that the
program repeats the same meals over and over. They have a lot of quesadillas for lunch. When it's not meal time, they are only allowed fruits
and veggies, they also have designated snack time several times a day. They want more than fruit and veggies. They have outings every other
week. Staff can do better, they need trauma informed skills. They don't like when staff uses the term self-harm. They like one specific staff who
is caring, she listens, she's warm hearted, not a pushover. Everyone in the house is vaccinated. Staff took the covid signs down around the
house. They were restrained after an altercation with a peer. The rules could be more clear, kids are disrespectful and staff don't do anything
about it.
Client #2: They have been here for 7 months. They have been in multiple programs throughout Oregon. They have no favorite staff. There is
lots of "bullshit" right now at the program, girls are being rude. They feel that staff are giving them attitude. They feel they are bullied by other
clients. The food is good, clients help make the menus. They have been restrained one time at the program. They speak to their family as often
as they want. They don't feel safe here because there is a lot of drama, other clients are talking behind her back and are being rude to her.
There is no discharge plan yet. They want a better MP3 player than what they have.
3

Observations
There are currently five clients in the program. The program was in good physical condition.

excerpt:
413-215-0576(3) (d) Activity specific Yes[ ] No The consent is contained in the Waiver for Higher risk Activities form, which is signed by
authorizations are pre-approved to the legal guardian.
allow children to participate in
potentially hazardous activities,
including but not limited to using
motorized yard equipment, swimming,
and horseback riding: "Client files did
not contain all the required authorizations
signed by the legal guardian. The
program shall ensure all required
authorizations are signed by the legal
guardian and placed in each client's file."
New Findings from Site Visit Comments
None
None


summary: Unannounced - 5 findings

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Licensee: A Village for One
Executive Director: Cassie Trahan
Date of Unannounced: 10/13/2022
Licensing Coordinator: Aubrey Kelly & Jorge Pelinski
Other Regulatory or Accrediting Agencies: Child welfare
Purpose: Per OAR 413-215-0101 (1) (b) Children’s Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Comments
Findings
Further Action
Needed
413-215-0541 (3)(a) Evacuation drill Yes☐ No Evacuation drills reviewed by Licensing Coordinator. The agencies Evacuation drills meet
occurs monthly under varying conditions, rule requirements.
is retained 2 yrs. And contains;
(A) Identify of person conducting drill
(B) date & time
(C) Notification method
(D) staff participating
(E) # of children & staff evacuated
(F) special conditions simulated
(G) problems encountered
413-215-0576(1) (e) Allow access as Yes☐ No Allow access as defined 413-215-0576(1) (e) – Meets rule requirements.
defined in 413-215-0091 & 0101: “Client
files did not contain all the required
consents signed by the legal guardian. The
program shall ensure all required consents
are signed by the legal guardian and place
in each client’s file.
1
(rev. 200115)
New Findings from Site Visit Comments
Physical Plant 413-215-0511(2)(a) &(c) Stairwell:
Buildings are smoke free, clean and in Up the stairs heading to the 2nd floor the stairwell wall was observed to have two holes.
good repair Program will ensure that the holes in the wall are patched.
Bedrooms:
The bedrooms were observed to have clutter.
Program will take steps to ensure that rooms are organized and less cluttered.
Interview Summary
Two youth were interviewed at the unannounced inspection. The first youth interviewed was 13 and the second youth interviewed was 14 years
old. The following information was obtained from the youth interviews:
 Both youths stated that they felt safe in the program.
 Both youths stated that they felt in the program and supported by staff.
 Both youths confirmed that they receive enough food to eat.
 Both youths stated that they get to make phone calls often.
 Both youths stated that they get to go on outings such as the park, fair or other events.
 One youth stated that they would not change anything about the program. The other youth interviewed stated that the only thing they
would change would be to have “personal animals” for all youth.
Observations
Staff and youth were observed at the programs during the inspection. The youth that were at the programs appeared to be at ease, energetic
and comfortable in the environment. All areas of the programs (inside and outside) where youth had access were observed to be well kept,
clean and in good repair (see minimal repairs needed above in the report). The program has added room-clean charts as well.
(rev. 07/21/2022)
Corrective Actions and Timeframes:
Please submit the following to verify compliance.
Within 45 days of receipt of this report A Village for One, 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, to the following address: Jorge.l.pelinski@dhsoha.state.or.us
Licensing Coordinator’s Signature: ________________________ Date: _1_0_._1_8_.2_0_2__2_ ________
Licensing Coordinator’s Signature: ________________________ Date: _1_0_/_1_9_/2_0__2_2_ ________
Manager Review: ______________________________________ Date: _1_0_-_1_7_-_2_0_2_2_ _______
(rev. 07/21/2022)

licensing_coordinator: Aubrey Kelly & Jorge Pelinski

purpose:
Per OAR 413-215-0101 (1) (b) Children's Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Comments
Findings
Further Action
Needed
413-215-0541 (3)(a) Evacuation drill Yes[ ] No Evacuation drills reviewed by Licensing Coordinator. The agencies Evacuation drills meet
occurs monthly under varying conditions, rule requirements.
is retained 2 yrs. And contains;
(A) Identify of person conducting drill
(B) date & time
(C) Notification method
(D) staff participating
(E) # of children & staff evacuated
(F) special conditions simulated
(G) problems encountered
413-215-0576(1) (e) Allow access as Yes[ ] No Allow access as defined 413-215-0576(1) (e) - Meets rule requirements.
defined in 413-215-0091 & 0101: "Client
files did not contain all the required
consents signed by the legal guardian. The
program shall ensure all required consents
are signed by the legal guardian and place
in each client's file.
1

New Findings from Site Visit Comments
Physical Plant 413-215-0511(2)(a) &(c) Stairwell:
Buildings are smoke free, clean and in Up the stairs heading to the 2nd floor the stairwell wall was observed to have two holes.
good repair Program will ensure that the holes in the wall are patched.
Bedrooms:
The bedrooms were observed to have clutter.
Program will take steps to ensure that rooms are organized and less cluttered.
Interview Summary
Two youth were interviewed at the unannounced inspection. The first youth interviewed was 13 and the second youth interviewed was 14 years
old. The following information was obtained from the youth interviews:
- Both youths stated that they felt safe in the program.
- Both youths stated that they felt in the program and supported by staff.
- Both youths confirmed that they receive enough food to eat.
- Both youths stated that they get to make phone calls often.
- Both youths stated that they get to go on outings such as the park, fair or other events.
- One youth stated that they would not change anything about the program. The other youth interviewed stated that the only thing they
would change would be to have "personal animals" for all youth.
Observations
Staff and youth were observed at the programs during the inspection. The youth that were at the programs appeared to be at ease, energetic
and comfortable in the environment. All areas of the programs (inside and outside) where youth had access were observed to be well kept,
clean and in good repair (see minimal repairs needed above in the report). The program has added room-clean charts as well.

excerpt:
413-215-0511(2)(a) &(c) Stairwell:
Buildings are smoke free, clean and in Up the stairs heading to the 2nd floor the stairwell wall was observed to have two holes.
good repair Program will ensure that the holes in the wall are patched.
Bedrooms:
The bedrooms were observed to have clutter.
Program will take steps to ensure that rooms are organized and less cluttered.
Physical Plant


summary: License Renewals - 10 findings

raw_content:
Licensed Child Caring Agency Site Visit Report
Residential Care
Licensee: A Village For One Date of site visit: 2.02.2023
Executive Director: Cassie Trahan Licensing Coordinator: Jorge Pelinski & Aubrey Kelly
Board Chairperson: Robert Edwards
Other Regulatory or Accrediting Agencies: Child Welfare
Program Compliance: The program was found to be compliant or will be compliant with OAR 419-400-0005 to 419-400-0310, Licensing Umbrella
Rules, and OAR 419-470-0010 to 419-470-0180, Licensing Residential Care Agencies Rules. Personnel records were reviewed and compliance
with required background checks was documented for employees in all programs.
Program Description(s): A Village for One – Anisa’s Place is a residential program serving clients who are identified as Commercially Sexually
Exploited Children (CSEC). The program uses a phase system. The Therapeutic Housing Program will use a phase system for youth to follow as
they progress through treatment. With each phase, there will be increased responsibility and opportunities. The following table provides a
description of the 4 phases, referred to as the SELF phases, as well as the Orientation period and Pause protocol. The Orientation period is the first
2 or more weeks after intake in which the youth is settling into the program and demonstrating an understanding of the program dynamics and
expectations with a focus on demonstrating safety. The Pause protocol will be implemented if a youth engages in unsafe behavior or consistently
refuses to engage in programming. After a Pause, the youth resume at the current Phase they were in prior to the Pause. The program places a
great emphasis on providing a nurturing, safe and trauma-informed milieu that allows for healing and growth.
Program type and services: A Village for One (Anisa’s Place) provides BRS residential Service, Individual mental health counseling, drug and
alcohol counseling, group mental health counseling, family counseling, education services, social and community activities, access to medical,
dental, and vision care, skills training, and job search/career development.
Capacity and Age Range: Females - 12-18; capacity of 7
Funding sources: ODHS, Corporate and Foundation Grants, Fee-for-Service (Medicaid Billing), General Donation.
Contracts and sources for referrals: Child welfare, ODHS, Juvenile Justice System
Average length of stay: 4 months
P a g e 1 | 17
Form Rev. 12/14/2022
Average daily population served: 5 children
Number of children served annually: 15 children
Use of seclusion or restraint: Restraint – Mandt. System, Seclusion – n/a
Interviews: One client was interviewed. They have been at the program since August 2022. They like the program; but it’s stressful when other
clients are having tantrums and throwing chairs. Staff does move the other clients away when another client is escalating. Their favorite staff are
Carolina, Kimberly, Melissa, and their therapist. They were previously at Rainbow Lodge and Taylor House. The food at the program is delicious,
the Mexican food they make is a favorite. They get enough to eat, and water is always available. They are working on their goals. They have phone
calls and in person visits with family.
Observations: The clients were observed to be relaxed and comfortable in the milieu. The house was clean, organized and well maintained. The
program keeps goats, and they have been moved to the backside of the property to make room for planned new construction to expand program
capacity.
Program Strengths: The program has strong community partnerships that allow youth to have high level of access to a diversity of
experience, both in the house and in the community. The dedication of the agency’s core administrative and clinical staff, allow them to
overcome various hurdles and challenges. The agency has the ability to individualize their services and supports in meeting the needs
of the clients in care. Another strength of the program is having the ability to safety plan with the youth that helps create a safe
environment for clients. The program is in a rural setting and keeps goats on the property, which staff and residents enjoy.
Program Challenges: Program challenges include the need to hire a qualified Assistant Program Director and clinical staff. Another challenge is
Law enforcement response – the length of time it takes for the response, and the fact that sometimes the program has been told by law
enforcement told to handle situations themselves. One final challenge the program has is keeping up with inflation and its impact on programmatic
costs (e.g., grocery, gas) and personnel costs (e.g., staff salaries).
Changes that have occurred in the last 2 years: The program has switched from a House Parent to House Manager position.
The program switched from 1:3 to 1:2 staff to youth ratio, to give more one-on-one attention to residents, which allows for more breaks
for staff, which supports reducing staff burnout.
Lawsuits: None
Grievances and complaints filed in the last two years: None
Corrective Actions and Timeframes: Please submit the following to verify compliance.
P a g e 2 | 17
Form Rev. 12/14/2022
Within 45 days of receipt of this report (insert name of agency) must submit a letter of verification indicating the agency is in compliance with the
specific rules cited above and describing how compliance will be maintained going forward. Along with the letter of verification, the agency must
submit any and all specific documentation requested in the body of this report. The letter of verification and any additional requested documents can
be emailed directly to (Licensing Coordinator and email address).
Recommendations: None
Exceptions: None
Changes in License: None
Summary of Review
Program and Services
Yes No N/A Corrective Actions/Comments
419-400-0020 (2)
Program and services are in scope of license X
Governance of the Agency
Yes No N/A Corrective Actions/Comments
419-400-0040
(1)(a) Minimum of 5 board members X
(2)(f) Formally evaluate the exec. Director’s
X
performance annually
(2)(g) Approves annual budget X
(2)(h) Obtain and review an annual
independent financial review or audit of X
financial records.
(2)(k) Written quality improvement program X
(2)(l) Meeting minutes X
Executive Director or Program Director
Yes No N/A Corrective Actions/Comments
419-400-0040
(3)(a) knowledge of requirements for
providing care and treatment appropriate to X
programs
(3)(g) Approval from BCU X
Discipline, Behavior Management, and
Suicide Prevention Yes No N/A Corrective Actions/Comments
419-400-0150
(3) Agency uses appropriate and positive
methods of behavior management and
X
nationally recognized non-violent crisis
intervention
P a g e 3 | 17
Form Rev. 12/14/2022
(3)(b)(C) Agency does not use chemical and
mechanical restraint (excluding medically X
necessary devices/prescriptions)
(3)(c) Agency uses appropriate time-out
rooms (adequate space, heat, light and
ventilation and is not capable of locking) and X
documents use in child’s record when
applicable
(3)(e) Agency uses seclusion
X
appropriately/consistent with policy
(4) Agency has adequate plan in place to
X
respond to suicidal behavior/warning signs
Contractors (if applicable)
Yes No N/A Corrective Actions/Comments
419-400-0120(6)
(a) Agency ensures the contractor meets the
requirements of this rule and Chapter 413 X
division 215
(b)(B) Contract includes the following:
(i) Services provided
(ii) Contractor fees
(iii) Disclosure of information from contractor
to agency
(iv) Lines of authority X
(v) Adherence to rules, including background
check
(vi) Any liability of the agency for acts of the
contractor, rights of indemnity and limitations
on liability
Restraints and Involuntary Seclusion
Yes No N/A Corrective Actions/Comments
419-400-0180
(11)(d) Each child caring agency that
submits a report under this section shall
make its quarterly report available to the
X
public upon request at the Child Caring
Agency’s main office and on the child caring
agency’s website if applicable.
Supplemental Information Provided by
Yes No N/A Corrective Actions/Comments
CCA
Documents as indicated on the form titled
X 419-470-0080(1) See page 16 for corrective action
“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”
P a g e 4 | 17
Form Rev. 12/14/2022
All required policies and procedures as
X
identified in “Agency Type Specific Rules”
Physical Plant
Yes No N/A Corrective Actions/Comments
419-400-0090(3)(a) Foster Rights Posted (if
X
children in DHS custody)
419-400-0100(1) Sufficient safe space,
X
equipment, and office equipment
419-400-0230(12) License is posted in
X
common area at each facility
419-470-0020(2)(a) &(c) Buildings are Environmental Health Inspection completed on 1.03.2023. Per Building inspector,
smoke free, clean and in good repair “Kitchen floor peeling up.”
X
Corrective Action: Agency will ensure that floors in kitchen are repaired. Executive
Director stated that Agency has scheduled a date with a company to come out and fix
flooring in the kitchen.
419-470-0020 (2)(d) Rooms are free of
X
harmful drafts, odors, and excessive noise
419-470-0020 (2)(e) Rooms are adequate in
X
size and arrangement
419-470-0020 (2)(f) System provides a
continuous supply of hot and cold water to X
taps located throughout the facility
419-470-0020 (2)(h) Building is well
ventilated and room temperature is within a X
normal comfort range
419-470-0030 (1) All parts of the facility
X
ensure the safety of children
Room and Space Requirements
Yes No N/A Corrective Actions/Comments
419-470-0030
(2) There is a separate living room or lounge X
area – 15 SF minimum per child
(5) There is a separate dining room with X
capacity for ½ of children in care and 15 SF
per child in care
(7) Laundry is separate from living, kitchen, X
and dining areas
(8) Separate storage areas are provided for X
food, kitchen supplies, utensils, clean linens,
soiled linens and clothing, cleaning supplies
and equip, poisons, chemicals, outdoor
recreational and maintenance equipment.
(Hazardous materials are properly labeled, in
original container and locked)
P a g e 5 | 17
Form Rev. 12/14/2022
(9) Outdoor activity area is protected from X Environmental Health Inspection completed on 1.03.2023. Per Building inspector, areas
vehicles and other hazards and of a size and used for recreation, “Tree care/trimming needed for safety.” Agency has contacted
availability appropriate to the age and needs arborist for an evaluation and the evaluation has been completed.
of children in care
Corrective Actions: Agency will ensure tree care/trimming is completed for safety and
provide pictures of completed work to Licensing.
(11) Time-out rooms: Rooms used for time X
out or quiet time must have adequate space,
heat, light and ventilation and must not be
capable of locking.
Room and Space Requirements
Bedrooms Yes No N/A Corrective Actions/Comments
419-470-0030(3)
(a) Adequate furnishings and personal items X
(b) Separate from rooms used for dining,
X
living, laundry, kitchen, and storage
(c) 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
Room and Space Requirements
Bathrooms Yes No N/A Corrective Actions/Comments
419-470-0030(4)
(a)(A)&(B) 1:8 ratio for toilets and sinks X
(a)(D) Hot and cold running water, soap, and
X
approved hand drying options
(a)(E) 1:10 ratio for shower or bathtub X
(a)(E) Individual privacy X
(a)(F) Window covering X
(a)(G) Permanently wired fixtures X
(a)(H) Adequate ventilation X
(b)&(c) Wooden racks on floors are
prohibited and impervious shower mats are X
disinfected & dried daily
Room and Space Requirements
Kitchen Yes No N/A Corrective Actions/Comments
419-470-0030(6)
(a) Used exclusively for storage, food
preparation, dishwashing, and activities X
related to eating
(b) Walls, floors are easily cleanable X
P a g e 6 | 17
Form Rev. 12/14/2022
(c) Equipment and utensils are easily
X
cleanable, durable, nontoxic, and kept clean
(e) Equipment is easy to clean beneath,
X
between and behind
Furnishings and Personal Items
Yes No N/A Corrective Actions/Comments
419-470-0040
(1) There is a bed with frame, 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
Food Services
Yes No N/A Corrective Actions/Comments
419-470-0070
(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.
Residential Care Safety
Yes No N/A Corrective Actions/Comments
419-470-0080
(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 X
contains:
P a g e 7 | 17
Form Rev. 12/14/2022
(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
Umbrella Safety
Yes No N/A Corrective Actions/Comments
419-400-0200
(5)(b) Vehicle has insurance policy, is smoke X
free, safe operating condition, and has first
aid kit and fire extinguisher 2-A:10-BC
(1)(b)(A) Each vehicle used to transport a X
child in care must be: properly registered,
covered by an insurance policy in full force
and effect, maintained in safe operating
condition, and smoke-free.
(3) If a child-caring agency has a swimming X
pool on the premises that is accessible to
children in care or if a child-caring agency
plans to have children in care engage in
swimming, the child-caring agency must
have and adhere to policies and procedures
that address, at a minimum, providing
disclosures and obtaining consents,
assessing swimming ability of children in
care, and ensuring the safety of pool access.
(4)(a) The school protects children from X
potentially harmful items and materials.
(4)(b) Direct supervision of children who do X
not have the ability to adjust and control
water temperature
(4)(c) Light fixtures have protective covers X
unless designed to be used without one
Medication
Yes No N/A Corrective Actions/Comments
419-470-0100
(3)&(7)(e) Medications have a prescription
and are stored in the original container with X
prescription label
(4)&(5) Herbal supplements and remedies,
medical treatments, special diets, physical
therapy, physical aides or limitations have a X
written order signed by a physician or
qualified medical professional.
P a g e 8 | 17
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(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
In review of the medication administration records (MARS), there is not a notation for
(b) description
when medication is taken outside the facility.
(c) dates and times
(d) missed doses X
Corrective Action: The program will document on the MAR when medication is taken
(e) medication disposed
outside the facility.
(f) method of administration
(g) ID of person administering
(h) possible adverse reactions
(i) medication taken outside facility
Extracurricular, Enrichment, Cultural &
Social Activities Yes No N/A Corrective Actions/Comments
419-470-0110
(2) Children have ongoing opportunities to X
participate in at least one age-appropriate or
developmentally appropriate activity
Minimum Staffing Requirements
Yes No N/A Corrective Actions/Comments
419-470-0130
(1)&(2) Supervision is adequate for the type X
of program, location, age and type of
children, ability of supervisor to respond,
electronic back-up systems.
Minimum ratios are maintained:
Under 30 months of age: 1:4
30 months to ˃ 6 years or non-ambulatory:
1:6
Ages 6 and older: 1:7
Overnight (staff awake)
1:10
(4)(a) When one staff on duty, there is X
additional staff immediately available with
max response time of 30 minutes
P a g e 9 | 17
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(5) There is at least one on-site employee X
authorized to apply the reasonable and
prudent parent standard
Separation of Residents
Yes No N/A Corrective Actions/Comments
419-470-0140
(1) Children are in separate bedrooms than X
adults, unless parent and child, or there is
written approval from guardian/parent and
licensing coordinator
(2) There is adequate supervision of children X
if both males and females are served by the
program
Personnel Files
Yes No N/A Corrective Actions/Comments
419-400-0120
Staff Name/Position X
(3)(g) Date of Hire X
(3)(a) record of education, training, and
X
previous employment
(1)(b) & (3)(b) reference checks completed
X
and documented
(1)(a) & (3)(c) Background check completed
X
and documented
(3)(d) Annual performance evaluations X
(3)(f) Record of personnel actions X
(3)(g) Termination date, reason for
X
termination
(3)(h) Current job description (1)(c)
Employee meets minimum qualifications X
stated in current job description
New Employee Orientation – Umbrella
Yes No N/A Corrective Actions/Comments
Requirements (30 days)
P a g e 10 | 17
Form Rev. 12/14/2022
419-400-0120(4)
(a) Agency policies and procedures X
(b) Ethical and professional guidelines X
(c) Suicide prevention and intervention X
In staff files reviewed, documentation of training in attributes of population served was not
consistently found.
(d) Attributes of population served X
Corrective Action: Agency will ensure that all required training is completed and
documented in all personnel files.
(e) & (5)(a) to (c) Mandatory reporting that
includes:
(a) legal definition of child abuse in ORS
418.257 and 419B.005 X
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to
the employee
(f) Privacy laws
(g) Emergency procedures
New Employee Orientation
Residential (30 days) Yes No N/A Corrective Actions/Comments
419-470-0120
(1)(a) Discipline and behavior management
including de-escalation, crisis prevention,
positive behavior management, and X
disciplinary techniques that are non-punitive
in nature
(1)(b) Restraint and seclusion (if applicable)
Crisis Intervention Training Standards
and Certification Yes No N/A Corrective Actions/Comments
419-400-0160(4) (as applicable)
(a)Complete a minimum of 12 hours of initial
training in person from a certified instructor, All files reviewed for Crisis Intervention had 10 hours of training, as opposed to the 12
including but not limited to a minimum of six hours of training needed.
hours of training focused on positive
X
behavior support, nonviolent crisis Corrective Action: Agency will ensure that all staff receive a minimum of 12 hours of
intervention and other methods of Crisis Intervention Training during their orientation period and before performing any
nonphysical intervention to support children physical restraints.
in care during a crisis
(d) Receive a certificate that states:
(A) The dates during which the certification
is current X
(B) The type of restraint which the individual
is certified to perform if applicable
P a g e 11 | 17
Form Rev. 12/14/2022
(C) The type of training the individual is
certified to conduct if applicable
(D) Any special endorsements earned by the
individual
(E) The level of training
(F) The name of the certified instructor who
conducted the training and administered the
assessment of proficiency.
(e) A certification issued:
(A) Must be personal to the individual
certified by the training provider X
(B) May be valid for no more than two years
with recertification
Ongoing Training Yes No N/A Corrective Actions/Comments
419-470-0070(2)(b) Employees who handle
food served to children have a valid food X
handler’s card
419-400-0200 (1) Employees transporting
children have: current driver’s license,
insurance, trained in emergency procedures X
and behavior management, and training for
15+ passenger vans if applicable)
419-470-0120 (2)(a) Environmental
X
emergencies
419-470-0120 (2)(b) Universal Precautions X
419-470-0120 (2)(c) Discipline and Behavior
X
Management
419-470-0120 (3) Staff providing direct care
must maintain current CPR/First Aid X
certification
419-470-0120 (4) Designated staff
authorized to apply reasonable and prudent
X
parent standard are trained in application of
the standard
419-400-0120(5) Mandatory reporting
(annually) that includes:
(a) legal definition of child abuse in ORS
418.257 and 419B.005 X
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to
the employee
P a g e 12 | 17
Form Rev. 12/14/2022
419-400-0160(4)(b) Receive continuing
education (as applicable on crisis
X
intervention training) from a certified
instructor on an annual basis
Comments:
Children’s Records Yes No N/A Corrective Actions/Comments
Health Services
419-470-0090
(2) Medical history obtained within 30 days
(significant findings, current immunizations,
history of surgical procedures-health issues- X
injuries, allergies, dental, vision, hearing,
behavioral health, and physician orders)
(2)(e) Documentation of age-appropriate
instruction – pregnancy prevention, nutrition,
X
prevention of HIV & AIDS, and prevention
and treatment of sexually transmitted disease
(4)(a) to (f) Medical exams (3 in first year of
life, 2,4,6,9,14) X
Consents
Yes No N/A Corrective Actions/Comments
419-470-0160(1)
(a) Provide routine and emergency medical
X
care
(b) Use the discipline and behavior
X
management system
(c) Use restraint or seclusion (if applicable).
Must specify the reasons for the intervention X
and how staff are trained and supervised
P a g e 13 | 17
Form Rev. 12/14/2022
(d) Restrict contact with persons outside of
X
the agency
Files reviewed did not have the consent to allow access.
(e) Allow access as defined in 419-400-0230
X
& 0240 Corrective Action: Agency will create a consent form to allow access as defined in 419-
400-0239 & 0240.
(f) Impose a dress code X
Files reviewed, did not have the consent to apply the reasonable and prudent parent
(g) Apply the reasonable and prudent parent standard.
X
standard
Corrective Action: Agency will ensure that all youth files will have the required consent.
Disclosures
419-470-0160(2) Yes No N/A Corrective Actions/Comments
Parent/guardian has acknowledged in writing:
(a) Information regarding personal or room
searches and protocols for confiscation of X
contraband
(b) Statement of Rights of Children and
X
Parents/Guardians
(c) Any policies and procedures upon request X
Authorizations
Yes No N/A Corrective Actions/Comments
419-470-0160(3)
(a) Disclose or exchange information with
X
others
(b) Child specific visitors X
(c) Visitation resources are pre-approved X
(d) Activity specific authorizations are pre-
approved to allow children to participate in
potentially hazardous activities, including but X
not limited to using motorized yard
equipment, swimming, and horseback riding.
Information about Children in Care
419-400-0190(1) Yes No N/A Corrective Actions/Comments
Summary sheet contains the following:
(a)The name, gender, date of birth, religious
X
preference, and previous address
(b) Name and location of previous and
X
current school
(c) Date of admission X
(d) Legal custody X
(e) The name, address, and telephone
number of:
(A) The child in care's parents. X
(B) The child in care's legal guardian, if
different than the parents, and a copy of
P a g e 14 | 17
Form Rev. 12/14/2022
the document that provides for his or her
authority over the child in care.
(C) Other persons significant to child
(D) Other professionals to be involved in
service planning (if applicable)
Service Planning
Yes No N/A Corrective Actions/Comments
419-470-0170(2)
Client files did not consistently have an intake document.
(b) Intake document is completed the date
Corrective Action: Agency will ensure that all client files have a completed intake
child accepted into care (emergency X
document.
placement 48 hours)
(d) Assessment is completed within 30 days
and contains relevant historical info., current
behavioral observations, identified need for X
services, and how agency will provide
services
(e) (A)&(B) Service plan within 60 days
(parent, guardian and child actively involved).
Describes how child’s issues will be X
addressed, anticipated outcomes, and
reviewed by child and guardian/parent.
(e)(C)&(D) Service plan is reviewed quarterly
and revised when information indicates other X
services should be provided
Case Management
Yes No N/A Corrective Actions/Comments
419-470-0170(3)
(a) Services are documented, progress
X
toward achieving goals is tracked
(b)-(d) discharge planning and instructions X
(f) Incident Reports X
Records Relating to Restraint &
Yes No N/A Corrective Actions/Comments
Involuntary Seclusion
419-400-0180 (12) Records X See pages 16-17 for corrective actions
419-400-0190(1) Information provided to
children in care relating to Restraint & X
Involuntary Seclusion
Financial Records
Yes No N/A Corrective Actions/Comments
419-470-0170(4)
Records contain date, amount, source,
X
purpose, signatures
Personal Possessions Records
Yes No N/A Corrective Actions/Comments
419-470-0170 (5)
P a g e 15 | 17
Form Rev. 12/14/2022
Individual written inventory of all personal
possessions is maintained and updated as X
needed
Records and Documentation
Yes No N/A Corrective Actions/Comments
419-400-0140
(1) Stored safely X
(2) Permanent, legible, dated, and signed X
(3)&(4) Uniform in organization, readily
identifiable and accessible, current, and
X
complete, containing all required info. No
eraser tape or white out.
(7) Permanent registry for each child
includes:
Name
Gender
X
Birth date
Names, addresses of parents or guardians
Dates of admission
Placement upon discharge
419-400-0180(13)(e) Each child caring agency shall provide notice regarding how to access the quarterly reports to the parents or guardians of
children in care in the program. The child caring agency shall provide the notice upon the child in care’s admission and at least two times each year
thereafter.
All files reviewed did not have documentation to verify that the above required information related to Quarterly Reports had been provided to parents/guardians.
Corrective Action: Agency will ensure parents/guardians are informed of how to access the Quarterly Reports, that this information is provided upon admission
and at least two times each year thereafter and that client files have documentation to verify this has occurred.
419-400-0180(12)(b) If a program places a child in care in a restraint or involuntary seclusion, the program shall provide the child in care’s case
manager, attorney, court appointed special advocate and parents or guardians with the following:
(A) Verbal or electronic notice that the restraint or involuntary seclusion was used as soon as practicable following the incident but not later than
the end of the next business day; and
(B) Written notice in compliance with OAR 419-400-0180(10)(c) that the restraint or involuntary seclusion was used as soon as practicable following
the incident but not later than the end of the next business day.
All files reviewed did not include documentation indicating that the required notice described above had been provided to the attorney or the Court Appointed
Special Advocate.
Corrective Action: Agency will ensure that the attorney and the Court Appointed Special Advocate l receive the notices described above, and the provision of
the required notice is documented on the associated incident report.
P a g e 16 | 17
Form Rev. 12/14/2022
419-400-0180(12)(d) If an incident requires notice under 419-400-0180(12)(b), not later than two business days following the date of the restraint or involuntary
seclusion, the program shall hold a debriefing meeting with each individual who was involved in the incident and with any other appropriate program staff, shall
take written notes of the debriefing meeting and shall provide copies of the written notes to the child in care’s case manager, attorney, court appointed special
advocate and parents or guardians.
All files reviewed did not contain written notes on the debriefing meeting and lacked documentation indicating debrief note had been provided to the identified
parties.
Corrective Action: Agency will ensure that all files will have written notes on the required debriefing meeting described above and documentation to verify
notes have been provided to the parties identified in the rule above.
419-470-0080
Residential Care Agencies: Safety
A residential care agency must meet all of the following requirements related to safety:
(1) Fire safety. Prior to licensure and every two years upon license renewal, the program must be assessed and approved by the State Fire Marshall or
designee for the following fire safety areas:
The program has made several attempts to schedule their Fire Marshal Inspection. However, the inspection has not been completed at the time of the review.
Corrective Action: The agency will ensure that the Fire Marshal Inspection is completed and provide a copy of the inspection report to Licensing. In the
meantime, the agency will provide copies of correspondence with Fire Inspection authorities related to scheduling the inspection.
2.15.2023
Licensing Coordinator’s Signature: ________________________ Date: ___________________
2-15-2023
Manager Review: ______________________________________ Date: __________________
P a g e 17 | 17
Form Rev. 12/14/2022

board_chairperson: Robert Edwards

licensing_coordinator: Jorge Pelinski & Aubrey Kelly

program_description:
A Village for One - Anisa's Place is a residential program serving clients who are identified as Commercially Sexually
Exploited Children (CSEC). The program uses a phase system. The Therapeutic Housing Program will use a phase system for youth to follow as
they progress through treatment. With each phase, there will be increased responsibility and opportunities. The following table provides a
description of the 4 phases, referred to as the SELF phases, as well as the Orientation period and Pause protocol. The Orientation period is the first
2 or more weeks after intake in which the youth is settling into the program and demonstrating an understanding of the program dynamics and
expectations with a focus on demonstrating safety. The Pause protocol will be implemented if a youth engages in unsafe behavior or consistently
refuses to engage in programming. After a Pause, the youth resume at the current Phase they were in prior to the Pause. The program places a
great emphasis on providing a nurturing, safe and trauma-informed milieu that allows for healing and growth.

program_services:
A Village for One (Anisa's Place) provides BRS residential Service, Individual mental health counseling, drug and
alcohol counseling, group mental health counseling, family counseling, education services, social and community activities, access to medical,
dental, and vision care, skills training, and job search/career development.

capacity_age_range: Females - 12-18; capacity of 7

average_length_of_stay: 4 months P a g e 1 | 17

average_daily_population_served: 5 children

number_of_children_served_annually: 15 children

use_of_seclusion_or_restraint: Restraint - Mandt. System, Seclusion - n/a Interviews: One client was interviewed. They have been at the program since August 2022. They like the program; but it's stressful when other clients are having tantrums and throwing chairs. Staff does move the other clients away when another client is escalating. Their favorite staff are Carolina, Kimberly, Melissa, and their therapist. They were previously at Rainbow Lodge and Taylor House. The food at the program is delicious, the Mexican food they make is a favorite. They get enough to eat, and water is always available. They are working on their goals. They have phone calls and in person visits with family. Observations: The clients were observed to be relaxed and comfortable in the milieu. The house was clean, organized and well maintained. The program keeps goats, and they have been moved to the backside of the property to make room for planned new construction to expand program capacity.

program_strengths:
The program has strong community partnerships that allow youth to have high level of access to a diversity of
experience, both in the house and in the community. The dedication of the agency's core administrative and clinical staff, allow them to
overcome various hurdles and challenges. The agency has the ability to individualize their services and supports in meeting the needs
of the clients in care. Another strength of the program is having the ability to safety plan with the youth that helps create a safe
environment for clients. The program is in a rural setting and keeps goats on the property, which staff and residents enjoy.

program_challenges:
Program challenges include the need to hire a qualified Assistant Program Director and clinical staff. Another challenge is
Law enforcement response - the length of time it takes for the response, and the fact that sometimes the program has been told by law
enforcement told to handle situations themselves. One final challenge the program has is keeping up with inflation and its impact on programmatic
costs (e.g., grocery, gas) and personnel costs (e.g., staff salaries).

excerpt:
Documents as indicated on the form titled
“Renewal Licensing Required Documents” 419-470-0080(1) See page 16 for corrective action

excerpt:
&(c) Buildings are
smoke free, clean and in good repair Environmental Health Inspection completed on 1.03.2023. Per Building inspector,
“Kitchen floor peeling up.”
Corrective Action: Agency will ensure that floors in kitchen are repaired. Executive
Director stated that Agency has scheduled a date with a company to come out and fix
flooring in the kitchen.

excerpt:
(9) Outdoor activity area is protected from
vehicles and other hazards and of a size and
availability appropriate to the age and needs
of children in care Environmental Health Inspection completed on 1.03.2023. Per Building inspector, areas
used for recreation, “Tree care/trimming needed for safety.” Agency has contacted
arborist for an evaluation and the evaluation has been completed.
Corrective Actions: Agency will ensure tree care/trimming is completed for safety and
provide pictures of completed work to Licensing.

excerpt:
(10) Written record of the administration of
medication includes:
(a) name
(b) description
(c) dates and times
(d) missed doses
(e) medication disposed
(f) method of administration
(g) ID of person administering
(h) possible adverse reactions
(i) medication taken outside facility In review of the medication administration records (MARS), there is not a notation for
when medication is taken outside the facility.
Corrective Action: The program will document on the MAR when medication is taken
outside the facility.

excerpt:
(d) Attributes of population served In staff files reviewed, documentation of training in attributes of population served was not
consistently found.
Corrective Action: Agency will ensure that all required training is completed and
documented in all personnel files.

excerpt:
(a)Complete a minimum of 12 hours of initial
training in person from a certified instructor,
including but not limited to a minimum of six
hours of training focused on positive
behavior support, nonviolent crisis
intervention and other methods of
nonphysical intervention to support children
in care during a crisis All files reviewed for Crisis Intervention had 10 hours of training, as opposed to the 12
hours of training needed.
Corrective Action: Agency will ensure that all staff receive a minimum of 12 hours of
Crisis Intervention Training during their orientation period and before performing any
physical restraints.

excerpt:
(e) Allow access as defined in 419-400-0230
& 0240 Files reviewed did not have the consent to allow access.
Corrective Action: Agency will create a consent form to allow access as defined in 419-
400-0239 & 0240.

excerpt:
(g) Apply the reasonable and prudent parent
standard Files reviewed, did not have the consent to apply the reasonable and prudent parent
standard.
Corrective Action: Agency will ensure that all youth files will have the required consent.

excerpt:
(b) Intake document is completed the date
child accepted into care (emergency
placement 48 hours) Client files did not consistently have an intake document.
Corrective Action: Agency will ensure that all client files have a completed intake
document.

excerpt: (12) Records See pages 16-17 for corrective actions