summary: Visit conducted on 6/21/24. No compliance issues identified. Implemented 1 corrective actions.

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

Field Visit Reporting Form

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

NAME OF FACILITY / PROGRAM:           Backcountry Wellness Residential Group Home

TIME OF VISIT (FROM - TO):  10:30am to 11:30am   	 DATE: 6/21/24

AGENCY PERSONNEL WHO PARTICIPATED:
Job Titles:
CEO/Program Director/Head teacher/Nurse

List of Areas / Topics covered during visit: This was a scheduled quarterly Licensing visit to obtain a program update and tour the physical plant.

A meeting was held with the CEO and Program Director. Topics discussed included:

•	LBC is 6.  Current census is 3 with 3 admissions pending.
•	Discussed clinical and day to day operations.
•	Discussed calls to emergency services during this quarter.
•	Discussed fire drills to be reviewed during next quarterly visit.
•	Personnel review for past 6 months of hires.
•	Discussed recreation, trips in the community and Friday outings.
•	New community outreach staff hired.

Milieu Observation:
•	Observed and talked to the residents who were working outside in the garden.

Physical Plant:
•	Toured the home with the Program Director and CEO. No safety concerns observed and the home was clean and maintained well. Outside wall being repaired.

Corrective Actions implemented as a result of previous visit:
NA

Areas of regulatory non-compliance identified during this visit:
NA

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

James Funaro  				Date:    6/24/24
Regulatory Consultant

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


state: CT

facility_name: Backcountry Wellness Residential Group Home #171

summary: Visit conducted on 3/13/24. No compliance issues identified. Implemented 1 corrective actions.

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

Field Visit Reporting Form

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

NAME OF FACILITY / PROGRAM:           Backcountry Wellness Residential Group Home

TIME OF VISIT (FROM - TO):  10:30am to 11:30am   	 DATE: 3/13/24

AGENCY PERSONNEL WHO PARTICIPATED:
Job Titles:
CEO
Program Director

List of Areas / Topics covered during visit: This was a scheduled quarterly Licensing visit to obtain a program update and tour the physical plant.

A meeting was held with the CEO and Program Director. Topics discussed included:

•	LBC is 6.  Current census is 3 with 2 admissions pending.
•	Discussed future hires for a 2nd shift nurse and HR coordinator.
•	Discussed calls to emergency services during this quarter.
•	Discussed plans to add security cameras to outside areas and common areas inside the home.
•	Discussed plans for community outreach through social media exposure and hiring outreach coordinator.
•	Next quarter a six month personnel review will be done.

Milieu Observation:
•	Clients observed participation in educational programming.

Physical Plant:
•	Toured the home with the Program Director and CEO. No safety concerns observed and the home was clean and maintained well.

Corrective Actions implemented as a result of previous visit:
NA

Areas of regulatory non-compliance identified during this visit:
NA

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

James Funaro  				Date:    3/15/24
Regulatory Consultant

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

personnel:
CEO
Program Director


raw_content:
November 17, 2023

Mr. Chase Bronfman
Executive Director
Back Country Wellness
7 Lincoln Ave
Greenwich, CT  06830

Re: Relicensing inspection –License #CCF-171
Regulatory Consultants: James Funaro, Kathleen Forsythe

Dear Mr. Bronfman,

On November 1-2, 2023, a biennial re-licensing inspection was conducted at the Back Country Wellness Residential Program, located at 6 Old Mill Rd, Greenwich, CT. This inspection was conducted to determine the compliance of this program with the DCF Regulations for Operation of Child-Caring Agencies and Facilities 17a-145-48 through 17a-145-124. Additionally, a review was conducted on 11-7-23 by DCF Nurse Consultant Errolee Miller, RN to determine the program’s compliance with the DCF Medication Administration Guidelines and the DCF Nursing Standards. A full standard of compliance was issued. A copy of the nursing site visit summary report is included with this report.

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

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

The areas of regulatory noncompliance are as follows:

17a-145-86	Instructions in Safety Procedures. Supervision
•	No fire drills were completed during the 3rd quarter of 2023.

Recommendation: No recommendations made in this report.

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

Sincerely,

James Funaro
_____________________________
James Funaro
DCF Regulatory Consultant

Copy: file
          Executive Director|

report_type: unstructured


summary: Visit conducted on 9/7/23. No compliance issues identified. Implemented 1 corrective actions.

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

Field Visit Reporting Form

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

NAME OF FACILITY / PROGRAM:           Backcountry Wellness Residential Group Home

TIME OF VISIT (FROM - TO):  10:00am to 1:30pm   	 DATE: 9/7/23

AGENCY PERSONNEL WHO PARTICIPATED:
Job Titles:
CEO
Program Director
Nurse
Care Coach
Clients (5)

List of Areas / Topics covered during visit: This was a scheduled quarterly Licensing visit to obtain a program update and tour the physical plant.

A meeting was held with the CEO and Program Director. Topics discussed included:
•	LBC is 6.  Current census is 5 with 1 admission pending.
•	Discussed most recent admission.
•	Staffing vacancies (1 Care Coach).
•	4 calls to emergency services during this quarter.
•	Discussed upcoming licensing inspection.
•	Discussed recreation/outings.
•	Recent projects-garden
•	Discussed meals/nutrition

Milieu Observation:
•	Clients observed eating lunch and participation in educational programming.
•	Met with clients as a group and one individually to discuss safety/well-being and the program.

Physical Plant:
•	Toured facilitated with Program Director and CEO. No safety concerns observed and the home was clean and maintained well.

Corrective Actions implemented as a result of previous visit:
A service development plan was submitted to DCF by Backcountry Wellness Residential group home following a June 2023 Licensing visit that addressed regulatory citations. The plan was accepted by the Department.

Areas of regulatory non-compliance identified during this visit:
NA

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

James Funaro  				Date:    9-8-23
Regulatory Consultant

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


summary: Visit conducted on 6-15-23. Visit covered 1 main areas/topics. Found 1 compliance issues.

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

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

NAME OF FACILITY / PROGRAM:           Backcountry Wellness Residential Group Home

TIME OF VISIT (FROM - TO):   11am-3:15pm            			 DATE: 6-15-23

AGENCY PERSONNEL WHO PARTICIPATED:
               Job Titles:
CEO
Program Director
Care Coach
Nurse
Therapist (2)
Clients (5)

List of Areas / Topics covered during visit:  This was a scheduled quarterly visit to obtain an update on the program and tour the physical plant to determine regulatory compliance. Additionally, a semi-annual personnel file review was conducted as well as a case record review for regulatory compliance.

A meeting was held with the CEO and Program Director. Topics discussed included:
•	Census = 6. Program is full.
•	Pending discharges and referrals
•	Staffing vacancies = 0
•	No calls for emergency services this quarter
•	Recreation outings
•	Listing group therapy on client treatment plans
•	Treatment plan review frequency and documentation
•	Garden
•	Visitors list
•	Use of periodic telehealth for therapy
•	Case record documentation
•	'Rock Ceremony' scheduled for today for client that will discharge soon

A meeting was held with the program Nurse. Topics discussed included:
•	Documentation of physical exams, dental exams, vision exams in client case records

Milieu Observation:
•	Teacher observed overseeing educational programming
•	Clients observed eating snack and lunch

Physical Plant:
•	Tour facilitated by Program Director. All areas appeared exceptionally clean and organized.
•	One sink out of order in a second floor bathroom with two sinks. Replacement reportedly on order.

Personnel File Review:
•	Two personnel files of new employees were reviewed remotely. See 'Areas of Regulatory Non-Compliance' below.

Case Record Review:
•	Two client case records were reviewed remotely. See 'Areas of Regulatory Non-Compliance' below.

Client Interviews:
•	A group interview was conducted with five residents.
•	All reported they feel safe in the program.
•	All report therapy and staff are very helpful.

Areas of regulatory non-compliance identified during this visit:

Section 46a-154. 	Internal monitoring, training and development of policies and procedures required and subject to state agency inspection.
1.	One personnel file (BP) did not contain evidence of restraint training provided by the facility.

Section 17a-145-94	Medical, Dental, Nursing Care.
Two client case records were reviewed. The following deficiencies were noted:
1.	Case record for one client (C.) does not contain documentation of a physical exam, dental exam, or vision exam.
2.	Case record for one client (H.) does not contain documentation of a physical exam.

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

Kathleen Forsythe, LCSW				Date:  6-16-23
Regulatory Consultant

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


summary: Visit conducted on 3-9-23. No compliance issues identified.

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

                                                           Field Visit Reporting Form

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

 NAME OF FACILITY / PROGRAM:           Backcountry Wellness Residential Group Home

 TIME OF VISIT (FROM - TO):     11:45am - 1:30pm                    		DATE:  3-9-23

 AGENCY PERSONNEL WHO PARTICIPATED:
Job Titles:
Program Director
Cook
Teacher
Direct Care Staff
Clients (6)
Nurse

List of Areas / Topics covered during visit:  This was an unannounced quarterly Licensing visit to obtain an update on the program and to tour the physical plant.

A meeting was held with the Program Director. The following topics were discussed:
•	Census = 6 females; 6 referrals on the waiting list; discharges in past three months; length of stays;
•	No incidents for restraint, AWOL, hospital visits, call for emergency services in the past three months;
•	No staff vacancies;
•	Additional nurse recently hired for evenings and weekends;
•	Cleaning crew on site three days per week; bathroom cleaning schedule; disinfection process after discharges
•	Infection control procedures for beds;
•	Holiday celebration activities;
•	Family involvement in program;
•	Treatment planning and review process;
•	Fire drill schedule;
•	Storage of water cooler bottles;
•	Biennial re-licensing inspection scheduled for Fall 2023.

The Program Director facilitated a tour of the physical plant:
•	All areas appeared exceptionally clean and organized;
•	Third floor/attic door found unsecured - corrected during visit;
•	Storage lockers scheduled for installation on first floor.

A meeting was held with the program nurse. Topics discussed:
•	Medication access, storage, destruction; Over-the counter medication & expiration date audits;
•	Documenting medication administration;
•	Medication refrigerator.

Milieu Observation:
•	Lunch prep & serving;
•	Interview with Cook;
•	Educational programming;
•	Group interview conducted with six clients.

Corrective Actions implemented as a result of previous visit: Not applicable.

Areas of regulatory non-compliance identified during this visit: None.

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

Kathleen Forsythe, LCSW                                			Date:  3-10-23
Regulatory Consultant

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


summary: Visit conducted on 12-8-22. Visit covered 14 main areas/topics. No compliance issues identified.

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

Field Visit Reporting Form

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

 NAME OF FACILITY / PROGRAM: Backcountry Wellness, LLC - Residential Group Home

 TIME OF VISIT (FROM - TO):       10:30am-1:00pm            DATE:  12-8-22

 AGENCY PERSONNEL WHO PARTICIPATED:
                                       Job Titles:
Chief Executive Officer
Program Director
Clients (5)
Care Coach
LPN day nurse
Therapist
Therapist/Culinary Director

List of Areas / Topics covered during visit: This was a scheduled quarterly Licensing visit to obtain an update on the program and to tour the physical plant. Additionally, a semiannual personnel file review was conducted. A meeting was held with the CEO and Program Director. The following areas were discussed:
•	Census = 6 females; program is full with a waiting list;
•	Staff vacancies = 0
•	Neighborhood;
•	Amended license issued last month to serve an age range of 11-20 years of age;
•	Group home approaching the one-year anniversary of opening;
•	Average length of stay and discharge planning;
•	Joint Commission accreditation awarded to Backcountry Wellness group home and outpatient psychiatric clinic for children last month for a three-year period;
•	Psychiatrist coverage;
•	Emergency planning, disaster/evaluation drills, future purchase of a house generator;
•	Culinary Director recently completed a graduate professional counseling degree and licensure and carries a small caseload in the group home;
•	Marketing, tracking referral sources;

Milieu Observation: Observed and conducted brief interviews with five residents in the kitchen while they finished morning snack. Residents explained the meal and snack schedule and routine. All five residents reported enjoying their stay at the group home very much. Two residents who had been in a placement prior to BCW group home reported that the BCW program was "the best" they had ever been in. Residents cited friendly staff, beautiful home, and helpful program as to what they liked best about BCW. Residents were later observed studying quietly during the educational program. One client was observed meeting with a therapist in a private room.

Physical Plant tour: All areas appeared extremely clean and organized. Discussed driveway repairs/additional parking area scheduled for 2023, and closing off unused bathroom in basement.

Personnel File review: A semi-annual personnel file review was conducted. Three personnel files were reviewed of new staff hired since July 2022. No regulatory deficiencies noted.

Corrective Actions implemented as a result of previous visit: N/A

Areas of regulatory non-compliance identified during this visit: None.

Kathleen Forsythe, LCSW                         			Date: 12-8-22
Regulatory Consultant

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


summary: Visit conducted on 9-7-22. No compliance issues identified. Implemented 1 corrective actions.

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

                                                      Field Visit Reporting Form

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

 NAME OF FACILITY / PROGRAM: Backcountry Wellness Residential Group Home

 TIME OF VISIT (FROM - TO):       10:30am-2:00pm                         DATE: 9-7-22

AGENCY PERSONNEL WHO PARTICIPATED:
Job Titles:
o	CEO
o	Program Director
o	Culinary Director
o	Care Coach
o	Clients (3)

List of Areas / Topics covered during visit:  This was a scheduled bimonthly visit to the group home for monitoring the program during its initial provisional license period.

Discussions:
•	Current census = 3
•	Meeting with CEO
•	Pursuing Joint Commission accreditation
•	Clinical coverage at the group home
•	Financial audit
•	Interstate compact requirements
•	Meeting with Program Director for program update
•	Restraint refresher training
•	Group therapies (family, DBT, medical, body image, art expression, cooking, etc.)
•	Structured program schedule reviewed
•	Utilization of office space
•	Milieu observation
•	Menus
•	Physical plant tour: all areas observed to be clean, organized and beautifully decorated
•	Client interviews during lunch
•	Fire drill documentation reviewed
•	Driveway appearance
•	Determination made to remove provisional license status and issue regular license

Corrective Actions implemented as a result of previous visit:
•	Completed service development plan submitted by BCW after last Licensing visit which addressed areas of criminal history background checks, DCF protective services background checks, physical exams, and TB testing during hire process for new staff.

Areas of regulatory non-compliance identified during this visit: None.

Kathleen Forsythe, LCSW                             			Date: 9-8-22
Regulatory Consultant

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


summary: Visit conducted on 7-12-22. Visit covered 5 main areas/topics. Found 5 compliance issues.

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

Field Visit Reporting Form

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

 NAME OF FACILITY / PROGRAM:        Backcountry Wellness Residential Group Home

 TIME OF VISIT (FROM - TO):      11:00am-2:15pm                                                 DATE: 7-12-22

 AGENCY PERSONNEL WHO PARTICIPATED:
                      Job Titles:
Chief Executive Officer
Program Director
Regional Program Director
Clients (5)
Property Manager
DCF Regulatory Consultant

List of Areas / Topics covered during visit:  This was a scheduled Licensing visit to conduct a semiannual personnel file review and tour the physical plant for determination in issuing a continued provisional license.
•	Meeting with CEO
•	Semiannual personnel file review
•	Program update meeting with Program Director and Regional Program Director
•	Milieu observation/client interview meeting
•	Physical Plant tour

Corrective Actions implemented as a result of previous visit: N/A

Areas of regulatory non-compliance identified during this visit:

17a-145-63	Chief Executive Officer.
•	The facility failed to secure the results of a criminal history background check through the Connecticut State Police prior to the employee assuming duties for two employees (DV, RBo).

•	The facility failed to secure the results of a child protective services background check through DCF prior to hire for two employees (MM, SBP).

17a-145-64	Personnel Policies and Procedures.
•	The facility failed to secure evidence of a physical exam that was conducted immediately prior to assuming duties for four employees (AR, RBo, RBy, SBP).

•	The facility failed to secure the results of TB testing that was conducted immediately prior to assuming duties for four employees (AR, RBo, RBy SBP).

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

Kathleen Forsythe, LCSW       				Date:    7-13-22
Regulatory Consultant

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

type: general

description: 63 Chief Executive Officer.


summary: Visit conducted on _5-4-22_______. No compliance issues identified. Implemented 1 corrective actions.

raw_content:
Field Visit Reporting Form

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

NAME OF FACILITY / PROGRAM: Backcountry Wellness Residential Group Home__________________

TIME OF VISIT (FROM - TO):       10:30am-2:00pm__________               DATE: _5-4-22_______

AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:
CEO
Property Manager
Chef
Program Director
Day LPN Nurse
Care Coaches (2)
One male and Three female clients

List of Areas / Topics covered during visit:  This was a scheduled visit to obtain a program update, tour the physical plant and interview clients. One case record review was conducted remotely after the visit. This new program is currently in a second provisional license period while the Dept. continues to monitor activities.

Discussions:
•	Menu review & documentation; grocery delivery; food storage; Registered Dietician menu approval
•	Welcome visit from neighbor
•	Program daily schedule
•	Recreation activities
•	Improvements to the physical plant; addition of doors on dining room
•	Enhancing privacy on windows
•	Garden installation and driveway expansion proposed for summer
•	Feedback given to Property Manager during physical plant tour
•	Window screens; privacy film
•	Age range of clients served
•	Case overview on client M.
•	Client interviews
•	One case record review

Observation
•	Lunch activities
•	Physical Plant

Corrective Actions implemented as a result of previous visit:
•	Window privacy film added to bathrooms

Areas of regulatory non-compliance identified during this visit: None

Kathleen Forsythe, LCSW
______________________________            ___5-6-22_______
Regulatory Consultant                                   Date

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM
Cc: J. Zweiman|


facility_name: Community Health Resources, Inc / CHR / Brook Hous

summary: Visit covered 13 main areas/topics. Found 1 compliance issues.

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

Field Visit Reporting Form

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

NAME OF FACILITY / PROGRAM: CHR/Brook House Group Home

TIME OF VISIT (FROM-TO) 11:30am to 2:00pm:             DATE: November 6, 2025

AGENCY PERSONNEL WHO PARTICIPATED:

Job Title
Program Director

Areas / Topics covered during visit:

•	Census: The program had four residents placed at the facility at the time of the quarterly visit.
•	Admissions: In the last quarter, the program confirmed that there was one new admission.
•	Discharges: The program reported that in the last quarter there were no discharges.
•	Staffing: The facility staffing consists of eight full-timers, two part-timers and four per-diem employees.
•	Staff vacancies: The program reported that it has one part-time and two per-diem employees' vacancies.
•	Staff hires: The program reported that there were two per-diem employees, and a nurse hired in the last quarter.
•	Physical plant: A walkthrough of the building was conducted with the program director to evaluate the program's compliance with regulatory standards.

SIU Reports: During the past quarter, licensing responded to two incidents and completed two incident response notes. The first incident occurred on 9/28/25, and it involved a youth going AWOL and using Marijuana on the premises of the group home.  The second incident occurred 10/30/25, and it involved a youth reporting that she did not feel safe at the group home.

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

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

Areas of regulatory non-compliance identified during this visit:
17a-145-63: Chief Administrative Officer. Upon review of case record documentation, it was noted on multiple occasions that staff documented clients vaping or smoking marijuana in their rooms or in common areas of the facility. There were also reports of a resident attempting to sell marijuana to other residents on the premises of the group home. There was no documentation in the files showing that actions taken to address these issues had been effective, but records indicate that high-risk behaviors have continued.

It has been determined that the program is not effectively ensuring the safety and well-being of the children in the group home. Despite efforts to address these issues, there continues to be an increase in high-risk behaviors at the facility. As a result, the children remain at risk for harm, and the program's ability to provide a safe and secure environment for them is in question.

Statute 17a-16: Rights of Children.  Upon review of case record documentation, it was noted that on two occasions staff denied a client access to the telephone as a form of discipline for inappropriate behaviors. This is a violation of regulatory statutes.

Please submit a plan of correction to address the above referenced areas of non-compliance within 7 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Penny Woodward, LCSW                         November 17, 2025
Regulatory Consultant                                           Date

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

regulation: Rights of Children.

facility_name: CHR/Brook House Group Home


raw_content:
April 23, 2025

Community Health Resources
2 Waterside Crossing
Windsor, CT. 06095

Re: Bi-annual licensing inspection was conducted at the Community Health Resources Brook House Group Home located in Enfield, CT, Consultant Penny Woodward and Nurse Errorlee Miller.

On 4/7/25 and 4/8/25, a bi-annual re-licensing inspection was conducted at the Brook House Program to determine compliance with Regulations for Operation of Child-Caring Agencies and Facilities 17a-145-48 through 17a-145-98, as well as the DCF Guidelines for the Administration of Medication by certified staff.

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

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

Section 17a-145-63: Chief Administrative Officer.
(Evidence) Upon reviewing incident reports, it was noted that residents have repeatedly refused to comply with the group home rules. If these incidents are not addressed promptly and appropriately, they have the potential to pose a safety risk to both the individuals involved and others within the program.

(Evidence) Upon inspection of the physical plant, the front door was worn from daily use, and it needs to be addressed.

Section 17a-145-74: Lavatory Facilities.
(Evidence) Upon inspection of the physical plant, the second-floor bathroom contained a light fixture with a rusted frame, and it needs to be addressed.

Section 17a-145-76: Kitchen.
(Evidence) Upon inspection of the physical plant, the dishwasher door was dented, and it needs to be addressed.

Section 17a-145-86: Instruction in Safety Procedure. Supervision.
(Evidence) Upon review of fire drill records, for 2024 there was no first shift drill conducted in the first quarter, and in 2025, there was no third shift conducted in the first quarter.

Once a finding is made that your agency has satisfactorily addressed the regulatory compliance issues, and all required supplementary materials have been received, the Department of Children and Families will be prepared to issue a regular license. Failure to submit a plan of correction or successfully implement a plan will result in the refusal to renew the license. Should you have any questions or comments regarding the contents of this report, please do not hesitate to call me at (959) 255-0615.

Sincerely,

Penny Woodward

Penny Woodward, LCSW
Regulatory Consultant
Department of Children and Families
505 Hudson Street
Hartford, CT. 06016
Phone: 959-255-0615
Fax: 860-550-6665
penny.woodward@ct.gov|


summary: Visit covered 12 main areas/topics. No compliance issues identified.

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

Field Visit Reporting Form

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

NAME OF FACILITY / PROGRAM: CHR/Brook House Group Home

TIME OF VISIT (FROM - TO) 11:00am to 12:30pm:         DATE: January 15, 2025

AGENCY PERSONNEL WHO PARTICIPATED:

Job Title
Program Director

Areas / Topics covered during visit:

•	Census: The program census were four youths at the time of the scheduled quarterly visit.
•	Admissions: In the last quarter the program confirmed that there was one new
  admissions.
•	Discharges: The program confirmed that in the last quarter there was one discharge.
•	Staffing: The facility staffing consists of six full-timers, four part-timers and two per-diem employees.
•	Staff vacancies: The group home has a therapist vacancy and two part-time vacancies.
•	Physical plant: A walkthrough of the building was conducted with the program director and the facility was being maintained according to regulatory standards.
•	Personnel: Employee records were not reviewed during the quarterly visit.
•	SIU Reports: There were no reports in this quarter.

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

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

Areas of regulatory non-compliance identified during this visit:
N/A

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

Penny Woodward, LCSW                         January 28, 2025
Regulatory Consultant                                   Date

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


summary: No compliance issues identified.

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

Field Visit Reporting Form

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

NAME OF FACILITY/PROGRAM: CHR/Brook House Group Home

TIME OF VISIT (FROM – TO): 11:00am to 1:00pm          DATE: October 8, 2024

AGENCY PERSONNEL WHO PARTICPATED:

Job Title
Brook House Program Director

Areas/Topics covered during visit:
•	Census: The program census was three youths at the time of the scheduled quarterly visit.
•	Admissions: In the last quarter the group home confirmed that there were two new admissions.
•	Discharges: The program confirmed that in the last quarter there were no discharges.
•	Staffing: The group home staffing consisted of six full-timers, four part-timers and two per-diem employees.
•	Staff vacancies: The program continues to have a clinician vacancy, two part-time vacancies and two per-diem vacancies.
•	Physical plant: A walkthrough of the building was conducted with the program director and the facility was being maintained according to regulatory standards.

•	Personnel records: Employees records and files were not reviewed in this quarter.

•	SIU reports: There were no reports in this quarter.

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

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

Areas of regulatory non-compliance identified during this visit:
N/A

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

Penny Woodward, LCSW                       October 22, 2024
Regulatory Consultant                                   Date

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


summary: Visit conducted on August 8, 2024. Visit covered 11 main areas/topics. No compliance issues identified.

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

Field Visit Reporting Form

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

  NAME OF FACILITY / PROGRAM: CHR/Brook House Group Home

 TIME OF VISIT (FROM - TO): 11:00am to 12:15pm              DATE: August 8, 2024

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Title
Brook House Program Director

Areas / Topics covered during visit:
•	Census: The program census was one resident at the time of the scheduled quarterly visit.
•	Admissions: In the last quarter the group home confirmed that there were no new admissions.
•	Discharges: The program confirmed that in the last quarter there were no discharges.
•	Staffing: The group home staffing consisted of six full-timers, four part-timers and two per diem employees.
•	Staff vacancies: The program has a clinician vacancy, two part-time vacancies and two per diem vacancies.
•	Physical plant: A walkthrough of the building was conducted with the program director and the facility was being maintained according to regulatory requirements.
•	Personnel records: Three employee files were reviewed on July 2, 2024, and all records contained the required criminal background checks.
•	SIU Reports: There were no reports in this quarter.

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

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

Areas of regulatory non-compliance identified during this visit:
N/A

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

Penny Woodward LCSW                          August 20, 2024
Regulatory Consultant                                   Date

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

visit_date: August 8, 2024


summary: Visit conducted on April 17, 2024. Visit covered 12 main areas/topics. No compliance issues identified. Includes 1 recommendations.

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

Field Visit Reporting Form

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

NAME OF FACILITY / PROGRAM: CHR/Brook House Group Home

 TIME OF VISIT (FROM - TO): 11:30am to 1:30pm                     DATE: April 17, 2024

AGENCY PERSONNEL WHO PARTICIPATED:

Job Title

Service Director

Areas / Topics covered during visit:

•	Census: The program census was one youth at the time of the scheduled quarterly visit.
•	Admissions: In the last quarter the program confirmed that there were no new admissions.
•	Discharges: The program confirmed that in the last quarter there were two discharges.
•	Staffing: The facility staffing consists of eight full-timers, four part-timers and four per-diem employees.
•	Staff vacancies: The group home has a director vacancy, a therapist vacancy and a part-time, 16-hour vacancy.
•	Physical plant: A walkthrough of the building was conducted with the service director and the facility was being maintained according to regulatory standards.
•	Personnel: Employee records were not reviewed during the quarterly visit.

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

Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning)
Upon inspection of the facility, bedroom four was unkempt and personal items in the closet were not properly stored. The room needs to be cleaned and better maintained. DCF is recommending that when the census increases, group home staff should work with residents on a consistent basis to keep rooms better organized.

Areas of regulatory non-compliance identified during this visit:
N/A

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

Penny Woodward, LCSW                          April 30, 2024
Regulatory Consultant                                      Date

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


summary: Visit conducted on January 25, 2024. No compliance issues identified.

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

Field Visit Reporting Form

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

NAME OF FACILITY / PROGRAM: CHR/Brook House Group Home

 TIME OF VISIT (FROM - TO): 11:15am to 2:00pm                     DATE: January 25, 2024

AGENCY PERSONNEL WHO PARTICIPATED:

Job Title
Brook House Program Director

Areas / Topics covered during visit:
The census was three female youths at the time of the quarterly visit and the group home's licensed bed capacity remains at five. A walkthrough of the physical plant was conducted with the Brook House Director and feedback was given on how the program could better maintain residents' bedrooms.

SIU Reports: The program had two SIU reports in the last quarter (10/31/23 and 12/11/23) that required follow-up and please see reports in file for additional information.

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

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

Areas of regulatory non-compliance identified during this visit:
N/A

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

Penny Woodward, LCSW                          February 7, 2023
Regulatory Consultant                                   Date

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

visit_date: January 25, 2024


summary: Visit conducted on November 7, 2023. Visit covered 1 main areas/topics. No compliance issues identified.

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

Field Visit Reporting Form

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

NAME OF FACILITY / PROGRAM: CHR/Brook House Group Home

TIME OF VISIT (FROM - TO): 11:00am to 1:30pm                     DATE: November 7, 2023

AGENCY PERSONNEL WHO PARTICIPATED:

Job Title
Brook House Program Director

Areas / Topics covered during visit:
The census was four female youths at the time of the quarterly visit and the group home's licensed bed capacity remains at five.  The program has two part-time vacancies and the agency expects to fill positions soon. A walkthrough of the physical plant was conducted with the Brook House Director and the facility was being maintained according to regulatory standards.

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

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

Areas of regulatory non-compliance identified during this visit:
N/A

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

Penny Woodward, LCSW                          December 6, 2023
Regulatory Consultant                                   Date

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

visit_date: November 7, 2023


summary: Visit conducted on July 27, 2023. Visit covered 1 main areas/topics. Found 1 compliance issues.

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

Field Visit Reporting Form

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

 NAME OF FACILITY/PROGRAM: CHR/ Brook House Group Home

 TIME OF VISIT (FROM - TO): 11:45am to 1:30pm                     DATE: July 27, 2023

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Title        Brook House Program Director

Areas / Topics covered during visit:
The census was five females at the time of the quarterly visit and the group home's licensed capacity is five. The program reported that there were two part-time staff vacancies and both positions are expected to be filled soon.  A walkthrough of the physical plant was conducted with the director and several deficiencies were identified.

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

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

Areas of regulatory non-compliance identified during this visit:
Section 17a-145-74: Lavatory facilities: Upon inspection of the physical plant, the upstairs' bathroom ceiling (in the shower area) contained a small black stain and it needs to be addressed.

Section 17a-145-77. Dining areas and supervision: Upon inspection of the physical plant, one of the dining room's walls contained two large repair patches and they need to be addressed.

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

Penny Woodward, LCSW                              August 14, 2023
Regulatory Consultant                                            Date

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

description: Section 17a-145-77.


raw_content:
May 23, 2023

Community Health Resources
2 Waterside Crossing
Windsor, CT. 06095

Re: Bi-annual licensing inspection was conducted at the Community Health Resources Brook House Group Home located in Enfield, CT, Consultants: Penny Woodward and Patrick Hughes.

On 5/2/23 and 5/3/23, a bi-annual re-licensing inspection was conducted at the Brook House Program to determine compliance with Regulations for Operation of Child-Caring Agencies and Facilities 17a-145-48 through 17a-145-98, as well as the DCF Guidelines for the Administration of Medication by certified staff.

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

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

Section 17a-145-61: Written policies and procedures.
(Evidence) Upon review of the program manual, some of the group home's policies were outdated and did not always reflect current practices.

Section 17a-145-63: Chief administrative officer.
(Evidence) Upon review of milieu documentation, clients were reported to be smoking at the facility while under the supervision of staff and the lack of intervention at the time of the incident by the program did not ensure the safety of residents at the group home.

 Section 17a-145-73: Sleeping accommodations.
(Evidence) Upon inspection of the physical plant, bedroom three contained a wall that had noticeable scuff marks and it needs to be addressed. Bedroom six's ceiling contained a large indentation from a recent construction project and it needs to be addressed.

 Section 17a-145-74: Lavatory Facilities.
(Evidence) Upon inspection of the physical plant, the second-floor bathroom contained cracked waterproof sealant around the shower area and it needs to be addressed.

Section 17a-145-86: Instruction in safety procedure. Supervision.
(Evidence) Upon review of fire drill records for 2021, a first shift drill was conducted on the second shift and it had not been done according to regulatory requirements. A first shift drill was not conducted by the program in the second quarter as required by regulations.

Section 17a-145-98: Case records.
(Evidence) Upon inspection of case records, all clients did not have placement agreements as required by regulations.

Once a finding is made that your agency has satisfactorily addressed the regulatory compliance issues, and all required supplementary materials have been received, the Department of Children and Families will be prepared to issue a regular license. Failure to submit a plan of correction or successfully implement a plan will result in the refusal to renew the license. Should you have any questions or comments regarding the contents of this report, please do not hesitate to call me at (959) 255-0615.

Sincerely,

Penny Woodward

Penny Woodward, LCSW
Regulatory Consultant
Department of Children and Families
505 Hudson Street
Hartford, CT. 06016
Phone: 959-255-0615
Fax: 860-550-6665
penny.woodward@ct.gov|


summary: Visit conducted on March 21, 2023. Visit covered 1 main areas/topics. No compliance issues identified.

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

Field Visit Reporting Form

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

NAME OF FACILITY / PROGRAM: CHR/Brook House Group Home

 TIME OF VISIT (FROM - TO): 10:30am to 12:00pm                     DATE: March 21, 2023

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Title
Brook House Program Director

Areas / Topics covered during visit:
The census was four females at the time of the quarterly visit and the group home's licensed bed capacity is five.  The program reported that there was one part-time vacancy and the agency expects to fill the position soon. A walkthrough of the physical plant was conducted with the Brook House Director and it was confirmed that the facility was being maintained according to regulatory standards.

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

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

Areas of regulatory non-compliance identified during this visit:
N/A

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

Penny Woodward, LCSW                          April 18, 2023
Regulatory Consultant                                   Date

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


facility_name: Community Health Resources, Inc. / Mills / GH #55

summary: Visit conducted on December 12, 2025. Visit covered 13 main areas/topics. No compliance issues identified.

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

Field Visit Reporting Form

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

 NAME OF FACILITY / PROGRAM: CHR /Mills House Group Home

 TIME OF VISIT (FROM - TO): 11:00am to 12:00pm       DATE: December 12, 2025

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Title
Program Supervisor

Areas / Topics covered during visit:

•	Census: The group home has four youths at the facility and the bed capacity remains full.
•	Admissions: There were no new admissions in the last quarter.
•	Discharges: There were no discharges in the last quarter.
•	Staff: The group home staffing included five full-timers, two part-timers and ten per-diem employees.
•	Staff vacancies: The program has two vacancies and expects to fill the positions soon.
•	Staff hires: The group home has hired one full-time employee and the worker's start date will be 1/5/26
•	Medication: The program currently has seventeen medication certified employees at the facility.
•	Physical plant: A walkthrough of the facility was conducted with the program supervisor to confirm the group home's compliance with regulatory standards.
•	Personnel files: An audit of personnel records was not conducted in this quarter.

During the past quarter, licensing responded to one incident and completed one incident response note. The incident occurred on 8/27/25, and it involved aggressive physical contact by a staff toward a resident.

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

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

Areas of regulatory non-compliance identified during this visit:
N/A

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

Penny Woodward, LCSW                                   December 16, 2025
Regulatory Consultant                                            Date

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

facility_name: CHR /Mills House Group Home

visit_date: December 12, 2025


raw_content:
10/16/25

Community Health Resources
2 Waterside Crossing
Windsor, CT 06095

Re: Bi-annual licensing inspection at the Mills House Group Home located in Windsor, CT. Regulatory Consultant Penny Woodward and Nurse Errolee Miller.

On 9/23/25 and 9/24/25, a bi-annual inspection was conducted at the Mills House Group Home to determine compliance with Regulations for Operation of Child-Caring Agencies and Facilities 17a-145-48 through 17a-145-98, as well as the DCF Guidelines for the Administration of Medication by certified staff.

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

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

Section 17a-145-63: Chief administrative officer.
(Evidence)
Upon inspection of the physical plant, the aluminum downspout located outside and on the right side of the building was covered in an unknown substance and it needs to be addressed.

(Evidence)
The outside AC Unit contained a plastic wall attachment that contained a hole, and it needs to be addressed.

Section 17a-145-75: Health and medical treatment.
(Evidence)
Upon evaluation of the medication administration system, 90-day written orders were not always kept up to date for residents at the facility as required by regulation.

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

Please contact me as soon as the regulatory violations have been addressed.  Should you have any questions or comments regarding the contents of this report please do not hesitate to call me at (959) 255-0615.

Sincerely,

Penny Woodward

Penny Woodward, LCSW
Regulatory Consultant
Cc: File|


summary: Visit conducted on June 24, 2025. Visit covered 8 main areas/topics. No compliance issues identified.

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

Field Visit Reporting Form

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

NAME OF FACILITY / PROGRAM: CHR /Mills House Group Home

 TIME OF VISIT (FROM - TO): Morning visit                         DATE: June 24, 2025

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Title

Program Supervisor

Areas / Topics covered during visit:

•	Census: The group home has four youths at the facility and the bed capacity is reported to be full.
•	Admissions: There were no new admissions in the last quarter.
•	Discharges: There were no discharges in the last quarter.
•	Staff vacancies: The program has a per-diem vacancy and anticipates filling the position soon.
•	Staff hires: The group home has selected two candidates to fill the vacant positions, however their start dates have not yet been determined.
•	Medication: The program currently has fourteen medication certified employees at the facility.
•	Physical plant: A walkthrough of the facility was conducted with the program supervisor to evaluate the group home's compliance with regulatory standards.

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

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

Areas of regulatory non-compliance identified during this visit:
N/A

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

Penny Woodward, LCSW                                   July 8, 2025
Regulatory Consultant                                              Date

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

visit_time: Morning


summary: Visit conducted on February 26, 2025. Visit covered 9 main areas/topics. No compliance issues identified.

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

Field Visit Reporting Form

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

NAME OF FACILITY / PROGRAM: CHR /Mills House Group Home

TIME OF VISIT (FROM - TO): 11:00am to 12:48pm            DATE: February 26, 2025

AGENCY PERSONNEL WHO PARTICIPATED:

Job Title
Program Director

Areas / Topics covered during visit:

•	Census: The group home has four youths at the facility and the bed capacity is reported to be full.
•	Admissions: There was one new admission in the last quarter.
•	Discharges: There was no discharge in the last quarter.
•	Staff vacancies: The group home has two staff vacancies, and the agency is actively looking to fill positions.
•	Staff hires: The group home hired four per-diem workers in the last quarter.
•	Medication: The program currently has fourteen medication certified employees at the facility. The group home nurse resigned in February, and coverage is being provided by another nurse until a replacement is hired.
•	Physical plant: A walkthrough of the facility was conducted with the program director to assess the program's compliance with regulatory standards.
•	Personnel: On 2/5/25, three employee records were reviewed, and all files contained the required background check information.

SIU Reports: During the past quarter, licensing responded to one incident and completed one incident response note. The incident occurred on 11/6/24, and it involved a medication error.

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

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

Areas of regulatory non-compliance identified during this visit:
N/A

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

Penny Woodward, LCSW                                  March 7, 2025
Regulatory Consultant                                            Date

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

visit_date: February 26, 2025


summary: Visit conducted on December 17, 2024. Visit covered 9 main areas/topics. No compliance issues identified.

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

Field Visit Reporting Form

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

  NAME OF FACILITY / PROGRAM: CHR /Mills House Group Home

 TIME OF VISIT (FROM - TO): 11:00am to 12:40pm                       DATE: December 17, 2024

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Title
Program Director
Program Supervisor

Areas / Topics covered during visit:

•	Census: The group home has three youths at the facility and the bed capacity remains at four.
•	Admissions: There were no new admissions in the last quarter.
•	Discharges: There was one discharge in the last quarter.
•	Staff vacancies: The group home has one staff vacancy, and the position is expected to be filled soon.
•	Staff hires: The group home hired one new per-diem staff in the month of October.
•	Medication: The program currently has fourteen medication certified employees at the facility.
•	Physical plant: A walkthrough of the facility was conducted with the program director and the building is being maintained according to regulatory standards.
•	Personnel: Employee records and files were not reviewed during the quarterly visit.

During the past quarter, licensing responded to one incident and completed one incident response note.  The incident occurred on 6/23/24, was reported to DCF on 10/29/24, and it involved plumbing issues at the facility.

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

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

Areas of regulatory non-compliance identified during this visit:
N/A

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

Penny Woodward, LCSW                            December 18, 2024
Regulatory Consultant                                             Date

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

visit_date: December 17, 2024

personnel:
Program Director
Program Supervisor


summary: Visit conducted on September 5, 2024. Visit covered 10 main areas/topics. No compliance issues identified.

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

Field Visit Reporting Form

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

NAME OF FACILITY / PROGRAM: CHR /Mills House Group Home

 TIME OF VISIT (FROM - TO): 11:30am to 1:00pm                       DATE: September 5, 2024

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Title
Program Director

Areas / Topics covered during visit:

•	Census: The group home has three residents at the facility and the bed capacity remains at four.
•	Admissions: There were no new admissions in the last quarter.
•	Discharges: There were no discharges in the last quarter.
•	Staff vacancies: The group home has three staff vacancies and open positions are expected to be filled soon.
•	Staff hires: The group home hired one new per-diem staff in the last quarter.
•	Medication: The program currently has fourteen medication certified employees at the facility.
•	Physical plant: A walkthrough of the facility was conducted with the program director and the building was being maintained according to regulatory requirements.
•	Personnel: Two employee records were reviewed on July 2, 2024, and both files contained the required criminal background checks.
•	SIU Reports: There were no reports in this quarter.

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

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

Areas of regulatory non-compliance identified during this visit:
N/A

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

Penny Woodward, LCSW                            September 19, 2024
Regulatory Consultant                                     Date

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

visit_date: September 5, 2024


summary: Visit conducted on May 23, 2024. Visit covered 8 main areas/topics. No compliance issues identified.

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

Field Visit Reporting Form

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

NAME OF FACILITY / PROGRAM: CHR /Mills House Group Home

 TIME OF VISIT (FROM - TO): 11:25am to 12:30pm                       DATE: May 23, 2024

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Title
Program Director

Areas / Topics covered during visit:

•	Census: The group home currently has three male youths at the facility and the bed capacity remains at four.
•	Admissions: There was one new admission in the last quarter.
•	Discharges: The group home reported that there were no discharges in the last quarter.
•	Staff vacancies: The group home has no vacancies and the program is operating at full capacity.
•	Staff hires: The group home hired one new residential counselor in the last quarter.
•	Medication: The program currently has fifteen medication certified employees at the facility.
•	Physical plant: A walkthrough of the facility was conducted with the program director and the building was being maintained according to regulatory requirements.
•	Personnel: Employee records and files were not reviewed during the quarterly visit.

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

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

Areas of regulatory non-compliance identified during this visit:
N/A

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

Penny Woodward, LCSW                            June 7, 2024
Regulatory Consultant                                     Date

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


summary: Visit conducted on March 13, 2024. Visit covered 10 main areas/topics. No compliance issues identified.

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

Field Visit Reporting Form

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

NAME OF FACILITY / PROGRAM: CHR /Mills House Group Home

 TIME OF VISIT (FROM - TO): 11:00am to 12:15pm                       DATE: March 13, 2024

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Title
Program Director

Areas / Topics covered during visit:

•	Census: The program's bed capacity has not changed and it remains at four.
•	Admissions: The program reported that there were no new admissions in the last quarter.
•	Discharges: The program reported that there were no planned or unplanned discharges since the last quarterly visit.
•	Staff vacancies: The group home has one staff vacancy and a candidate has been selected to fill the position.
•	Staff Hires: In the last quarter, a per-diem position and a 16-hour part-time position were filled.
•	Physical Plant: A walkthrough of the facility was conducted with the program director and the building was being maintained according to regulatory standards.
•	Medication: The nursing status remains the same and the program has fifteen medication certified employees.

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

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

Areas of regulatory non-compliance identified during this visit:
N/A

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

Penny Woodward, LCSW                            April 2, 2024
Regulatory Consultant                                     Date

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


summary: Visit conducted on October 2, 2023. Visit covered 1 main areas/topics. No compliance issues identified.

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

Field Visit Reporting Form

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

  NAME OF FACILITY / PROGRAM: CHR /Mills House Group Home

 TIME OF VISIT (FROM - TO): 11:00am to 2:00pm                     DATE: October 2, 2023

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Title
Program Director

Areas / Topics covered during visit:
It was reported that there were two youths placed at the facility and the group home's licensed bed capacity continues to be four.  The program reported that there was one vacant part-time position that is expected to be filled soon. A walkthrough of the physical plant was conducted with the group home director and no citations were identified. The kitchen area has been refurbished and the cabinets, floor and backsplash areas have been updated.

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

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

Areas of regulatory non-compliance identified during this visit:
N/A

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

Penny Woodward, LCSW                          October 31, 2023
Regulatory Consultant                                   Date

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

visit_date: October 2, 2023


raw_content:
9/8/23

Re: Bi-annual licensing inspection at the Mills House Group Home located in Windsor, CT. Regulatory Consultants: Penny Woodward and Patrick Hughes.

On 8/30/23 and 8/31/23, a bi-annual inspection was conducted at the Mills House Group Home to determine compliance with Regulations for Operation of Child-Caring Agencies and Facilities 17a-145-48 through 17a-145-98, as well as the DCF Guidelines for the Administration of Medication by certified staff.

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

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

Section 17a-145-63: Chief administrative officer.
(Evidence)
Upon inspection of the physical plant, the front patio contained wood flooring that was rotted and in disrepair and it needs to be addressed.

Section 17a-145-64: Personnel policies and procedure.
(Evidence) Upon review of personnel files, one record contained a CT State Police check that was completed after the employee's hire date and one file contained a CT DCF check that was completed after the employee's hire date.

Section 17a-145-71: Living room lounge.
(Evidence) Upon review of the physical plant, the first floor and second floor lounges' ceilings contained unpainted areas from the removal of electronic devices and they need to be addressed.

Section 17a-145-73: Sleeping accommodations.
(Evidence) Upon inspection of the physical plant, the ceilings in bedrooms two and four  contained unpainted areas from the removal of electronic devices and they need to be addressed.

Section 17a-145-74: Lavatory facilities.
(Evidence) Upon inspection of the physical plant, bathroom one contained a vent light that had not been properly cleaned and it needs to be addressed.

 Section: 17a-145-98: Case records.
(Evidence) Upon review of case records, one file did not contain a discharge summary that included information on who the client was discharged to as required by regulations.

Once a finding is made that your agency has satisfactorily addressed the regulatory compliance issues, and all required supplementary materials have been received, the Department of Children and Families will be prepared to issue a regular license. Failure to submit a plan of correction or successfully implement a plan will result in the refusal to renew the license.  Please contact me as soon as the regulatory violations have been addressed.  Should you have any questions or comments regarding the contents of this report please do not hesitate to call me at (959) 255-0615.

Sincerely,

Penny Woodward, LCSW
Regulatory Consultant

Cc: File|


summary: Visit conducted on May 25, 2023. Visit covered 1 main areas/topics. No compliance issues identified.

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

Field Visit Reporting Form

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

NAME OF FACILITY / PROGRAM: CHR /Mills House Group Home

 TIME OF VISIT (FROM - TO): 11:30pm to 1:00pm                     DATE: May 25, 2023

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Title
Program Director

Areas / Topics covered during visit:
The program census was one male youth and one transgender youth and the group home's licensed bed capacity is four.  The program reported that there were two part-time vacancies and the agency expects to fill positions soon.
A walkthrough of the physical plant was conducted with the group home director and no citations were identified.

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

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

Areas of regulatory non-compliance identified during this visit:
N/A

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

Penny Woodward, LCSW                          May 26, 2023
Regulatory Consultant                                   Date

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


summary: Visit conducted on March 21, 2023. Visit covered 3 main areas/topics. No compliance issues identified.

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

Field Visit Reporting Form

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

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

Field Visit Reporting Form

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

NAME OF FACILITY / PROGRAM: CHR /Mills House Group Home

 TIME OF VISIT (FROM - TO): 12:30pm to 1:30pm                     DATE: March 21, 2023

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Title
                                                                         Program Director

Areas / Topics covered during visit:
The group home census was one male youth and one transgender youth and the program's licensed bed capacity is four.  The program reported that there was one part-time vacancy, one full-time vacancy and a candidate has been selected to fill the full-time position. A walkthrough of the physical plant was conducted with the director and no citations were identified.

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

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

Areas of regulatory non-compliance identified during this visit:
N/A

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

Penny Woodward, LCSW                          April 18, 2023
Regulatory Consultant                                   Date

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


summary: Visit conducted on November 29, 2022. No compliance issues identified.

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

Field Visit Reporting Form

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

  NAME OF FACILITY / PROGRAM: CHR /Mills House Group Home

 TIME OF VISIT (FROM - TO): 10:30pm to 11:00pm                     DATE: November 29, 2022

 AGENCY PERSONNEL WHO PARTICIPATED:

Name	Job Title
N/A	                       Program Director

Areas / Topics covered during visit:
The Department of Children and Families conducted a scheduled quarterly inspection visit at the Mills House Program on November 29, 2022.  Topics covered during the quarterly visit included staffing and training, physical plant inspection and medication administration system.

Physical plant: A walkthrough of the facility was conducted with the group home director to confirm the program was following and in compliance with regulatory requirements.

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

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

Areas of regulatory non-compliance identified during this visit:
N/A

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

Penny Woodward, LCSW                          January 5, 2023
Regulatory Consultant                                   Date

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

visit_date: November 29, 2022

personnel: N/A	                       Program Director


summary: Visit conducted on September 1, 2022. No compliance issues identified.

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

Field Visit Reporting Form

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

  NAME OF FACILITY / PROGRAM: CHR /Mills House Group Home

 TIME OF VISIT (FROM - TO): 10:30pm to 12:00pm                     DATE: September 1, 2022

 AGENCY PERSONNEL WHO PARTICIPATED:

Name	Job Title
N/A	                       Program Director

Areas / Topics covered during visit:
The Department of Children and Families conducted a scheduled quarterly inspection visit at the Mills House Program on September 1, 2022.  Topics covered during the quarterly visit included staffing and training, physical plant inspection and medication administration system.

Physical plant: A walkthrough of the facility was conducted with the program director to confirm the program was following and in compliance with regulatory requirements.

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

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

Areas of regulatory non-compliance identified during this visit:
N/A

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

Penny Woodward, LCSW                          September 23, 2022
Regulatory Consultant                                   Date

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

visit_date: September 1, 2022


summary: Visit conducted on May 24, 2022. Found 2 compliance issues.

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

Field Visit Reporting Form

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

  NAME OF FACILITY / PROGRAM: CHR /Mills House Group Home

 TIME OF VISIT (FROM - TO): 11:00pm to 12:30pm                     DATE: May 24, 2022

 AGENCY PERSONNEL WHO PARTICIPATED:

Name	Job Title
N/A	                       Program Director

Areas / Topics covered during visit:
The Department of Children and Families conducted a scheduled quarterly inspection visit at the Mills House Group Home on May 24, 2022.  Topics covered during the quarterly visit included staffing and training, physical plant inspection, and medication administration system.

Physical plant: During the quarterly visit a walkthrough of the facility was conducted with the director and citations were identified. Please see citations that are listed below in the area of regulatory non-compliance section.

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

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

Areas of regulatory non-compliance identified during this visit:
17a-145-74. Lavatory facilities: The second-floor bathroom contained a window frame that was misaligned and a clogged sink and they need to be addressed.

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

Penny Woodward, LCSW                          June 28, 2022
Regulatory Consultant                                   Date

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

description: 74. Lavatory facilities: The second


facility_name: Community Health Resources, Inc./ Grant House GH

summary: Visit conducted on June 25, 2025. Visit covered 8 main areas/topics. No compliance issues identified.

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

Field Visit Reporting Form

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

NAME OF FACILITY / PROGRAM: CHR /Grant House Group Home

 TIME OF VISIT (FROM - TO): 11:30am to 1:00pm                       DATE: June 25, 2025

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Title
Senior Program Director

Areas / Topics covered during visit:

•	Census: The group home has three residents at the facility and the bed capacity remains at four.
•	Admissions: There were no new admissions in the last quarter.
•	Discharges: There were no discharges in the last quarter.
•	Staff vacancies: The group home has a nurse vacancy, and a candidate has been selected to fill the position.
•	Staff hires: The group home did not report any new hires in the last quarter.
•	Medication: The program currently has eight employees qualified to administer medication at the facility.
•	Physical plant: A walkthrough of the facility was conducted with the senior program director to assess the group home's compliance with regulatory standards.

•	SIU Reports: There were no reports in this quarter.

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

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

Areas of regulatory non-compliance identified during this visit:
N/A

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

Penny Woodward, LCSW                                  July 9, 2025
Regulatory Consultant                                              Date

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

facility_name: CHR /Grant House Group Home


summary: Visit conducted on March 12, 2025. Visit covered 9 main areas/topics. No compliance issues identified.

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

Field Visit Reporting Form

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

  NAME OF FACILITY / PROGRAM: CHR /Grant House Group Home

 TIME OF VISIT (FROM - TO): 11:28 am to 12:47pm                       DATE: March 12, 2025

AGENCY PERSONNEL WHO PARTICIPATED:

Job Title
Program Director

Areas / Topics covered during visit:

•	Census: The group home has three youths at the facility and the bed capacity remains at four.
•	Admissions: There was one new admission in the last quarter.
•	Discharges: There were no discharges in the last quarter.
•	Staff vacancies: The group home has a nurse vacancy, and the agency is actively looking to fill the position.
•	Staff hires: The group home hired three part-time workers in the last quarter.
•	Medication: The program currently has seven employees qualified to administer medication at the facility.
•	Physical plant: A walkthrough of the facility was conducted with the program director to assess the program's compliance with regulatory standards.
•	Personnel: On 2/5/25, seven employee records were reviewed, and all files contained the required background check information.

SIU Reports: There were no reports in this quarter.

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

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

Areas of regulatory non-compliance identified during this visit:
N/A

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

Penny Woodward, LCSW                                  March 22, 2025
Regulatory Consultant                                            Date

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


summary: Visit conducted on November 4, 2024. Visit covered 10 main areas/topics.

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

Field Visit Reporting Form

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

 NAME OF FACILITY / PROGRAM: CHR /Grant House Group Home

 TIME OF VISIT (FROM - TO): 11:00am to 12:15pm                       DATE: November 4, 2024

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Title
Senior Program Director
Program Director
DCF Nurse
CHR Nursing Manager

Areas / Topics covered during visit:

•	Census: The group home currently has one client at the facility and the bed capacity remains at four.
•	Admissions: There were no new admissions in the last quarter.
•	Discharges: The group home reported that there were no discharges in the last quarter.
•	Staff vacancies: The group home has three part-time vacancies, one nurse vacancy and expects to fill positions soon.
•	Staff hires: The program reported that a new program director and residential supervisor were hired in the last quarter.
•	Medication: The program currently has six medication certified employees at the facility.
•	Physical plant: A walkthrough of the facility was conducted with the new program director to confirm that the group home was complying with regulatory standards.
•	Personnel: Employee records and files were not reviewed during the quarterly visit.
•	SIU Reports: There were no reports in this quarter.

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

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

Areas of regulatory non-compliance identified during this visit:

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

Penny Woodward, LCSW                            November 7, 2024
Regulatory Consultant                                     Date

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

visit_date: November 4, 2024