raw_content:
June 28, 2024

The Grove School, Inc.
175 Copse Road, P.O. Box 646
Madison, CT 06443
Attention: Richard Chorney, Executive Director

Regarding Licensing Inspection for Grove School, Inc.
Inspectors Keith Bryan, Penny Woodward and Thomas Cuchara

Dear Mr. Chorney
On 6/10/24, 6/11/24 and 6/12/24 a biennial licensing inspection was conducted at your facility. This inspection was conducted to determine the compliance of this facility with the Regulations for Operation of Child Caring Agencies and Facilities Sections 17a-145-48 through 17a-151-98, as well as the DCF Guidelines for the Administration of Medication for Certified Staff. DCF has determined that the program is in compliance with all applicable regulatory provisions except those itemized below. Please review the sections identified and submit a plan of correction to address each area. The plan must be submitted within 30 days of receipt of this letter and should identify: 1. the steps to be taken to correct the areas of non-compliance; 2. the date correction(s) will be completed; and 3. plan to prevent recurrence of the citation(s). The areas of non-compliance are as follows:

Section 17a-145-63. Chief administrative officer
There shall be a chief administrative officer who shall be in charge of the overall management of the facility and carry out the policies of the governing board. Each facility shall provide the staff and complementary services to enhance the physical and emotional well-being and ensure the safety of the children.
•	Five of 20 personnel files reviewed did not present with state police background checks as required. Dates were given for when the checks were conducted but the actual form with the documented results shall be presented for compliance.

Section 17a-145-64. Personnel policies and procedures
Personnel policies and operating procedures regarding facility employment and personnel practices shall be in writing and on file with the department. A copy shall be given to each employee and volunteer worker. A record containing personnel and health information shall be maintained by the facility for each employee. All direct care personnel shall have a physical examination, including a test for tuberculosis, immediately prior to assuming assigned duties.
•	Two of 20 personnel files reviewed contained medical review forms for employment but the forms did not state that the employees were examined.
Section 17a-131 of the CGS Cardiopulmonary Resuscitation Training required for persons who directly supervise children.
Any person who has direct supervision of children placed by the state in a state facility or private institution shall be required to be trained in cardiopulmonary resuscitation.
•	One out of 20 personnel files reviewed did not contain documentation of CPR training and one employees had expired.
Sec. 46a-154. Internal monitoring, training and development of policies and procedures required and subject to state agency inspection.
(a) Each institution or facility that provides direct care, education or supervision of a person at risk shall develop policies and procedures that (1) establish monitoring and internal reporting of the use of physical restraint and seclusion on persons at risk, and (2) require training of all providers and assistant providers of care, education or supervision of persons at risk in the use of physical restraint and seclusion on persons at risk. Such training shall include, but not be limited to: Verbal defusing or de-escalation; prevention strategies; types of physical restraint; the differences between life-threatening physical restraint and other varying levels of physical restraint; the differences between permissible physical restraint and pain compliance techniques; monitoring to prevent harm to a person physically restrained or in seclusion and recording and reporting procedures on the use of restraints and seclusion.
•	One out of 20 personnel files reviewed did not contain documentation of restraint training.
Once a finding is made that your agency has satisfactorily addressed the regulatory compliance issues DCF will be prepared to renew your agency’s license.

Please take note that failure to submit an acceptable plan of correction or to successfully implement a plan will result in a licensing action being taken against your agency, including but not limited to suspension and / or non renewal.

Any questions, comments or concerns you have regarding these findings should be addressed to this Department. Your response will become part of the permanent record of your organization.

Sincerely,

Keith Bryan
DCF Regulatory Consultant
Department of Children and Families
505 Hudson Street
Hartford, CT 06106
Phone: 860-560-5050
Fax: 860-550-6665
keith.bryan@ct.gov
cc: Kathleen DiTuccio, Licensing Program Supervisor, TSS
file|


state: CT

facility_name: Grove School, Inc. / RE #4

summary: Visit conducted on _03/22/24____. Visit covered 1 main areas/topics. No compliance issues identified. Implemented 4 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: Grove School

 TIME OF VISIT (FROM - TO):       ____First shift__________________              DATE: _03/22/24____

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:
Executive Director
Residential Director

List of Areas / Topics covered during visit:
Status of the campus and the female housing of the physical plant. There were a total of 81 youth residing on campus, 49 female and 32 male. There were 13-day students for a total of 94 youth at the school. The results of a personnel file review will be attached to this report at a later date.

The following is from the review of the female dorms. There were 8 freshmen youth residing in Middle House. There were 9 sophomore and junior residents residing n Patch House. There were 6 sophomore and junior youth residing in Emmerich House. There were 6 sophomore and junior youth residing in Charles House. There were 10 junior and senior youth residing in Olshin House. There were 10 senior youth residing in Tessler House.

Corrective Actions implemented as a result of previous visit:
Section 17a-145-73. Sleeping accommodations; Section 17a-145-74. Lavatory facilities. Toilet articles and linens; and Section 17a-145-76. Kitchens, equipment, food-handling; were all responded to satisfactorily.

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

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.

_Keith Bryan___________                     __03/22/24____
Regulatory Consultant                                   Date

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

facility_name: Grove School

personnel:
Executive Director
Residential Director


areas_topics_covered: day students for a total of 94 youth at the school. The results of a personnel file review will be attached to this report at a later date. The following is from the review of the female dorms. There were 8 freshmen youth residing in Middle House. There were 9 sophomore and junior residents residing n Patch House. There were 6 sophomore and junior youth residing in Emmerich House. There were 6 sophomore and junior youth residing in Charles House. There were 10 junior and senior youth residing in Olshin House. There were 10 senior youth residing in Tessler House.

corrective_actions: 73. Sleeping accommodations; Section 17a

corrective_actions: 74. Lavatory facilities. Toilet articles and linens; and Section 17a

corrective_actions: handling; were all responded to satisfactorily.


summary: Visit conducted on _11/15/23____. Found 6 compliance issues. Implemented 4 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: Grove School

 TIME OF VISIT (FROM - TO):       ____First shift__________________              DATE: _11/15/23____

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:
President & CEO
Executive Director
A first shift supervisor

List of Areas / Topics covered during visit:
Status of the campus and the physical plant. There 6 male sophomore residents residing in Pearlman House. There were 9 male junior residents residing in Redlich House, including 1 youth in the hospital. There were 5 male 8th grade residents residing in White House. There were 8 male senior residents residing in Lodge House. There were 6 sophomore and junior residents residing in Blue House. All youth were in school. Staff were at the school with the youth.

Corrective Actions implemented as a result of previous visit:
Section 17a-145-73. Sleeping accommodations; Section 17a-145-74. Lavatory facilities. Toilet articles and linens; and Section 17a-145-76. Kitchens, equipment, food-handling; were all responded to satisfactorily.

Areas of regulatory non-compliance identified during this visit:
Section 17a-145-73. Sleeping accommodations
(a) Sleeping accommodations for each child shall have adequate area, spacing and equipment in accordance with the child's age and needs. Bedrooms shall contain a window unless there is a 24-hour ventilation system approved by the state or local health department. Heating facilities shall be sufficient to maintain a room temperature consistent with existing department of health services' guidelines. Separate sleeping quarters shall be provided for children of the opposite sex six years of age or over. The facility shall provide each such child with a single bed with adequate linens and covers suitable for the temperature, and a locker, dresser or other storage space for the child's private use conveniently located in or near the child's sleeping room.
•	Bedroom #3 needed cleaning.
•	The handrail leading upstairs to bedrooms in White House needed painting.

Section 17a-145-76. Kitchens, equipment, food-handling
All kitchens shall be clean, well-lighted, properly ventilated and screened, and provided with essential and proper equipment for the preparation and serving of food. Storage, refrigeration and freezer facilities shall be adequate for the number of persons to be served. All perishable foods shall be refrigerated at a temperature at or below 45° Fahrenheit. Freezers and frozen food compartments shall be maintained at minus 10° to 0° Fahrenheit. Cooking utensils, dishes and tableware shall be in good condition and proper cleaning facilities for this equipment shall be provided. dishes shall be stored in a clean, dry place protected from flies, dust or other contamination. Food preparation and serving areas shall comply with Section 19-13-B42 of the public health code. Proper food handling techniques and sanitation to minimize the possibility of the spread of food-borne diseases shall be maintained.
•	The handle on refrigerator in White House was broken.
•	The outside of the refrigerator in Lodge House was rusted and the handle needed cleaning.
•	Thermometers were missing from the refrigerator and freezer in Blue House.

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.

_Keith Bryan___________                     ___11/15/23____
Regulatory Consultant                                   Date

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

type: general

description: Bedroom #3 needed cleaning.


summary: Visit conducted on _09/29/23____. Found 5 compliance issues.

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

Field Visit Reporting Form

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

  NAME OF FACILITY / PROGRAM: Grove School

 TIME OF VISIT (FROM - TO):       ____First shift__________________              DATE: _09/29/23____

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:
President & CEO
Executive Director
A first shift supervisor

List of Areas / Topics covered during visit:
Status of the transition house and the physical plant. There were 10 youth residing in the home, two were transgendered, 1 female and 7 males. Two youth were on campus, 6 were on home visits and 2 were in the home.

There was 1 staff and 1 supervisor on duty.

Corrective Actions implemented as a result of previous visit:
None required:

Areas of regulatory non-compliance identified during this visit:
Section 17a-145-73. Sleeping accommodations
(a) Sleeping accommodations for each child shall have adequate area, spacing and equipment in accordance with the child's age and needs. Bedrooms shall contain a window unless there is a 24-hour ventilation system approved by the state or local health department. Heating facilities shall be sufficient to maintain a room temperature consistent with existing department of health services' guidelines. Separate sleeping quarters shall be provided for children of the opposite sex six years of age or over. The facility shall provide each such child with a single bed with adequate linens and covers suitable for the temperature, and a locker, dresser or other storage space for the child's private use conveniently located in or near the child's sleeping room.
•	A window shade was missing in the 3 persons bedroom upstairs.

Section 17a-145-74. Lavatory facilities. Toilet articles and linens
(a) At least one toilet and washbasin shall be provided near sleeping quarters, recreation areas, and dining rooms respectively and shall have adequate hot and cold running water, equipment and supplies. Adequate bath facilities shall be in the same building as, and accessible to, sleeping quarters. The bathroom equipment for children shall be of appropriate size and height for the children's use. Each facility shall provide for bathrooms and toilets which shall allow for individual privacy.
•	The drain in the tub of the 3 persons bathroom upstairs was matted with hair and the bathroom needed cleaning.
•	The ceiling light was out in the bathroom located downstairs.

Section 17a-145-76. Kitchens, equipment, food-handling
All kitchens shall be clean, well lighted, properly ventilated and screened, and provided with essential and proper equipment for the preparation and serving of food. Storage, refrigeration and freezer facilities shall be adequate for the number of persons to be served. All perishable foods shall be refrigerated at a temperature at or below 45° Fahrenheit. Freezers and frozen food compartments shall be maintained at minus 10° to 0° Fahrenheit. Cooking utensils, dishes and tableware shall be in good condition and proper cleaning facilities for this equipment shall be provided. dishes shall be stored in a clean, dry place protected from flies, dust or other contamination. Food preparation and serving areas shall comply with Section 19-13-B42 of the public health code. Proper food handling techniques and sanitation to minimize the possibility of the spread of food-borne diseases shall be maintained.
•	There were no thermometers found in one refrigerator and freezer. Two items were found not sealed in the freezer.

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.

_Keith Bryan___________                     ___9/29/23____
Regulatory Consultant                                   Date

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


summary: Visit conducted on _06/30/23____. No compliance issues identified.

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

Field Visit Reporting Form

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

  NAME OF FACILITY / PROGRAM: Grove School

 TIME OF VISIT (FROM - TO):       ____Second shift__________________              DATE: _06/30/23____

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:
President & CEO

List of Areas / Topics covered during visit:
Status of the campus and the physical plant. Students had either left campus or were waiting for transportation to leave campus for summer break. Ample staff were on duty to facilitate the transition. Dorms, cafeteria and gymnasium were reviewed with the school's President and CEO. The dorms had either been cleaned or in the process of being cleaned, along with any minor necessary repairs.

Corrective Actions implemented as a result of previous visit:
None required:

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

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.

_Keith Bryan___________                     ___6/30/23____
Regulatory Consultant                                   Date

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


summary: Visit conducted on _03/31/23____. No compliance issues identified.

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

Field Visit Reporting Form

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

  NAME OF FACILITY / PROGRAM: Grove School

 TIME OF VISIT (FROM - TO):       ____Second shift__________________              DATE: _03/31/23____

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:
Maintenance Person

List of Areas / Topics covered during visit:
This was an unannounced visit and the maintenance person informed me that all youth, staff and administrators were away from campus for spring vacation.

Corrective Actions implemented as a result of previous visit:
None required:

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

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.

_Keith Bryan___________                     ___3/31/23____
Regulatory Consultant                                   Date

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


summary: Visit conducted on _12/9/22___________. No compliance issues identified.

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

Field Visit Reporting Form

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

  NAME OF FACILITY / PROGRAM: Grove School

 TIME OF VISIT (FROM - TO):       ____First shift__________________              DATE: _12/9/22___________

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:
Executive Director
Supervisor (females)

List of Areas / Topics covered during visit:
The status of the campus and the physical plant. The dorms that the female residents reside were inspected. In Middle House there were 9 students between the ages of 14 & 16 with 2 staff members. In Charles House there were 5 students between the ages of 15 & 16 with 2 staff members. In Olshin House there were 9 students between the ages of 16 & 18 with 2 staff members. In Tessler House there were 10 youth between the ages of 17 & 18 with 2 staff members. In Emmerich House there were 5 students between the ages of 16 & 18 with 2 staff members. The agency's president, several clinicians and 2 psychiatrist were on duty.

Corrective Actions implemented as a result of previous visit:
None required:

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

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.

_Keith Bryan___________                     ___12/12/22____
Regulatory Consultant                                   Date

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

personnel:
Executive Director
Supervisor (females)


facility_name: Waterford Country School, Inc./Therapeutic Boardin

summary: Visit conducted on __1-29-26______. Visit covered 13 main areas/topics. Found 5 compliance issues. 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: _____Waterford Country School - RE_________________________________

 TIME OF VISIT (FROM - TO):       __________________________         DATE:__1-29-26______

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:

DV

List of Areas / Topics covered during visit:
•	Census - 7. There was a recent new admission. One resident indicated that he did not go to school because he did not sleep well the night before. He began to get ready to go to school (located in the other buildings on the hill.)
•	Some of the staff assigned to the ITTC have been working at the boarding program. DV indicated that he is assigned to 3rd shift but sometimes picks up additional shifts. He said that per diem staff will pick up open shifts, if needed.
•	The previous Executive Director is no longer there. There is currently an Interim Executive Director.
•	Common areas were clean.
•	There was food in some of the bedrooms. Agency policy is that no food be allowed in bedrooms however enforcement of the policy appears to be inconsistent across programs. The issue of open food containers contributing to vermin and bugs, especially in the summer, was discussed. Closed Tupperware containers for storage was discussed.
•	The bathroom was clean. Some rust was visible where the exterior wall meets the bottom of the shower pan.
•	In one bedroom a plugged in power strip was up against the bed. It was suggested that either the bed or power strip be moved. In another room a fan was plugged in and placed near the head of the bed. It was suggested that this be moved off of the bed. Because of the risk of electrical appliances causing a fire they should not be placed on or in close proximity to bed linens.
•	In one room some clothing was on the floor and bed linens were in need of washing.
•	A couple of garbage cans were in need of emptying.
•	A review of case record. The date of admission was 5-5-25.  A 3 month plan review was conducted on 9-3-25. There was no plan in the record for December.

Corrective Actions implemented as a result of previous visit: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Areas of regulatory non-compliance identified during this visit:
Section 17a-145-73 Sleeping accommodations.
•	One bedroom had clothing on the floor and the bed linens were in need of washing.
•	Two rooms had trash cans that were in need of emptying.
•	Two rooms had electrical appliances (power strip & a fan) placed on the beds in direct contact with bed linens.
•	In the record reviewed there was no current treatment plan review (December 2025).

Please submit a service development plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The service development plan must be submitted to the attention of the undersigned at the address listed above.
        Terri Bohara                                            2-2-26
______________________________            _________________
Regulatory Consultant                                   Date

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

description: 73 Sleeping accommodations.


summary: Visit conducted on ___11-12-25_____. Visit covered 8 main areas/topics. Found 1 compliance issues. Implemented 1 corrective actions.

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

Field Visit Reporting Form

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

  NAME OF FACILITY / PROGRAM: _____WCS - RE_________________________________

 TIME OF VISIT (FROM - TO):       _____Afternoon_____________________         DATE:___11-12-25_____

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:

NH - Supervisor
RF - Supervisor

List of Areas / Topics covered during visit:
•	Census - 7. There was a new admission since the last visit. Residents returned home from school during the visit.
•	Staff from the RE will be transitioning to the new ITTC program once it is opened.  Both RE supervisors will be leaving to supervise the new program with RF and EA moving into the supervisor roles. There may be one full time position open once all the staff movement is concluded.
•	Staff and residents have indicated that they like the new unit location.  There is a large sectional in the living room that allows residents to get comfortable. A new table was purchased for the upstairs living room area.  A new TV was purchased for the downstairs recreation area. There are two grills on the deck that allow staff to cook out.  The supervisor reported he recently cooked breakfast for the residents on one of the grills.
•	Bedrooms were clean and fairly well organized. One room had a slight odor (shoes) and it was suggested that products be purchased to address the shoe odor and that the room be aired out periodically by opening the door and window. Bathrooms were cleaned.
•	Recreation activities include Go-Karts, Gym, and shopping for the holidays. Staff are reportedly pursuing membership to the new community center in New London. On the day of the visit the school staff were preparing food for a "Friendsgiving" dinner.  Residents were planning to attend. Staff will be preparing a Thanksgiving meal for residents. Events are also being planned for Xmas.
•	It was recommended that low level lighting be utilized in the downstairs recreation area and that rugs be purchased to help with buffering the sound.

Corrective Actions implemented as a result of previous visit: ______________________________________________________________________________________________

Areas of regulatory non-compliance identified during this visit:

•	There were no citations noted.

Please submit a service development plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The service development plan must be submitted to the attention of the undersigned at the address listed above.
    Terri Bohara                                                   11-13-25
______________________________            _________________
Regulatory Consultant                                   Date

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

description: There were no citations noted.

personnel:
NH - Supervisor
RF - Supervisor


raw_content:
July 17, 2025

Waterford Country School
78 Hunts Brook Rd.
PO Box 408
Quaker Hill, CT  06375
Attn: Mr. Christopher Lacey

Re: Licensing Inspection for Waterford Country School Therapeutic Boarding Program (RE)
Inspectors: Terri Bohara, Pat Hughes & Jim Funaro

Dear Mr. Lacey,

During July 2025 a biennial re-licensing inspection was conducted at the Waterford Country School therapeutic boarding program (Residential Educational).  This inspection was conducted to determine the compliance of this facility with the 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.  Below are listed the areas of regulatory non-compliance which were identified during the re-licensing inspection. Please review the areas identified and submit a regulatory compliance plan to address each area.  The plan must be submitted within 30 days of receipt of this letter and should identify: 1. the steps to be taken to correct the non-compliance; and 2. the date the correction(s) will be completed.  The areas of non-compliance are listed below.   Also included in the 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.  Recommendations do not require the submission of a plan of correction.

Section 17a-145-98 Case Records. Confidentiality.
•	A plan for discharge was not noted in the documentation reviewed.
Once licensing has reviewed and accepted the Regulatory Compliance 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 call me at (860) 550-6395/959-255-0614.

Sincerely,
Terri Bohara
_______________________________________
Terri Bohara
Regulatory Consultant
Department of Children and Families
505 Hudson St.
Hartford, CT 06106
Phone: 959-255-0614
Fax: 860-860-550-6665
Theresa. Bohara@ct.gov

Copy: file|

report_type: unstructured


summary: Visit conducted on __6-12-25______. Visit covered 13 main areas/topics. Implemented 1 corrective actions.

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

Field Visit Reporting Form

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

  NAME OF FACILITY / PROGRAM: ___WCS Residential Educational ___________________________________

 TIME OF VISIT (FROM - TO):       __________________________         DATE:__6-12-25______

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:
JS - Supervisor
NH - Supervisor

List of Areas / Topics covered during visit:

•	Census - 7  There are possible admissions being reviewed.
•	There are no staff openings.
•	One of the residents is staying an extra year with a focus on improving his vocational skills. This was approved by the Board of Education.
•	Common areas of the unit were clean.  The living room was nicely furnished. The kitchen was clean and contained food sent by the campus kitchen.
•	Bedrooms were clean. There was a faint smearing on the wall in one room. It was suggested that this area be washed. Windows were open and there was a deodorizer present. There were no noticeable odors.
•	Bathrooms were clean.
•	The unit (and campus) held a Memorial Day cook out.  Once summer school vacation ends, the daily schedule will change to a half-day academic program (approx.9am-12pm) followed by an activity. The program has season passes to 6 Flags and Ocean Beach. Options in the area also include crabbing, deep sea fishing, golf, trampoline park and go-karts.
•	Discussed upcoming re-licensing visit scheduled for July 9, 2025.

Corrective Actions implemented as a result of previous visit: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Areas of regulatory non-compliance identified during this visit:

Please submit a service development plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The service development plan must be submitted to the attention of the undersigned at the address listed above.
    Terri Bohara                                              6-17-25
______________________________            _________________
Regulatory Consultant                                   Date

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

personnel:
JS - Supervisor
NH - Supervisor


summary: Visit conducted on __2-5-25______. Visit covered 11 main areas/topics. Found 3 compliance issues. Implemented 1 corrective actions.

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

Field Visit Reporting Form

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

  NAME OF FACILITY / PROGRAM: _____WCS - Residential Education program ________
 TIME OF VISIT (FROM - TO):       __________________________         DATE:__2-5-25______

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:
JH
NH

List of Areas / Topics covered during visit:
•	Census - 7
•	There are currently no staff openings.
•	Bedrooms, common areas and bathrooms were clean.  One room had a strong shoe odor. It was suggested that the shoes be treated to prevent the odor.
•	Staff continue to cook dinner on the unit with supplies provided by the kitchen.
•	The program will be putting on a Super Bowl party for residents this Sunday. They noted that 4 residents are on the honor roll at the school.
•	There are proposed renovations to the unit kitchen and the outdoor area. A kitchen upgrade is being planned in the future. There are also plans to create an outdoor patio area on the side of the building.
•	Residents have the opportunity to earn money by doing chores in the unit.
•	Use of the Urgent Crisis Center in New London was discussed as a possible option for residents who may be dysregulated.
•	Review of two case records.  No identified issues.
•	Review of one personnel record on 11-5-24. There was no documentation of a state police check, CPR certification and TCI certification.

Corrective Actions implemented as a result of previous visit: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Areas of regulatory non-compliance identified during this visit:

Section 17a-145-64 Personnel policies and procedures.
•	One file was reviewed.
•	The file did not have evidence of a state police check, CPR or restraint certification.

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

____Terri Bohara     ______________________2-19-25____________________
Regulatory Consultant                                   Date

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

description: 64 Personnel policies and procedures.

description: One file was reviewed.

personnel: JH NH


summary: Visit conducted on _10-23-24_______. Visit covered 10 main areas/topics. Found 2 compliance issues. Implemented 1 corrective actions.

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

Field Visit Reporting Form

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

  NAME OF FACILITY / PROGRAM: __WCS - Residential Ed____________________________________

 TIME OF VISIT (FROM - TO):       __Afternoon________________________  DATE:_10-23-24_______

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:
Supervisors (NH & JH)

List of Areas / Topics covered during visit:
•	Census - 8
•	There is one staff opening for a Lead CCW.
•	The unit was decorated inside and out for the holidays. Common areas and the kitchen were clean and free from clutter.
•	Staff are now preparing meals with food provided by the campus kitchen.  The residents appear to like this arrangement as the meals can be prepared with additional spices to the residents' liking. During the week staff prepare dinner but on weekends they do all the cooking in the unit. The RE program just got a new grill (flat top) that allows them to cook large quantities of food including pancakes and bacon for residents on the weekend. All staff have taken the "Serve Safe" training.
•	Program treatment plans (Individualized Boarding Plans) now focus on the Social and Life Skills aspects of the program and are reviewed quarterly. Any required clinical services are now provided through the OPCC located in another section of the campus.
•	Bedrooms were fairly neat. One room had an odor (source unclear). It was suggested that the room be aired out.
•	The bathroom shower curtains were discolored on the bottom. It was suggested that these be washed to determine if the staining was permanent (and curtains need to possibly be replaced.)
•	There was some graffiti on one wall in one bedroom.
•	It was suggested the plastic hooks be provided in the room so residents have some place to hang towels, coats, etc.
•	Fire drills for 2024 were reviewed. All were successfully completed.

Corrective Actions implemented as a result of previous visit: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Areas of regulatory non-compliance identified during this visit:
Section 17a-145-73 Sleeping accommodations.
•	Walls in one of the bedrooms had graffiti.

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

__Terri Bohara____________________________            __11-1-24_______________
Regulatory Consultant                                   Date

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

description: 73 Sleeping accommodations.


summary: Visit conducted on ____7-31-24______________. Visit covered 7 main areas/topics. Found 4 compliance issues. 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: ____Waterford Country School - Therapeutic Boarding

 TIME OF VISIT (FROM - TO):       __________________________               DATE: ____7-31-24______________

 AGENCY PERSONNEL WHO PARTICIPATED:

Name	Job Title
JH	Supervisor

List of Areas / Topics covered during visit:
•	Census - 7. Some residents were discharged since the last visit. Other residents go home at the end of the summer session.
•	The program has no staff openings.
•	Physical plant tour. Floors in bedrooms were in varying states of cleanliness. There were in items on the shower floor. Showers are cleaned by both unit staff and maintenance.  One resident didn't have sheets. He indicated that they were in the wash. One resident indicated that the lack of pillow cases was because he did not like the feel of them. He further indicated that they had been made available to him and were in his room. The supervisor opened a closet to show a supply of linens available to residents.
•	The kitchen cabinets were showing areas of wear. A kitchen renovation is reportedly planned at some point in the future. The freezer and refrigerator had food spills and was in need of cleaning.
•	House meetings are held every afternoon. Activities are suggested by both staff and residents. Activities offered this summer include going to the gym, the farm, a zoo in MA, the movies and crabbing. One resident is involved in photography while another resident took a class in dog training.
•	The supervisor reported that the population of the program tends to be youth on the autistic spectrum, so the program works to have a predictable schedule. This becomes a bit more challenging in the summer as residents aren't in school.

Corrective Actions implemented as a result of previous visit: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Areas of regulatory non-compliance identified during this visit:
Section 17a-145-73 Sleeping accommodations.
•	Bedroom floors were in varying states of cleanliness.

Section 17a-145-74 Lavatory facilities. Toilet articles and linens.
•	Items were left on the shower floor.

Section 17a-145-76. Kitchens, equipment, food- handling.
•	The inside of the freezer and refrigerator had food spills.

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.

_____Terri Bohara_____________________8-6-24___ _________________
Regulatory Consultant                                   Date

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

description: 73 Sleeping accommodations.


summary: Visit conducted on __5-22-24______. Visit covered 5 main areas/topics. Implemented 1 corrective actions.

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

Field Visit Reporting Form

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

  NAME OF FACILITY / PROGRAM: ______Waterford CS - Residential Education program ____

 TIME OF VISIT (FROM - TO):       __________________________         DATE:__5-22-24______

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:
JH - Program Supervisor
NH - Supervisor II
JB - Dir. Of Residential Services

List of Areas / Topics covered during visit:
•	Current census is 10. A couple of residents will be leaving after graduation.
•	Renovations have been made to the building. New furniture has been purchased for the upstairs living room. The downstairs area has new flooring and has been painted. The "game room" has been painted and decorated. The conference room has new furniture and has been painted. It is used for staff meetings and family meetings.
•	Several windows do not yet have screens installed. Staff reported that some of the frames are bent and are blown out during wind storms. Windows should not be opened until screens have been installed.
•	Bedrooms and bathrooms were clean. Shower stalls were recently steam cleaned.
•	Case record review.  Child has been in the program for approx. 3 years. The goals and objectives noted in the treatment plan were the same for the entire time. The most recent clinical notes in the record were from January.

Corrective Actions implemented as a result of previous visit: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Areas of regulatory non-compliance identified during this visit:

Please submit a service development plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The service development plan must be submitted to the attention of the undersigned at the address listed above.
 Terri Bohara                                                       6-12-24
______________________________            _________________
Regulatory Consultant                                   Date

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


summary: Visit conducted on ___2-14-24_____. Visit covered 9 main areas/topics. Found 2 compliance issues. Implemented 1 corrective actions.

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

Field Visit Reporting Form

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

  NAME OF FACILITY / PROGRAM: ___WCS - Therapeutic Boarding___________________________________

 TIME OF VISIT (FROM - TO):       _Afternoon____________         DATE:___2-14-24_____

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:
NH
MH

List of Areas / Topics covered during visit:
•	Census - 9  A few pre-placements have occurred.
•	The program clinician left approximately 2 weeks ago. Clinical services are being provided by clinicians from other programs. There are currently no staff openings.
•	Tour of physical plant. The common areas, kitchen, bedrooms and bathrooms were clean and well organized. A grate in the bathroom floor was rusted.
•	Review of fire drills from 2023-2024. All drills were conducted as required.
•	Residents were home from school and most were in their rooms at the time of the visit.
•	Food was sent up from the main kitchen for dinner. Staff occasionally cook meals for residents.

Corrective Actions implemented as a result of previous visit: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Areas of regulatory non-compliance identified during this visit:

Section 17a-145-74 Lavatory facilities. Toilet articles and linens.
•	The grate on the bathroom floor was heavily rusted. This is a repeat citation.

Please submit a service development plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The service development plan must be submitted to the attention of the undersigned at the address listed above.
     Terri Bohara                                                2-20-24
______________________________            _________________
Regulatory Consultant                                   Date

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

personnel: NH MH


summary: Visit conducted on ___11-16-23_ ________. Visit covered 9 main areas/topics. Found 4 compliance issues. 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 tak

NAME OF FACILITY / PROGRAM: ___WCS - Therapeutic Boarding___________________________________

 TIME OF VISIT (FROM - TO):       __________________________         DATE: ___11-16-23_ ________

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:
NH

List of Areas / Topics covered during visit:
•	Census - 9.
•	There are no open staff positions.
•	Review of two personnel files. One staff did not have evidence of CPR certification.
•	The program was planning a Thanksgiving dinner for residents, staff and some family members for Monday 11/20/23.
•	The unit common areas were clean.
•	Overall bedrooms were clean with some clutter. It was suggested to store extra items in the basement.
•	There was a rusted grate in the floor of one of the bathrooms.
•	The agency is planning a campus wide holiday celebration in December. The residents will be on vacation from December 25, 2023- January 2, 2024.

Corrective Actions implemented as a result of previous visit: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Areas of regulatory non-compliance identified during this visit:
Section 17a-145-64. Personnel policies and procedures.
•	Two personnel files were reviewed.
•	One file did not have documentation of CPR certification.

Section 17a-145-74 Lavatory facilities. Toilet articles and linens.
•	The grate on the floor was heavily rusted.

Please submit a service development plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The service development plan must be submitted to the attention of the undersigned at the address listed above.
Terri Bohara                                                  11-30-23
______________________________            _________________
Regulatory Consultant                                   Date

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

description: 64. Personnel policies and procedures.

description: Two personnel files were reviewed.


summary: Visit conducted on ____8-16-23 ____. Visit covered 4 main areas/topics. Found 4 compliance issues. Implemented 1 corrective actions.

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

Field Visit Reporting Form

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

  NAME OF FACILITY / PROGRAM: _______WCS - Therapeutic Boarding ___________________

 TIME OF VISIT (FROM - TO):       _____Afternoon_____________________     DATE: ____8-16-23 ____

 AGENCY PERSONNEL WHO PARTICIPATED:

Name	Job Title
JE
MH
Program clinician - SP

List of Areas / Topics covered during visit:
•	Census is 9 however several residents were home on school break.
•	Tour of bedrooms. There were several bedrooms that were in disarray with clothing and other items on the floor.  Staff reported that the residents had left for school vacation leaving their rooms in this condition.  When questioned regarding program expectations staff reported that rooms should be cleaned before leaving the unit.
•	A couple of the toilets were dirty and in need of cleaning. One of the shower stalls had mold and an unidentified substance on the shower floor. This was later addressed by a staff member. The grate in the bathroom floor was rusty.
•	Residents spent the summer participating in summer school, recreational activities, working on the farm and working at the summer camp in addition to other activities.

Corrective Actions implemented as a result of previous visit: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Areas of regulatory non-compliance identified during this visit:
Section 17a-145-73. Sleeping accommodations.
•	Several bedrooms were in disarray with clothing and other items on the floor.

Section 17a-145-74 Lavatory facilities. Toilet articles and linens.
•	Toilets were dirty and in need of cleaning.
•	One shower stall had mold and a substance on the floor of the shower.

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.

__Terri Bohara      ____________________________            __8-23-23_______________
Regulatory Consultant                                   Date

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

description: 73. Sleeping accommodations.

personnel:
JE
MH
Program clinician - SP


summary: Visit conducted on ___1-18-23_______________. Visit covered 12 main areas/topics. Found 1 compliance issues. 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: ____Waterford Country School - HBA __________________

 TIME OF VISIT (FROM - TO):       __________________________               DATE: ___1-18-23_______________

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:
ET - COO
JB - Director of Residential Programs

List of Areas / Topics covered during visit:
•	Census - 6
•	Staff vacancies - 1 full time (2nd shift) All staff are trained in TCI.
•	Common areas and kitchen were clean.
•	Bedrooms were clean.
•	The program has created an additional recreational and gaming area in the basement of the building.
•	There was an area of discoloration in one of the shower units. It was recommended that regular (monthly) power washing of the shower units be conducted.
•	Review of case record. One treatment plan (9-21-22) was not completed. Approvals of the plans by parents and youth were not consistently captured.
•	Review of one personnel file on 12-1-22. There were no issues.
•	Staff and residents built a large firepit in an area that is close to the unit. They have already done some outdoor cooking. Benches will be added.

Corrective Actions implemented as a result of previous visit: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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.
Terri Bohara                                                      1-24-23
______________________________            _________________
Regulatory Consultant                                   Date

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


summary: Visit conducted on _____10-11-22_____________. Visit covered 8 main areas/topics. Found 1 compliance issues. 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: ____Waterford Country School  -  Residential Educational______________

 TIME OF VISIT (FROM - TO):       __________________________               DATE: _____10-11-22_____________

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:
ET - COO

List of Areas / Topics covered during visit:
•	The current census is 7.
•	There is 1 full time child care worker position open.
•	Staff have been participating in the TCI re-certification.
•	The program has relocated to the (former) Bent shelter building. The building was renovated to accommodate the residential educational building. These renovations included new flooring, new decking, the removal of the staff office and painting throughout the building.  Feedback has been positive from the residents as they now have single rooms.
•	A new supervisor (JH) recently started in the program.
•	New cushions are being ordered for the couches in the living room.
•	Overall bedrooms were clean and well organized. One room was somewhat disheveled due to a resident being dysregulated and throwing his clothing around that morning.

Corrective Actions implemented as a result of previous visit:
•	Staff are currently participating in TCI/CPR trainings.

Areas of regulatory non-compliance identified during this visit:
•	No regulatory citations were noted 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.
Terri Bohara                                                  10-17-22
______________________________            _________________
Regulatory Consultant                                   Date

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


summary: Visit conducted on _____8-2-22. Visit covered 8 main areas/topics. Found 4 compliance issues. Implemented 1 corrective actions.

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

Field Visit Reporting Form

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

  NAME OF FACILITY / PROGRAM: _______WCS -Hunts Brook Academy (RE program) _________________
 TIME OF VISIT (FROM - TO):       ____Afternoon______________________       DATE: _____8-2-22

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:

MH - CCW

List of Areas / Topics covered during visit:
•	Census - 8
•	The Hunts Brook RE will be moving to the Bent building (across from the main campus). The Bent building is currently being renovated and HBA residents are slated to move in prior to the beginning of school. New flooring has been installed on the main floor. The staff office "pod' has been removed and the deck flooring has been replaced with Trex. The basement area has also been renovated.
•	The previous therapist left and was replaced with an internal candidate.
•	Three HBA staff are in need of TCI training.
•	The common areas were clean. Two handles were missing from drawers in the kitchen. It was noted that no repairs were being made at this due to the pending move. Overall bedrooms were clean.
•	Room #2 had multiple holes in the walls. There were stains on the carpet and a door missing off the clothing cabinet.
•	The missing panel in the bathroom door has not been repaired.
•	One resident was sitting in the hallway. Another resident was in his room. The other residents were either out on an outing or had left for a summer break.

Corrective Actions implemented as a result of previous visit: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Areas of regulatory non-compliance identified during this visit:
Section 17a-145-64 Personnel policies and procedures.
•	Three staff are in need of TCI certification.

Section 17a-145-73 Sleeping accommodations.
•	One bedroom had several holes in the wall. Stains in the carpet and a missing door on the clothing cabinet.

Section 17a-145-74 Lavatory facilities. Toilet articles and linens.
•	The lower panel from the bathroom door has not been repaired. This was noted during the last 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.
Terri Bohara                                                 8-15-22
______________________________            _________________
Regulatory Consultant                                   Date

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

description: 64 Personnel policies and procedures.


summary: Visit conducted on ____5-17-22______________. Visit covered 10 main areas/topics. Found 8 compliance issues. Implemented 1 corrective actions.

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

Field Visit Reporting Form

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

  NAME OF FACILITY / PROGRAM: ______Waterford Country School - Hunts Brooks - RE

 TIME OF VISIT (FROM - TO):       _________________________     DATE: ____5-17-22______________

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:
JF -                         Supervisor

List of Areas / Topics covered during visit:
•	The current program census is 8.
•	There are currently no staff vacancies.
•	The HB Residential program will be moving into the Bent building. Target date is September.
•	There is a water stain on the ceiling in room #1.
•	There were no curtains in the window of Room #2 and holes in the walls (several patched areas).
•	A ventilation plate on the bottom of a bathroom door was broken/missing.
•	Standing Orders were reviewed. There were no current standing orders.
•	There was no indication that Standing Orders were being reviewed every 90 days.
•	Physicians Orders were not signed.
•	Supplements were being provided to a resident without an indication that they have been prescribed/approved by a physician.

Corrective Actions implemented as a result of previous visit: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Areas of regulatory non-compliance identified during this visit:
Section 17a-145-73 Sleeping accommodations.
•	One of the bedrooms had no curtains on the windows, holes in the walls and several patches areas on the walls.
•	One of the bedrooms has a water stain on the ceiling.

Section 17a-145-74. Lavatory facilities. Toilet articles and linens.
•	There is a hole in bottom (missing ventilation plate) of a bathroom door.

Section 17a-145-75. Health and medical treatment. Administration of first aid. Prescription medication. Administration of medicine or treatment. Written records. Storage of drugs, medicines and instruments. Sick room, telephone.
•	The Standing Orders were not signed at the required 90 day intervals.
•	The Standing Orders were not current.
•	There was no indication of a physician approval for supplements being provided to a resident.
•	Physician Orders were not signed.

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.
Terri Bohara                                                 5-20-22
______________________________            _________________
Regulatory Consultant                                   Date

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

description: 73 Sleeping accommodations.

description: The Standing Orders were not current.

description: Physician Orders were not signed.


facility_name: Adelbrook Community Services, Inc.(CHOC)/ RT/Shilo

summary: Visit conducted on May 19,2025. Visit covered 6 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: Adelbrook
TIME OF VISIT (FROM - TO):  9:00 am                       DATE:    May 19,2025

 AGENCY PERSONNEL WHO PARTICIPATED:
Job Title
Adelbrook Director of Residential Services
Adelbrook Assistant Director of Residential Services

    List of Areas / Topics covered during visit:

•	The current census for Adelbrook is 35 and the licensed bed capacity it 35.

•	Discussion of Adelbrook's current staffing levels, vacant positions, and hiring activities.

•	Discussion with Adelbrook staff regarding the status of Adelbrook's milieu, the clinical programming, the summer time programming and recreational opportunities for the Adelbrook residents.

•	Observations of the Adelbrook residents in the milieu, and observations of the interactions between Adelbrook staff and the Adelbrook residents.

•	Inspection of the Adelbrook physical plant to assess the cleanliness of the facility, as well as to ensure there are no health or safety concerns.

•	Discussion and update on the renovations currently in progress across the Adelbrook program.

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

Areas of regulatory non-compliance identified during this visit:
•	None observed at the time of this quarterly visit.

Patrick Hughes                                       _5/30/2025
Regulatory Consultant                                 Date

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

facility_name: Adelbrook


summary: Visit conducted on March 24,2025. Visit covered 6 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: Adelbrook
TIME OF VISIT (FROM - TO):  9:00 am                       DATE:    March 24,2025

 AGENCY PERSONNEL WHO PARTICIPATED:
Job Title
Adelbrook Director of Residential Services
Adelbrook Charge Supervisor
Adelbrook Supervisor Clinical Services

    List of Areas / Topics covered during visit:

•	The current census for Adelbrook is 35 and the licensed bed capacity it 35. There are 3 pending discharges and 2 pending admissions.

•	Discussion of Adelbrook's current staffing levels, vacant positions, and hiring activities.

•	Discussion with Adelbrook staff regarding the status of Adelbrook's milieu, the clinical programming, and recreational and other activities for the residents.

•	Observations of the Adelbrook residents in the milieu, and observations of the interactions between Adelbrook staff and the Adelbrook residents.

•	Inspection of the Adelbrook physical plant to assess the cleanliness of the facility, as well as to ensure there are no health or safety concerns.

•	Discussion and update on the renovations currently in progress across the Adelbrook program.

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

Areas of regulatory non-compliance identified during this visit:
•	None observed at the time of this quarterly visit.

Patrick Hughes                                                      3/25/2025
Regulatory Consultant                                             Date

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


summary: Visit conducted on December 16, 2024. Visit covered 6 main areas/topics. 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: Adelbrook
TIME OF VISIT (FROM - TO):  9:15 am                       DATE:    December 16, 2024

 AGENCY PERSONNEL WHO PARTICIPATED:
Job Title
Adelbrook Director of Residential Services
Adelbrook Charge Supervisor

    List of Areas / Topics covered during visit:

•	The current census for Adelbrook is 35 and the licensed bed capacity it 35.

•	Discussion of Adelbrook's current staffing levels, vacant positions, and hiring activities.

•	Discussion with Adelbrook staff regarding the status of Adelbrook's milieu, the clinical programming, and recreational and other activities for the residents.

•	Observations of the Adelbrook residents in the milieu, and observations of the interactions between Adelbrook staff and the Adelbrook residents.

•	Inspection of the Adelbrook physical plant to assess the cleanliness of the facility, as well as to ensure there are no health or safety concerns.

•	Discussion and update on the renovations currently in progress across the Adelbrook program.

Corrective Actions implemented as a result of previous visit:
•	The floors on Shiloh House are in the process of being cleaned to remove the scuff marks.

Areas of regulatory non-compliance identified during this visit:
•	None observed at the time of this quarterly visit.

Patrick Hughes                                                           12/16/2024
Regulatory Consultant                                              Date

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

visit_date: December 16, 2024


raw_content:
October 15, 2024

Alyssa Goduti, President, and CEO
Adelbrook
60 Hicksville Road
Cromwell, CT 06416

RE: CCF# 3 Adelbrook RT

Dear Ms. Goduti,

On September 16th and September 17th, 2024, a biennial licensing inspection was conducted at your facility. This inspection was conducted to determine the compliance of this facility with the Regulations for Operation of Child-Caring Agencies and Facilities 17a-145-48 through 17a-145-98, the Psychiatric Residential Treatment Facilities Guidelines, and the DCF Guidelines for the Administration of Medication by Certified Staff.

Please review the areas identified and submit the regulatory compliance plan of correction to address each area. The plan must be submitted within 30 days of receipt of this letter and should identify: 1. the steps to be taken to correct the non-compliance and 2. the date correction(s) will be completed. The areas of non-compliance are as follows:

17a-145-73 Sleeping accommodations.
Evidence: The Shiloh House bedroom floors have a considerable amount of scuff marks. This issue was identified by Adelbrook prior to the relicensing visit and Adelbrook has already scheduled for the floors to be cleaned. Since the cleaning of the bedroom floors is already scheduled, a Regulation Compliance Plan is not required.

DCF licensing has determined that your agency has met the requirements for a regular license. This license is effective as of October 30, 2024, and is valid for twenty-four months.

Sincerely,
Patrick Hughes
Patrick Hughes
DCF Licensing Unit
860-550-6552p 860-716-2199c
patrick.hughes@ct.gov|


summary: Visit conducted on May 20, 2024. Visit covered 6 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: Adelbrook

TIME OF VISIT (FROM - TO):  10:00 am                       DATE:    May 20, 2024

 AGENCY PERSONNEL WHO PARTICIPATED:
Job Title
Adelbrook Director of Residential Services
Adelbrook Charge Supervisor

    List of Areas / Topics covered during visit:

•	The current census for Adelbrook is 33 and the licensed bed capacity is 35.

•	Discussion of Adelbrook's current staffing levels, vacant positions, and hiring activities.

•	Discussion with Adelbrook staff regarding the status of Adelbrook's milieu, the clinical programming, and recreational and other activities for the residents.

•	Observations of the Adelbrook residents in the milieu, and observations of the interactions between Adelbrook staff and the Adelbrook residents.

•	Inspection of the Adelbrook physical plant to assess the cleanliness of the facility, as well as to ensure there are no health or safety concerns.

•	Discussion and update on the renovations currently in progress across the Adelbrook program.

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

Areas of regulatory non-compliance identified during this visit:
•	None observed at the time of this quarterly visit.

Patrick Hughes                                       _6/24/2024
Regulatory Consultant                                              Date|


summary: Visit conducted on February 26, 2024. Visit covered 6 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: Adelbrook

TIME OF VISIT (FROM - TO):  10:00 am                       DATE:    February 26, 2024

 AGENCY PERSONNEL WHO PARTICIPATED:
 Job Title
Adelbrook Director of Residential Services
Adelbrook Charge Supervisor

    List of Areas / Topics covered during visit:

•	The current census for Adelbrook is 32 and the licensed bed capacity it 35.

•	Discussion of Adelbrook's current staffing levels, vacant positions, and hiring activities.

•	Discussion with Adelbrook staff regarding the status of Adelbrook's milieu, the clinical programming, and recreational and other activities for the residents.

•	Observations of the Adelbrook residents in the milieu, and observations of the interactions between Adelbrook staff and the Adelbrook residents.

•	Inspection of the Adelbrook physical plant to assess the cleanliness of the facility, as well as to ensure there are no health or safety concerns.

•	Discussion and update on the renovations currently in progress across the Adelbrook program.

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

Areas of regulatory non-compliance identified during this visit:
•	None observed at the time of this quarterly visit.

Patrick Hughes                                       _                3/7/2023
Regulatory Consultant                                              Date|

visit_date: February 26, 2024


summary: Visit conducted on August 14, 2023. Visit covered 7 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: Adelbrook
 TIME OF VISIT (FROM - TO):  10:00 am                       DATE:    August 14, 2023

 AGENCY PERSONNEL WHO PARTICIPATED:
Job Title
Adelbrook Director of Residential Services
Adelbrook Charge Supervisor

    List of Areas / Topics covered during visit:
•	The current census for Adelbrook is 34 and the licensed bed capacity it 35.

•	Discussion of Adelbrook's current staffing levels, vacant positions, and hiring activities.

•	Discussion with Adelbrook staff regarding the status of Adelbrook's milieu, the clinical programming, and summer activities for the residents.

•	Observations of the Adelbrook residents in the milieu, and observations of the interactions between Adelbrook staff and the Adelbrook residents.

•	Brief interviews / discussions with the Adelbrook residents.

•	Inspection of the Adelbrook physical plant to assess the cleanliness of the facility, as well as to ensure there are no health or safety concerns.

•	Received an update on the renovations in progress across the Adelbrook program.

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

Areas of regulatory non-compliance identified during this visit:
•	None observed at the time of this quarterly visit.

Patrick Hughes                                       _8/15/2023
Regulatory Consultant                              Date|


summary: Visit conducted on June 26, 2023. Visit covered 5 main areas/topics. No compliance issues identified.

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: Adelbrook

 TIME OF VISIT (FROM - TO):  10:00 am                       DATE:    June 26, 2023

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Title
Adelbrook Director of Residential Services
Adelbrook Charge Supervisor

    List of Areas / Topics covered during visit:

•	The current census for Adelbrook is 35 and the licensed bed capacity it 35.

•	Discussion of Adelbrook's current staffing levels, vacant positions, and hiring activities.

•	Discussion with Adelbrook staff regarding the status of Adelbrook's milieu, the clinical programming, and summer activities for the residents.

•	Observations of the Adelbrook residents and observations of the interactions between Adelbrook staff and the Adelbrook residents.

•	Inspection of the Adelbrook physical plant to assess the cleanliness of the facility, as well as to ensure there are no health or safety concerns. Discussion of the current bedroom renovations being completed.

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

Areas of regulatory non-compliance identified during this visit:
•	None observed at the time of this quarterly visit.

Patrick Hughes                                                6/26/2023
Regulatory Consultant                              Date|


summary: Visit conducted on March 15, 2023. Visit covered 4 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: Adelbrook

 TIME OF VISIT (FROM - TO):  10:00 am                       DATE:    March 15, 2023

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Title
Adelbrook Director of Residential Services
Adelbrook Charge Supervisor

    List of Areas / Topics covered during visit:

•	The current census for Adelbrook is 34 and the licensed bed capacity it 35. There is a scheduled admission this coming Monday. There are several residents on discharge delays waiting for their next placement to finalized.
•	Staffing at Adelbrook has gotten better during this quarter.  All first shift direct care positions are filled, there are only 3 overnight direct care vacancies, and the most direct care vacancies continue to be on 2nd shift.  The vacant Recreation Therapist position has been filled. Adelbrook is able to maintain the required staffing ratios for all 3 shifts.
•	The residents are doing well at Adelbrook this quarter. There are no longer any covid restrictions in place, so the residents are in the community often. Adelbrook is now using Floreo; a virtual reality autism education App. Floreo has many lesson plans for children with autism including social skills, and coping skills. Many of the residents are involved with special Olympics. All Adelbrook residents will soon be participating in the Miracle League Baseball program. The newly installed splash pad is operational and ready to use when the weather permits.
•	Adelbrook has started renovating the residents' bedrooms. The renovations include painting, new floors, closets, and windows. During this quarterly visit a physical plant inspection was completed; all areas of the Adelbrook campus and the extension homes were inspected, with no health or safety concerns observed.

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

Areas of regulatory non-compliance identified during this visit:
•	Not at the time of this quarterly visit.

Patrick Hughes                                                3/17/23
Regulatory Consultant                              Date|


summary: Visit conducted on December 21, 2022. Visit covered 6 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: Adelbrook

 TIME OF VISIT (FROM - TO):  9:00 am                       DATE:    December 21, 2022

 AGENCY PERSONNEL WHO PARTICIPATED:

Name	Job Title
ENW-B	Adelbrook Director of Residential Services
JS	Adelbrook Charge Supervisor

    List of Areas / Topics covered during visit:

•	The current census for Adelbrook is 33 and the licensed bed capacity it 35. There are 2 referrals pending for the 2 current vacancies. There is also an upcoming discharge. Adelbrook has received more out of state referrals lately. Adelbrook currently has residents placed by DCF, DDS, and local school districts.
•	The residents are doing well at Adelbrook this quarter. There have been more activities on and off grounds, and the Winter Ball is happening soon. More parents have been visiting on grounds this quarter. The outdoor pool has been replaced with a splash pad that will be ready for the spring. The residents have winter vacation next week.
•	Adelbrook is in a better position with their staffing this quarter as there have been 11 new hires.  Adelbrook is able to maintain the proper staffing ratios for all 3 shifts.
•	During this quarterly visit this regulatory consultant walked through the school building.  At the time of this visit the school building was calm and quiet and the residents were observed engaged in their school programming. A few residents were moving through the school building with school staff. The residents were observed and appeared well-cared for and comfortable in their surrounds.
•	During this quarterly visit a physical plant inspection was completed; all areas of the Adelbrook campus and the extension homes were visited with no health or safety concerns observed.

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

Areas of regulatory non-compliance identified during this visit:
•	Not at the time of this quarterly visit.

Patrick Hughes                                                2/10/23
Regulatory Consultant                                   Date
A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

visit_date: December 21, 2022


raw_content:
September 30, 2022

Alyssa Goduti, President and CEO
Adelbrook
60 Hicksville Road
Cromwell, CT 06416

RE: CCF# 3 Adelbrook RT

Dear Ms. Goduti,

On August 30th through August 31st, 2022, a biennial licensing inspection was conducted at your facility. This inspection was conducted to determine the compliance of this facility with the 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. Below are the areas of regulatory non-compliance which were identified during the re-licensing inspection.

Please review the areas of non-compliance identified on the enclosed Service Development Plan and submit your responses on the enclosed Service Development Plan to address each area.  The plan must be submitted within 30 days of receipt of this letter and should identify:  1. the steps to be taken to correct the non-compliance; and 2. the date the correction(s) will be completed.  The areas of non-compliance are listed on the attached DCF Licensing Service Development Plan.

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.

Sincerely,

¬¬¬¬¬Patrick Hughes
Patrick Hughes
DCF Regulatory Consultant

DCF LICENSING UNIT
INSPECTION REPORT

Date of Licensing Visit:

August 30th & 31st, 2022	Date Licensing Report Received by Facility:
October 4, 2022	License Type:

CCF	License No. #:

CCF- 3	Date Service Development Plan Submitted to Licensing Unit:

Corporate Name:
Adelbrook 	Corporate Address:
60 Hicksville Road, Cromwell, CT

Program Name:
Adelbrook Residential Facility	Program Address:
60 Hicksville Road, Cromwell, CT

Person Submitting Plan (Name and Title):
	Person Approving Plan (Name and Title):
	Date:

  Statute/
Licensing
Regulation #	Non-Compliance Citation	Plan of Correction/Service Development Plan	A System to Prevent
Re-Occurrence	Completion Date	Title Responsible to Monitor Plan

17a-145-86. Instructions in safety procedures. Supervision

17a-6(g)-15 (a - g)
Medication Management of Youth in Care
DCF Regulation)

17a -6(g) - 16 (c) (Health Care Standards and Practice for Children and Youth in Care).

For the year 2021 there is no evidence that 3rd shift fire drills were conducted.

For the year 2022 there is a 3rd shift fire drill missing for the 1st quarter, and a 2nd shift and 3rd shift fire drill missing for the 2nd quarter.

During the review of medication orders, three cases did not have signed orders.

During the inspection the external and internal medications were stored together.

Based on the review of the training records the facility failed to provide quarterly training for all medication certified staff.

A review of the training records found the facility failed to provide an annual skill check for 3 medication certified staff and provided the annual skill check late for three other staff members.

October 19, 2022

Alyssa Goduti / President & CEO
Adelbrook
60 Hicksville Road
Cromwell, CT 06416

RE: CCF/RT- 3 Adelbrook Residential Treatment Center

Dear Ms. Goduti,

On August 30th & 31st, 2022 a re-licensing inspection was conducted at your facility. This inspection was conducted to determine the compliance of this facility with the Regulation 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.

We have received your agency's service development plan.  The plan submitted by your agency addresses the areas of non-compliance identified in the inspection report. The Department accepts the service development plan and has determined that your agency has met the requirements for a regular license.

This license is effective as of October 30, 2022 and is valid for twenty-four months.

Sincerely,
Patrick Hughes

Patrick Hughes
Regulatory Consultant
Department of Children and Families
505 Hudson Street
Hartford, CT  06106
(w) 860-550-6552 / (c) 860-716-2199|


summary: Visit conducted on May 16, 2022. Visit covered 9 main areas/topics. Found 1 compliance issues.

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

Field Visit Reporting Form

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

  NAME OF FACILITY / PROGRAM: Adelbrook

 TIME OF VISIT (FROM - TO):  10:30 am                       DATE:    May 16, 2022

 AGENCY PERSONNEL WHO PARTICIPATED:

Name	Job Title
ENW-B  	Adelbrook Director of Residential Services
JS   	Adelbrook Charge Supervisor

List of Areas / Topics covered during visit:

•	The current census for Adelbrook is 37 and the licensed bed capacity it 35. Adelbrook has a DCF licensing waiver for the 2 additional residents. There are several residents scheduled to discharge in the next few weeks. Adelbrook currently has residents placed by DCF, DDS, and local school districts.
•	Discussed the progress of the Adelbrook residents and the status of the Adelbrook milieu.
•	Discussed Adelbrook employment vacancies and hiring updates. Hiring has increased over this past quarter. A new Nursing Director has been hired.
•	Discussed the lessening of covid-19 restrictions; residents are slowly returning to off-grounds activities.
•	Physical plant inspection of the facility; all areas of the Adelbrook campus and the extension homes were visited with no health or safety concerns observed.
•	Observation of the residents in the milieu; residents were observed and appeared well-cared for and comfortable in their surrounds.

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

Areas of regulatory non-compliance identified during this visit:
•	Not at the time of this quarterly 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.

Patrick Hughes                                                5/18/22
Regulatory Consultant                                   Date|