summary: Unannounced - 22 findings

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Residential Care
Licensee: Native American Rehabilitation Association of the Northwest, Inc (NARA)
Executive Director: Jacqueline Mercer Date of Unannounced: December 3, 2024
Program Director(s): Lucy LaDue Licensing Coordinator: Robin DuVal
Other Regulatory or Accrediting Agencies: Oregon Health Authority (OHA)
Purpose: Per OAR 419-400-0240 (1)(b) Children’s Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Findings Comments
License Renewal Site Visit 01/29-30/2024 Further Action Needed
Installation and Use of Video Equipment Used to Monitor or Record Yes☐ No✓ This policy and procedure has been updated and
Children in Care 419-400-0145(1)If a child-caring agency installs video meets licensing requirements.
equipment to monitor or record a child in care, all employees, volunteers,
parents or guardians, and children in care must be informed about the
intended use and locations of the equipment.
The agency will submit their policy and procedure for review, as well as the
method of informing those noted in this rule about the intended use and
locations of the equipment.
Supplemental Information Provided by CCA Yes☐ No✓ These policies and procedures have been
All required policies and procedures as identified in the “Umbrella Rules” updated and meet licensing requirements.
Upon review of the following policies and procedures, there are minor to
moderate edits needed.
Corrective Action: The agency shall update the following policies and
procedures pursuant to each OAR and submit for review.
• Conflict of Interest per OAR 419-400-0070
• Rights of Children and Families per OAR 419-400-0090(2)
• Grievance Procedures per OAR 419-400-0090(2)
• Mandatory Abuse Reporting per OAR 419-400-0110(2)(a)
• Privacy per OAR 419-400-0130
• Behavior Management per OAR 419-400-0150
Form Rev. 11/14/2023 P age 1 | 6
• Searches per OAR 419-400-0200(2)
If applicable, submit a written policy for compliance with Interstate Compact on
the Placement of Children (ICPC).
Supplemental Information Provided by CCA Yes☐ No✓ This policy and procedure has been updated and
All required policies and procedures as identified in “Agency Type Specific meets licensing requirements.
Rules”
The agency shall update the following policy and procedure pursuant to the
OAR and submit for review: Medications in OAR 419-470-0110
Residential Care Safety Yes☐ No✓ The plan has been updated and meets licensing
419-470-0080(2)Written emergency plan that includes: requirements.
(a) Identifying the types of emergencies most likely to happen where the
residential care agency is located
(b) Identifying a place to meet for each type of emergency identified
(c) Identifying an alternate shelter if necessary
(d) Ensuring access to necessary medications or medical equipment
(e) How to help each child in care recover after a disaster
• Requirement (b), (d), (e) are unmet.
Corrective Action: The agency shall update the emergency plan(s) and
submit for review.
Residential Care Safety Yes✓ No☐ Documentation confirm fire drills are occurring
419-470-0080 (5)(a) Evacuation drill occurs monthly under varying conditions, monthly.
is retained 2 years and contains:
(A) identify of person conducting drill The agency is utilizing the updated form,
(B) date & time however “special conditions simulated” are
(C) notification method documented as “none at this time”.
(D) staff participating
(E) # of children & staff evacuated Corrective Action: The agency shall ensure a
(F) special conditions simulated special condition is simulated for each drill and
(G) problems encountered simulations are different from month-to-month.
(H) time to complete (REPEAT FINDING)
A review of records for the last 24 months identified three months without
documented drills.
Requirement (F) “special conditions simulated” was not consistently
documented. This licensor recommended updating the form to include this
requirement.
Corrective Action: The agency shall ensure evacuation drills occur monthly;
and ensure the updated form is utilized to ensure all requirements are
documented appropriately.
Form Rev. 11/14/2023 P age 2 | 6
Medication 419-470-0100(8) Medications are disposed in accordance with Yes☐ No✓ Records were reviewed, and this requirement
state and federal law. was met. There’s no further corrective action
needed at this time.
Unopened unused prescribed medications must also be appropriately
disposed of and cannot be used for other children in care, or any other
purpose. Documentation and the practice of the method was unclear.
Corrective Action: the agency shall ensure proper disposal requirements are
met and staff are clear on the procedure. While on-site, this was discussed,
and the agency swiftly addressed this.
Medication 419-470-0100(9) Written record of the disposal of medications is Yes☐ No✓ Records were reviewed, and this requirement
maintained and includes: was met. There’s no further corrective action
(a) description and amount needed at this time.
(b) name
(c) reason
(d) method
(e) staff & witness signature
The document entry for “method” noted “return to stock” (RTS). Upon
discussion, it was unclear whether RTS meant return to pharmacy stock or
return to NARA stock. Unopened unused prescribed medications must be
disposed of and cannot be used for other children in care.
Corrective Action: the agency shall ensure proper disposal requirements are
met and staff are clear on the procedure. While on-site, this was discussed,
and the agency swiftly addressed this.
New Employee Orientation – Umbrella Requirements (30 days) Yes☐ No✓ Records were reviewed, and this requirement
419-400-0120(4)(c) Suicide prevention and intervention was met. There’s no further corrective action
needed at this time.
This training did not occur within 30 days of hire for one employee.
Corrective Action: The agency shall ensure all employees receive this
training within 30 days of hire.
New Employee Orientation – Umbrella Requirements (30 days) Yes☐ No✓ Records were reviewed, and this requirement
419-400-0120(4)(e) & (5)(a) to (c) Mandatory reporting that includes: was met. There’s no further corrective action
(a) legal definition of child abuse in ORS 418.257 and 419B.005 needed at this time.
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to the employee
This training did not occur within 30 days of hire for one employee.
Corrective Action: The agency shall ensure all employees receive this
training within 30 days of hire.
Form Rev. 11/14/2023 P age 3 | 6
New Employee Orientation - Residential (Prior to working alone and within Yes☐ No✓ Records were reviewed, and this requirement
30 days) was met. There’s no further corrective action
needed at this time.
419-470-0120(1)(e) Training on the agency’s policy on suicide prevention and
suicide risk assessment tool
This training did not occur within 30 days of hire for one employee.
Corrective Action: The agency shall ensure all employees receive this
training within 30 days of hire.
Disclosures 419-470-0160(2) Parent/guardian has acknowledged in writing: Yes☐ No✓ Records were reviewed, and this requirement
(b) Statement of Rights of Children and Parents/Guardians was met. There’s no further corrective action
needed at this time.
There were two versions of the Statement of Rights in child files that did not
meet requirement in its entirety.
Corrective Action: The agency shall ensure the form is updated pursuant to
the OAR required statements of rights and ensure the use of the updated form
going forward. It was recommended to add the revised date to the footer of the
form.
Information about Children in Care 419-400-0190(1) Yes☐ No✓ Records were reviewed, and this requirement
Summary sheet contains the following: (a)The name, gender, date of birth, was met. There’s no further corrective action
religious preference, and previous address. needed at this time.
Religious preference and gender were not consistently documented on the
summary sheet. This is a repeat violation.
Corrective Action: The agency shall ensure an entry is noted for each.
Service Planning 419-470-0170(2) (e) (A)&(B) Service plan within 60 days Yes✓ No☐ This requirement remains unmet.
(parent, guardian and child actively involved). Describes how child’s issues will
be addressed, anticipated outcomes, and reviewed by child and Corrective Action: The agency shall ensure this
guardian/parent. requirement is met.
Documentation was unclear demonstrating that a parent/guardian was actively Comment: While on-site, the agency identified
involved in service planning and that the service plan was reviewed by the possible changes to their electronic system to
parent/guardian. ensure this is met and consistently met.
(REPEAT FINDING)
Corrective Action: the agency shall ensure the documentation appropriately
captures involvement of the parent/guardian. If there is not involvement, the
agency shall document the reason.
Form Rev. 11/14/2023 P age 4 | 6
Case Management 419-470-0170(3)(c) Discharge summary must include: Yes✓ No☐ Records were reviewed, and requirement (C) is
(A)Current medications met; however, requirements A, B, and G.
(B)Name of the physician or qualified medical professional who prescribed
each medication Corrective Action: The agency shall ensure
(C)Any outstanding medical or other appointments discharge summaries include all requirements
(D)Summary of the child’s participation in the program and progress achieved outlined in this rule.
(E)Results of evaluations
(F)Recommendations regarding services Comment: While on-site, the agency identified
(G)Discharge destination possible changes to forms to ensure this is
consistently met.
Discharge summaries were missing requirements A, B, C, G. (REPEAT FINDING)
Corrective Action: the agency shall ensure discharge summaries include all
requirements outlined in this rule.
Records Relating to Restraint & Involuntary Seclusion Yes☐ No✓ Records were reviewed, and this requirement
419-400-0180(13)(e) Each child caring agency shall provide notice regarding was met. There’s no further corrective action
how to access the quarterly reports to the parents or guardians of children in needed at this time.
care in the program. The child caring agency shall provide the notice upon the
child in care’s admission and at least two times each year thereafter.
This requirement is unmet. This licensor will provide some examples for the
agency to implement.
Records Relating to Restraint & Involuntary Seclusion Yes☐ No✓ Records were reviewed, and this requirement
419-400-0190(1) Information provided to children in care relating to Restraint & was met. There’s no further corrective action
Involuntary Seclusion needed at this time.
This requirement is unmet. This licensor will provide some examples for the
agency to implement.
New Findings from Site Visit Comments
None
Form Rev. 11/14/2023 P age 5 | 6
Interview Summary
Upon arrival, neither of the program managers were on-site, although the two supervisors covering were welcoming, accommodating and professional.
Two youth were individually interviewed, ages 16 and 13, with approximate stays of 2 months and 1 month, respectfully. Both report feeling safe and described
ways the program is helping them. The food is good and plentiful. Staff are trusting, they get medications as ordered, and peer relationships are going ok.
Activities within the program and outings were described, and both expressed how they like that part of this program compared to other programs. Youth are
involved in their treatment plans, and they feel listened to. They report that program staff really care about the youth and that the program pays attention to their
individual needs as well as providing for their basic needs. Peer group circles and talking through problems is helpful. Communication with approved outside
people occurs several times a week, and they are provided privacy while communicating with approved people. When asked what the agency could improve
on, neither could think of anything.
Observations
The environment is welcoming, in good condition and clean. The milieus are spacious with comfortable couches and video gaming machines as well as mounted
TVs. All bedrooms, bathrooms, and shower rooms were observed, including the ADA room and bathroom. Other areas observed were the staff area, medication
room, and group rooms.
Corrective Actions and Timeframes: Please submit the following to verify compliance.
Within 45 days of receipt of this report Native American Rehabilitation Association of the Northwest, Inc. (NARA) must submit a letter of
verification indicating the agency is in compliance with the specific rules cited above and describing how compliance will be maintained going forward.
Along with the letter of verification, the agency must submit any and all specific documentation requested in the body of this report. The letter of
verification and any additional requested documents can be emailed directly to Robin DuVal at robin.m.duval@odhsoha.oregon.gov.
Licensing Coordinator’s Signature: ________________________ Date: _1_2_/1_6_/_2_0_2_4__________
Manager Review: ______________________________________ Date: _1_2_-1_2_-_2_0_2_4_________
Form Rev. 11/14/2023 P age 6 | 6

program_director: Lucy LaDue

visit_date: December 3, 2024

other_regulatory_agencies: Oregon Health Authority (OHA)

purpose:
Per OAR 419-400-0240 (1)(b) Children's Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Findings Comments
License Renewal Site Visit 01/29-30/2024 Further Action Needed
Installation and Use of Video Equipment Used to Monitor or Record Yes[ ] No✓ This policy and procedure has been updated and
Children in Care 419-400-0145(1)If a child-caring agency installs video meets licensing requirements.
equipment to monitor or record a child in care, all employees, volunteers,
parents or guardians, and children in care must be informed about the
intended use and locations of the equipment.
The agency will submit their policy and procedure for review, as well as the
method of informing those noted in this rule about the intended use and
locations of the equipment.
Supplemental Information Provided by CCA Yes[ ] No✓ These policies and procedures have been
All required policies and procedures as identified in the "Umbrella Rules" updated and meet licensing requirements.
Upon review of the following policies and procedures, there are minor to
moderate edits needed.
Corrective Action: The agency shall update the following policies and
procedures pursuant to each OAR and submit for review.
- Conflict of Interest per OAR 419-400-0070
- Rights of Children and Families per OAR 419-400-0090(2)
- Grievance Procedures per OAR 419-400-0090(2)
- Mandatory Abuse Reporting per OAR 419-400-0110(2)(a)
- Privacy per OAR 419-400-0130
- Behavior Management per OAR 419-400-0150

- Searches per OAR 419-400-0200(2)
If applicable, submit a written policy for compliance with Interstate Compact on
the Placement of Children (ICPC).
Supplemental Information Provided by CCA Yes[ ] No✓ This policy and procedure has been updated and
All required policies and procedures as identified in "Agency Type Specific meets licensing requirements.
Rules"
The agency shall update the following policy and procedure pursuant to the
OAR and submit for review: Medications in OAR 419-470-0110
Residential Care Safety Yes[ ] No✓ The plan has been updated and meets licensing
419-470-0080(2)Written emergency plan that includes: requirements.
(a) Identifying the types of emergencies most likely to happen where the
residential care agency is located
(b) Identifying a place to meet for each type of emergency identified
(c) Identifying an alternate shelter if necessary
(d) Ensuring access to necessary medications or medical equipment
(e) How to help each child in care recover after a disaster
- Requirement (b), (d), (e) are unmet.
Corrective Action: The agency shall update the emergency plan(s) and
submit for review.
Residential Care Safety Yes✓ No[ ] Documentation confirm fire drills are occurring
419-470-0080 (5)(a) Evacuation drill occurs monthly under varying conditions, monthly.
is retained 2 years and contains:
(A) identify of person conducting drill The agency is utilizing the updated form,
(B) date & time however "special conditions simulated" are
(C) notification method documented as "none at this time".
(D) staff participating
(E) # of children & staff evacuated Corrective Action: The agency shall ensure a
(F) special conditions simulated special condition is simulated for each drill and
(G) problems encountered simulations are different from month-to-month.
(H) time to complete (REPEAT FINDING)
A review of records for the last 24 months identified three months without
documented drills.
Requirement (F) "special conditions simulated" was not consistently
documented. This licensor recommended updating the form to include this
requirement.
Corrective Action: The agency shall ensure evacuation drills occur monthly;
and ensure the updated form is utilized to ensure all requirements are
documented appropriately.

Medication 419-470-0100(8) Medications are disposed in accordance with Yes[ ] No✓ Records were reviewed, and this requirement
state and federal law. was met. There's no further corrective action
needed at this time.
Unopened unused prescribed medications must also be appropriately
disposed of and cannot be used for other children in care, or any other

previous_findings:
Repeat Findings Comments
License Renewal Site Visit 01/29-30/2024 Further Action Needed
Installation and Use of Video Equipment Used to Monitor or Record Yes[ ] No✓ This policy and procedure has been updated and
Children in Care 419-400-0145(1)If a child-caring agency installs video meets licensing requirements.
equipment to monitor or record a child in care, all employees, volunteers,
parents or guardians, and children in care must be informed about the
intended use and locations of the equipment.
The agency will submit their policy and procedure for review, as well as the
method of informing those noted in this rule about the intended use and
locations of the equipment.
Supplemental Information Provided by CCA Yes[ ] No✓ These policies and procedures have been
All required policies and procedures as identified in the "Umbrella Rules" updated and meet licensing requirements.
Upon review of the following policies and procedures, there are minor to
moderate edits needed.
Corrective Action: The agency shall update the following policies and
procedures pursuant to each OAR and submit for review.
- Conflict of Interest per OAR 419-400-0070
- Rights of Children and Families per OAR 419-400-0090(2)
- Grievance Procedures per OAR 419-400-0090(2)
- Mandatory Abuse Reporting per OAR 419-400-0110(2)(a)
- Privacy per OAR 419-400-0130
- Behavior Management per OAR 419-400-0150

- Searches per OAR 419-400-0200(2)
If applicable, submit a written policy for compliance with Interstate Compact on
the Placement of Children (ICPC).
Supplemental Information Provided by CCA Yes[ ] No✓ This policy and procedure has been updated and
All required policies and procedures as identified in "Agency Type Specific meets licensing requirements.
Rules"
The agency shall update the following policy and procedure pursuant to the
OAR and submit for review: Medications in OAR 419-470-0110
Residential Care Safety Yes[ ] No✓ The plan has been updated and meets licensing
419-470-0080(2)Written emergency plan that includes: requirements.
(a) Identifying the types of emergencies most likely to happen where the
residential care agency is located
(b) Identifying a place to meet for each type of emergency identified
(c) Identifying an alternate shelter if necessary
(d) Ensuring access to necessary medications or medical equipment
(e) How to help each child in care recover after a disaster
- Requirement (b), (d), (e) are unmet.
Corrective Action: The agency shall update the emergency plan(s) and
submit for review.
Residential Care Safety Yes✓ No[ ] Documentation confirm fire drills are occurring
419-470-0080 (5)(a) Evacuation drill occurs monthly under varying conditions, monthly.
is retained 2 years and contains:
(A) identify of person conducting drill The agency is utilizing the updated form,
(B) date & time however "special conditions simulated" are
(C) notification method documented as "none at this time".
(D) staff participating
(E) # of children & staff evacuated Corrective Action: The agency shall ensure a
(F) special conditions simulated special condition is simulated for each drill and
(G) problems encountered simulations are different from month-to-month.
(H) time to complete (REPEAT FINDING)
A review of records for the last 24 months identified three months without
documented drills.
Requirement (F) "special conditions simulated" was not consistently
documented. This licensor recommended updating the form to include this
requirement.
Corrective Action: The agency shall ensure evacuation drills occur monthly;
and ensure the updated form is utilized to ensure all requirements are
documented appropriately.

Medication 419-470-0100(8) Medications are disposed in accordance with Yes[ ] No✓ Records were reviewed, and this requirement
state and federal law. was met. There's no further corrective action
needed at this time.
Unopened unused prescribed medications must also be appropriately
disposed of and cannot be used for other children in care, or any other
purpose. Documentation and the practice of the method was unclear.
Corrective Action: the agency shall ensure proper disposal requirements are
met and staff are clear on the procedure. While on-site, this was discussed,
and the agency swiftly addressed this.
Medication 419-470-0100(9) Written record of the disposal of medications is Yes[ ] No✓ Records were reviewed, and this requirement
maintained and includes: was met. There's no further corrective action
(a) description and amount needed at this time.
(b) name
(c) reason
(d) method
(e) staff & witness signature
The document entry for "method" noted "return to stock" (RTS). Upon
discussion, it was unclear whether RTS meant return to pharmacy stock or
return to NARA stock. Unopened unused prescribed medications must be
disposed of and cannot be used for other children in care.
Corrective Action: the agency shall ensure proper disposal requirements are
met and staff are clear on the procedure. While on-site, this was discussed,
and the agency swiftly addressed this.
New Employee Orientation - Umbrella Requirements (30 days) Yes[ ] No✓ Records were reviewed, and this requirement
419-400-0120(4)(c) Suicide prevention and intervention was met. There's no further corrective action
needed at this time.
This training did not occur within 30 days of hire for one employee.
Corrective Action: The agency shall ensure all employees receive this
training within 30 days of hire.
New Employee Orientation - Umbrella Requirements (30 days) Yes[ ] No✓ Records were reviewed, and this requirement
419-400-0120(4)(e) & (5)(a) to (c) Mandatory reporting that includes: was met. There's no further corrective action
(a) legal definition of child abuse in ORS 418.257 and 419B.005 needed at this time.
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to the employee
This training did not occur within 30 days of hire for one employee.
Corrective Action: The agency shall ensure all employees receive this
training within 30 days of hire.

New Employee Orientation - Residential (Prior to working alone and within Yes[ ] No✓ Records were reviewed, and this requirement
30 days) was met. There's no further corrective action
needed at this time.
419-470-0120(1)(e) Training on the agency's policy on suicide prevention and
suicide risk assessment tool
This training did not occur within 30 days of hire for one employee.
Corrective Action: The agency shall ensure all employees receive this
training within 30 days of hire.
Disclosures 419-470-0160(2) Parent/guardian has acknowledged in writing: Yes[ ] No✓ Records were reviewed, and this requirement
(b) Statement of Rights of Children and Parents/Guardians was met. There's no further corrective action
needed at this time.
There were two versions of the Statement of Rights in child files that did not
meet requirement in its entirety.
Corrective Action: The agency shall ensure the form is updated pursuant to
the OAR required statements of rights and ensure the use of the updated form
going forward. It was recommended to add the revised date to the footer of the
form.
Information about Children in Care 419-400-0190(1) Yes[ ] No✓ Records were reviewed, and this requirement
Summary sheet contains the following: (a)The name, gender, date of birth, was met. There's no further corrective action
religious preference, and previous address. needed at this time.
Religious preference and gender were not consistently documented on the
summary sheet. This is a repeat violation.
Corrective Action: The agency shall ensure an entry is noted for each.
Service Planning 419-470-0170(2) (e) (A)&(B) Service plan within 60 days Yes✓ No[ ] This requirement remains unmet.
(parent, guardian and child actively involved). Describes how child's issues will
be addressed, anticipated outcomes, and reviewed by child and Corrective Action: The agency shall ensure this
guardian/parent. requirement is met.
Documentation was unclear demonstrating that a parent/guardian was actively Comment: While on-site, the agency identified
involved in service planning and that the service plan was reviewed by the possible changes to their electronic system to
parent/guardian. ensure this is met and consistently met.
(REPEAT FINDING)
Corrective Action: the agency shall ensure the documentation appropriately
captures involvement of the parent/guardian. If there is not involvement, the
agency shall document the reason.

Case Management 419-470-0170(3)(c) Discharge summary must include: Yes✓ No[ ] Records were reviewed, and requirement (C) is
(A)Current medications met; however, requirements A, B, and G.
(B)Name of the physician or qualified medical professional who prescribed
each medication Corrective Action: The agency shall ensure
(C)Any outstanding medical or other appointments discharge summaries include all requirements
(D)Summary of the child's participation in the program and progress achieved outlined in this rule.
(E)Results of evaluations
(F)Recommendations regarding services Comment: While on-site, the agency identified
(G)Discharge destination possible changes to forms to ensure this is
consistently met.
Discharge summaries were missing requirements A, B, C, G. (REPEAT FINDING)
Corrective Action: the agency shall ensure discharge summaries include all
requirements outlined in this rule.
Records Relating to Restraint & Involuntary Seclusion Yes[ ] No✓ Records were reviewed, and this requirement
419-400-0180(13)(e) Each child caring agency shall provide notice regarding was met. There's no further corrective action
how to access the quarterly reports to the parents or guardians of children in needed at this time.
care in the program. The child caring agency shall provide the notice upon the
child in care's admission and at least two times each year thereafter.
This requirement is unmet. This licensor will provide some examples for the
agency to implement.
Records Relating to Restraint & Involuntary Seclusion Yes[ ] No✓ Records were reviewed, and this requirement
419-400-0190(1) Information provided to children in care relating to Restraint & was met. There's no further corrective action
Involuntary Seclusion needed at this time.
This requirement is unmet. This licensor will provide some examples for the
agency to implement.
New Findings from Site Visit Comments
None

excerpt:
419-400-0150
- Searches per OAR

excerpt:
419-400-0190(1) Information provided to children in care relating to Restraint & was met. There's no further corrective action
Involuntary Seclusion needed at this time.
This requirement is unmet. This licensor will provide some examples for the
agency to implement.
New Findings from Site Visit Comments
None
None


state: OR

summary: Unannounced - 3 findings

raw_content:
Licensed Child Caring Agency Site Visit Report
Residential Care - Unannounced
Licensee: Native American Rehabilitation Association of the Northwest, Inc. (NARA) Date of site visit: July 16, 2025
Executive Director: Jacqueline Mercer Licensing Coordinator: Robin DuVal
Program Director: Luci LaDue
Other regulatory or accrediting agencies: Oregon Health Authority (OHA)
Purpose: Per OAR 419-400-0240 (1)(b) Children’s Care Licensing is required to perform at least one unannounced site visit a year
where children in care reside.
Previous findings Repeat findings
Unannounced Site Visit – 12/03/2024 further action Comments
needed
Residential Care Safety
419-470-0080 (5)(a) Evacuation drill occurs monthly under varying
conditions, is retained 2 years and contains:
(A) identify of person conducting drill
(B) date & time
(C) notification method
(D) staff participating
Records were reviewed and this
(E) # of children & staff evacuated
No requirement was met. There’s no further
(F) special conditions simulated
action at this time.
(G) problems encountered
(H) time to complete
Documentation confirm fire drills are occurring monthly.
The agency is utilizing the updated form, however “special
conditions simulated” are documented as “none at this time”.
(REPEAT FINDING)
Form Rev. 3/12/2025 P a g e 1 | 4
Previous findings Repeat findings
Unannounced Site Visit – 12/03/2024 further action Comments
needed
Corrective Action: The agency shall ensure a special condition is
simulated for each drill and simulations are different from month-to-
month.
Service Planning 419-470-0170(2) (e) (A)&(B) Service plan within
60 days (parent, guardian and child actively involved). Describes how
child’s issues will be addressed, anticipated outcomes, and reviewed
by child and guardian/parent.
Records were reviewed and this
No requirement was met. There’s no further
This requirement remains unmet. (REPEAT FINDING)
action at this time.
Corrective Action: The agency shall ensure this requirement is met.
Comment: While on-site, the agency identified possible changes to
their electronic system to ensure this is met and consistently met.
Case Management 419-470-0170(3)(c) Discharge summary must
include:
(A)Current medications
(B)Name of the physician or qualified medical professional who prescribed
each medication
(C)Any outstanding medical or other appointments
Records were reviewed and this
(D)Summary of the child’s participation in the program and progress
requirement was met. There’s no further
achieved
(E)Results of evaluations action at this time.
(F)Recommendations regarding services No
(G)Discharge destination Recommendation provided to document
“N/A” if the youth discharges with no
Records were reviewed, and requirement (C) is met; however,
medications.
requirements A, B, and G were unmet. (REPEAT FINDING)
Corrective Action: The agency shall ensure discharge summaries
include all requirements outlined in this rule.
Comment: While on-site, the agency identified possible changes to
forms to ensure this is consistently met.
Form Rev. 3/12/2025 P a g e 2 | 4
New findings from site visit Comments
None
Interview summary
Two youth were individually interviewed, ages 14 and 16, with approximate stays in the program of one week and one month. Both
report feeling safe and described ways the program is helping them. The food is good and plentiful. Staff are trusting, they get
medications as ordered, and peer relationships are going well with one describing it as a “good bond” of peers. Activities within the
program and outings were described, and they shared what they’re working on in school. Youth are involved in their treatment plans,
and they feel listened to. Communication with approved outside people occurs several times a week, in various formats (phone, virtually
and in-person) and they are provided privacy while communicating with approved people. They report that program does well at
supporting the youth, giving them hope, and state staff are flexible and do well at deescalating youth to avoid runaways. When asked
if they could change anything about the program, one reported they wished they could have their personal cell phone.
Observations
The program director accompanied me on the walk-thru, and I also interacted with the operations manager and clinical supervisor. The
environment is welcoming, in good condition, clean and within comfortable temperatures. The milieus are spacious with comfortable
couches and video gaming machines as well as mounted TVs. All bedrooms, bathrooms, and shower rooms were observed, including
the ADA room and bathroom. Other areas observed were the staff area and the classroom.
Corrective actions and timeframes: Please submit the following to verify compliance.
Within 45 days of receipt of this report Native American Rehabilitation Association of the Northwest, Inc. (NARA) must submit a
letter of verification indicating the agency is in compliance with the specific rules cited above and describing how compliance will be
maintained going forward. Along with the letter of verification, the agency must submit any and all specific documentation requested in
the body of this report. The letter of verification and any additional requested documents can be emailed directly to Robin DuVal at
robin.m.duval@odhsoha.oregon.gov.
Form Rev. 3/12/2025 P a g e 3 | 4
7-30-2025
7/29/2025
Robin DuVal Harry Gilmore
Licensing Coordinator's signature Manager Review
Form Rev. 3/12/2025 P a g e 4 | 4

program_name: Youth Residential Treatment Center (YRTC)

program_type: (RC) Residential Care Programs

report_type: Unannounced

view_code: RC

facility_type: Residential Care - Unannounced

executive_director: Jacqueline Mercer

program_director: Luci LaDue

licensing_coordinator: Robin DuVal

purpose:
Per OAR 419-400-0240 (1)(b) Children's Care Licensing is required to perform at least one unannounced site visit a year
where children in care reside.
Previous findings Repeat findings
Unannounced Site Visit - 12/03/2024 further action Comments
needed
Residential Care Safety
419-470-0080 (5)(a) Evacuation drill occurs monthly under varying
conditions, is retained 2 years and contains:
(A) identify of person conducting drill
(B) date & time
(C) notification method
(D) staff participating
Records were reviewed and this
(E) # of children & staff evacuated
No requirement was met. There's no further
(F) special conditions simulated
action at this time.
(G) problems encountered
(H) time to complete
Documentation confirm fire drills are occurring monthly.
The agency is utilizing the updated form, however "special
conditions simulated" are documented as "none at this time".
(REPEAT FINDING)

Previous findings Repeat findings
Unannounced Site Visit - 12/03/2024 further action Comments
needed
Corrective Action: The agency shall ensure a special condition is
simulated for each drill and simulations are different from month-to-
month.
Service Planning 419-470-0170(2) (e) (A)&(B) Service plan within
60 days (parent, guardian and child actively involved). Describes how
child's issues will be addressed, anticipated outcomes, and reviewed
by child and guardian/parent.
Records were reviewed and this
No requirement was met. There's no further
This requirement remains unmet. (REPEAT FINDING)
action at this time.
Corrective Action: The agency shall ensure this requirement is met.
Comment: While on-site, the agency identified possible changes to
their electronic system to ensure this is met and consistently met.
Case Management 419-470-0170(3)(c) Discharge summary must
include:
(A)Current medications
(B)Name of the physician or qualified medical professional who prescribed
each medication
(C)Any outstanding medical or other appointments
Records were reviewed and this
(D)Summary of the child's participation in the program and progress
requirement was met. There's no further
achieved
(E)Results of evaluations action at this time.
(F)Recommendations regarding services No
(G)Discharge destination Recommendation provided to document
"N/A" if the youth discharges with no
Records were reviewed, and requirement (C) is met; however,
medications.
requirements A, B, and G were unmet. (REPEAT FINDING)
Corrective Action: The agency shall ensure discharge summaries
include all requirements outlined in this rule.
Comment: While on-site, the agency identified possible changes to
forms to ensure this is consistently met.

New findings from site visit Comments
None
Interview summary
Two youth were individually interviewed, ages 14 and 16, with approximate stays in the program of one week and one month. Both
report feeling safe and described ways the program is helping them. The food is good and plentiful. Staff are trusting, they get
medications as ordered, and peer relationships are going well with one describing it as a "good bond" of peers. Activities within the
program and outings were described, and they shared what they're working on in school. Youth are involved in their treatment plans,
and they feel listened to. Communication with approved outside people occurs several times a week, in various formats (phone, virtually
and in-person) and they are provided privacy while communicating with approved people. They report that program does well at
supporting the youth, giving them hope, and state staff are flexible and do well at deescalating youth to avoid runaways. When asked
if they could change anything about the program, one reported they wished they could have their personal cell phone.
Observations
The

excerpt:
419-470-0170(3)(c) Discharge summary must
include:
(A)Current medications
(B)Name of the physician or qualified medical professional who prescribed
each medication
(C)Any outstanding medical or other appointments
Records were reviewed and this
(D)Summary of the child's participation in the program and progress
requirement was met. There's no further
achieved
(E)Results of evaluations action at this time.
(F)Recommendations regarding services No
(G)Discharge destination Recommendation provided to document
"N/A" if the youth discharges with no
Records were reviewed, and requirement (C) is met; however,
medications.
requirements A, B, and G were unmet. (REPEAT FINDING)
Corrective Action: The agency shall ensure discharge summaries
include all requirements outlined in this rule.
Comment: While on-site, the agency identified possible changes to
forms to ensure this is consistently met.
New findings from site visit Comments
None
None


facility_name: Nexus Family Healing - Walden Crossing

summary: 6-month - 5 findings

raw_content:
Licensed Child Caring Agency Site Visit Report
Residential Care
Licensee: Nexus Family Healing – Walden Crossing Date of site visit: 08.27.2024
Executive Director: Kyle Dolmage Licensing Coordinator: Aubrey Kelly
Other Regulatory or Accrediting Agencies: OHA
Program Compliance: The program was found to be compliant or will be compliant with OAR 419-400-0005 to 419-400-0310, Licensing Umbrella
Rules, and OAR 419-470-0010 to 419-470-0180, Licensing Residential Care Agencies Rules. Personnel records were reviewed and compliance
with required background checks was documented for employees in all programs.
Program Description(s): Nexus residential programs are designed to keep families engaged throughout the treatment process—and to ensure
wrap-around support is needed during this difficult time. The program helps youth build skills and stability in their lives, and also helps the rest of the
family deal with the impact of trauma and mental health issues. Nexus Family Healing’s Walden Crossing, provides individualized, trauma-informed
Psychiatric Residential Treatment Facility (PRTF) services for youth ages 10-17 with mental and developmental disabilities who have become
involved in the justice system. This location offers secure placement and clinical services during this pause in the youth’s life when the court has
ordered it. A healing environment for the youth while the large legal and justice issues are being sorted through and restorative services are being
provided. Youth experience on-campus education, individualized programming and therapy and recreational opportunities.
Walden Crossing is a welcoming safe space for up to six youth, each having their own bedroom and ample space for therapeutic, educational, daily
living and recreation activities daily. The youth served are at a crossroads where the path forward is often uncertain. This can be an emotionally
stressful time, but it can also be a time for reflection, learning and skill building for whatever comes next for the youth.
The services, planning and treatment course we provide is highly individualized and based on the needs and abilities of each youth. Nexus Family
Healing staff will also be working with families to create strong planning upon discharge and provide support to those plans.
As a secure PRTF location, Walden Crossing has high staff to youth ratios as well as 24/7 nursing, recreational and therapeutic professionals,
psychiatric services, and an array of other types of therapies as indicated. We work together, as a team, to restore hope and reshape futures.
Interviews, Observations:
Client: They have been in the program for 4 months, and this is their first program. They came from detention. They like most staff, though some
aren’t as good. They have individual therapy once a week and family therapy once a week. They were recently injured while in the community and
staff got them medical attention upon their return to the program. The food is ok, but they like the food in detention better. They don’t like having the
same teacher for all subjects at the program; it’s boring. They feel safe here. They have private phone calls in their bedroom through an intercom
system. They enjoy the outings.
Corrective Actions and Timeframes: Please submit the following to verify compliance.
P age 1 | 15
Form Rev. 1/2/2024
Within 45 days of receipt of this report Nexus Family Healing – Walden Crossing must submit a letter of verification indicating the agency is in
compliance with the specific rules cited above and describing how compliance will be maintained going forward. Along with the letter of verification,
the agency must submit any and all specific documentation requested in the body of this report. The letter of verification and any additional
requested documents can be emailed directly to Aubrey Kelly at Aubrey.J.Kelly@odhsoha.oregon.gov.
Summary of Review
Program and Services
Yes No N/A Corrective Actions/Comments
419-400-0020 (2)
Program and services are in scope of license X
Executive Director or Program Director
Yes No N/A Corrective Actions/Comments
419-400-0040
(3)(a) knowledge of requirements for
providing care and treatment appropriate to X
programs
(3)(g) Approval from BCU X
Installation and Use of Video Equipment
Used to Monitor or Record Children in
Yes No N/A Corrective Actions/Comments
Care
419-400-0145
(1) If a child-caring agency installs video
equipment to monitor or record a child in
care, all employees, volunteers, parents or
X
guardians, and children in care must be
informed about the intended use and
locations of the equipment.
Discipline, Behavior Management, and
Suicide Prevention Yes No N/A Corrective Actions/Comments
419-400-0150
(3) Agency uses appropriate and positive
methods of behavior management and
X
nationally recognized non-violent crisis
intervention
(3)(b)(C) Agency does not use chemical and
mechanical restraint (excluding medically X
necessary devices/prescriptions)
(3)(c) Agency uses appropriate time-out
rooms (adequate space, heat, light and
ventilation and is not capable of locking) and X
documents use in child’s record when
applicable
(3)(e) Agency uses seclusion
X
appropriately/consistent with policy
(4) Agency has adequate plan in place to
x
respond to suicidal behavior/warning signs
P age 2 | 15
Form Rev. 1/2/2024
Restraints and Involuntary Seclusion
Yes No N/A Corrective Actions/Comments
419-400-0180
(13)(d) Each child caring agency that
submits a report under this section shall
make its quarterly report available to the
X
public upon request at the Child Caring
Agency’s main office and on the child caring
agency’s website if applicable.
Physical Plant
Yes No N/A Corrective Actions/Comments
419-400-0090(3)(a) Foster Rights Posted (if
X
children in DHS custody)
419-400-0100(1) Sufficient safe space,
X
equipment, and office equipment
419-400-0230(12) License is posted in
X
common area at each facility
419-470-0020(2)(a) &(c) Buildings are
X
smoke free, clean and in good repair
419-470-0020 (2)(d) Rooms are free of
X
harmful drafts, odors, and excessive noise
419-470-0020 (2)(e) Rooms are adequate in
X
size and arrangement
419-470-0020 (2)(f) System provides a
continuous supply of hot and cold water to X
taps located throughout the facility
419-470-0020 (2)(h) Building is well
ventilated and room temperature is within a X
normal comfort range
419-470-0030 (1) All parts of the facility
X
ensure the safety of children
Room and Space Requirements
Yes No N/A Corrective Actions/Comments
419-470-0030
(2) There is a separate living room or lounge X
area – 15 SF minimum per child
(5) There is a separate dining room with X
capacity for ½ of children in care and 15 SF
per child in care
(7) Laundry is separate from living, kitchen, X
and dining areas
(8) Separate storage areas are provided for X
food, kitchen supplies, utensils, clean linens,
soiled linens and clothing, cleaning supplies
and equip, poisons, chemicals, outdoor
recreational and maintenance equipment.
(Hazardous materials are properly labeled, in
original container and locked)
P age 3 | 15
Form Rev. 1/2/2024
(9) Outdoor activity area is protected from X
vehicles and other hazards and of a size and
availability appropriate to the age and needs
of children in care
(11) Time-out rooms: Rooms used for time X
out or quiet time must have adequate space,
heat, light and ventilation and must not be
capable of locking.
Room and Space Requirements
Bedrooms Yes No N/A Corrective Actions/Comments
419-470-0030(3)
(a) Adequate furnishings and personal items X
(b) Separate from rooms used for dining,
X
living, laundry, kitchen, and storage
(c) Meet Oregon Fire Code Requirements X
(d) Be an outside room, with a window that
operates as designed. If the window is
modified from its original design, the fire
X
marshal must approve the modification and
indicate this room still meets applicable
Oregon Fire Code.
(d) Ceiling at least 90 inches X
(e) Minimum 60 SF per occupant X
(f) No more than 25 if dorm style X
(g) Permanently wired fixtures X
(h) Window covering X
Room and Space Requirements
Bathrooms Yes No N/A Corrective Actions/Comments
419-470-0030(4)
(a)(A)&(B) 1:8 ratio for toilets and sinks X
(a)(D) Hot and cold running water, soap, and
X
approved hand drying options
(a)(E) 1:10 ratio for shower or bathtub X
(a)(E) Individual privacy X
(a)(F) Window covering X
(a)(G) Permanently wired fixtures X
(a)(H) Adequate ventilation X
(b)&(c) Wooden racks on floors are
prohibited and impervious shower mats are
X
disinfected & dried daily be in good condition
and free of mold
Room and Space Requirements
Kitchen Yes No N/A Corrective Actions/Comments
419-470-0030(6)
P age 4 | 15
Form Rev. 1/2/2024
(a) Used exclusively for storage, food
preparation, dishwashing, and activities
X
related to eating and food preparation
activities
(b) Walls, floors are easily cleanable X
(c) Equipment and utensils are easily
X
cleanable, durable, nontoxic, and kept clean
(e) Equipment is easy to clean beneath,
X
between and behind
Furnishings and Personal Items
Yes No N/A Corrective Actions/Comments
419-470-0040
(1) There is a bed with frame, X
(1)(b) clean mattress in good condition,
X
with a minimum thickness of five inches
(1)(c) a pillow in good condition X
(1)(d) a private dresser, closet, or similar
storage area for personal belongings that X
is readily accessible
(2) Linens are in good repair. There is a
waterproof mattress cover or mattress.
X
Linens are appropriate and towels and
washcloths are provided
(3) Bedding is changed weekly or when
X
soiled
(4)&(5) Personal hygiene supplies and
X
appropriate clothing are provided
Food Services
Yes No N/A Corrective Actions/Comments
419-470-0070
(1)(a) Meals are arranged daily, consistent
with normal mealtimes that occur during the
X
hours of operation and provide snacks
between mealtimes
(1)(b) Menus are prepared in advance in
accordance with USDA guidelines, provide a
X
variety of foods and are adjusted for
seasonal changes including snacks
(1)(b) Menus are kept for at least 6 months X
(1)(c) Drinking water is freely available X
(2)(a) Food is stored, prepared & served in a
X
sanitary manner
(2)(c) & (d) Food products are obtained from
commercial suppliers (exception of fruits & X
vegetables), unpasteurized juice is
P age 5 | 15
Form Rev. 1/2/2024
prohibited, and only Grade A pasteurized
and fortified milk in appropriate container.
Residential Care Safety
Yes No N/A Corrective Actions/Comments
419-470-0080
(2) Written emergency plan that includes X
(a) Identifying the types of emergencies most
likely to happen where the residential care
agency is located
(b) Identifying a place to meet for each type
X
of emergency identified
(c) Identifying an alternate shelter if
X
necessary
(d) Ensuring access to necessary
X
medications or medical equipment
(e) How to help each child in care recover
X
after a disaster
(3) Telephone numbers for local police, fire
department, poison control, after hours
medical advice and other appropriate X
emergency numbers must be posted near all
telephones.
(4) Operative flashlights sufficient in number
X
are readily available to staff
(5)(a) Evacuation drill occurs monthly under
varying conditions, is retained 2 years and
contains:
(A) identify of person conducting drill
(B) date & time
(C) notification method X
(D) staff participating
(E) # of children & staff evacuated
(F) special conditions simulated
(G) problems encountered
(H) time to complete
Umbrella Safety
Yes No N/A Corrective Actions/Comments
419-400-0200
(5)(b) Vehicle has insurance policy, is smoke X
free, safe operating condition, and has first
aid kit and fire extinguisher 2-A:10-BC
(1)(b)(A) Each vehicle used to transport a X
child in care must be: properly registered,
covered by an insurance policy in full force
and effect, maintained in safe operating
condition, and smoke-free.
(3) If a child-caring agency has a swimming x
pool on the premises that is accessible to
P age 6 | 15
Form Rev. 1/2/2024
children in care or if a child-caring agency
plans to have children in care engage in
swimming, the child-caring agency must
have and adhere to policies and procedures
that address, at a minimum, providing
disclosures and obtaining consents,
assessing swimming ability of children in
care, and ensuring the safety of pool access.
(4)(a) The program protects children from X
potentially harmful items and materials.
(4)(b) Direct supervision of children who do X
not have the ability to adjust and control
water temperature
(4)(c) Light fixtures have protective covers X
unless designed to be used without one
Medication
Yes No N/A Corrective Actions/Comments
419-470-0100
(3)&(7)(e) Medications have a prescription
and are stored in the original container with X
prescription label
(4)&(5) Herbal supplements and remedies,
medical treatments, special diets, physical
therapy, physical aides or limitations have a
written order signed by a physician or
qualified medical professional. A written X
order, signed by a physician or qualified
medical professional, is also required before
a restriction on diet or physical activity is
imposed.
(7)(c) Medications are inaccessible to
children and stored behind at least two
X
locking mechanisms. This does not apply to
Naloxone.
(8) Medications are disposed in accordance
X
with state and federal law
(9) Written record of the disposal of
medications is maintained and includes:
(a) description and amount
The method of disposal was missing from medication disposal logs. The program shall
(b) name X
ensure the method of disposal is on all medication logs.
(c) reason
(d) method
(e) staff & witness signature
(10) Written record of the administration of
medication includes:
X
(a) name
(b) description
P age 7 | 15
Form Rev. 1/2/2024
(c) dates and times
(d) missed doses
(e) medication disposed
(f) method of administration
(g) ID of person administering
(h) possible adverse reactions
(i) medication taken outside facility
Extracurricular, Enrichment, Cultural &
Social Activities Yes No N/A Corrective Actions/Comments
419-470-0110
(2) Children have ongoing opportunities to X
participate in at least one age-appropriate or
developmentally appropriate activity
Minimum Staffing Requirements
Yes No N/A Corrective Actions/Comments
419-470-0130
(1)&(2) Supervision is adequate for the type X
of program, location, age and type of
children, ability of supervisor to respond,
electronic back-up systems.
Minimum ratios are maintained:
Under 30 months of age: 1:4
30 months to ˃ 6 years or non-ambulatory:
1:6
Ages 6 and older: 1:7
Overnight (staff awake)
1:10
(4)(a) When one staff on duty, there is X
additional staff immediately available with
max response time of 30 minutes
(5) There is at least one on-site employee X
authorized to apply the reasonable and
prudent parent standard
Sleeping Arrangements
Yes No N/A Corrective Actions/Comments
419-470-0140
(1) Children are in separate bedrooms than X
adults, unless parent and child, or there is
written approval from guardian/parent and
licensing coordinator
(2) There is adequate supervision of children X
when sleeping
(3) When assigning bedrooms a residential X
care agency must consider all of the
following:
(a) Chronological age
P age 8 | 15
Form Rev. 1/2/2024
(b) Developmental age
(c) Gender identity
(d) Personal history, including medical,
mental health, behavioral health, and past
adverse experiences including any physical
or sexual abuse
Personnel Files
Yes No N/A Corrective Actions/Comments
419-400-0120
Staff Name/Position X
(3)(g) Date of Hire X
(3)(a) record of education, training, and
X
previous employment
(1)(b) & (3)(b) reference checks completed
X
and documented
One staff personnel file did not contain a completed background check. Since the onsite
(1)(a) & (3)(c) Background check completed review, the program has submitted the staff’s background check request to the
X
and documented background check unit. The program shall ensure the completed background check is
documented.
(3)(d) Annual performance evaluations X
(3)(f) Record of personnel actions X
(3)(g) Termination date, reason for
X
termination
(3)(h) Current job description (1)(c)
Employee meets minimum qualifications X
stated in current job description
New Employee Orientation – Umbrella
Requirements (30 days) Yes No N/A Corrective Actions/Comments
419-400-0120(4)
(a) Agency policies and procedures X
(b) Ethical and professional guidelines X
(c) Suicide prevention and intervention X
(d) Attributes of population served X
(e) & (5)(a) to (c) Mandatory reporting that
includes:
(a) legal definition of child abuse in ORS
418.257 and 419B.005 X
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to
the employee
(f) Privacy laws X
(g) Emergency procedures X
New Employee Orientation Yes No N/A Corrective Actions/Comments
P age 9 | 15
Form Rev. 1/2/2024
Residential (Prior to working alone and
within 30 days)
419-470-0120(1)
(a) Discipline and behavior management
including de-escalation, crisis prevention,
positive behavior management, and X
disciplinary techniques that are non-punitive
in nature
(b) CPR and First Aid sufficient to retain a
X
current certification
(c) Universal precautions and hygiene X
(d) Application of the reasonable and
X
prudent parent standard
(e) Training on the agency’s policy on
suicide prevention and suicide risk X
assessment tool
Crisis Intervention Training Standards
and Certification Yes No N/A Corrective Actions/Comments
419-400-0160(4) (as applicable)
(a)Complete a minimum of 12 hours of initial
training in person from a certified instructor,
including but not limited to a minimum of six
hours of training focused on positive
X
behavior support, nonviolent crisis
intervention and other methods of
nonphysical intervention to support children
in care during a crisis
(d) Receive a certificate that states:
(A) The dates during which the certification
is current
(B) The type of restraint which the individual
is certified to perform if applicable
(C) The type of training the individual is Staff personnel files did not contain evidence of a certificate for completion of crisis
certified to conduct if applicable X intervention training. The program shall ensure a certificate is issued with all required
(D) Any special endorsements earned by the information when crisis intervention training is completed.
individual
(E) The level of training
(F) The name of the certified instructor who
conducted the training and administered the
assessment of proficiency.
(e) A certification issued: Staff personnel files did not contain evidence of a certificate for completion of crisis
(A) Must be personal to the individual X intervention training. The program shall ensure a certificate is issued with all required
certified by the training provider information when crisis intervention training is completed.
P age 10 | 15
Form Rev. 1/2/2024
(B) May be valid for no more than two years
with recertification
Ongoing Training Yes No N/A Corrective Actions/Comments
419-470-0070(2)(b) Employees who handle
food served to children have a valid food X
handler’s card
419-400-0200 (1) Employees transporting
children have: current driver’s license,
insurance, trained in emergency procedures X
and behavior management, and training for
15+ passenger vans if applicable)
419-470-0120 (2)(a) Environmental
X
emergencies
419-470-0120 (2)(b) Universal Precautions X
419-470-0120 (2)(c) Discipline and Behavior
X
Management
419-470-0120 (2)(d) Agency’s policy on
X
suicide prevention and risk assessment tool
419-470-0120 (3) Staff providing direct care
must maintain current CPR/First Aid X
certification
419-470-0120 (4) Designated staff
authorized to apply reasonable and prudent
X
parent standard are trained in application of
the standard
419-400-0120(5) Mandatory reporting
(annually) that includes:
(a) legal definition of child abuse in ORS
418.257 and 419B.005 X
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to
the employee
419-400-0160(4)(b) Receive continuing
education (as applicable on crisis
X
intervention training) from a certified
instructor on an annual basis
Children’s Records Yes No N/A Corrective Actions/Comments
Health Services
419-470-0090
P age 11 | 15
Form Rev. 1/2/2024
(2) Medical history obtained within 30 days
(significant findings, current immunizations,
history of surgical procedures-health issues- X
injuries, allergies, dental, vision, hearing,
behavioral health, and physician orders)
(4)(a) to (f) Medical exams (3 in first year of
life, 2,4,6,9,14) X
(g) Have a physical examination within the
first 60 days after admission of a child in
care. Documentation of a physical X
examination having occurred within the
calendar year will meet this requirement.
Consents
Yes No N/A Corrective Actions/Comments
419-470-0160(1)
(a) Provide routine and emergency medical
X
care
(b) Use the discipline and behavior
X
management system
(c) Use restraint or seclusion (if applicable).
Must specify the reasons for the intervention X
and how staff are trained and supervised
(d) Restrict contact with persons outside of
X
the agency
(e) Allow access as defined in 419-400-0230
X
& 0240
(f) Impose a dress code X
(g) Apply the reasonable and prudent parent
X
standard
Disclosures
419-470-0160(2) Yes No N/A Corrective Actions/Comments
Parent/guardian has acknowledged in writing:
(a) Information regarding personal or room
searches and protocols for confiscation of X
contraband
(b) Statement of Rights of Children and
X
Parents/Guardians
(c) Any policies and procedures upon request X
Authorizations
Yes No N/A Corrective Actions/Comments
419-470-0160(3)
(a) Disclose or exchange information with
X
others
(b) Child specific visitors X
(c) Visitation resources are pre-approved X
P age 12 | 15
Form Rev. 1/2/2024
(d) Activity specific authorizations are pre-
approved to allow children to participate in
potentially hazardous activities, including but X
not limited to using motorized yard
equipment, swimming, and horseback riding.
Information about Children in Care
419-400-0190(1) Yes No N/A Corrective Actions/Comments
Summary sheet contains the following:
(a)The name, gender, date of birth, religious
X
preference, and previous address
(b) Name and location of previous and
X
current school
(c) Date of admission X
(d) Legal custody X
(e) The name, address, and telephone
number of:
(A) The child in care's parents.
(B) The child in care's legal guardian, if
different than the parents, and a copy of
X
the document that provides for his or her
authority over the child in care.
(C) Other persons significant to child
(D) Other professionals to be involved in
service planning (if applicable)
Service Planning
Yes No N/A Corrective Actions/Comments
419-470-0170(2)
(b) Intake document is completed the date
child accepted into care (emergency X
placement 48 hours)
(d) Assessment is completed within 30 days
and contains relevant historical info., current
behavioral observations, identified need for X
services, and how agency will provide
services
(e) (A)&(B) Service plan within 60 days
(parent, guardian and child actively involved).
Describes how child’s issues will be X
addressed, anticipated outcomes, and
reviewed by child and guardian/parent.
(e)(C)&(D) Service plan is reviewed quarterly
and revised when information indicates other X
services should be provided
Case Management
Yes No N/A Corrective Actions/Comments
419-470-0170(3)
P age 13 | 15
Form Rev. 1/2/2024
(a) Services are documented, progress
X
toward achieving goals is tracked
(c) Discharge summary must include:
(A)Current medications
(B)Name of the physician or qualified medical
professional who prescribed each medication
(C)Any outstanding medical or other
appointments X
(D)Summary of the child’s participation in the
program and progress achieved
(E)Results of evaluations
(F)Recommendations regarding services
(G)Discharge destination
(e) Follow up services X
(f) Incident Reports X
Records Relating to Restraint &
Yes No N/A Corrective Actions/Comments
Involuntary Seclusion
419-400-0180 (12) Records X
419-400-0180(13)(e) Each child caring
agency shall provide notice regarding how to
access the quarterly reports to the parents or There was no documentation guardians are given notice of how to access quarterly
guardians of children in care in the program. X reports regarding seclusion and restraint. The program shall ensure all guardians are
The child caring agency shall provide the given notice of how to access quarterly reports regarding seclusion and restraint.
notice upon the child in care’s admission and
at least two times each year thereafter.
419-400-0190(1) Information provided to
children in care relating to Restraint & X
Involuntary Seclusion
Financial Records
Yes No N/A Corrective Actions/Comments
419-470-0170(4)
Records contain date, amount, source,
X
purpose, signatures
Personal Possessions Records
Yes No N/A Corrective Actions/Comments
419-470-0170 (5)
Individual written inventory of all personal
possessions is maintained and updated as X
needed
Records and Documentation
Yes No N/A Corrective Actions/Comments
419-400-0140
(1) Stored safely X
(2) Permanent, legible, dated, and signed X
(3)&(4) Uniform in organization, readily
X
identifiable and accessible, current, and
P age 14 | 15
Form Rev. 1/2/2024
complete, containing all required info. No
eraser tape or white out.
(7) Permanent registry for each child
includes:
Name
Gender
X
Birth date
Names, addresses of parents or guardians
Dates of admission
Placement upon discharge
Licensing Coordinator’s Signature: ________________________ Date: ____0_9_/1__1_/2_0_2_4_______
Manager Review: ______________________________________ Date: __________________
P age 15 | 15
Form Rev. 1/2/2024

agency_name: Nexus Family Healing (NFH)

facility_type: Residential Care

licensee: Nexus Family Healing - Walden Crossing

executive_director: Kyle Dolmage

licensing_coordinator: Aubrey Kelly

other_regulatory_agencies: OHA

program_description:
Nexus residential programs are designed to keep families engaged throughout the treatment process-and to ensure
wrap-around support is needed during this difficult time. The program helps youth build skills and stability in their lives, and also helps the rest of the
family deal with the impact of trauma and mental health issues. Nexus Family Healing's Walden Crossing, provides individualized, trauma-informed
Psychiatric Residential Treatment Facility (PRTF) services for youth ages 10-17 with mental and developmental disabilities who have become
involved in the justice system. This location offers secure placement and clinical services during this pause in the youth's life when the court has
ordered it. A healing environment for the youth while the large legal and justice issues are being sorted through and restorative services are being
provided. Youth experience on-campus education, individualized programming and therapy and recreational opportunities.
Walden Crossing is a welcoming safe space for up to six youth, each having their own bedroom and ample space for therapeutic, educational, daily
living and recreation activities daily. The youth served are at a crossroads where the path forward is often uncertain. This can be an emotionally
stressful time, but it can also be a time for reflection, learning and skill building for whatever comes next for the youth.
The services, planning and treatment course we provide is highly individualized and based on the needs and abilities of each youth. Nexus Family
Healing staff will also be working with families to create strong planning upon discharge and provide support to those plans.
As a secure PRTF location, Walden Crossing has high staff to youth ratios as well as 24/7 nursing, recreational and therapeutic professionals,
psychiatric services, and an array of other types of therapies as indicated. We work together, as a team, to restore hope and reshape futures.

interviews_observations:
Client: They have been in the program for 4 months, and this is their first program. They came from detention. They like most staff, though some
aren't as good. They have individual therapy once a week and family therapy once a week. They were recently injured while in the community and
staff got them medical attention upon their return to the program. The food is ok, but they like the food in detention better. They don't like having the
same teacher for all subjects at the program; it's boring. They feel safe here. They have private phone calls in their bedroom through an intercom
system. They enjoy the outings.

excerpt:
(9) Written record of the disposal of
medications is maintained and includes:
(a) description and amount
(b) name
(c) reason
(d) method
(e) staff & witness signature The method of disposal was missing from medication disposal logs. The program shall
ensure the method of disposal is on all medication logs.

excerpt:
(1)(a) & (3)(c) Background check completed
and documented One staff personnel file did not contain a completed background check. Since the onsite
review, the program has submitted the staff’s background check request to the
background check unit. The program shall ensure the completed background check is
documented.

excerpt:
(d) Receive a certificate that states:
(A) The dates during which the certification
is current
(B) The type of restraint which the individual
is certified to perform if applicable
(C) The type of training the individual is
certified to conduct if applicable
(D) Any special endorsements earned by the
individual
(E) The level of training
(F) The name of the certified instructor who
conducted the training and administered the
assessment of proficiency. Staff personnel files did not contain evidence of a certificate for completion of crisis
intervention training. The program shall ensure a certificate is issued with all required
information when crisis intervention training is completed.

excerpt:
(e) A certification issued:
(A) Must be personal to the individual
certified by the training provider Staff personnel files did not contain evidence of a certificate for completion of crisis
intervention training. The program shall ensure a certificate is issued with all required
information when crisis intervention training is completed.

excerpt:
Each child caring
agency shall provide notice regarding how to
access the quarterly reports to the parents or
guardians of children in care in the program.
The child caring agency shall provide the
notice upon the child in care’s admission and
at least two times each year thereafter. There was no documentation guardians are given notice of how to access quarterly
reports regarding seclusion and restraint. The program shall ensure all guardians are
given notice of how to access quarterly reports regarding seclusion and restraint.