summary: Unannounced - 12 findings

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Licensee: Lane County Youth Services (Phoenix Program)
Executive Director: Greg Rikhoff
Program Director/Assistant Division Director: Patti Robb
Date of Unannounced: November 2, 2022
Licensing Coordinator: Holly Ivey
Other Regulatory or Accrediting Agencies: The Oregon Health Authority
Purpose: Per OAR 413-215-0101 (1) (b) Children’s Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Comments
Findings
Further Action
Needed
The following Renewal Required Documents Yes☐ No The following Renewal Required Documents must be submitted to the Licensing
must be submitted to the Licensing Coordinator:
Coordinator:  Fire Marshal Inspection (scheduled to occur 8.16.22)
 Fire Marshal Inspection (scheduled to Patti Robb, Assistant Division Director, emailed the inspection to the
occur 8.16.22) Licensing Coordinator, Holly Ivey, on 8.22.2022
 Resume of the Executive Director.  Resume of the Executive Director.
Patti Robb, emailed the resume of Greg Rikhoff to the Licensing Coordinator,
on 9.19.2022
Supplemental Information Provided by Yes No☐ Supplemental Information Provided by CCA All required policies and procedures as
CCA All required policies and procedures as identified in the “Umbrella Rules”
identified in the “Umbrella Rules”  Required policy revisions are stated in detail at the end of the report.
 Required policy revisions are stated in Patti Robb provided policy revisions with the Letter of Correction which met
detail at the end of the report. the Licensing Rule Requirements and were approved to the Licensing
 413-215-0077 Licensing Umbrella Coordinator.
Rules: Restraints and Involuntary
Seclusion (Amended 07/01/2022)  413-215-0077 Licensing Umbrella Rules: Restraints and Involuntary
(13) Reporting Requirements (e) Seclusion (Amended 07/01/2022) (13) Reporting Requirements (e) Each child
1
(rev. 07/21/2022)
Each child caring agency shall caring agency shall provide notice regarding how to access the quarterly reports to
provide notice regarding how to the parents or guardians of children in care in the program. The child caring
access the quarterly reports to the agency shall provide the notice upon the child in care’s admission and at least two
parents or guardians of children in times each year thereafter.
care in the program. The child caring  Documentation of the notice described above having been provided to the
agency shall provide the notice upon guardian was not found in the youth file reviewed; documentation must be
the child in care’s admission and at kept regarding this requirement. (Repeat Finding)
least two times each year thereafter.
Supplemental Information Provided by Yes☐ No Supplemental Information Provided by CCA All required policies and procedures as
CCA All required policies and procedures as identified in the “Umbrella Rules”
identified in the “Umbrella Rules”  *Required policy revisions are stated in detail at the end of the report.
 *Required policy revisions are stated Patti Robb, provided policy revisions with the Letter of Correction which met
in detail at the end of the report. the Licensing Rule Requirements and were approved by the Licensing
Coordinator.
Physical Plant 413-215-0511(2)(a) &(c) Yes☐ No Physical Plant 413-215-0511(2)(a) &(c) Buildings are smoke free, clean and in good
Buildings are smoke free, clean and in good repair
repair  The blinds were broken and in need of repair in bedroom 163.
 The blinds were broken and in need On 9.19.2022, Patti Robb sent pictures verifying the blinds had been
of repair in bedroom 163. replaced. On 11.2.2022, at the unannounced inspection, the Licensing
Coordinator verified the blinds were in good repair.
Safety413-215-05413) (a) Evacuation drill Yes☐No Safety413-215-05413) (a) Evacuation drill occurs monthly under varying conditions, is
occurs monthly under varying conditions, is retained 2 yrs.
retained 2 yrs.  Over the two-year span reviewed, some of the fire drill logs were not found.
 Over the two-year span reviewed, On 11.2.2022, at the unannounced inspection, the Licensing Coordinator
some of the fire drill logs were not reviewed evacuation drill reports since June 2022, (the date of the last
found. Licensing Review) and verified that drills have been occurring monthly.
New Employee Orientation – Umbrella Yes☐ No New Employee Orientation – Umbrella Requirements (30 days) 413-215-0061(4) (a)
Requirements (30 days) 413-215-0061(4) (a) Agency policies and procedures(d) Attributes of population served.
Agency policies and procedures(d) Attributes On November 8, 2022, Timothy Davis, Shift Supervisor, sent verification of
of population served. the required orientation trainings of recently hired staff to the Licensing
Coordinator.
Consents 413-215-0576(1) (c) Use restraint Yes☐ No Consents 413-215-0576(1) (c) Use restraint or seclusion (if applicable). Must specify the
or seclusion (if applicable). Must specify the reasons for the intervention and how staff are trained and supervised
reasons for the intervention and how staff are  The consents signed by guardians did not specify the reasons for the intervention
trained and supervised and how staff are trained and supervised.
 The consents signed by guardians did No longer applicable, after the Licensing Review in June 2022, the agency
not specify the reasons for the decided to no longer utilize restraints.
intervention and how staff are trained
and supervised.
2
Information about Children in Care Yes☐ No Information about Children in Care
413-215-0581(1) Summary sheet contains the 413-215-0581(1) Summary sheet contains the following: (a) gender.
following: (a) gender.
Identification of youths’ gender was not found on the summary sheets reviewed.
Identification of youths’ gender was not found On 11.2.2022, at the unannounced inspection, the Licensing Coordinator verified the
on the summary sheets reviewed. required information was being documented on the Summary Sheet.
New Findings from Site Visit Comments
Safety - Transporting Children in Care Safety - Transporting Children in Care 413-215-0761(3)(a) (E) Fire extinguisher – secured
413-215-0761(3)(a) (E) Fire extinguisher -  The program’s van did not have a fire extinguisher, which is required by the above stated rule.
secured On November 11, 2022, Tim Davis sent the Licensing Coordinator a picture of the fire
extinguisher that was put in the van after the unannounced inspection. There is nothing
further that needs to be done by the agency regarding this finding.
Interview Summary
During the unannounced inspection, two staff were informally interviewed, as they assisted with the walk-through of the facility and inspection of
the program’s vehicles. Staff reported that there were 4 youth residing in the program. Staff stated that home visits were reinstated as they had
been on a pause due to the Covid 19 Pandemic.
Two youth were privately interviewed at the inspection. When asked what they appreciated most about the Phoenix Program, the youth
reported: “The helpfulness of the staff, it’s a place to help you.” Both youth shared that they get enough food at the program and are provided
daily snacks. Both youth shared that they have daily private phone contact with their approved contacts. Visits at the program with approved
contacts were reported to happen every Sunday. The youth reported the following recreational activities: “Playing: pool, video games,
basketball, going on outings, going to the YMCA, going to parks as a group. We get to go on three paid outings a week.” The youth shared that
hygiene products were provided by the program. When the youth were asked what they would change about the program, they stated: “Make
the food better, I would make it optional to go to Horticulture Crew.” (The Crew Work is organized through the MLK School where the youth
attend). Both youth shared that they felt safe at the program and respected by the staff.
Observations
A walk-through of the facility was conducted by Holly Ivey, Licensing Coordinator. All areas of the programs where youth had access were
observed to be well kept, clean and in good repair. It was reported that youth clean their bedrooms once a week. A contracted agency in the
Lane County Detention Facility is responsible for all meals, which are prepared in the detention facilities kitchen. Meals are brought from
detention to the Phoenix Program’s Kitchen at mealtime. The DHS Licensing Coordinator observed the Lane County Detention Kitchen where
food is prepared. The kitchen in the Lane County Detention Center was observed to be clean and in good repair. The Licensing Coordinator
observed food in the refrigerator, freezer, and pantry. The kitchen at the Phoenix Program was also observed to be clean and in good repair.
The DHS Licensing Coordinator observed food in the refrigerator at the Phoenix Program, and snacks available for the youth. Medication was
observed to be in a cabinet behind a locked door in the staff office which was inaccessible to the youth. The DHS Licensing Coordinator
observed the vehicles that staff utilizes to transport youth in the program. One vehicle that is used to transport youth, was missing a fire
extinguisher, which was the only deficiency observed, and it has already been corrected.
3
Corrective Actions and Timeframes:
Please submit the following to verify compliance.
Within 45 days of receipt of this report Lane County Phoenix Program, 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 Hollyivey@dhsoha.state.or.us
Licensing Coordinator’s Signature: ________________________ Date: _1_2_-0_2_-_2_0_2_2_ _________
Manager Review: ______________________________________ Date: _1_2_-_0_1_-_2_0_2_2_ _______
4

executive_director: Greg Rikhoff

visit_date: November 2, 2022

purpose:
Per OAR 413-215-0101 (1) (b) Children's Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Comments
Findings
Further Action
Needed
The following Renewal Required Documents Yes[ ] No The following Renewal Required Documents must be submitted to the Licensing
must be submitted to the Licensing Coordinator:
Coordinator: - Fire Marshal Inspection (scheduled to occur 8.16.22)
- Fire Marshal Inspection (scheduled to Patti Robb, Assistant Division Director, emailed the inspection to the
occur 8.16.22) Licensing Coordinator, Holly Ivey, on 8.22.2022
- Resume of the Executive Director. - Resume of the Executive Director.
Patti Robb, emailed the resume of Greg Rikhoff to the Licensing Coordinator,
on 9.19.2022
Supplemental Information Provided by Yes No[ ] Supplemental Information Provided by CCA All required policies and procedures as
CCA All required policies and procedures as identified in the "Umbrella Rules"
identified in the "Umbrella Rules" - Required policy revisions are stated in detail at the end of the report.
- Required policy revisions are stated in Patti Robb provided policy revisions with the Letter of Correction which met
detail at the end of the report. the Licensing Rule Requirements and were approved to the Licensing
- 413-215-0077 Licensing Umbrella Coordinator.
Rules: Restraints and Involuntary
Seclusion (Amended 07/01/2022) - 413-215-0077 Licensing Umbrella Rules: Restraints and Involuntary
(13) Reporting Requirements (e) Seclusion (Amended 07/01/2022) (13) Reporting Requirements (e) Each child
1

Each child caring agency shall caring agency shall provide notice regarding how to access the quarterly reports to
provide notice regarding how to the parents or guardians of children in care in the program. The child caring
access the quarterly reports to the agency shall provide the notice upon the child in care's admission and at least two
parents or guardians of children in times each year thereafter.
care in the program. The child caring - Documentation of the notice described above having been provided to the
agency shall provide the notice upon guardian was not found in the youth file reviewed; documentation must be
the child in care's admission and at kept regarding this requirement. (Repeat Finding)
least two times each year thereafter.
Supplemental Information Provided by Yes[ ] No Supplemental Information Provided by CCA All required policies and procedures as
CCA All required policies and procedures as identified in the "Umbrella Rules"
identified in the "Umbrella Rules" - *Required policy revisions are stated in detail at the end of the report.
- *Required policy revisions are stated Patti Robb, provided policy revisions with the Letter of Correction which met
in detail at the end of the report. the Licensing Rule Requirements and were approved by the Licensing
Coordinator.
Physical Plant 413-215-0511(2)(a) &(c) Yes[ ] No Physical Plant 413-215-0511(2)(a) &(c) Buildings are smoke free, clean and in good
Buildings are smoke free, clean and in good repair
repair - The blinds were broken and in need of repair in bedroom 163.
- The blinds were broken and in need On 9.19.2022, Patti Robb sent pictures verifying the blinds had been
of repair in bedroom 163. replaced. On 11.2.2022, at the unannounced inspection, the Licensing
Coordinator verified the blinds were in good repair.
Safety413-215-05413) (a) Evacuation drill Yes[ ]No Safety413-215-05413) (a) Evacuation drill occurs monthly under varying conditions, is
occurs monthly under varying conditions, is retained 2 yrs.
retained 2 yrs. - Over the two-year span reviewed, some of the fire drill logs were not found.
- Over the two-year span reviewed, On 11.2.2022, at the unannounced inspection, the Licensing Coordinator
some of the fire drill logs were not reviewed evacuation drill reports since June 2022, (the date of the last
found. Licensing Review) and verified that drills have been occurring monthly.
New Employee Orientation - Umbrella Yes[ ] No New Employee Orientation - Umbrella Requirements (30 days) 413-215-0061(4) (a)
Requirements (30 days) 413-215-0061(4) (a) Agency policies and procedures(d) Attributes of population served.
Agency policies and procedures(d) Attributes On November 8, 2022, Timothy Davis, Shift Supervisor, sent verification of
of population served. the required orientation trainings of recently hired staff to the Licensing
Coordinator.
Consents 413-215-0576(1) (c) Use restraint Yes[ ] No Consents 413-215-0576(1) (c) Use restraint or seclusion (if applicable). Must specify the
or seclusion (if applicable). Must specify the reasons for the intervention and how staff are trained and supervised
reasons for the intervention and how staff are - The consents signed by guardians did not specify the reasons for the intervention
trained and supervised and how staff are trained and supervised.
- The consents signed by guardians did No longer applicable, after the Licensing Review in June 2022, the agency
not specify the reasons for the decided to no longer utilize restraints.
intervention and how staff are trained
and supervised.
2
Information about Children in Care Yes[ ] No Information about Children in Care
413-215-0581(1) Summary sheet contains the 413-215-0581(1) Summary sheet contains the following: (a) gender.
following: (a) gender.
Identification of youths' gender was not found on the summary sheets reviewed.
Identification of youths' gender was not found On 11.2.2022, at the unannounced inspection, the Licensing Coordinator verified the
on the summary sheets reviewed. required information was being documented on the Summary Sheet.
New Findings from Site Visit Comments
Safety - Transporting Children in Care Safety - Transporting Children in Care 413-215-0761(3)(a) (E) Fire extinguisher - secured
413-215-0761(3)(a) (E) Fire extinguisher - - The program's van did not have a fire extinguisher, which is required by the above stated rule.
secured On November 11, 2022, Tim Davis sent the Licensing Coordinator a picture of the fire
extinguisher that was put in the van after the unannounced inspection. There is nothing
further that needs to be done by the agency regarding this finding.
Interview Summary
During the unannounced inspection, two staff were informally interviewed, as they assisted with the walk-through of the facility and inspection of
the program's vehicles. Staff reported that there were 4 youth residing in the program. Staff stated that home visits were reinstated as they had
been on a pause due to the Covid 19 Pandemic.
Two youth were privately interviewed at the inspection. When asked what they appreciated most about the Phoenix Program, the youth
reported: "The helpfulness of the staff, it's a place to help you." Both youth shared that they get enough food at the program and are provided
daily snacks. Both youth shared that they have daily private phone contact with their approved contacts. Visits at the program with approved
contacts were reported to happen every Sunday. The youth reported the following recreational activities: "Playing: pool, video games,
basketball, going on outings, going to the YMCA, going to parks as a group. We get to go on three paid outings a week." The youth shared that
hygiene products were provided by the program. When the youth were asked what they would change about the program, they stated: "Make
the food better, I would make it optional to go to Horticulture Crew." (The Crew Work is organized through the MLK School where the youth
attend). Both youth shared that they felt safe at the program and respected by the staff.
Observations
A walk-through of the facility was conducted by Holly Ivey, Licensing Coordinator. All areas of the programs where youth had access were
observed to be well kept, clean and in good repair. It was reported that youth clean their bedrooms once a week. A contracted agency in the
Lane County Detention Facility is responsible for all meals, which are prepared in the detention facilities kitchen. Meals are brought from
detention to the Phoenix Program's Kitchen at mealtime. The DHS Licensing Coordinator observed the Lane County Detention Kitchen where
food is prepared. The kitchen in the Lane County Detention Center was observed to be clean and in good repair. The Licensing Coordinator
observed food in the refrigerator, freezer, and pantry. The kitchen at the Phoenix Program was also observed to be clean and in good repair.
The DHS Licensing Coordinator observed food in the refrigerator at the Phoenix Program, and snacks available for the youth. Medication was
observed to be in a cabinet behind a locked door in the staff office which was inaccessible to the youth. The DHS Licensing Coordinator
observed the vehicles that staff utilizes to transport youth in the program. One vehicle that is used to transport youth, was missing a fire
extinguisher, which was the only deficiency observed, and it has already been corrected.
3

excerpt:
413-215-0761(3)(a) (E) Fire extinguisher - - The program's van did not have a fire extinguisher, which is required by the above stated rule.
secured On November 11, 2022, Tim Davis sent the Licensing Coordinator a picture of the fire
extinguisher that was put in the van after the unannounced inspection. There is nothing
further that needs to be done by the agency regarding this finding.
Safety - Transporting Children in Care Safety - Transporting Children in Care


state: OR

facility_name: Lane County Youth Services, Phoenix Program

summary: Unannounced - 5 findings

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Residential Care
Licensee: Lane County Youth Services (Phoenix Program)
Executive Director: Greg Rikhoff
Program Director/Assistant Division Director: Patti Robb
Date of Unannounced: June 27, 2023
Licensing Coordinator: Holly Ivey
Other Regulatory or Accrediting Agencies: The Oregon Health Authority
Purpose: Per OAR 419-400-0240 (1)(b) Children’s Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Comments
Unannounced Site Visit 11/02/2022 Findings
Further Action
Needed
Supplemental Information Provided by Yes☐ No 413-215-0077 Licensing Umbrella Rules: Restraints and Involuntary Seclusion
CCA All required policies and procedures as (Amended 07/01/2022) (13) Reporting Requirements (e) Each child caring agency shall
identified in the “Umbrella Rules” provide notice regarding how to access the quarterly reports to the parents or guardians of
 Required policy revisions are stated in children in care in the program. The child caring agency shall provide the notice upon the
detail at the end of the report. child in care’s admission and at least two times each year thereafter.
413-215-0077 Licensing Umbrella Rules:  At the unannounced inspection, Holly Ivey, Licensing Coordinator, reviewed
Restraints and Involuntary Seclusion two files that verified compliance regarding the above stated finding. There
(Amended 07/01/2022) (13) Reporting is nothing further that is required regarding this finding.
Requirements (e) Each child caring agency
shall provide notice regarding how to access Supplemental Information Provided by CCA All required policies and procedures as
the quarterly reports to the parents or identified in the “Umbrella Rules”
guardians of children in care in the program.  Required policy revisions are stated in detail at the end of the report.
The child caring agency shall provide the Patti Robb provided policy revisions with the Letter of Correction which met
notice upon the child in care’s admission and the Licensing Rule Requirements and were approved by the Licensing
at least two times each year thereafter. Coordinator. There is nothing further that is required regarding this finding.
1 |P ag e
Form Rev. 01/23/2023
Supplemental Information Provided by
CCA All required policies and procedures as
identified in the “Umbrella Rules”
 Required policy revisions are stated in
detail at the end of the report.
Patti Robb provided policy
revisions with the Letter of
Correction which met the
Licensing Rule Requirements and
were approved to the Licensing
Coordinator.
 413-215-0077 Licensing Umbrella
Rules: Restraints and Involuntary
Seclusion (Amended 07/01/2022)
(13) Reporting Requirements (e)
Each child caring agency shall
provide notice regarding how to
access the quarterly reports to the
parents or guardians of children in
care in the program. The child caring
agency shall provide the notice upon
the child in care’s admission and at
least two times each year thereafter.
 Documentation of the notice
described above having been
provided to the guardian was not
found in the youth file reviewed;
documentation must be kept
regarding this requirement.
(Repeat Finding)
Safety - Transporting Children in Care Yes☐ No Safety - Transporting Children in Care
413-215-0761(3)(a) (E) Fire extinguisher – 413-215-0761(3)(a) (E) Fire extinguisher – secured
secured
 Holly Ivey, Licensing Coordinator, inspected the car utilized to transport
Safety - Transporting Children in Care 413- youth and verified a fire extinguisher was in the vehicle. There is nothing
215-0761(3)(a) (E) Fire extinguisher – further that is required regarding this finding.
secured
 The program’s van did not have a fire
extinguisher, which is required by the
above stated rule.
On November 11, 2022, Tim Davis sent the
Licensing Coordinator a picture of the fire
extinguisher that was put in the van after
2 |P ag e
Form Rev. 01/23/2023
the unannounced inspection. There is
nothing further that needs to be done by
the agency regarding this finding.
New Findings from Site Visit Comments
N/A
Interview Summary
Holly Ivey, ODHS Licensing Coordinator, interviewed the only youth that was at the program the day of the inspection. The youth stated that
things were going well for her at the program. She appreciated the staff being helpful to her. She enjoyed playing soccer, puzzles, coloring,
board and card games. While at the program she has gone to the beach, Wildlife Safari, the aquarium, and an aviation museum. She stated
she could have private phone calls during free time with people approved by her guardian. She stated the food was good and that she had
enough to eat to include daily snacks. She stated hygiene products were provided by the program. She stated she felt respected by staff and
always felt safe at the program.
Observations
At the Unannounced Inspection, the Program Director, Timothy Davis, assisted with a walk through with Holly Ivey, ODHS Licensing
Coordinator. All areas of the programs (inside and outside) where youth had access were observed to be well kept, clean and in good repair.
The agency vehicle that the youth ride in was observed and met the requirements per Licensing Rules. Both kitchen’s (in the Residential
Program, and the Lane County Detention Center- where food is prepared and brought to the youth) were observed to be clean and had food in
the refrigerators and pantries. Medication was observed to locked medication and inaccessible to youth. One youth was observed to be at the
program during the walk-through inspection. The youth appeared to be comfortable and at ease in the program.
Corrective Actions and Timeframes:
N/A there were no compliance issues or concerns found while conducting the Unannounced Inspection. There is nothing the agency needs to send
to ODHS Licensing regarding the inspection.
Licensing Coordinator’s Signature: ________________________ Date: _7_-_2_0_-2_0__2_3_ _________
Manager Review: ______________________________________ Date: _7_-2_0_-_2_0_2_3_ _________
3 | P a g e
Form Rev. 01/23/2023

agency_name: Lane County Youth Service CCA (LCYS)

program_name: Phoenix

program_type: (RC) Residential Care Programs

report_type: Unannounced

view_code: RC

facility_type: Residential Care

licensing_coordinator: Holly Ivey

other_regulatory_agencies: The Oregon Health Authority

purpose:
Per OAR 419-400-0240 (1)(b) Children's Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Comments
Unannounced Site Visit 11/02/2022 Findings
Further Action
Needed
Supplemental Information Provided by Yes[ ] No 413-215-0077 Licensing Umbrella Rules: Restraints and Involuntary Seclusion
CCA All required policies and procedures as (Amended 07/01/2022) (13) Reporting Requirements (e) Each child caring agency shall
identified in the "Umbrella Rules" provide notice regarding how to access the quarterly reports to the parents or guardians of
- Required policy revisions are stated in children in care in the program. The child caring agency shall provide the notice upon the
detail at the end of the report. child in care's admission and at least two times each year thereafter.
413-215-0077 Licensing Umbrella Rules: - At the unannounced inspection, Holly Ivey, Licensing Coordinator, reviewed
Restraints and Involuntary Seclusion two files that verified compliance regarding the above stated finding. There
(Amended 07/01/2022) (13) Reporting is nothing further that is required regarding this finding.
Requirements (e) Each child caring agency
shall provide notice regarding how to access Supplemental Information Provided by CCA All required policies and procedures as
the quarterly reports to the parents or identified in the "Umbrella Rules"
guardians of children in care in the program. - Required policy revisions are stated in detail at the end of the report.
The child caring agency shall provide the Patti Robb provided policy revisions with the Letter of Correction which met
notice upon the child in care's admission and the Licensing Rule Requirements and were approved by the Licensing
at least two times each year thereafter. Coordinator. There is nothing further that is required regarding this finding.

Supplemental Information Provided by
CCA All required policies and procedures as
identified in the "Umbrella Rules"
- Required policy revisions are stated in
detail at the end of the report.
Patti Robb provided policy
revisions with the Letter of
Correction which met the
Licensing Rule Requirements and
were approved to the Licensing
Coordinator.
- 413-215-0077 Licensing Umbrella
Rules: Restraints and Involuntary
Seclusion (Amended 07/01/2022)
(13) Reporting Requirements (e)
Each child caring agency shall
provide notice regarding how to
access the quarterly reports to the
parents or guardians of children in
care in the program. The child caring
agency shall provide the notice upon
the child in care's admission and at
least two times each year thereafter.
- Documentation of the notice
described above having been
provided to the guardian was not
found in the youth file reviewed;
documentation must be kept
regarding this requirement.
(Repeat Finding)
Safety - Transporting Children in Care Yes[ ] No Safety - Transporting Children in Care
413-215-0761(3)(a) (E) Fire extinguisher - 413-215-0761(3)(a) (E) Fire extinguisher - secured
secured
- Holly Ivey, Licensing Coordinator, inspected the car utilized to transport
Safety - Transporting Children in Care 413- youth and verified a fire extinguisher was in the vehicle. There is nothing
215-0761(3)(a) (E) Fire extinguisher - further that is required regarding this finding.
secured
- The program's van did not have a fire
extinguisher, which is required by the
above stated rule.
On November 11, 2022, Tim Davis sent the

observations:
At the Unannounced Inspection, the Program Director, Timothy Davis, assisted with a walk through with Holly Ivey, ODHS Licensing
Coordinator. All areas of the programs (inside and outside) where youth had access were observed to be well kept, clean and in good repair.
The agency vehicle that the youth ride in was observed and met the requirements per Licensing Rules. Both kitchen's (in the Residential
Program, and the Lane County Detention Center- where food is prepared and brought to the youth) were observed to be clean and had food in
the refrigerators and pantries. Medication was observed to locked medication and inaccessible to youth. One youth was observed to be at the
program during the walk-through inspection. The youth appeared to be comfortable and at ease in the program.

previous_findings:
Repeat Comments
Unannounced Site Visit 11/02/2022 Findings
Further Action
Needed
Supplemental Information Provided by Yes[ ] No 413-215-0077 Licensing Umbrella Rules: Restraints and Involuntary Seclusion
CCA All required policies and procedures as (Amended 07/01/2022) (13) Reporting Requirements (e) Each child caring agency shall
identified in the "Umbrella Rules" provide notice regarding how to access the quarterly reports to the parents or guardians of
- Required policy revisions are stated in children in care in the program. The child caring agency shall provide the notice upon the
detail at the end of the report. child in care's admission and at least two times each year thereafter.
413-215-0077 Licensing Umbrella Rules: - At the unannounced inspection, Holly Ivey, Licensing Coordinator, reviewed
Restraints and Involuntary Seclusion two files that verified compliance regarding the above stated finding. There
(Amended 07/01/2022) (13) Reporting is nothing further that is required regarding this finding.
Requirements (e) Each child caring agency
shall provide notice regarding how to access Supplemental Information Provided by CCA All required policies and procedures as
the quarterly reports to the parents or identified in the "Umbrella Rules"
guardians of children in care in the program. - Required policy revisions are stated in detail at the end of the report.
The child caring agency shall provide the Patti Robb provided policy revisions with the Letter of Correction which met
notice upon the child in care's admission and the Licensing Rule Requirements and were approved by the Licensing
at least two times each year thereafter. Coordinator. There is nothing further that is required regarding this finding.

Supplemental Information Provided by
CCA All required policies and procedures as
identified in the "Umbrella Rules"
- Required policy revisions are stated in
detail at the end of the report.
Patti Robb provided policy
revisions with the Letter of
Correction which met the
Licensing Rule Requirements and
were approved to the Licensing
Coordinator.
- 413-215-0077 Licensing Umbrella
Rules: Restraints and Involuntary
Seclusion (Amended 07/01/2022)
(13) Reporting Requirements (e)
Each child caring agency shall
provide notice regarding how to
access the quarterly reports to the
parents or guardians of children in
care in the program. The child caring
agency shall provide the notice upon
the child in care's admission and at
least two times each year thereafter.
- Documentation of the notice
described above having been
provided to the guardian was not
found in the youth file reviewed;
documentation must be kept
regarding this requirement.
(Repeat Finding)
Safety - Transporting Children in Care Yes[ ] No Safety - Transporting Children in Care
413-215-0761(3)(a) (E) Fire extinguisher - 413-215-0761(3)(a) (E) Fire extinguisher - secured
secured
- Holly Ivey, Licensing Coordinator, inspected the car utilized to transport
Safety - Transporting Children in Care 413- youth and verified a fire extinguisher was in the vehicle. There is nothing
215-0761(3)(a) (E) Fire extinguisher - further that is required regarding this finding.
secured
- The program's van did not have a fire
extinguisher, which is required by the
above stated rule.
On November 11, 2022, Tim Davis sent the
Licensing Coordinator a picture of the fire
extinguisher that was put in the van after

the unannounced inspection. There is
nothing further that needs to be done by
the agency regarding this finding.
New Findings from Site Visit Comments
N/A

excerpt:
413-215-0761(3)(a) (E) Fire extinguisher - secured
secured
- Holly Ivey, Licensing Coordinator, inspected the car utilized to transport
Safety - Transporting Children in Care 413- youth and verified a fire extinguisher was in the vehicle. There is nothing
215-0761(3)(a) (E) Fire extinguisher - further that is required regarding this finding.
secured
- The program's van did not have a fire
extinguisher, which is required by the
above stated rule.
On November 11, 2022, Tim Davis sent the
Licensing Coordinator a picture of the fire
extinguisher that was put in the van after
the unannounced inspection. There is
nothing further that needs to be done by
the agency regarding this finding.
New Findings from Site Visit Comments
N/A
N/A


summary: Unannounced - 04/08/2024

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Licensee: Lane County Youth Services, Phoenix Program
Executive Director: Greg Rikhoff
Program Director(s): Patti Robb
Date of Unannounced: April 8, 2024
Licensing Coordinator: Holly Ivey
Other Regulatory or Accrediting Agencies: The Oregon Youth Authority
Purpose: Per OAR 419-400-0240 (1)(b) Children’s Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Comments
Findings
Further Action
Needed
N/A Yes☐ No✓ There were no violations recorded at the time of the previous Unannounced
Licensing Inspection in 2023.
New Findings from Site Visit Comments
N/A No violations were noted during the 2024 Unannounced Licensing Inspection.
Form Rev. 11/14/2023 P age 1 | 2
Interview Summary
Youth were not interviewed as there were no youth in the program at the time of the unannounced inspection. The program is in the process of
terminating the BRS Residential Service Contract with the Oregon Health Authority (OHA). The agency has expressed interest with OHA, in
being one of the first agencies to provide In-Home BRS Services for youth, starting fall of 2024. The program is also planning to develop
residential services in the Phoenix building sometime within the next year. The building will be housing a new outpatient clinical program, which
will support the future residential programming.
Observations
At the Unannounced Inspection, Holly Ivey, ODHS Licensing Coordinator, walked through the program. All areas of the programs (inside and
outside) where youth could have access were observed to be well kept, clean and in good repair. There were no concerns of the building
observed by the Licensing Coordinator at the walkthrough regarding any Licensing Rule Violations.
Corrective Actions and Timeframes: N/A there were no compliance issues or concerns found while conducting the Unannounced Inspection.
There is nothing the agency needs to send to ODHS Licensing, regarding the 2024 Unannounced Inspection.
Licensing Coordinator’s Signature: ________________________ Date: _5_-3_-_2_0_2_4____________
Manager Review: ______________________________________ Date: _5_-_3_-2_0_2__4__________
Form Rev. 11/14/2023 P age 2 | 2

program_director: Patti Robb

other_regulatory_agencies: The Oregon Youth Authority

purpose:
Per OAR 419-400-0240 (1)(b) Children's Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Comments
Findings
Further Action
Needed
N/A Yes[ ] No✓ There were no violations recorded at the time of the previous Unannounced
Licensing Inspection in 2023.
New Findings from Site Visit Comments
N/A No violations were noted during the 2024 Unannounced Licensing Inspection.

Interview Summary
Youth were not interviewed as there were no youth in the program at the time of the unannounced inspection. The program is in the process of
terminating the BRS Residential Service Contract with the Oregon Health Authority (OHA). The agency has expressed interest with OHA, in
being one of the first agencies to provide In-Home BRS Services for youth, starting fall of 2024. The program is also planning to develop
residential services in the Phoenix building sometime within the next year. The building will be housing a new outpatient clinical program, which
will support the future residential programming.
Observations
At the Unannounced Inspection, Holly Ivey, ODHS Licensing Coordinator, walked through the program. All areas of the programs (inside and
outside) where youth could have access were observed to be well kept, clean and in good repair. There were no concerns of the building
observed by the Licensing Coordinator at the walkthrough regarding any Licensing Rule Violations.


facility_name: Looking Glass Community Services - RCC

summary: Unannounced - 1 finding

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Licensee: Looking Glass Community Services – RCC and Pathways
Executive Director: Craig Opperman
Program Director(s): Maleigha Myers
Date of Unannounced: October 11 & 13, 2022
Licensing Coordinator: Todd Cooley
Other Regulatory or Accrediting Agencies: Child Welfare and OHA
Purpose: Per OAR 413-215-0101 (1) (b) Children’s Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Comments
Findings
Further Action
Needed
413-215-0541(5)(a) Employees transporting Yes✓No☐
children have: current driver’s license, Random pull of staff files from AYS and RCC was done during the unannounced visit.
insurance, trained in emergency procedures AYS files all contained driver’s licenses. From the random RCC files there was one file
and behavior management, and training for missing a current license and HR also informed there were other files also missing current
15+ passenger vans if applicable: driver’s licenses. Repeat Finding.
• AYS – Reviewed files were missing the Will coordinate with LGCS on plan to obtain current DLs for all staff who transport clients.
following documentation: These files will be reviewed again at the next unannounced or full site review, whichever
-Current Driver’s License comes first.
RCC – None of the reviewed files contained
documentation of current driver’s license.
New Findings from Site Visit Comments
No new findings.
1
(rev. 200115)
Interview Summary
Pathways (AYS)
During the unannounced visit at Pathways I had the opportunity to interview two clients and one staff.
The first client interviewed had been at the program for approximately five months. They stated they feel very involved in their treatment and treatment
planning. Client said they are able to call mom twice a day and feel supported by staff as well but had a better relationship with previous staff as compared to
current staff. They are comfortable communicating concerns to staff and staff make them feel safe. Client is currently not in school due to graduating at 16
and has plans to attend community college upon discharge. Their anticipated discharge is approximately three months away and the plan is to go to a foster
home placement. Client stated there is plenty of food, but it is only edible, and they noted the chicken is always pink. Snacks are provided and they are never
hungry. When asked about changes they would make, the conversation was around staffing. Client had seen a large turnover in staff, and with the new staff
there were obvious differences between staff with experience and those without. Client also stated sometimes the newer staff get into unnecessary power
struggles with clients, but they felt it was only because of their perceived lack of experience. Client also stated staff were easily distracted or just unaware of a
lot of inappropriate conversations going on with the client’s peers. They also felt there could be more consistency. Client did not have anything to say when
asked what they felt the staff do really well.
The second Pathways client had been in program around seven months. They were overall very positive about the program. Client said they are able to call
family twice a day, and on weekends they can pretty much use the phone whenever they ask. Client has been able to go on multiple home passes to their
parents home where they are anticipated to discharge to. Client stated they are involved in the treatment plan and had a good understanding of it. Client is
currently getting caught up in math classes and feels like they will be on pace to transition to public school as a senior when they discharge. Regarding food,
client feels like they are “overfed” and said there is always plenty of decent food, as well as snacks available to them. Client and peers go to the YMCA a
minimum of three times a week, but more often it is daily. When there, they play a lot of volleyball and basketball. Client stated they wish staff were a bit
more consistent but felt even the new staff do a good job of staying on top of the rules. They also wished Suanne and Batina were on the floor more instead
of working in their offices. Client said staff do a really good job of advocating, listening and checking-in (almost always available).
Staff that was interviewed has worked at Looking Glass for two years and recently stepped down from a supervisor role as they were pursuing further
education, and they have been interning with the case managers. Staff said they received a significant amount of training before working with youth and
continue to receive a lot of ongoing training in various areas related to their work. Staff found management to be very supportive of staff when it came to both
their personal and professional lives. Staff can request various trainings, which are typically accommodated, and supervisors are flexible when it comes to
school and additional training. The one take-away from the staff interview is that the individuals who are making the rules should spend some time on the floor
or seek input from front line staff prior to implementing something new to avoid obvious pitfalls and unintended consequences. Describes the workplace as a
“professional family”.
RCC
Two clients were interviewed during the unannounced visit at RCC. First client has been at RCC around 3 months and anticipates graduating soon. They
stated they have been a little bit involved in their service plan. Client says staff make them feel safe in the program, but they wish it wasn’t as “locked” down.
This was in reference to the fence around the building and their perspective that not all clients need the same level of supervision. They get plenty to eat but
are not a fan of the homemade soup. Enchiladas are a favorite and there are always plenty of snacks available to everyone. Client said school is going well
for them, and they like the variety. They spoke of the cultural awareness and sensitivity they see exhibited by the staff at the program. They also said they
feel like they are heard, and staff do a great job of trying to understand their feelings.
Second client had been at the program just over a week and said it was good so far and liked it better than their previous placements. They are already
comfortable with staff and feel like they can talk to many of them if there are any concerns or issues. Client is not a fan of the food saying they serve a lot of
(rev. 07/21/2022)
black beans and other foods that “mess” up their stomachs. Client stated they do not have any identified allergies, and don’t require a special diet, but they
have let the program know of their concerns. Due to the client being newer to the program and placed on run risk and constant supervision, they have not
been in the classroom for school most days. Client stated they are able to talk to their family every day on the phone and are very involved in their treatment
plan. They stated again they like it way better than other programs noting staff listen, are understanding and recognize when to give space.
Observations
Overall, the facility was clean and in good repair. There was some graffiti observed in one youth’s room, but it was later relayed it was very new and would be
cleaned up after the client was off constant observation, which they were on during the visit. Client interviews were conducted at both facilities. Additionally,
there was one staff interview at the Pathways Program (AYS).
Information obtained from the interviews were discussed with management.
Corrective Actions and Timeframes:
Please submit the following to verify compliance.
Within 45 days of receipt of this report Looking Glass Community Services 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 Todd Cooley, todd.cooley@dhsoha.state.or.us
Licensing Coordinator’s Signature: ________________________ Date: _1_1_-_8_-2__0_2_2_ _________
Manager Review: ______________________________________ Date: _1_1_-_7_-2__0_2_2_ ________
(rev. 07/21/2022)

agency_name: Looking Glass Community Services (LGCS)

program_name: AYS

licensee: Looking Glass Community Services - RCC and Pathways

executive_director: Craig Opperman

program_director: Maleigha Myers

licensing_coordinator: Todd Cooley

other_regulatory_agencies: Child Welfare and OHA

purpose:
Per OAR 413-215-0101 (1) (b) Children's Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Comments
Findings
Further Action
Needed
413-215-0541(5)(a) Employees transporting Yes✓No[ ]
children have: current driver's license, Random pull of staff files from AYS and RCC was done during the unannounced visit.
insurance, trained in emergency procedures AYS files all contained driver's licenses. From the random RCC files there was one file
and behavior management, and training for missing a current license and HR also informed there were other files also missing current
15+ passenger vans if applicable: driver's licenses. Repeat Finding.
- AYS - Reviewed files were missing the Will coordinate with LGCS on plan to obtain current DLs for all staff who transport clients.
following documentation: These files will be reviewed again at the next unannounced or full site review, whichever
-Current Driver's License comes first.
RCC - None of the reviewed files contained
documentation of current driver's license.
New Findings from Site Visit Comments
No new findings.
1

Interview Summary
Pathways (AYS)
During the unannounced visit at Pathways I had the opportunity to interview two clients and one staff.
The first client interviewed had been at the program for approximately five months. They stated they feel very involved in their treatment and treatment
planning. Client said they are able to call mom twice a day and feel supported by staff as well but had a better relationship with previous staff as compared to
current staff. They are comfortable communicating concerns to staff and staff make them feel safe. Client is currently not in school due to graduating at 16
and has plans to attend community college upon discharge. Their anticipated discharge is approximately three months away and the plan is to go to a foster
home placement. Client stated there is plenty of food, but it is only edible, and they noted the chicken is always pink. Snacks are provided and they are never
hungry. When asked about changes they would make, the conversation was around staffing. Client had seen a large turnover in staff, and with the new staff
there were obvious differences between staff with experience and those without. Client also stated sometimes the newer staff get into unnecessary power
struggles with clients, but they felt it was only because of their perceived lack of experience. Client also stated staff were easily distracted or just unaware of a
lot of inappropriate conversations going on with the client's peers. They also felt there could be more consistency. Client did not have anything to say when
asked what they felt the staff do really well.
The second Pathways client had been in program around seven months. They were overall very positive about the program. Client said they are able to call
family twice a day, and on weekends they can pretty much use the phone whenever they ask. Client has been able to go on multiple home passes to their
parents home where they are anticipated to discharge to. Client stated they are involved in the treatment plan and had a good understanding of it. Client is
currently getting caught up in math classes and feels like they will be on pace to transition to public school as a senior when they discharge. Regarding food,
client feels like they are "overfed" and said there is always plenty of decent food, as well as snacks available to them. Client and peers go to the YMCA a
minimum of three times a week, but more often it is daily. When there, they play a lot of volleyball and basketball. Client stated they wish staff were a bit
more consistent but felt even the new staff do a good job of staying on top of the rules. They also wished Suanne and Batina were on the floor more instead
of working in their offices. Client said staff do a really good job of advocating, listening and checking-in (almost always available).
Staff that was interviewed has worked at Looking Glass for two years and recently stepped down from a supervisor role as they were pursuing further
education, and they have been interning with the case managers. Staff said they received a significant amount of training before working with youth and
continue to receive a lot of ongoing training in various areas related to their work. Staff found management to be very supportive of staff when it came to both
their personal and professional lives. Staff can request various trainings, which are typically accommodated, and supervisors are flexible when it comes to
school and additional training. The one take-away from the staff interview is that the individuals who are making the rules should spend some time on the floor
or seek input from front line staff prior to implementing something new to avoid obvious pitfalls and unintended consequences. Describes the workplace as a
"professional family".
RCC
Two clients were interviewed during the unannounced visit at RCC. First client has been at RCC around 3 months and anticipates graduating soon. They
stated they have been a little bit involved in their service plan. Client says staff make them feel safe in the program, but they wish it wasn't as "locked" down.
This was in reference to the fence around the building and their perspective that not all clients need the same level of supervision. They get plenty to eat but
are not a fan of the homemade soup. Enchiladas are a favorite and there are always plenty of snacks available to everyone. Client said school is going well
for them, and they like the variety. They spoke of the cultural awareness and sensitivity they see exhibited by the staff at the program. They also said they
feel like they are heard, and staff do a great job of trying to understand their feelings.
Second client had been at the program just over a week and said it was good so far and liked it better than their previous placements. They are already
comfortable with staff and feel like they can talk to many of them if there are any concerns or issues. Client is not a fan of the food saying they serve a lot of

black beans and other foods that "mess" up their stomachs. Client stated they do not have any identified allergies, and don't require a special diet, but they
have let the program know of their concerns. Due to the client being newer to the program and placed on run risk and constant supervision, they have not
been in the classroom for school most days. Client stated they are able to talk to their family every day on the phone and are very involved in their treatment
plan. They stated again they like it way better than other programs noting staff listen, are understanding and recognize when to give space.
Observations
Overall, the facility was clean and in good repair. There was some graffiti observed in one youth's room, but it was later relayed it was very new and would be
cleaned up after the client was off constant observation, which they were on during the visit. Client interviews were conducted at both facilities. Additionally,
there was one staff interview at the Pathways Program (AYS).
Information obtained from the interviews were discussed with management.

new_findings:
No new findings.
1

excerpt:
413-215-0541(5)(a) Employees transporting Yes✓No[ ]
children have: current driver's license, Random pull of staff files from AYS and RCC was done during the unannounced visit.
insurance, trained in emergency procedures AYS files all contained driver's licenses. From the random RCC files there was one file
and behavior management, and training for missing a current license and HR also informed there were other files also missing current
15+ passenger vans if applicable: driver's licenses. Repeat Finding.
- AYS - Reviewed files were missing the Will coordinate with LGCS on plan to obtain current DLs for all staff who transport clients.
following documentation: These files will be reviewed again at the next unannounced or full site review, whichever
-Current Driver's License comes first.
RCC - None of the reviewed files contained
documentation of current driver's license.
New Findings from Site Visit Comments
No new findings.
1
No new findings.
1