state: OR

facility_name: The Next Door, Klahre House Residential Date of site visit: 5-27, 5-28 and 5-29-25

summary: License Renewals - 72 findings

raw_content:
Licensed Child Caring Agency Site Visit Report
Residential Care – License Renewal
Licensee: The Next Door, Klahre House Residential Date of site visit: 5-27, 5-28 and 5-29-25
Executive Director: Janet Hamada Licensing Coordinator: Irvin Minten, M.S.W.
Program Director: Melanie Kelly Board Chairperson: Ann Harris
Other Regulatory or Accrediting Agencies: Oregon Youth Authority (OYA) and Oregon Department of Human Services,
Treatment Services Unit.
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 provided by The Next Door: The Next Door, Inc. provides services to children and families in the
community, including foster care, day treatment and residential care. The program provides a highly structured, therapeutic
environment that emphasizes individual treatment planning, experiential growth, academic progress and behavior change. The
residential care program serves OYA youth. All youth enrolled in the residential program attend The Next Door’s Klahre House
Day Treatment Program.
Program type and services: The program provides residential care services for youth in OYA custody. Any needed sex
offender, mental health, and drug and alcohol treatment services, as well as Independent Living Program (ILP) and mentoring
services, are provided on-site by staff employed through The Next Door. Educational services are provided on-site by staff.
Capacity and age range: The program serves males, ages 13-18. The program’s capacity is 5 youth.
Funding sources: OYA and ODHS
Contracts and sources for referrals: Referrals come from OYA and ODHS.
Form revised 4/28/2025 Page 1 of 33
Average length of stay: The average length of stay in the program is between 9-18 months.
Average daily population served: The average daily population is about 5 youth.
Number of children served annually: The program estimates it serves about 6-8 youth annually.
Use of seclusion or restraint: The program does not utilize seclusion or restraint.
Interviews/observations: During the 2-year licensing review, 1 program line staff and 2 youth currently enrolled at the program
were randomly selected and individually interviewed. A walkthrough of the facility and the facility’s outdoor area was also
completed. During the review, there was also a great deal of discussion with Melanie Kelly, Program Director, Adriana Clayton,
Program Manager, and Melissa Benedict, Supervisor. The program’s medication cabinet and 2 Medication Administration
Records were also observed.
During individual interviews with the 2 youth, both reported they feel safe in the program, both during the day and at night. Both
youth stated that staff “check on them” throughout the night. One of the youth stated that he has been in multiple programs and
this program is “a lot better than any of the others.” Both youth stated that the program’s staff are welcoming, inviting and nice
and one of the youth said he can tell “staff care” about him. One youth also stated when he is having a really bad day, staff “are
there for him, they act like they care, they sit near, and give support.” Both youth also stated that the staff assist them in talking
about their feelings, thoughts and emotions and are teaching them better coping skills to deal with their anger. One youth stated
he has learned how to “walk away from things” when he gets upset and is also learning skills that will help him to “live on his own
someday.” Both youth also reported the program’s staff are sufficiently trained to assist them in meeting their goals and both
youth denied ever being treated badly by staff in the program or being placed in seclusion or restraint or observing another youth
in the program being treated badly or placed in seclusion or restraint. Both youth also stated they get lots of good food to eat
and that they can have seconds when they want. Both youth reported they can call people on their approved contact list on the
weekends and one day each week, and that although the calls are pretty private, staff can hear what they are talking about and
do say something to them if they begin to talk inappropriately or begin to talk about something they should not. Both youth also
stated they enjoy the program’s school and that their teacher is a good teacher. Both youth also reported they are able to
provide input into their treatment and discharge plans. Finally, when asked if they would change anything about the program,
one youth could not think of anything and the other stated he wished they could go into the community more but understood why
they could not since they were currently short staffed.
Form revised 4/28/2025 Page 2 of 33
During an individual telephonic interview with 1 program staff, it was reported the program is a good place to work and they feel
as though they are well trained and supported. They also stated that if they ever have a question, they can contact their
supervisor and, if their supervisor is not available, they can call the agency’s on-call staff person. They also reported that the
culture of the program is positive and supportive and that if anyone has an idea to make a process better, they can try it out and,
if it works, it will be implemented. This staff also stated that although there has been some staff turnover in the last couple
months, they are encouraged by the new supervisor’s vision and appreciate her leadership style, even though her style is
different than that of the previous supervisor. This staff also reported they very much support the values of the program,
appreciates seeing the positive changes the youth in the program make over time, and believes the program is very welcoming
and supportive to the LGBTQ community. This staff also stated they like that the job keeps them busy throughout the day and
that there isn’t much “down time.” When asked if the program could improve in any way, they couldn’t identify anything
significant.
During walkthrough of the program, it was observed that although the program was still well furnished and had nice and inviting
living areas and windows, the condition of both the inside and outside of the program was found in poor repair. The areas found
to be in poor repair included multiple ceiling CAN wafer lights which were not fully secured against the ceiling sheet rock in the
kitchen and main living areas. There were also small holes in the sheet rock in multiple areas and rooms throughout the
program. Small holes were observed in the dining room, living room, hallway, stairwell, upstairs recreation area, and laundry
room. In addition, the floor baseboard moulding was in need of paint and some repair in the kitchen and dining area, stairwell
landing, stairwell, and main living areas. There were also holes in the doors of the pantry and an upstairs bedroom door and the
double pantry door in the kitchen needed some new paint around the pull knobs. The toilet paper fixture in the small downstairs
bathroom had also fallen off the wall, leaving only the mounting. There was also sheetrock around the door of the main
downstairs bathroom which needed repair. The backyard was also found to be littered with some landscape bricks, 2 longer
pieces of exterior wood, a tarp, and other items which made the area appear unkept. Finally, the exterior flood light was no
longer securely mounted on the house above the main patio and was hanging by the electrical wires of the light.
Program strengths: The program’s supervisor and the one program staff interviewed, reported staff do a very good job of
meeting youth where they are at, connecting and listening to them, and teaching them skills to better manage their thoughts,
behavior, and emotions. The program’s supervisor and the one staff interviewed were also proud of how welcoming and inviting
the program was to the LGBTQ community. During my individual interviews with the 2-youth enrolled in the program, both
reported they liked the staff of the program and that the staff were teaching them valuable skills. Both youth also stated that staff
did a very good job of connecting with them, listening to them, and acting as though they cared about them. Both youth also
reported they liked living at the program.
Form revised 4/28/2025 Page 3 of 33
Program challenges: Although some of the staff working at the program have worked at the program since the program’s
opening about 3 years ago, the program’s management reports it has been difficult recruiting and retaining staff for the swing
and night shifts. The program is currently recruiting and interviewing for 2 staff to fill positions within the swing and night shifts.
Changes that have occurred in the last two years: In April 2025, a new supervisor of the residential program, Melissa
Benedict, was promoted from within the agency. Ms. Benedict brings some great experience into the position.
Lawsuits: There have not been any lawsuits filed in the past 2 years.
Grievances and complaints filed in the last two years: There have not been any formal grievances or complaints filed in the
past 2 years.
Corrective actions and timeframes: Please submit the following to verify compliance.
Within 45 days of receipt of this report The Next Door, Klahre House Residential 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 Irvin Minten at
Irvin.Minten@odhsoha.oregon.gov.
Recommendations: There are not any recommendations.
Exceptions: There are not any exceptions.
Changes in license: There are not any changes in the license.
Form revised 4/28/2025 Page 4 of 33
Summary of Review
Program and services Yes/No
Corrective actions/comments
419-400-0020 (2) or N/A
Program and services are in scope of license Yes
Governance of the agency Yes/No
Corrective actions/comments
419-400-0040 or N/A
(1)(a) Minimum of 5 board members Yes
(2)(f) Formally evaluate the Executive Director’s
Yes
performance annually
(2)(g) Approves annual budget Yes
(2)(h) Obtain and review an annual independent
Yes
financial review or audit of financial records.
(2)(k) Written quality improvement program Yes
(2)(l) Meeting minutes Yes
Executive Director or Program Director Yes/No
Corrective actions/comments
419-400-0040 or N/A
(3)(a) knowledge of requirements for providing
Yes
care and treatment appropriate to programs
(3)(g) Approval from BCU Yes
Installation and use of video equipment used
Yes/No
to monitor or record children in care Corrective actions/comments
or N/A
419-400-0145
(1) If a child-caring agency installs video - The program utilizes video equipment to monitor or
equipment to monitor or record a child in care, all No record children in care, among others. The program is
employees, volunteers, parents or guardians and not informing employees, volunteers, parents, or
Form revised 4/28/2025 Page 5 of 33
Installation and use of video equipment used
Yes/No
to monitor or record children in care Corrective actions/comments
or N/A
419-400-0145
children in care must be informed about the guardians and children in care about the intended use
intended use and locations of the equipment. and locations of the equipment. The program must
inform employees, volunteers, parents, or guardians
and children in care about the intended use of the
video and the locations of the equiptment.
Discipline, behavior management and suicide
Yes/No
prevention Corrective actions/comments
or N/A
419-400-0150
(3) Agency uses appropriate and positive methods
of behavior management and nationally Yes
recognized non-violent crisis intervention
(3)(b)(C) Agency does not use chemical and
mechanical restraint (excluding medically Yes - The program does not utilize restraints of any type.
necessary devices/prescriptions)
(3)(c) Agency uses appropriate time-out rooms
(adequate space, heat, light and ventilation and is
N/A - The program does not utilize time out.
not capable of locking) and documents use in
child’s record when applicable
(3)(e) Agency uses seclusion
N/A - The program does not utilize seclusion or restraint.
appropriately/consistent with policy
(4) Agency has adequate plan in place to respond - The program has a good plan in place to respond to
to suicidal behavior/warning signs suicidal behavior/warning signs. During interview and
Yes discussion with staff of the program during this review,
the staff were well versed on the program’s policy and
procedure specific to suicide prevention.
Form revised 4/28/2025 Page 6 of 33
Contractors (if applicable) Yes/No
Corrective actions/comments
419-400-0120(6) or N/A
(a) Agency ensures the contractor meets the
requirements of this rule and Chapter 413 division N/A - The program does not utilize contractors.
215
(b)(B) Contract includes the following:
(i) Services provided
(ii) Contractor fees
(iii) Disclosure of information from contractor to
agency
(iv) Lines of authority N/A
(v) Adherence to rules, including background
check
(vi) Any liability of the agency for acts of the
contractor, rights of indemnity and limitations on
liability
Restraints and Involuntary Seclusion Yes/No
Corrective actions/comments
419-400-0180 or N/A
(13)(d) Each child caring agency that submits a
report under this section shall make its quarterly
report available to the public upon request at the Yes
child caring agency’s main office and on the child
caring agency’s website if applicable.
Supplemental information provided by CCA Yes/No Corrective actions/comments
or N/A
Documents as indicated on the form titled
Yes
“Renewal Licensing Required Documents”
Documents as indicated on form titled “Required
Yes
Financial Documents and Information”
Form revised 4/28/2025 Page 7 of 33
Supplemental information provided by CCA Yes/No Corrective actions/comments
or N/A
All required policies and procedures as identified
Yes
in the “Umbrella Rules”
All required policies and procedures as identified
Yes
in “Agency Type Specific Rules”
Yes/No
Physical plant Corrective actions/comments
or N/A
419-400-0090(3)(a) Foster Rights Posted (if - The program's policies were closely reviewed prior to
Yes
children in ODHS custody) the on-site review.
419-400-0100(1) Sufficient safe space, equipment
Yes
and office equipment
419-400-0230(12) License is posted in common
Yes
area at each facility
419-470-0020(2)(a) and (c) Buildings are smoke - During walkthrough of the program and the program’s
free, clean and in good repair back yard area, the program was found in not good
repair. The areas found in not good repair included
multiple ceiling CAN wafer lights which were not fully
secured against the ceiling sheet rock in the kitchen
and main living areas. There were also small holes in
the sheet rock in multiple areas throughout the
program. Small holes in the sheetrock were observed
No in the dining room, living room, hallway, stairwell,
upstairs recreation area, and laundry room. In addition,
the floor baseboard moulding needed paint and some
repair in the kitchen and dining area, stairwell landing,
stairwell, and main living areas. There were also holes
in the doors of the pantry and an upstairs bedroom
door, and the double pantry door needed some fresh
paint around the door pulls. The toilet paper fixture in
the small downstairs bathroom had also fallen off the
Form revised 4/28/2025 Page 8 of 33
Yes/No
Physical plant Corrective actions/comments
or N/A
wall. There was also sheetrock around the door of the
main bathroom downstairs which was in need of repair.
The backyard was also found to be littered with
landscape bricks, 2 longer pieces of exterior wood, a
tarp, and other items which made the area look unkept.
Finally, the exterior flood light mounted on the house
above the main patio was no longer secured and was
hanging by the electrical wires of the light. The
program must ensure that both the interior and exterior
of the program is clean and in good repair.
419-470-0020 (2)(d) Rooms are free of harmful
Yes
drafts, odors and excessive noise
419-470-0020 (2)(e) Rooms are adequate in size
Yes
and arrangement
419-470-0020 (2)(f) System provides a continuous
supply of hot and cold water to taps located Yes
throughout the facility
419-470-0020 (2)(h) Building is well ventilated and
room temperature is within a normal comfort Yes
range
419-470-0030 (1) All parts of the facility ensure
Yes
the safety of children
Room and space requirements Yes/No
Corrective actions/comments
419-470-0030 or N/A
(2) There is a separate living room or lounge area
Yes
– 15 SF minimum per child
(5) There is a separate dining room with capacity
for ½ of children in care and 15 SF per child in Yes
care
Form revised 4/28/2025 Page 9 of 33
Room and space requirements Yes/No
Corrective actions/comments
419-470-0030 or N/A
(7) Laundry is separate from living, kitchen and
Yes
dining areas
(8) Separate storage areas are provided for food,
kitchen supplies, utensils, clean linens, soiled
linens and clothing, cleaning supplies and
equipment, poisons, chemicals, outdoor Yes
recreational and maintenance equipment.
(Hazardous materials are properly labeled, in
original container and locked)
(9) Outdoor activity area is protected from
vehicles and other hazards and of a size and
Yes
availability appropriate to the age and needs of
children in care
(11) Time-out rooms: Rooms used for time out or
quiet time must have adequate space, heat, light
N/A - The program does not utilize time out.
and ventilation and must not be capable of
locking.
Room and space requirements -bedrooms Yes/No
Corrective actions/comments
419-470-0030(3) or N/A
(a) Adequate furnishings and personal items Yes
(b) Separate from rooms used for dining, living,
Yes
laundry, kitchen and storage
(c) Meet Oregon Fire Code Requirements Yes
(d) Be an outside room, with a window that
operates as designed. If the window is modified
from its original design, the fire marshal must Yes
approve the modification and indicate this room
still meets applicable Oregon Fire Code.
(d) Ceiling at least 90 inches Yes
Form revised 4/28/2025 Page 10 of 33
Room and space requirements -bedrooms Yes/No
Corrective actions/comments
419-470-0030(3) or N/A
(e) Minimum 60 SF per occupant Yes
(f) No more than 25 if dorm style Yes
(g) Permanently wired fixtures Yes
(h) Window covering Yes
Room and space requirements - bathrooms Yes/No
Corrective actions/comments
419-470-0030(4) or N/A
(a)(A) and (B) 1:8 ratio for toilets and sinks Yes
(a)(D) Hot and cold running water, soap and
Yes
approved hand drying options
(a)(E) 1:10 ratio for shower or bathtub Yes
(a)(E) Individual privacy Yes
(a)(F) Window covering Yes
(a)(G) Permanently wired fixtures Yes
(a)(H) Adequate ventilation Yes
(b) and (c) Wooden racks on floors are prohibited
and impervious shower mats are disinfected and Yes
dried daily be in good condition and free of mold
Room and space requirements -
Yes/No
kitchen Corrective actions/comments
or N/A
419-470-0030(6)
(a) Used exclusively for storage, food preparation,
dishwashing and activities related to eating and Yes
food preparation activities
(b) Walls, floors are easily cleanable Yes
(c) Equipment and utensils are easily cleanable,
Yes
durable, nontoxic and kept clean
Form revised 4/28/2025 Page 11 of 33
Room and space requirements -
Yes/No
kitchen Corrective actions/comments
or N/A
419-470-0030(6)
(e) Equipment is easy to clean beneath, between
Yes
and behind
Furnishings and personal items Yes/No
Corrective actions/comments
419-470-0040 or N/A
(1) There is a bed with frame Yes
(1)(b) clean mattress in good condition, with a
Yes
minimum thickness of five inches
(1)(c) a pillow in good condition Yes
(1)(d) a private dresser, closet, or similar storage
area for personal belongings that is readily Yes
accessible
(2) Linens are in good repair. There is a
waterproof mattress cover or mattress. Linens are
Yes
appropriate and towels and washcloths are
provided
(3) Bedding is changed weekly or when soiled Yes
(4) and (5) Personal hygiene supplies and
Yes
appropriate clothing are provided
Food services Yes/No
Corrective actions/comments
419-470-0070 or N/A
(1)(a) Meals are arranged daily, consistent with
normal mealtimes that occur during the hours of Yes
operation and provide snacks between mealtimes
(1)(b) Menus are prepared in advance in - Since the program is not keeping menus for an
accordance with USDA guidelines, provide a No extended period and for 6 months, it is not known if the
program is preparing menus in advance in accordance
Form revised 4/28/2025 Page 12 of 33
Food services Yes/No
Corrective actions/comments
419-470-0070 or N/A
variety of foods and are adjusted for seasonal with USDA guidelines, and that they are providing a
changes including snacks variety of foods to youth in the program and are
adjusting their menus for seasonal changes, including
snacks. The program must ensure that menus are
prepared in advance in accordance with USDA
guidelines and that they are providing the youth in the
program with a variety of foods, adjusted for the
season.
(1)(b) Menus are kept for at least 6 months - The program is not keeping menus for 6 months, as
No only a few menus could be located. The program must
ensure that menus are kept for at least 6 months.
(1)(c) Drinking water is freely available Yes
(2)(a) Food is stored, prepared and served in a
Yes
sanitary manner
(2)(c) and (d) Food products are obtained from
commercial suppliers (exception of fruits and
- The program purchases food products from The Dalles
vegetables), unpasteurized juice is prohibited, and Yes
Fred Meyer.
only Grade A pasteurized and fortified milk in
appropriate container.
Residential care safety Yes/No
Corrective actions/comments
419-470-0080 or N/A
(2) Written emergency plan that includes Yes
(a) Identifying the types of emergencies most
likely to happen where the residential care agency Yes
is located
(b) Identifying a place to meet for each type of
Yes
emergency identified
(c) Identifying an alternate shelter if necessary Yes
Form revised 4/28/2025 Page 13 of 33
Residential care safety Yes/No
Corrective actions/comments
419-470-0080 or N/A
(d) Ensuring access to necessary medications or
Yes
medical equipment
(e) How to help each child in care recover after a
Yes
disaster
(3) Telephone numbers for local police, fire - The program is not posting telephone numbers for local
department, poison control, after hours medical police, fire department, poison control, after hours
advice and other appropriate emergency numbers medical advice and other appropriate emergency
must be posted near all telephones. Yes numbers near all telephones. The program must post
telephone numbers for local police, fire department,
poison control, after hours medical advice and other
appropriate emergency numbers near all telephones.
(4) Operative flashlights sufficient in number are - The program does not have operative flashlights
readily available to staff sufficient in number readily available to staff. The
Yes
program must have operative flashlights sufficient in
number readily available to staff.
(5)(a) Evacuation drill occurs monthly under
varying conditions, is retained 2 years and
contains: - The program is not completing monthly fire drills and
(A) identify of person conducting drill the program’s fire drill log does not contain all required
(B) date and time fields, including the identity of the person conducting
(C) notification method the drill, notification method, special conditions
No
(D) staff participating simulated, problems encountered, and time to
(E) number of children and staff evacuated complete. The program must complete monthly fire
(F) special conditions simulated drills and the program’s fire drill log must contain all
(G) problems encountered required fields.
(H) time to complete
Form revised 4/28/2025 Page 14 of 33
Umbrella safety Yes/No
Corrective actions/comments
419-400-0200 or N/A
(5)(b) Vehicle has insurance policy, is smoke free,
safe operating condition, and has first aid kit and Yes
fire extinguisher 2-A:10-BC
(1)(b)(A) Each vehicle used to transport a child in
care must be: properly registered,
covered by an insurance policy in full force and Yes
effect, maintained in safe operating condition and
smoke-free.
(3) If a child-caring agency has a swimming pool
on the premises that is accessible to children in
care or if a child-caring agency plans to have
children in care engage in swimming, the child-
caring agency must have and adhere to policies N/A - The program does not have a swimming pool.
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
Yes
potentially harmful items and materials.
(4)(b) Direct supervision of children who do not
have the ability to adjust and control water Yes
temperature
(4)(c) Light fixtures have protective covers unless
Yes
designed to be used without one
Medication Yes/No
Corrective actions/comments
419-470-0100 or N/A
(3) and (7)(e) Medications have a prescription and
are stored in the original container with Yes
prescription label
Form revised 4/28/2025 Page 15 of 33
Medication Yes/No
Corrective actions/comments
419-470-0100 or N/A
(4) and (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
Yes
medical professional. A written 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 locking mechanisms. Yes
This does not apply to Naloxone.
(8) Medications are disposed in accordance with - The program’s medications which need disposal are
state and federal law Yes taken to the Klahre House Day Treatment Program and
are disposed in accordance with state and federal law.
(9) Written record of the disposal of medications is
maintained and includes:
(a) description and amount - The program’s written record of disposal of medications
(b) name Yes is maintained at the Klahre House Day Treatment
(c) reason Program.
(d) method
(e) staff and witness signature
(10) Written record of the administration of
medication includes:
(a) name - The program’s MAR contains all required fields and
(b) description staff are completing the MAR accurately. It is
(c) dates and times recommended that, as noted on the MAR being used
Yes
(d) missed doses by he program, that the program staff note all
(e) medication disposed medication refusals by youth on the space provided on
(f) method of administration the back of each individual MAR.
(g) ID of person administering
(h) possible adverse reactions
Form revised 4/28/2025 Page 16 of 33
Medication Yes/No
Corrective actions/comments
419-470-0100 or N/A
(i) medication taken outside facility
Extracurricular, enrichment, cultural and
Yes/No
social activities Corrective actions/comments
or N/A
419-470-0110
(2) Children have ongoing opportunities to
participate in at least one age-appropriate or Yes
developmentally appropriate activity
Minimum staffing requirements Yes/No
Corrective actions/comments
419-470-0130 or N/A
(1) and (2) Supervision is adequate for the type of
program, location, age and type of children, ability
of supervisor to respond, electronic back-up
systems.
Minimum ratios are maintained:
Yes
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 additional
staff immediately available with max response Yes
time of 30 minutes
(5) There is at least one on-site employee
authorized to apply the reasonable and prudent Yes
parent standard
Form revised 4/28/2025 Page 17 of 33
Sleeping arrangements Yes/No
Corrective actions/comments
419-470-0140 or N/A
(1) Children are in separate bedrooms than
adults, unless parent and child, or there is written
Yes
approval from guardian/parent and licensing
coordinator
(2) There is adequate supervision of children
Yes
when sleeping
(3) When assigning bedrooms a residential care
agency must consider all of the following:
(a) Chronological age
(b) Developmental age
- The program’s policy and procedure on grouping of
(c) Gender identity Yes
youth in bedrooms meets all rule requirements.
(d) Personal history, including medical, mental
health, behavioral health and past adverse
experiences including any physical or sexual
abuse
Personnel files Yes/No
Corrective actions/comments
419-400-0120 or N/A
Staff name/position - 4 employee personnel files of employees of the Klahre
House Residential Program were reviewed during this
review. The files for the program were maintained by
Yes
The Next Door's HR Department and all files were
found to be well organized and to contain all required
information.
(3)(g) Date of hire Yes
(3)(a) record of education, training and previous
Yes
employment
(1)(b) and (3)(b) reference checks completed and
Yes
documented
Form revised 4/28/2025 Page 18 of 33
Personnel files Yes/No
Corrective actions/comments
419-400-0120 or N/A
(1)(a) and (3)(c) Background check completed
Yes
and documented
(3)(d) Annual performance evaluations Yes
(3)(f) Record of personnel actions Yes
(3)(g) Termination date, reason for termination Yes
(3)(h) Current job description (1)(c) Employee
meets minimum qualifications stated in current job Yes
description
New employee orientation – Umbrella
Yes/No
Requirements (30 days) Corrective actions/comments
or N/A
419-400-0120(4)
(a) Agency policies and procedures - There was not any employee training records reviewed
during this review as, despite the fact there were
multiple employees working at the program, program
staff was not able to locate residential program
employee training files which to review. The employee
training tracking sheet also DID NOT contain all
required trainings for residential employees in rule.
Since there was not any residential employee training
No files reviewed, all new employee orientation training
requirements will be given a “No” finding.
- The program is not maintaining training records for
employees showing that they have received new
employee orientation training on agency policies and
procedures. The program must ensure and maintain
records that all employees receive new employee
orientation training on agency policies and procedures.
Form revised 4/28/2025 Page 19 of 33
New employee orientation – Umbrella
Yes/No
Requirements (30 days) Corrective actions/comments
or N/A
419-400-0120(4)
(b) Ethical and professional guidelines - The program is not maintaining training records for
employees showing that they have received new
employee orientation training on ethical and
No professional guidelines. The program must ensure and
maintain records that all employees receive new
employee orientation training on ethical and
professional guidelines.
(c) Suicide prevention and intervention - The program is not maintaining training records for
employees showing that they have received new
employee orientation training on suicide prevention and
No intervention. The program must ensure and maintain
records that all employees receive new employee
orientation training on suicide prevention and
intervention.
(d) Attributes of population served - The program is not maintaining training records for
employees showing that they have received new
employee orientation training on attributes of
No population served. The program must ensure and
maintain records that all employees receive new
employee orientation training on attributes of
population served.
(e) and (5)(a) to (c) Mandatory reporting that
- The program is not maintaining training records for
includes:
employees showing that they have received new
(a) legal definition of child abuse in ORS 418.257
employee orientation training on mandatory reporting.
and 419B.005 No
The program must ensure and maintain records that all
(b) legal responsibility to immediately report
employees receive new employee orientation training
(c) legal responsibility to report is personal to the
on mandatory reporting.
employee
Form revised 4/28/2025 Page 20 of 33
New employee orientation – Umbrella
Yes/No
Requirements (30 days) Corrective actions/comments
or N/A
419-400-0120(4)
(f) Privacy laws - The program is not maintaining training records for
employees showing that they have received new
employee orientation training on privacy laws. The
No
program must ensure and maintain records that all
employees receive new employee orientation training
on privacy laws.
(g) Emergency procedures - The program is not maintaining training records for
employees showing that they have received new
employee orientation training on emergency
No
procedures. The program must ensure and maintain
records that all employees receive new employee
orientation training on emergency procedures.
New employee orientation
residential (prior to working alone and within Yes/No
Corrective actions/comments
30 days) or N/A
419-470-0120(1)
(a) Discipline and behavior management including - The program is not maintaining training records for
de-escalation, crisis prevention, positive behavior employees showing that they have received new
management and disciplinary techniques that are employee orientation training on discipline and
non-punitive in nature behavior management. The program must ensure and
No maintain records that all employees receive new
employee orientation training on discipline and
behavior management including de-escalation, crisis
prevention, positive behavior management and
disciplinary techniques that are non-punitive in nature.
(b) CPR and First Aid sufficient to retain a current - The program is not maintaining training records for
certification No employees showing that they have received new
employee orientation training on CPR and First Aid
Form revised 4/28/2025 Page 21 of 33
New employee orientation
residential (prior to working alone and within Yes/No
Corrective actions/comments
30 days) or N/A
419-470-0120(1)
sufficient to retain a current certification. The program
must ensure and maintain records that all employees
receive new employee orientation training on CPR and
First Aid sufficient to retain a current certification.
(c) Universal precautions and hygiene - The program is not maintaining training records for
employees showing that they have received new
employee orientation training on universal precautions
No and hygiene. The program must ensure and maintain
records that all employees receive new employee
orientation training on universal precautions and
hygiene.
(d) Application of the reasonable and prudent - The program is not maintaining training records for
parent standard employees showing that they have received new
employee orientation training on the application of the
No reasonable and prudent parent standard. The program
must ensure and maintain records that all employees
receive new employee orientation training on the
reasonable and prudent parent standard.
(e) Training on the agency’s policy on suicide - The program is not maintaining training records for
prevention and suicide risk assessment tool employees showing that they have received new
employee orientation training on suicide prevention and
the program’s suicide risk assessment tool. The
No
program must ensure and maintain records that all
employees receive new employee orientation training
on suicide prevention and the program’s risk
assessment tool.
Form revised 4/28/2025 Page 22 of 33
Crisis intervention training standards and
Yes/No
certification Corrective actions/comments
or N/A
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 behavior support, N/A
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 certified
to conduct if applicable N/A
(D) Any special endorsements earned by the
individual
(E) The level of training
(F) The name of the certified instructor who
conducted the training and administered the
assessment of proficiency.
(e) A certification issued:
(A) Must be personal to the individual certified by
the training provider N/A
(B) May be valid for no more than two years with
recertification
Form revised 4/28/2025 Page 23 of 33
Yes/No
Ongoing training Corrective actions/comments
or N/A
419-470-0070(2)(b) Employees who handle food - There was not any employee training records
served to children have a valid food handler’s reviewed during this review as, despite the fact
card there were multiple employees working at the
program, program staff was not able to locate
residential program employee training files which to
review. The employee training tracking sheet also
DID NOT contain all required trainings for
residential employees in rule. Since there was not
No any residential employee training files reviewed, all
employee ongoing/yearly training requirements will
be given a “No” finding.
- The program is not maintaining records for
employees who handle food served to children and
ensuring that employees who handle food have a
valid food handler’s card. The program must ensure
that all employees who handle food have a valid
food handler’s card.
419-400-0200 (1) Employees transporting - The program is not maintaining records that
children have: current driver’s license, insurance, employees transporting children have current
trained in emergency procedures and behavior driver’s license, insurance, are trained in
management and training for 15+ passenger vans emergency procedures and behavior management
if applicable) and training for 15-plus passenger vans, if
No applicable. The program must ensure they are
maintaining records that employees transporting
children have current driver’s license, insurance,
are trained in emergency procedures and behavior
management and training for 15-plus passenger
vans, if applicable.
419-470-0120 (2)(a) Environmental emergencies - The program is not maintaining training records for
No employees showing that they have received
yearly/ongoing training on environmental
Form revised 4/28/2025 Page 24 of 33
Yes/No
Ongoing training Corrective actions/comments
or N/A
emergencies. The program must ensure and
maintain records that all employees receive
annual/ongoing training on environmental
emergencies.
419-470-0120 (2)(b) Universal precautions - The program is not maintaining training records for
employees showing that they have received
yearly/ongoing training on universal precautions. The
No
program must ensure and maintain records that all
employees receive annual/ongoing training on
universal precautions.
419-470-0120 (2)(c) Discipline and behavior - The program is not maintaining training records for
management employees showing that they have received
yearly/ongoing training on discipline and behavior
No
management. The program must ensure and maintain
records that all employees receive annual/ongoing
training on discipline and behavior management.
419-470-0120 (2)(d) Agency’s policy on suicide - The program is not maintaining training records for
prevention and risk assessment tool employees showing that they have received
yearly/ongoing training on suicide prevention and the
No program’s risk assessment tool. The program must
ensure and maintain records that all employees receive
annual/ongoing training on suicide prevention and the
program’s risk assessment tool.
419-470-0120 (3) Staff providing direct care must - The program is not maintaining training records for
maintain current CPR/First Aid certification employees providing direct care showing that they
have maintained current CPR/First Aid certification.
No
The program must ensure and maintain records that all
employees providing direct care maintain current
CPS/First Aid certification.
Form revised 4/28/2025 Page 25 of 33
Yes/No
Ongoing training Corrective actions/comments
or N/A
419-470-0120 (4) Designated staff authorized to - The program is not maintaining training records for
apply reasonable and prudent parent standard employees showing that they have received
are trained in application of the standard yearly/ongoing training on the reasonable and prudent
No parent standard. The program must ensure and
maintain records that all employees receive
annual/ongoing training on the reasonable and prudent
parent standard.
419-400-0120(5) Mandatory reporting (annually)
- The program is not maintaining training records for
that includes:
employees showing that they have received
(a) legal definition of child abuse in ORS 418.257
yearly/ongoing training on mandatory reporting. The
and 419B.005 No
program must ensure and maintain records that all
(b) legal responsibility to immediately report
employees receive annual/ongoing training on
(c) legal responsibility to report is personal to the
mandatory reporting.
employee
419-400-0160(4)(b) Receive continuing education
(as applicable on crisis intervention training) from N/A
a certified instructor on an annual basis
Children’s records
Yes/No
health services Corrective actions/comments
or N/A
419-470-0090
(2) Medical history obtained within 30 days
(significant findings, current immunizations,
history of surgical procedures-health issues- Yes
injuries, allergies, dental, vision, hearing,
behavioral health and physician orders)
(4)(a) to (f) Medical exams (3 in first year of life,
Yes
2,4,6,9,14)
Form revised 4/28/2025 Page 26 of 33
Children’s records
Yes/No
health services Corrective actions/comments
or N/A
419-470-0090
(g) Have a physical examination within the first 60
days after admission of a child in care.
Documentation of a physical examination having Yes
occurred within the calendar year will meet this
requirement.
Consents Yes/No
Corrective actions/comments
419-470-0160(1) or N/A
(a) Provide routine and emergency medical care Yes
(b) Use the discipline and behavior management
Yes
system
(c) Use restraint or seclusion (if applicable). Must
specify the reasons for the intervention and how N/A - The program does not utilize seclusion or restraint.
staff are trained and supervised
(d) Restrict contact with persons outside of the
Yes
agency
(e) Allow access as defined in 419-400-0230 and - The program’s child files do not contain a signed
0240 consent that the program will allow access to the
program by the child’s parent, caseworker, court
No appointed attorney, and CASA, as defined in 419-400-
0230 and 0240. The program must ensure that all child
files contain a signed consent that the program will
allow access as defined in 419-400-0230 and 0240.
(f) Impose a dress code Yes
(g) Apply the reasonable and prudent parent
Yes
standard
Form revised 4/28/2025 Page 27 of 33
Disclosures
Yes/No
419-470-0160(2) Corrective actions/comments
or N/A
Parent/guardian has acknowledged in writing:
(a) Information regarding personal or room
searches and protocols for confiscation of Yes
contraband
(b) Statement of Rights of Children and - The program’s Statement of Rights of Children and
Parents/Guardians Parents/Guardians does not state that children and
parents have the right to uncensored communication.
In addition, during individual interviews of children
enrolled in the program, it was reported that staff of the
residential program monitor and sometimes listen in to
No
telephone calls between the child and their parents or
other identified persons on the child’s approved contact
list. The program must ensure that telephone calls
between the child and their parents and other persons
on the child’s approved contact list are not monitored
or listened to by staff, rather the calls must be private.
(c) Any policies and procedures upon request Yes
Authorizations Yes/No
Corrective actions/comments
419-470-0160(3) or N/A
(a) Disclose or exchange information with others Yes
(b) Child specific visitors Yes
(c) Visitation resources are pre-approved Yes
(d) Activity specific authorizations are pre-
approved to allow children to participate in
potentially hazardous activities, including but not Yes
limited to using motorized yard equipment,
swimming and horseback riding.
Form revised 4/28/2025 Page 28 of 33
Information about children in care
Yes/No
419-400-0190(1) Corrective actions/comments
or N/A
Summary sheet contains the following:
(a)The name, gender, date of birth, religious
Yes
preference and previous address
(b) Name and location of previous and current
Yes
school
(c) Date of admission Yes
(d) Legal custody Yes
(e) The name, address and telephone number of: - The program’s summary sheet does not clearly depict
(A) The child in care's parents. all required fields. Currently, the child’s summary
(B) The child in care's legal guardian, if sheet has a field for “Important Relationships.” The
different than the parents and a copy of the program’s summary sheet does not include the
document that provides for his or her authority required fields of (C) Other persons significant to child
over the child in care. No and (D) Other professionals to be involved in service
(C) Other persons significant to child planning, if applicable. The program’s summary sheet
(D) Other professionals to be involved in service must clearly depict all required fields including “Other
planning (if applicable) persons significant to the child” and “Other
professionals to be involved in service planning, if
applicable.”
Service planning Yes/No
Corrective actions/comments
419-470-0170(2) or N/A
(b) Intake document is completed the date child - Although the program’s Intake documents are well
accepted into care (emergency placement 48 written and comprehensive, the program’s Intake
hours) document is not being completed on the date the child
is accepted into placement. Three child files of the
No
residential program were randomly pulled for review.
Of these 3 files, the intake documents were completed
at 1, 2, and 3 days after the child entered the program.
The program must ensure that their Intake document is
Form revised 4/28/2025 Page 29 of 33
Service planning Yes/No
Corrective actions/comments
419-470-0170(2) or N/A
created on the date the child enters the program, or
within 48 hours if an emergency placement.
(d) Assessment is completed within 30 days and
contains relevant historical information, current - The assessment and service plans were well written
Yes
behavioral observations, identified need for and detailed to the specific needs of the child.
services and how agency will provide services
(e) (A) and (B) Service plan within 60 days
(parent, guardian and child actively involved).
Describes how child’s issues will be addressed, Yes
anticipated outcomes and reviewed by child and
guardian/parent.
(e)(C) and (D) Service plan is reviewed quarterly
and revised when information indicates other Yes
services should be provided
Case management Yes/No
Corrective actions/comments
419-470-0170(3) or N/A
(a) Services are documented, progress toward
Yes
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
- A discharge summary was not reviewed during this
(C)Any outstanding medical or other
N/A review, as none of the files pulled involved children
appointments
who had been discharged from the program.
(D)Summary of the child’s participation in the
program and progress achieved
(E)Results of evaluations
(F)Recommendations regarding services
Form revised 4/28/2025 Page 30 of 33
Case management Yes/No
Corrective actions/comments
419-470-0170(3) or N/A
(G)Discharge destination
(e) Follow up services Yes
(f) Incident reports Yes
Records relating to Restraint and Involuntary Yes/No
Corrective actions/comments
Seclusion or N/A
419-400-0180 (12) Records Yes
419-400-0180(13)(e) Each child caring agency
shall provide notice regarding how to access the
quarterly reports to the parents or guardians of
children in care in the program. The child caring Yes
agency shall provide the 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 and Involuntary Yes
Seclusion
Financial records Yes/No
Corrective actions/comments
419-470-0170(4) or N/A
Records contain date, amount, source, purpose, - The program is maintaining a financial record for each
signatures child in care. However, the financial record log does
not contain all required fields. It does not include (4)(b)
No source, (4)(c) purpose and (4)(d) signature of child.
The program must ensure they are maintaining
accurate financial records for each child in care and
that their financial record log has all required fields.
Form revised 4/28/2025 Page 31 of 33
Personal possessions records Yes/No
Corrective actions/comments
419-470-0170 (5) or N/A
Individual written inventory of all personal
possessions is maintained and updated as Yes
needed
Records and documentation Yes/No
Corrective actions/comments
419-400-0140 or N/A
(1) Stored safely Yes
(2) Permanent, legible, dated and signed Yes
(3) and (4) Uniform in organization, readily
identifiable and accessible, current and complete,
Yes
containing all required info. No eraser tape or
white out.
(7) Permanent registry for each child includes:
Name
Gender
Birth date Yes
Names, addresses of parents or guardians
Dates of admission
Placement upon discharge
Comments:
Form revised 4/28/2025 Page 32 of 33
6-4-2025 6-3-2025
Irvin Minten, M.S.W. Harry Gilmore
Licensing Coordinator's signature Manager Review
Form revised 4/28/2025 Page 33 of 33

agency_name: The Next Door (TND)

program_type: (RC) Residential Care Programs

report_type: License Renewals

view_code: RC

report_title: Licensed Child Caring Agency Site Visit Report

facility_type: Residential Care - License Renewal

licensee: The Next Door, Klahre House Residential Date of site visit: 5-27, 5-28 and 5-29-25

executive_director: Janet Hamada Licensing Coordinator: Irvin Minten, M.S.W.

program_director: Melanie Kelly Board Chairperson: Ann Harris

board_chairperson: Ann Harris

licensing_coordinator: Irvin Minten, M.S.W.

other_regulatory_agencies: Oregon Youth Authority (OYA) and Oregon Department of Human Services, Treatment Services Unit.

capacity_age_range: The program serves males, ages 13-18. The program's capacity is 5 youth.

funding_sources: OYA and ODHS

contracts_and_referrals:
Referrals come from OYA and ODHS.
Form revised 4/28/2025 Page 1 of 33

average_length_of_stay: The average length of stay in the program is between 9-18 months.

average_daily_population_served: The average daily population is about 5 youth.

number_of_children_served_annually: The program estimates it serves about 6-8 youth annually.

use_of_seclusion_or_restraint: The program does not utilize seclusion or restraint. Interviews/observations: During the 2-year licensing review, 1 program line staff and 2 youth currently enrolled at the program were randomly selected and individually interviewed. A walkthrough of the facility and the facility's outdoor area was also completed. During the review, there was also a great deal of discussion with Melanie Kelly, Program Director, Adriana Clayton, Program Manager, and Melissa Benedict, Supervisor. The program's medication cabinet and 2 Medication Administration Records were also observed. During individual interviews with the 2 youth, both reported they feel safe in the program, both during the day and at night. Both youth stated that staff "check on them" throughout the night. One of the youth stated that he has been in multiple programs and this program is "a lot better than any of the others." Both youth stated that the program's staff are welcoming, inviting and nice and one of the youth said he can tell "staff care" about him. One youth also stated when he is having a really bad day, staff "are there for him, they act like they care, they sit near, and give support." Both youth also stated that the staff assist them in talking about their feelings, thoughts and emotions and are teaching them better coping skills to deal with their anger. One youth stated he has learned how to "walk away from things" when he gets upset and is also learning skills that will help him to "live on his own someday." Both youth also reported the program's staff are sufficiently trained to assist them in meeting their goals and both youth denied ever being treated badly by staff in the program or being placed in seclusion or restraint or observing another youth in the program being treated badly or placed in seclusion or restraint. Both youth also stated they get lots of good food to eat and that they can have seconds when they want. Both youth reported they can call people on their approved contact list on the weekends and one day each week, and that although the calls are pretty private, staff can hear what they are talking about and do say something to them if they begin to talk inappropriately or begin to talk about something they should not. Both youth also stated they enjoy the program's school and that their teacher is a good teacher. Both youth also reported they are able to provide input into their treatment and discharge plans. Finally, when asked if they would change anything about the program, one youth could not think of anything and the other stated he wished they could go into the community more but understood why they could not since they were currently short staffed. Form revised 4/28/2025 Page 2 of 33 During an individual telephonic interview with 1 program staff, it was reported the program is a good place to work and they feel as though they are well trained and supported. They also stated that if they ever have a question, they can contact their supervisor and, if their supervisor is not available, they can call the agency's on-call staff person. They also reported that the culture of the program is positive and supportive and that if anyone has an idea to make a process better, they can try it out and, if it works, it will be implemented. This staff also stated that although there has been some staff turnover in the last couple months, they are encouraged by the new supervisor's vision and appreciate her leadership style, even though her style is different than that of the previous supervisor. This staff also reported they very much support the values of the program, appreciates seeing the positive changes the youth in the program make over time, and believes the program is very welcoming and supportive to the LGBTQ community. This staff also stated they like that the job keeps them busy throughout the day and that there isn't much "down time." When asked if the program could improve in any way, they couldn't identify anything significant. During walkthrough of the program, it was observed that although the program was still well furnished and had nice and inviting living areas and windows, the condition of both the inside and outside of the program was found in poor repair. The areas found to be in poor repair included multiple ceiling CAN wafer lights which were not fully secured against the ceiling sheet rock in the kitchen and main living areas. There were also small holes in the sheet rock in multiple areas and rooms throughout the program. Small holes were observed in the dining room, living room, hallway, stairwell, upstairs recreation area, and laundry room. In addition, the floor baseboard moulding was in need of paint and some repair in the kitchen and dining area, stairwell landing, stairwell, and main living areas. There were also holes in the doors of the pantry and an upstairs bedroom door and the double pantry door in the kitchen needed some new paint around the pull knobs. The toilet paper fixture in the small downstairs bathroom had also fallen off the wall, leaving only the mounting. There was also sheetrock around the door of the main downstairs bathroom which needed repair. The backyard was also found to be littered with some landscape bricks, 2 longer pieces of exterior wood, a tarp, and other items which made the area appear unkept. Finally, the exterior flood light was no longer securely mounted on the house above the main patio and was hanging by the electrical wires of the light.

program_strengths:
The program's supervisor and the one program staff interviewed, reported staff do a very good job of
meeting youth where they are at, connecting and listening to them, and teaching them skills to better manage their thoughts,
behavior, and emotions. The program's supervisor and the one staff interviewed were also proud of how welcoming and inviting
the program was to the LGBTQ community. During my individual interviews with the 2-youth enrolled in the program, both
reported they liked the staff of the program and that the staff were teaching them valuable skills. Both youth also stated that staff
did a very good job of connecting with them, listening to them, and acting as though they cared about them. Both youth also
reported they liked living at the program.
Form revised 4/28/2025 Page 3 of 33

program_challenges:
Although some of the staff working at the program have worked at the program since the program's
opening about 3 years ago, the program's management reports it has been difficult recruiting and retaining staff for the swing
and night shifts. The program is currently recruiting and interviewing for 2 staff to fill positions within the swing and night shifts.

changes_in_last_two_years:
In April 2025, a new supervisor of the residential program, Melissa
Benedict, was promoted from within the agency. Ms. Benedict brings some great experience into the position.

lawsuits: There have not been any lawsuits filed in the past 2 years.

grievances_and_complaints:
There have not been any formal grievances or complaints filed in the
past 2 years.

recommendations: There are not any recommendations.

exceptions: There are not any exceptions.

changes_in_license:
There are not any changes in the license.
Form revised 4/28/2025 Page 4 of 33

excerpt:
419-400-0020 (2) or N/A
Program and services are in scope of license Yes
Governance of the agency Yes/No
Corrective actions/comments

excerpt:
419-400-0040 or N/A
(1)(a) Minimum of 5 board members Yes
(2)(f) Formally evaluate the Executive Director's
Yes
performance annually
(2)(g) Approves annual budget Yes
(2)(h) Obtain and review an annual independent
Yes
financial review or audit of financial records.
(2)(k) Written quality improvement program Yes
(2)(l) Meeting minutes Yes
Executive Director or Program Director Yes/No
Corrective actions/comments

excerpt:
419-400-0150
(3) Agency uses appropriate and positive methods
of behavior management and nationally Yes
recognized non-violent crisis intervention
(3)(b)(C) Agency does not use chemical and
mechanical restraint (excluding medically Yes - The program does not utilize restraints of any type.
necessary devices/prescriptions)
(3)(c) Agency uses appropriate time-out rooms
(adequate space, heat, light and ventilation and is
N/A - The program does not utilize time out.
not capable of locking) and documents use in
child's record when applicable
(3)(e) Agency uses seclusion
N/A - The program does not utilize seclusion or restraint.
appropriately/consistent with policy
(4) Agency has adequate plan in place to respond - The program has a good plan in place to respond to
to suicidal behavior/warning signs suicidal behavior/warning signs. During interview and
Yes discussion with staff of the program during this review,
the staff were well versed on the program's policy and
procedure specific to suicide prevention.
Form revised 4/28/2025 Page 6 of 33
Contractors (if applicable) Yes/No
Corrective actions/comments

excerpt:
419-400-0180 or N/A
(13)(d) Each child caring agency that submits a
report under this section shall make its quarterly
report available to the public upon request at the Yes
child caring agency's main office and on the child
caring agency's website if applicable.
Supplemental information provided by CCA Yes/No Corrective actions/comments
or N/A
Documents as indicated on the form titled
Yes
"Renewal Licensing Required Documents"
Documents as indicated on form titled "Required
Yes
Financial Documents and Information"
Form revised 4/28/2025 Page 7 of 33
Supplemental information provided by CCA Yes/No Corrective actions/comments
or N/A
All required policies and procedures as identified
Yes
in the "Umbrella Rules"
All required policies and procedures as identified
Yes
in "Agency Type Specific Rules"
Yes/No
Physical plant Corrective actions/comments
or N/A

excerpt:
419-400-0090(3)(a) Foster Rights Posted (if - The program's policies were closely reviewed prior to
Yes
children in ODHS custody) the on-site review.

excerpt:
419-400-0100(1) Sufficient safe space, equipment
Yes
and office equipment

excerpt:
419-400-0230(12) License is posted in common
Yes
area at each facility

excerpt:
419-470-0020(2)(a) and (c) Buildings are smoke - During walkthrough of the program and the program's
free, clean and in good repair back yard area, the program was found in not good
repair. The areas found in not good repair included
multiple ceiling CAN wafer lights which were not fully
secured against the ceiling sheet rock in the kitchen
and main living areas. There were also small holes in
the sheet rock in multiple areas throughout the
program. Small holes in the sheetrock were observed
No in the dining room, living room, hallway, stairwell,
upstairs recreation area, and laundry room. In addition,
the floor baseboard moulding needed paint and some
repair in the kitchen and dining area, stairwell landing,
stairwell, and main living areas. There were also holes
in the doors of the pantry and an upstairs bedroom
door, and the double pantry door needed some fresh
paint around the door pulls. The toilet paper fixture in
the small downstairs bathroom had also fallen off the
Form revised 4/28/2025 Page 8 of 33
Yes/No
Physical plant Corrective actions/comments
or N/A
wall. There was also sheetrock around the door of the
main bathroom downstairs which was in need of repair.
The backyard was also found to be littered with
landscape bricks, 2 longer pieces of exterior wood, a
tarp, and other items which made the area look unkept.
Finally, the exterior flood light mounted on the house
above the main patio was no longer secured and was
hanging by the electrical wires of the light. The
program must ensure that both the interior and exterior
of the program is clean and in good repair.

excerpt:
419-470-0020 (2)(d) Rooms are free of harmful
Yes
drafts, odors and excessive noise

excerpt:
419-470-0020 (2)(e) Rooms are adequate in size
Yes
and arrangement

excerpt:
419-470-0020 (2)(f) System provides a continuous
supply of hot and cold water to taps located Yes
throughout the facility

excerpt:
419-470-0020 (2)(h) Building is well ventilated and
room temperature is within a normal comfort Yes
range

excerpt:
419-470-0030 (1) All parts of the facility ensure
Yes
the safety of children
Room and space requirements Yes/No
Corrective actions/comments

excerpt:
419-470-0030 or N/A
(2) There is a separate living room or lounge area
Yes
- 15 SF minimum per child
(5) There is a separate dining room with capacity
for ½ of children in care and 15 SF per child in Yes
care
Form revised 4/28/2025 Page 9 of 33
Room and space requirements Yes/No
Corrective actions/comments

excerpt:
419-470-0030(6)
(e) Equipment is easy to clean beneath, between
Yes
and behind
Furnishings and personal items Yes/No
Corrective actions/comments

excerpt:
419-470-0080 or N/A
(d) Ensuring access to necessary medications or
Yes
medical equipment
(e) How to help each child in care recover after a
Yes
disaster
(3) Telephone numbers for local police, fire - The program is not posting telephone numbers for local
department, poison control, after hours medical police, fire department, poison control, after hours
advice and other appropriate emergency numbers medical advice and other appropriate emergency
must be posted near all telephones. Yes numbers near all telephones. The program must post
telephone numbers for local police, fire department,
poison control, after hours medical advice and other
appropriate emergency numbers near all telephones.
(4) Operative flashlights sufficient in number are - The program does not have operative flashlights
readily available to staff sufficient in number readily available to staff. The
Yes
program must have operative flashlights sufficient in
number readily available to staff.
(5)(a) Evacuation drill occurs monthly under
varying conditions, is retained 2 years and
contains: - The program is not completing monthly fire drills and
(A) identify of person conducting drill the program's fire drill log does not contain all required
(B) date and time fields, including the identity of the person conducting
(C) notification method the drill, notification method, special conditions
No
(D) staff participating simulated, problems encountered, and time to
(E) number of children and staff evacuated complete. The program must complete monthly fire
(F) special conditions simulated drills and the program's fire drill log must contain all
(G) problems encountered required fields.
(H) time to complete
Form revised 4/28/2025 Page 14 of 33
Umbrella safety Yes/No
Corrective actions/comments

excerpt:
419-470-0100 or N/A
(4) and (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
Yes
medical professional. A written 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 locking mechanisms. Yes
This does not apply to Naloxone.
(8) Medications are disposed in accordance with - The program's medications which need disposal are
state and federal law Yes taken to the Klahre House Day Treatment Program and
are disposed in accordance with state and federal law.
(9) Written record of the disposal of medications is
maintained and includes:
(a) description and amount - The program's written record of disposal of medications
(b) name Yes is maintained at the Klahre House Day Treatment
(c) reason Program.
(d) method
(e) staff and witness signature
(10) Written record of the administration of
medication includes:
(a) name - The program's MAR contains all required fields and
(b) description staff are completing the MAR accurately. It is
(c) dates and times recommended that, as noted on the MAR being used
Yes
(d) missed doses by he program, that the program staff note all
(e) medication disposed medication refusals by youth on the space provided on
(f) method of administration the back of each individual MAR.
(g) ID of person administering
(h) possible adverse reactions
Form revised 4/28/2025 Page 16 of 33
Medication Yes/No
Corrective actions/comments

excerpt:
419-470-0100 or N/A
(i) medication taken outside facility
Extracurricular, enrichment, cultural and
Yes/No
social activities Corrective actions/comments
or N/A

excerpt:
419-470-0140 or N/A
(1) Children are in separate bedrooms than
adults, unless parent and child, or there is written
Yes
approval from guardian/parent and licensing
coordinator
(2) There is adequate supervision of children
Yes
when sleeping
(3) When assigning bedrooms a residential care
agency must consider all of the following:
(a) Chronological age
(b) Developmental age
- The program's policy and procedure on grouping of
(c) Gender identity Yes
youth in bedrooms meets all rule requirements.
(d) Personal history, including medical, mental
health, behavioral health and past adverse
experiences including any physical or sexual
abuse
Personnel files Yes/No
Corrective actions/comments

excerpt:
419-400-0120 or N/A
(1)(a) and (3)(c) Background check completed
Yes
and documented
(3)(d) Annual performance evaluations Yes
(3)(f) Record of personnel actions Yes
(3)(g) Termination date, reason for termination Yes
(3)(h) Current job description (1)(c) Employee
meets minimum qualifications stated in current job Yes
description
New employee orientation - Umbrella
Yes/No
Requirements (30 days) Corrective actions/comments
or N/A

excerpt:
419-400-0120(4)
(a) Agency policies and procedures - There was not any employee training records reviewed
during this review as, despite the fact there were
multiple employees working at the program, program
staff was not able to locate residential program
employee training files which to review. The employee
training tracking sheet also DID NOT contain all
required trainings for residential employees in rule.
Since there was not any residential employee training
No files reviewed, all new employee orientation training
requirements will be given a "No" finding.
- The program is not maintaining training records for
employees showing that they have received new
employee orientation training on agency policies and
procedures. The program must ensure and maintain
records that all employees receive new employee
orientation training on agency policies and procedures.
Form revised 4/28/2025 Page 19 of 33
New employee orientation - Umbrella
Yes/No
Requirements (30 days) Corrective actions/comments
or N/A

excerpt:
419-400-0120(4)
(b) Ethical and professional guidelines - The program is not maintaining training records for
employees showing that they have received new
employee orientation training on ethical and
No professional guidelines. The program must ensure and
maintain records that all employees receive new
employee orientation training on ethical and
professional guidelines.
(c) Suicide prevention and intervention - The program is not maintaining training records for
employees showing that they have received new
employee orientation training on suicide prevention and
No intervention. The program must ensure and maintain
records that all employees receive new employee
orientation training on suicide prevention and
intervention.
(d) Attributes of population served - The program is not maintaining training records for
employees showing that they have received new
employee orientation training on attributes of
No population served. The program must ensure and
maintain records that all employees receive new
employee orientation training on attributes of
population served.
(e) and (5)(a) to (c) Mandatory reporting that
- The program is not maintaining training records for
includes:
employees showing that they have received new
(a) legal definition of child abuse in ORS 418.257
employee orientation training on mandatory reporting.
and 419B.005 No
The program must ensure and maintain records that all
(b) legal responsibility to immediately report
employees receive new employee orientation training
(c) legal responsibility to report is personal to the
on mandatory reporting.
employee
Form revised 4/28/2025 Page 20 of 33
New employee orientation - Umbrella
Yes/No
Requirements (30 days) Corrective actions/comments
or N/A

excerpt:
419-470-0120(1)
sufficient to retain a current certification. The program
must ensure and maintain records that all employees
receive new employee orientation training on CPR and
First Aid sufficient to retain a current certification.
(c) Universal precautions and hygiene - The program is not maintaining training records for
employees showing that they have received new
employee orientation training on universal precautions
No and hygiene. The program must ensure and maintain
records that all employees receive new employee
orientation training on universal precautions and
hygiene.
(d) Application of the reasonable and prudent - The program is not maintaining training records for
parent standard employees showing that they have received new
employee orientation training on the application of the
No reasonable and prudent parent standard. The program
must ensure and maintain records that all employees
receive new employee orientation training on the
reasonable and prudent parent standard.
(e) Training on the agency's policy on suicide - The program is not maintaining training records for
prevention and suicide risk assessment tool employees showing that they have received new
employee orientation training on suicide prevention and
the program's suicide risk assessment tool. The
No
program must ensure and maintain records that all
employees receive new employee orientation training
on suicide prevention and the program's risk
assessment tool.
Form revised 4/28/2025 Page 22 of 33
Crisis intervention training standards and
Yes/No
certification Corrective actions/comments
or N/A

excerpt:
419-470-0070(2)(b) Employees who handle food - There was not any employee training records
served to children have a valid food handler's reviewed during this review as, despite the fact
card there were multiple employees working at the
program, program staff was not able to locate
residential program employee training files which to
review. The employee training tracking sheet also
DID NOT contain all required trainings for
residential employees in rule. Since there was not
No any residential employee training files reviewed, all
employee ongoing/yearly training requirements will
be given a "No" finding.
- The program is not maintaining records for
employees who handle food served to children and
ensuring that employees who handle food have a
valid food handler's card. The program must ensure
that all employees who handle food have a valid
food handler's card.

excerpt:
419-400-0200 (1) Employees transporting - The program is not maintaining records that
children have: current driver's license, insurance, employees transporting children have current
trained in emergency procedures and behavior driver's license, insurance, are trained in
management and training for 15+ passenger vans emergency procedures and behavior management
if applicable) and training for 15-plus passenger vans, if
No applicable. The program must ensure they are
maintaining records that employees transporting
children have current driver's license, insurance,
are trained in emergency procedures and behavior
management and training for 15-plus passenger
vans, if applicable.

excerpt:
419-470-0120 (2)(d) Agency's policy on suicide - The program is not maintaining training records for
prevention and risk assessment tool employees showing that they have received
yearly/ongoing training on suicide prevention and the
No program's risk assessment tool. The program must
ensure and maintain records that all employees receive
annual/ongoing training on suicide prevention and the
program's risk assessment tool.

excerpt:
419-400-0160(4)(b) Receive continuing education
(as applicable on crisis intervention training) from N/A
a certified instructor on an annual basis
Children's records
Yes/No
health services Corrective actions/comments
or N/A

excerpt:
419-470-0090
(2) Medical history obtained within 30 days
(significant findings, current immunizations,
history of surgical procedures-health issues- Yes
injuries, allergies, dental, vision, hearing,
behavioral health and physician orders)
(4)(a) to (f) Medical exams (3 in first year of life,
Yes
2,4,6,9,14)
Form revised 4/28/2025 Page 26 of 33
Children's records
Yes/No
health services Corrective actions/comments
or N/A

excerpt:
419-400-0230 and - The program's child files do not contain a signed
0240 consent that the program will allow access to the
program by the child's parent, caseworker, court
No appointed attorney, and CASA, as defined in 419-400-
0230 and 0240. The program must ensure that all child
files contain a signed consent that the program will
allow access as defined in

excerpt:
419-400-0230 and 0240.
(f) Impose a dress code Yes
(g) Apply the reasonable and prudent parent
Yes
standard
Form revised 4/28/2025 Page 27 of 33
Disclosures
Yes/No

excerpt:
419-470-0160(2) Corrective actions/comments
or N/A
Parent/guardian has acknowledged in writing:
(a) Information regarding personal or room
searches and protocols for confiscation of Yes
contraband
(b) Statement of Rights of Children and - The program's Statement of Rights of Children and
Parents/Guardians Parents/Guardians does not state that children and
parents have the right to uncensored communication.
In addition, during individual interviews of children
enrolled in the program, it was reported that staff of the
residential program monitor and sometimes listen in to
No
telephone calls between the child and their parents or
other identified persons on the child's approved contact
list. The program must ensure that telephone calls
between the child and their parents and other persons
on the child's approved contact list are not monitored
or listened to by staff, rather the calls must be private.
(c) Any policies and procedures upon request Yes
Authorizations Yes/No
Corrective actions/comments

excerpt:
419-400-0190(1) Corrective actions/comments
or N/A
Summary sheet contains the following:
(a)The name, gender, date of birth, religious
Yes
preference and previous address
(b) Name and location of previous and current
Yes
school
(c) Date of admission Yes
(d) Legal custody Yes
(e) The name, address and telephone number of: - The program's summary sheet does not clearly depict
(A) The child in care's parents. all required fields. Currently, the child's summary
(B) The child in care's legal guardian, if sheet has a field for "Important Relationships." The
different than the parents and a copy of the program's summary sheet does not include the
document that provides for his or her authority required fields of (C) Other persons significant to child
over the child in care. No and (D) Other professionals to be involved in service
(C) Other persons significant to child planning, if applicable. The program's summary sheet
(D) Other professionals to be involved in service must clearly depict all required fields including "Other
planning (if applicable) persons significant to the child" and "Other
professionals to be involved in service planning, if
applicable."
Service planning Yes/No
Corrective actions/comments

excerpt:
419-470-0170(2) or N/A
(b) Intake document is completed the date child - Although the program's Intake documents are well
accepted into care (emergency placement 48 written and comprehensive, the program's Intake
hours) document is not being completed on the date the child
is accepted into placement. Three child files of the
No
residential program were randomly pulled for review.
Of these 3 files, the intake documents were completed
at 1, 2, and 3 days after the child entered the program.
The program must ensure that their Intake document is
Form revised 4/28/2025 Page 29 of 33
Service planning Yes/No
Corrective actions/comments

excerpt:
419-470-0170(2) or N/A
created on the date the child enters the program, or
within 48 hours if an emergency placement.
(d) Assessment is completed within 30 days and
contains relevant historical information, current - The assessment and service plans were well written
Yes
behavioral observations, identified need for and detailed to the specific needs of the child.
services and how agency will provide services
(e) (A) and (B) Service plan within 60 days
(parent, guardian and child actively involved).
Describes how child's issues will be addressed, Yes
anticipated outcomes and reviewed by child and
guardian/parent.
(e)(C) and (D) Service plan is reviewed quarterly
and revised when information indicates other Yes
services should be provided
Case management Yes/No
Corrective actions/comments

excerpt:
419-470-0170(3) or N/A
(a) Services are documented, progress toward
Yes
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
- A discharge summary was not reviewed during this
(C)Any outstanding medical or other
N/A review, as none of the files pulled involved children
appointments
who had been discharged from the program.
(D)Summary of the child's participation in the
program and progress achieved
(E)Results of evaluations
(F)Recommendations regarding services
Form revised 4/28/2025 Page 30 of 33
Case management Yes/No
Corrective actions/comments

excerpt:
419-400-0180(13)(e) Each child caring agency
shall provide notice regarding how to access the
quarterly reports to the parents or guardians of
children in care in the program. The child caring Yes
agency shall provide the notice upon the child in
care's admission and at least two times each year
thereafter.

excerpt:
419-400-0190(1) Information provided to children
in care relating to Restraint and Involuntary Yes
Seclusion
Financial records Yes/No
Corrective actions/comments


facility_name: CFH-Sequoia

summary: Unannounced - 2 findings

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Licensee: Trillium Family Services, Children’s Farm Home
Executive Director: Kim Scott, CEO
Program Director(s): Amy McAdams
Date of Unannounced: April 22, 2021
Licensing Coordinator: Todd Cooley
Other Regulatory or Accrediting Agencies: OHA, Joint Commission
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
No previous findings from last review. Yes☐ No☐
Yes☐ No☐
New Findings from Site Visit Comments
413-215-0511(2)(a) &(c) Buildings are Sequoia Cottage had derogatory writing on the walls of the common area to the effect of, “I must die” and “You
smoke free, clean and in good repair are trash”.
413-215-0516(1) All parts of the facility Cummings Cottage had 2-3 rooms which appeared cluttered. Trillium has historically limited the amount of
ensure the safety of children belongings and personal items allowed in individual rooms in order to minimize the potential safety hazard.
1
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 200115)
Interview Summary
Licensing met with Amy McAdams, VP of Operations for Children’s Farm Home (CFH), on April 22, 2021 after arriving on campus for an unannounced visit.
The purpose of the unannounced visit was explained and McAdams provided a tour of all operating cottages at CFH, which is currently at four. During the
tour licensing was able to interview clients from various cottages, but due to current staffing levels no staff interviews were conducted. Contact information for
licensing was provided if any staff wanted to be interviewed at a later time.
In general the clients felt their needs were being met and were comfortable talking with staff about any concerns they might have. One client did state
personal concerns over their ability to stay safe around staff and peers and did not feel like they received enough support. These concerns were
communicated to management at the time they were disclosed.
Clients stated school was going well and they were either ahead or on schedule as far as credits except for one client who said they have historically struggled
with school. One was working on their diploma and another was almost a full year ahead and seemed very focused on staying on top of school work.
The clients had mixed reviews on the food at Farm Home. From gross and could be better to it is good, but greasy. They all said there is always plenty to eat
and snacks are available when asked for. A salad bar is offered daily along with a main course cooked in a central kitchen.
Clients also had varying opinions on the amount of recreation and outside time they had. Some felt it was plenty while others wanted a lot more. One
common theme among all of the clients around recreation and life on the units in general was staffing. Clients were acutely aware of the low staffing and
some stated it has been an ongoing issue for a long time (1+ years). The clients felt the staffing contributed to fewer check-ins, fewer walks and other
activities across campus. Clients also recognized it affected other parts of their daily routine as staff were frequently engaged with peers and not able to
provide the personal attention they felt they needed or deserved.
When asked if there was anything they would change, communication between staff and finding ways to calm kids down were the two comments. It was felt
sometimes staff either on shift or between shifts did not always communicate client needs as well as they could. Another client thought staff needed to be
more aware of clients triggers and calming strategies to be able to calm clients before they tried to self-harm or became aggressive and required a restraint.
Clients were also asked what they thought staff did well. Most clients stated staff listened well and really seemed to care. Staff made clients feel like they
were not just there for a paycheck, but really engaged with the clients.
2
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 200115)
Observations
Overall, the campus was in good condition other than the graffiti noted above. With the addition of the Redwood building Trillium has been working on
updating the older cottages of Powers and Cummings. As observed in the client interviews and confirmed by management, the current staffing levels are very
low right now. Lower census levels are being self-imposed down to 9 clients per cottage from the usual 12. Management has open and ongoing recruitment,
but stated it is very difficult to attract applicants right now. The current license is set to expire in September, and a full license renewal review will be
scheduled and conducted prior to that time.
Corrective Actions and Timeframes:
Please submit the following to verify compliance.
Within 45 days of receipt of this report Trillium Family 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 or sent by regular mail to the following address:
Department of Human Services
Children’s Care Licensing Program
Attn: Todd Cooley, Licensing Coordinator
201 High St. SE Suite 500
Salem, OR 97301
Licensing Coordinator’s Signature: ________________________ Date: ___________________
05-06-2021
Manager Review: ______________________________________ Date: __________________
3
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 200115)

agency_name: Trillium Family Services (TFS)

program_name: CFH-Sequoia

report_type: Unannounced

licensee: Trillium Family Services, Children's Farm Home

executive_director: Kim Scott, CEO

program_director: Amy McAdams

licensing_coordinator: Todd Cooley

other_regulatory_agencies: OHA, Joint Commission

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
No previous findings from last review. Yes[ ] No[ ]
Yes[ ] No[ ]
New Findings from Site Visit Comments
413-215-0511(2)(a) &(c) Buildings are Sequoia Cottage had derogatory writing on the walls of the common area to the effect of, "I must die" and "You
smoke free, clean and in good repair are trash".
413-215-0516(1) All parts of the facility Cummings Cottage had 2-3 rooms which appeared cluttered. Trillium has historically limited the amount of
ensure the safety of children belongings and personal items allowed in individual rooms in order to minimize the potential safety hazard.
1

Interview Summary
Licensing met with Amy McAdams, VP of Operations for Children's Farm Home (CFH), on April 22, 2021 after arriving on campus for an unannounced visit.
The purpose of the unannounced visit was explained and McAdams provided a tour of all operating cottages at CFH, which is currently at four. During the
tour licensing was able to interview clients from various cottages, but due to current staffing levels no staff interviews were conducted. Contact information for
licensing was provided if any staff wanted to be interviewed at a later time.
In general the clients felt their needs were being met and were comfortable talking with staff about any concerns they might have. One client did state
personal concerns over their ability to stay safe around staff and peers and did not feel like they received enough support. These concerns were
communicated to management at the time they were disclosed.
Clients stated school was going well and they were either ahead or on schedule as far as credits except for one client who said they have historically struggled
with school. One was working on their diploma and another was almost a full year ahead and seemed very focused on staying on top of school work.
The clients had mixed reviews on the food at Farm Home. From gross and could be better to it is good, but greasy. They all said there is always plenty to eat
and snacks are available when asked for. A salad bar is offered daily along with a main course cooked in a central kitchen.
Clients also had varying opinions on the amount of recreation and outside time they had. Some felt it was plenty while others wanted a lot more. One
common theme among all of the clients around recreation and life on the units in general was staffing. Clients were acutely aware of the low staffing and
some stated it has been an ongoing issue for a long time (1+ years). The clients felt the staffing contributed to fewer check-ins, fewer walks and other
activities across campus. Clients also recognized it affected other parts of their daily routine as staff were frequently engaged with peers and not able to
provide the personal attention they felt they needed or deserved.
When asked if there was anything they would change, communication between staff and finding ways to calm kids down were the two comments. It was felt
sometimes staff either on shift or between shifts did not always communicate client needs as well as they could. Another client thought staff needed to be
more aware of clients triggers and calming strategies to be able to calm clients before they tried to self-harm or became aggressive and required a restraint.
Clients were also asked what they thought staff did well. Most clients stated staff listened well and really seemed to care. Staff made clients feel like they
were not just there for a paycheck, but really engaged with the clients.
2

Observations
Overall, the campus was in good condition other than the graffiti noted above. With the addition of the Redwood building Trillium has been working on
updating the older cottages of Powers and Cummings. As observed in the client interviews and confirmed by management, the current staffing levels are very
low right now. Lower census levels are being self-imposed down to 9 clients per cottage from the usual 12. Management has open and ongoing recruitment,
but stated it is very difficult to attract applicants right now. The current license is set to expire in September, and a full license renewal review will be
scheduled and conducted prior to that time.