summary: Unannounced - 12 findings

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Licensee: Affect Youth Services, Inc.
Executive Director: Mandy Augsburger
Board Chairperson: Mandy Straus
Date of Unannounced: September 22, 2021
Licensing Coordinator: Robin DuVal
Other Regulatory or Accrediting Agencies: Oregon Department of Human Services (ODHS) Child Welfare Treatment Services.
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 Findings Comments
License Renewal 04-30-2021 Further Action Needed
413-215-0021(2)(f) Formally evaluate the exec. Director’s Yes☐ No
performance annually: “Performance evaluations of the Executive
Director are conducted annually, however not signed by the board
chairperson as required by OAR 413-215-0021(2)(f). The agency
shall ensure the board chairperson is involved in the annual
performance evaluation and signed by the board chairperson.”
413-215-0551(8) Medications are disposed in accordance with Yes☐ No
state and federal law: “Unused medications were being stored in a
separate container from current medications in the locked
medication closet, to be given to the youth’s guardian when
available. The agency shall ensure all unused medications be
disposed of and in a manner that ensures that they cannot be
retrieved.”
413-215-0551(9) Written record of the disposal of medications Yes☐ No
is maintained and includes:
(a) description and amount
(b) name
(c) reason
(d) method
1
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(e) staff & witness signature
“Unused medications were not documented on a written disposal
record as required. The agency shall ensure all unused
medications are documented utilizing the already established
medication disposal form, capturing all required elements (a-e). The
written disposal record shall be thoroughly completed and
maintained.”
413-215-0551(10) Written record of the administration of Yes☐ No
medication includes: (e) medication disposed; (i) medication
taken outside facility: “The Medication Administration Record
(MAR) form was missing required elements. The agency shall
update the MAR form to include (e) and (i), and document
appropriately going forward. The written MAR shall be thoroughly
completed and maintained.”
413-215-0061(3)(f) Record of personnel actions: “Records of Yes☐ No
personnel actions were missing from personnel files. The agency
shall develop and implement a personnel action form for all
employees to be utilized when there is a personnel action to be
recorded or requires payroll action.”
413-215-0556(1)(b) Restraint and seclusion (if applicable): Yes☐ No
“Two staff have not received restraint training to date. The agency
shall ensure:
1) All current untrained employees are trained utilizing “Right
Response” methods as their nationally recognized crisis
intervention model.
2) Provide documentation when completed.
3) All new employees are trained within 30 days of hire.
413-215-0576(1) (c) Use restraint or seclusion (if applicable).
Must specify the reasons for the intervention and how staff are
trained and supervised:
“The consent form was missing the agency’s use of restraint.
The agency had previously updated their restraint and behavior
consent form. However, it wasn’t updated in the intake packet,
therefore the program is using the old form. The agency shall
ensure the updated restraint consent is:
1) Included in all future intakes and retained in the youths file, and
2) Provided to and signed by all current youth guardians.
413-215-0576(3) (a) Disclose or exchange information with Yes☐ No
others: “Authorization to disclose or exchange information was
missing from youth records. The agency shall:
1) Develop and implement an authorization document to disclose
or exchange information with others, and
2) Ensure this authorization is included in all future intakes and
retained in the youth’s record.
2 of 4
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413-215-0581(1) Summary sheet contains the following: (a)The Yes No☐ The agency shall ensure the updated summary sheet
name, gender, date of birth, religious preference, and previous containing all required elements is utilized with all new
address: admissions.
“Previous address was missing from the summary sheet. The
agency shall ensure:
1) The form is updated to include previous address.
2) The previous address is documented on the summary sheet.
Religious preference was not consistently documented on the
summary sheet. The agency shall ensure an entry is noted for
religious preference.
413-215-0581(4) Records contain date, amount, source, Yes☐ No
purpose, signatures:
“The financial form was missing required elements. The
agency shall:
1) Update the form to include the source, purpose, and signatures
(not initials).
2) Utilize the form when youth have any money, gift cards, etc.
that are received or dispersed.
413-215-0071(3)&(4) Uniform in organization, readily Youth records are incomplete missing required elements
identifiable and accessible, current, and complete, containing on the summary sheet. See comment above.
all required info. No eraser tape or white out:
“Personnel and youth records are incomplete missing items noted
above.
The agency shall ensure the revised date is noted on documents
(forms, policies, procedures, etc.) when revised.”
New Findings from Site Visit Comments
None
Interview Summary
The current census is 11 youth with an average age of 14 or 15. Mandy, Executive Director, shared that the Child Welfare grant money allows
for educational training, and the program is utilizing that towards bilingual Spanish training for two staff and for Mandy to become a certified suicide
prevention trainer, through QPR Institute, for three years. The program currently uses Right Response de-escalation techniques, and the team
regularly checks in with each other about their “optimal performance range” (OPR). Youth became interested in staff talking about OPR, so the
trainer, Chris, reviewed this concept with the youth.
3 of 4
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Youth J is 17 years old, has been in the program for approximately one year, and it’s their first program. Feels the program is helping with school
and sobriety. Likes it here and feels safe. Staff are trusting and caring, and want to see the youth succeed, and they talk a lot about integrity.
Football, basketball, cards, board games, going swimming and to the park are some of the things they do for fun. Talks to people outside the
program and is given enough time. Food is good and gets enough. Provides input into service plan and feels listened to. No issues with getting
medications as prescribed. Has school online, gets help and is on target to graduate in March. Favorite thing about this program is “definitely”
the people and the food. Least favorite is not having their cell phone 24/7. The program does well at supporting the kids, sports, and school.
Youth K is 13 years old, has been in the program for approximately 6 weeks, and it’s their first program. Feels the program is helping with integrity
of doing the right thing when no one is watching. Staff are trusting, likes staff Chris. Likes it here and feels safe but doesn’t like being away from
mom. Basketball, scooter, playing pool, card games, going to parks, skate parks, the mall are some things they do for fun. Talks to people outside
the program and is given enough time. Food is great and gets enough. Gives input into service plan and feels listened to. No issues with getting
medications as prescribed. When asked if there was something to change about this program, nothing came to mind. States the program does
well at “everything”. Favorite thing is some of the other youth.
Observations
The program was clean and in good repair, although the youth bathroom sink could benefit from a good scrubbing. Youth sheets were off beds
for weekly washing. Plenty of food was observed in the pantry, refrigerator, and freezers. Medications and logs were observed and met licensing
requirements.
Corrective Actions and Timeframes:
Please submit the following to verify compliance.
Within 45 days of receipt of this report, Affect Youth 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 are
to be emailed directly to Robin DuVal, ROBIN.M.DuVal@dhsoha.state.or.us.
10/19/2021
Licensing Coordinator’s Signature: ________________________ Date: ___________________
10-19-2021
Manager Review: ______________________________________ Date: __________________
4 of 4
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licensee: Affect Youth Services, Inc.

executive_director: Mandy Augsburger

visit_date: September 22, 2021

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 Findings Comments
License Renewal 04-30-2021 Further Action Needed
413-215-0021(2)(f) Formally evaluate the exec. Director's Yes[ ] No
performance annually: "Performance evaluations of the Executive
Director are conducted annually, however not signed by the board
chairperson as required by OAR 413-215-0021(2)(f). The agency
shall ensure the board chairperson is involved in the annual
performance evaluation and signed by the board chairperson."
413-215-0551(8) Medications are disposed in accordance with Yes[ ] No
state and federal law: "Unused medications were being stored in a
separate container from current medications in the locked
medication closet, to be given to the youth's guardian when
available. The agency shall ensure all unused medications be
disposed of and in a manner that ensures that they cannot be
retrieved."
413-215-0551(9) Written record of the disposal of medications Yes[ ] No
is maintained and includes:
(a) description and amount
(b) name
(c) reason
(d) method
1

(e) staff & witness signature
"Unused medications were not documented on a written disposal
record as required. The agency shall ensure all unused
medications are documented utilizing the already established
medication disposal form, capturing all required elements (a-e). The
written disposal record shall be thoroughly completed and
maintained."
413-215-0551(10) Written record of the administration of Yes[ ] No
medication includes: (e) medication disposed; (i) medication
taken outside facility: "The Medication Administration Record
(MAR) form was missing required elements. The agency shall
update the MAR form to include (e) and (i), and document
appropriately going forward. The written MAR shall be thoroughly
completed and maintained."
413-215-0061(3)(f) Record of personnel actions: "Records of Yes[ ] No
personnel actions were missing from personnel files. The agency
shall develop and implement a personnel action form for all
employees to be utilized when there is a personnel action to be
recorded or requires payroll action."
413-215-0556(1)(b) Restraint and seclusion (if applicable): Yes[ ] No
"Two staff have not received restraint training to date. The agency
shall ensure:
1) All current untrained employees are trained utilizing "Right
Response" methods as their nationally recognized crisis
intervention model.
2) Provide documentation when completed.
3) All new employees are trained within 30 days of hire.
413-215-0576(1) (c) Use restraint or seclusion (if applicable).
Must specify the reasons for the intervention and how staff are
trained and supervised:
"The consent form was missing the agency's use of restraint.
The agency had previously updated their restraint and behavior
consent form. However, it wasn't updated in the intake packet,
therefore the program is using the old form. The agency shall
ensure the updated restraint consent is:
1) Included in all future intakes and retained in the youths file, and
2) Provided to and signed by all current youth guardians.
413-215-0576(3) (a) Disclose or exchange information with Yes[ ] No
others: "Authorization to disclose or exchange information was
missing from youth records. The agency shall:
1) Develop and implement an authorization document to disclose
or exchange information with others, and
2) Ensure this authorization is included in all future intakes and
retained in the youth's record.
2 of 4

413-215-0581(1) Summary sheet contains the following: (a)The Yes No[ ] The agency shall ensure the updated summary sheet
name, gender, date of birth, religious preference, and previous containing all required elements is utilized with all new
address: admissions.
"Previous address was missing from the summary sheet. The
agency shall ensure:
1) The form is updated to include previous address.
2) The previous address is documented on the summary sheet.
Religious preference was not consistently documented on the
summary sheet. The agency shall ensure an entry is noted for
religious preference.
413-215-0581(4) Records contain date, amount, source, Yes[ ] No

interview_summary:
The current census is 11 youth with an average age of 14 or 15. Mandy, Executive Director, shared that the Child Welfare grant money allows
for educational training, and the program is utilizing that towards bilingual Spanish training for two staff and for Mandy to become a certified suicide
prevention trainer, through QPR Institute, for three years. The program currently uses Right Response de-escalation techniques, and the team
regularly checks in with each other about their "optimal performance range" (OPR). Youth became interested in staff talking about OPR, so the
trainer, Chris, reviewed this concept with the youth.
3 of 4

Youth J is 17 years old, has been in the program for approximately one year, and it's their first program. Feels the program is helping with school
and sobriety. Likes it here and feels safe. Staff are trusting and caring, and want to see the youth succeed, and they talk a lot about integrity.
Football, basketball, cards, board games, going swimming and to the park are some of the things they do for fun. Talks to people outside the
program and is given enough time. Food is good and gets enough. Provides input into service plan and feels listened to. No issues with getting
medications as prescribed. Has school online, gets help and is on target to graduate in March. Favorite thing about this program is "definitely"
the people and the food. Least favorite is not having their cell phone 24/7. The program does well at supporting the kids, sports, and school.
Youth K is 13 years old, has been in the program for approximately 6 weeks, and it's their first program. Feels the program is helping with integrity
of doing the right thing when no one is watching. Staff are trusting, likes staff Chris. Likes it here and feels safe but doesn't like being away from
mom. Basketball, scooter, playing pool, card games, going to parks, skate parks, the mall are some things they do for fun. Talks to people outside
the program and is given enough time. Food is great and gets enough. Gives input into service plan and feels listened to. No issues with getting
medications as prescribed. When asked if there was something to change about this program, nothing came to mind. States the program does
well at "everything". Favorite thing is some of the other youth.

previous_findings:
Repeat Findings Comments
License Renewal 04-30-2021 Further Action Needed
413-215-0021(2)(f) Formally evaluate the exec. Director's Yes[ ] No
performance annually: "Performance evaluations of the Executive
Director are conducted annually, however not signed by the board
chairperson as required by OAR 413-215-0021(2)(f). The agency
shall ensure the board chairperson is involved in the annual
performance evaluation and signed by the board chairperson."
413-215-0551(8) Medications are disposed in accordance with Yes[ ] No
state and federal law: "Unused medications were being stored in a
separate container from current medications in the locked
medication closet, to be given to the youth's guardian when
available. The agency shall ensure all unused medications be
disposed of and in a manner that ensures that they cannot be
retrieved."
413-215-0551(9) Written record of the disposal of medications Yes[ ] No
is maintained and includes:
(a) description and amount
(b) name
(c) reason
(d) method
1

(e) staff & witness signature
"Unused medications were not documented on a written disposal
record as required. The agency shall ensure all unused
medications are documented utilizing the already established
medication disposal form, capturing all required elements (a-e). The
written disposal record shall be thoroughly completed and
maintained."
413-215-0551(10) Written record of the administration of Yes[ ] No
medication includes: (e) medication disposed; (i) medication
taken outside facility: "The Medication Administration Record
(MAR) form was missing required elements. The agency shall
update the MAR form to include (e) and (i), and document
appropriately going forward. The written MAR shall be thoroughly
completed and maintained."
413-215-0061(3)(f) Record of personnel actions: "Records of Yes[ ] No
personnel actions were missing from personnel files. The agency
shall develop and implement a personnel action form for all
employees to be utilized when there is a personnel action to be
recorded or requires payroll action."
413-215-0556(1)(b) Restraint and seclusion (if applicable): Yes[ ] No
"Two staff have not received restraint training to date. The agency
shall ensure:
1) All current untrained employees are trained utilizing "Right
Response" methods as their nationally recognized crisis
intervention model.
2) Provide documentation when completed.
3) All new employees are trained within 30 days of hire.
413-215-0576(1) (c) Use restraint or seclusion (if applicable).
Must specify the reasons for the intervention and how staff are
trained and supervised:
"The consent form was missing the agency's use of restraint.
The agency had previously updated their restraint and behavior
consent form. However, it wasn't updated in the intake packet,
therefore the program is using the old form. The agency shall
ensure the updated restraint consent is:
1) Included in all future intakes and retained in the youths file, and
2) Provided to and signed by all current youth guardians.
413-215-0576(3) (a) Disclose or exchange information with Yes[ ] No
others: "Authorization to disclose or exchange information was
missing from youth records. The agency shall:
1) Develop and implement an authorization document to disclose
or exchange information with others, and
2) Ensure this authorization is included in all future intakes and
retained in the youth's record.
2 of 4

413-215-0581(1) Summary sheet contains the following: (a)The Yes No[ ] The agency shall ensure the updated summary sheet
name, gender, date of birth, religious preference, and previous containing all required elements is utilized with all new
address: admissions.
"Previous address was missing from the summary sheet. The
agency shall ensure:
1) The form is updated to include previous address.
2) The previous address is documented on the summary sheet.
Religious preference was not consistently documented on the
summary sheet. The agency shall ensure an entry is noted for
religious preference.
413-215-0581(4) Records contain date, amount, source, Yes[ ] No
purpose, signatures:
"The financial form was missing required elements. The
agency shall:
1) Update the form to include the source, purpose, and signatures
(not initials).
2) Utilize the form when youth have any money, gift cards, etc.
that are received or dispersed.
413-215-0071(3)&(4) Uniform in organization, readily Youth records are incomplete missing required elements
identifiable and accessible, current, and complete, containing on the summary sheet. See comment above.
all required info. No eraser tape or white out:
"Personnel and youth records are incomplete missing items noted
above.
The agency shall ensure the revised date is noted on documents
(forms, policies, procedures, etc.) when revised."
New Findings from Site Visit Comments
None

excerpt:
413-215-0071(3)&(4) Uniform in organization, readily Youth records are incomplete missing required elements
identifiable and accessible, current, and complete, containing on the summary sheet. See comment above.
all required info. No eraser tape or white out:
"Personnel and youth records are incomplete missing items noted
above.
The agency shall ensure the revised date is noted on documents
(forms, policies, procedures, etc.) when revised."
New Findings from Site Visit Comments
None
None


state: OR

facility_name: Affect Youth Services Date of site visit: March 11 & 12, 2025

summary: Unannounced - 2 findings

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Licensee: Affect Youth Services, Inc. Date of Unannounced: December 7, 2022
Executive Director: Mandy Augsburger Licensing Coordinator: Robin DuVal
Board Chairperson: Mandy Straus
Other Regulatory or Accrediting Agencies: Oregon Department of Human Services (ODHS) Child Welfare Treatment Services.
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: Unannounced Visit 9/22/2021 Repeat Findings Comments
Further Action
Needed?
413-215-0581(1) Summary sheet contains the following: (a)The name, gender, date of Yes☐ No Two client summary sheets were
birth, religious preference, and previous address: reviewed, and this requirement is met.
No further corrective action needed.
Previous address was missing from the summary sheet. The agency shall ensure:
1) The form is updated to include previous address.
2) The previous address is documented on the summary sheet.
Religious preference was not consistently documented on the summary sheet. The
agency shall ensure an entry is noted for religious preference.
The agency shall ensure the updated summary sheet containing all required elements is
utilized with all new admissions.
413-215-0071(3)&(4) Uniform in organization, readily identifiable and accessible, Yes☐ No This requirement is met. No further
current, and complete, containing all required info. No eraser tape or white out: corrective action needed.
Personnel and youth records are incomplete missing items noted above.
The agency shall ensure the revised date is noted on documents (forms, policies,
procedures, etc.) when revised. Youth records are incomplete missing required
elements on the summary sheet.
Page 1 of 2
New Findings from Site Visit
None
Interview Summary
Two youth, ages 12 and 15, were individually interviewed and have been in the program 1 year and 6 months respectively. Both youth provided
examples of how the agency is helping them. They report feeling safe, that peer relationships are average, staff are trusting, they have regular
unrestricted contact with family and people on their approved contact list, and the food is good and plentiful. They described outings and onsite
activities, but said the agency could improve on providing more variety of activities to mix it up. The program does well at figuring out solutions
and providing good food.
Observations
The environment was welcoming, clean, in good condition, and decorated for the season. An adequate food supply was observed in the pantry,
freezers, and refrigerators. The agency converted a room within an outbuilding for multiuse purposes as a visitation room and to house music
equipment. The recreation building, termed as the “barn”, was observed to be spacious and clean, with a pool table and an open loft area with
three TV and gaming set-ups with seating for each. There is a garage heater. However, it does not fully heat the entire space. The agency is
utilizing some grant money to professionally insulate the building, and this work is scheduled for January 2023. Fully insulating the area will make
it easier to heat. Big fans will also be purchased for cooling in the summer/warmer months.
Corrective Actions and Timeframes: Please submit the following to verify compliance.
Within 45 days of receipt of this report, Affect Youth 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 are
to be emailed directly to Robin DuVal, ROBIN.M.DuVal@dhsoha.state.or.us.
Licensing Coordinator’s Signature: ________________________ Date: _1_2_/_1_3_/2_0_2__2_________
Manager Review: ______________________________________ Date: _1_2_-_1_3_-_2_0_2_2_ _______
Page 2 of 2

agency_name: Affect Youth Services, Inc. (AYS)

program_type: (RC) Residential Care Programs

report_type: Unannounced

view_code: RC

board_chairperson: Mandy Straus

visit_date: December 7, 2022

licensing_coordinator: Robin DuVal

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: Unannounced Visit 9/22/2021 Repeat Findings Comments
Further Action
Needed?
413-215-0581(1) Summary sheet contains the following: (a)The name, gender, date of Yes[ ] No Two client summary sheets were
birth, religious preference, and previous address: reviewed, and this requirement is met.
No further corrective action needed.
Previous address was missing from the summary sheet. The agency shall ensure:
1) The form is updated to include previous address.
2) The previous address is documented on the summary sheet.
Religious preference was not consistently documented on the summary sheet. The
agency shall ensure an entry is noted for religious preference.
The agency shall ensure the updated summary sheet containing all required elements is
utilized with all new admissions.
413-215-0071(3)&(4) Uniform in organization, readily identifiable and accessible, Yes[ ] No This requirement is met. No further
current, and complete, containing all required info. No eraser tape or white out: corrective action needed.
Personnel and youth records are incomplete missing items noted above.
The agency shall ensure the revised date is noted on documents (forms, policies,
procedures, etc.) when revised. Youth records are incomplete missing required
elements on the summary sheet.
Page 1 of 2
New Findings from Site Visit
None
Interview Summary
Two youth, ages 12 and 15, were individually interviewed and have been in the program 1 year and 6 months respectively. Both youth provided
examples of how the agency is helping them. They report feeling safe, that peer relationships are average, staff are trusting, they have regular
unrestricted contact with family and people on their approved contact list, and the food is good and plentiful. They described outings and onsite
activities, but said the agency could improve on providing more variety of activities to mix it up. The program does well at figuring out solutions
and providing good food.
Observations
The environment was welcoming, clean, in good condition, and decorated for the season. An adequate food supply was observed in the pantry,
freezers, and refrigerators. The agency converted a room within an outbuilding for multiuse purposes as a visitation room and to house music
equipment. The recreation building, termed as the "barn", was observed to be spacious and clean, with a pool table and an open loft area with
three TV and gaming set-ups with seating for each. There is a garage heater. However, it does not fully heat the entire space. The agency is
utilizing some grant money to professionally insulate the building, and this work is scheduled for January 2023. Fully insulating the area will make
it easier to heat. Big fans will also be purchased for cooling in the summer/warmer months.


summary: Unannounced - 22 findings

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Residential Care
Licensee: Affect Youth Services, Inc. Date of Unannounced: December 15, 2023
Executive Director: Mandy Augsburger Licensing Coordinator: Robin DuVal
Board Chairperson: Ben Putren
Other Regular or Accrediting Agencies: Oregon Department of Human Services (ODHS) Child Welfare Treatment Services.
Purpose: Per OAR 419-400-0240 (1)(b) Children’s Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Findings
Corrective Actions / Comments
License Renewal Site Visit 03/01/2023 Further Action Needed?
Supplemental Information Provided by CCA Yes✓No☐ The agency submitted update drafts. This
All required policies and procedures as identified in the Umbrella Rules. licensor reviewed and provided edits for the
agency to update before finalizing.
Corrective Action: The agency shall update the following policies and
procedures pursuant to each OAR and submit for review.* Corrective Action:
• Conflict of Interest in OAR 419-400-0070. • The agency shall update and re-submit
• Rights of Children and Families in OAR 419-400-0090 for review before finalization.
• Grievance Procedures in OAR 419-400-0090(2)
• Mandatory Abuse Reporting in OAR 419-400-0110(1)(a)
• Privacy in OAR 419-400-0130.
• Personnel in OAR 419-400-0120.
• Discipline, behavior management, and suicide prevention in OAR 419-400-
0150, and restraints in OAR 419-400-0180.
*Please document the revision date and highlight or utilize “track changes” for
areas changed.
Corrective Action: Ensure policies are updated when needed to align with
changes to ODHS licensing rules for child-caring agencies.
1| P age
Form Rev. 01/23/2023
Supplemental Information Provided by CCA: All required policies and Yes✓No☐ The agency submitted update drafts. This
procedures as identified in Residential Care Specific Rules. licensor reviewed and provided edits for the
agency to update before finalizing.
Corrective Action: The agency shall update the following policies and
procedures pursuant to each OAR and submit for review*: Corrective Action:
• Medication Administration, specifically regarding self-administration, in OAR • The agency shall update and re-submit
419-470-0100. for review before finalization.
• Overnight Supervision Policy: update to include approved exception details.
Ensure disclosure is provided to parents/guardians at intake.
*Please document the revision date and highlight or utilize “track changes” for
areas changed.
Corrective Action: Ensure policies are updated when needed to align with
changes to ODHS licensing rules for child-caring agencies.
Supplemental Information Provided by CCA Yes✓No☐ The agency submitted update drafts. This
Additional Actions: Submit the following written policies and procedures, or licensor reviewed and provided edits for the
information, meeting requirements pursuant to each OAR, for review. agency to update before finalizing.
• 419-400-0110(b): documenting, reporting, and saving information about
critical events and other types of incidents. Corrective Action:
• 419-400-0200(1): agency transporting children in care. • The agency shall update and re-submit
• 419-400-0200(2): searches on children in care or visitors. for review before finalization.
• 419-400-0200(4): addressing potentially harmful materials that are in areas
accessible to the children in care in the program of on the grounds of the
program.
• 419-400-0190: Information provided to children in care.
Residential Care Safety 419-470-0080(3)(a) Evacuation drill occurs monthly Yes☐ No✓ Evacuation drill logs were observed, and
under varying conditions, is retained 2 years and contains: this requirement is met.
(A) identify of person conducting drill
(B) date & time • No further corrective action needed at
(C) notification method this time.
(D) staff participating
(E) # of children & staff evacuated
(F) special conditions simulated
(G) problems encountered
(H) time to complete
• Special conditions simulated (F) are blank on the fire drill logs.
Corrective Action: The agency shall ensure a variety of simulations are
practiced, i.e., kitchen fire, dorm room area, odor of Natural Gas, etc. and
appropriately documented.
2| P age
Form Rev. 01/23/2023
Medication 419-470-0100(10) Written record of the administration of Yes☐ No✓ Medication logs and possible adverse
medication includes: reaction documentation were observed, and
(a) name this requirement is met.
(b) description
(c) dates and times • No further corrective action needed at
(d) missed doses this time.
(e) medication disposed
(f) method of administration
(g) ID of person administering
(h) possible adverse reactions
(i) medication taken outside facility
Corrective Action:
(10)(h) The agency shall ensure that possible adverse reactions (side effects) are
listed for all medication types.
Recommendation: Add a notation on the medication administration record at
times when medications are not available. A notation should be made anytime a
medication is not administered at a prescribed time for any reason.
Personnel Files 419-400-0120(3)(d) Annual performance evaluations Yes☐ No☐ N/A✓ Performance appraisals for 2023 will occur
Performance appraisals were not completed for the year 2021. January 2024; therefore, nothing to review
at this time.
Corrective Action: The agency shall ensure performance appraisals occur
annually and are appropriately documented.
Authorizations 419-470-0160(3) Disclose or exchange information with Yes✓No☐ This requirement remains challenging to
others. obtain from guardians. The agency provided
an example letter for review, and this
Corrective action: The agency shall make extra efforts to obtain authorizations licensor will provide edits and
from guardians to disclose or exchange information with others. recommendations.
• This is a repeat violation.
• Corrective Action: Once finalized, the
agency shall ensure this requirement is
met.
Service Planning 419-470-0170(2)(e) (A)&(B) Service plan within 60 days Yes☐ No✓ Two service plans were observed, and this
(parent, guardian and child actively involved). Describes how child’s issues requirement is met.
will be addressed, anticipated outcomes, and reviewed by child and
guardian/parent. • The agency shall continue their efforts
for service plans to more individualized
Service Plans had generic child information, and there were some records as well as involving the child in the
missing documentation of the child’s involvement and review. creation and review of the plan and
document accordingly.
Corrective Action:
• The agency shall ensure each child in care’s service plan is individualized • No further corrective action needed at
describing how the child’s issues will be addressed and anticipated outcomes. this time.
3| P age
Form Rev. 01/23/2023
• The agency shall ensure the creation of the service plan involves the child in
care and that it’s reviewed by the child in care and documented appropriately.
Case Management 419-470-0170(3)(b)-(d) discharge planning and Yes☐ No✓ One file was reviewed where discharge
instructions. Discharge planning had minimal or no information. planning was noted.
Corrective Action: The agency shall ensure discharge planning and instructions • The agency shall continue their efforts
are included in case management documentation. to document discharge planning.
• No further corrective action needed at
this time.
Records Relating to Restraint & Involuntary Seclusion Yes✓No☐ This requirement remains unmet.
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 Corrective Action: The agency shall
in care in the program. The child caring agency shall provide the notice ensure this notice is provided and document
upon the child in care’s admission and at least two times each year having provided it.
thereafter. • This licensor will provide examples
and/or discuss areas to implement in
Corrective Action: The agency shall ensure this notice is provided, as outlined in already established documents.
rule, upon admission and at least two times each year thereafter, and document
having provided it.
Records Relating to Restraint & Involuntary Seclusion Yes✓No☐ This requirement remains unmet.
419-400-0190(1) Information provided to children in care relating to
Restraint & Involuntary Seclusion Corrective Action: The agency shall
ensure this notice is provided and document
Corrective Action: The agency shall ensure this notice is provided, as outlined in having provided it.
rule, upon admission and at least two times each year thereafter, and document • This licensor will provide examples
having provided it. and/or discuss areas to implement in
already established documents.
New Findings from Site Visit Corrective Actions
419-470-0170(2)(a)(C) The service plan must be reviewed at least quarterly. The requirement to update service plans quarterly is unmet.
• Corrective Action: The agency shall ensure all service plans are
updated and implement a system to ensure service plans are
reviewed and updated quarterly.
4| P age
Form Rev. 01/23/2023
Interview Summary
Two youth were individually interviewed, ages 13 and 16, with stays in the program of 2 years and 6 months, respectively. Both gave examples of how the
program is helping them, that they feel safe, and staff are trusting. Their peer community is fine, peers could be kinder to each other, food is good and plentiful,
and there’s been no issues getting medications as prescribed. They report the agency does well at their approach of teaching, vs. “being bossy”, and talking
about life skills. When asked if they could change anything about the program, they reported that the agency could be stricter with the rules around swearing
language, intervene with youth to be kinder, to allow youth to have their electronics more, and more staff to accommodate transportation to various activities,
i.e., school games. They described recreation and activities on-and-off site. They have regular phone calls with approved contact people, and there are two
specific areas to have those calls in privacy.
Observations
Upon entrance, the living and dining room, and kitchen were clean, tidy, and decorated for the holidays. Youth were doing a variety of activities in the conference
and dining rooms. Downstairs, the youths’ individual bedrooms, two dorm room areas, both bathrooms, and the laundry room were observed to be clean, odor
free, and in good repair. There’s a fist sized hole in the wall at one youth’s beds from being punched, and it’s scheduled to be repaired. The recreation center
was observed to be clean, tidy, and odor free. The agency reported that the heater had just went out, and a new one is ordered for replacement.
Corrective Actions and Timeframes: Please submit the following to verify compliance.
Within 45 days of receipt of this report Affect Youth Services, Inc. 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 are to be emailed directly to Robin
DuVal at robin.m.duval@odhsoha.oregon.gov.
Licensing Coordinator’s Signature: ________________________ Date: _1_2_/2_9_/_2_0_2_3__________
Manager Review: ______________________________________ Date: _1_2_-2_9_-_2_0_2_3_ ________
5| P age
Form Rev. 01/23/2023

facility_type: Residential Care

visit_date: December 15, 2023

purpose:
Per OAR 419-400-0240 (1)(b) Children's Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Findings
Corrective Actions / Comments
License Renewal Site Visit 03/01/2023 Further Action Needed?
Supplemental Information Provided by CCA Yes✓No[ ] The agency submitted update drafts. This
All required policies and procedures as identified in the Umbrella Rules. licensor reviewed and provided edits for the
agency to update before finalizing.
Corrective Action: The agency shall update the following policies and
procedures pursuant to each OAR and submit for review.* Corrective Action:
- Conflict of Interest in OAR 419-400-0070. - The agency shall update and re-submit
- Rights of Children and Families in OAR 419-400-0090 for review before finalization.
- Grievance Procedures in OAR 419-400-0090(2)
- Mandatory Abuse Reporting in OAR 419-400-0110(1)(a)
- Privacy in OAR 419-400-0130.
- Personnel in OAR 419-400-0120.
- Discipline, behavior management, and suicide prevention in OAR 419-400-
0150, and restraints in OAR 419-400-0180.
*Please document the revision date and highlight or utilize "track changes" for
areas changed.
Corrective Action: Ensure policies are updated when needed to align with
changes to ODHS licensing rules for child-caring agencies.

Supplemental Information Provided by CCA: All required policies and Yes✓No[ ] The agency submitted update drafts. This
procedures as identified in Residential Care Specific Rules. licensor reviewed and provided edits for the
agency to update before finalizing.
Corrective Action: The agency shall update the following policies and
procedures pursuant to each OAR and submit for review*: Corrective Action:
- Medication Administration, specifically regarding self-administration, in OAR - The agency shall update and re-submit
419-470-0100. for review before finalization.
- Overnight Supervision Policy: update to include approved exception details.
Ensure disclosure is provided to parents/guardians at intake.
*Please document the revision date and highlight or utilize "track changes" for
areas changed.
Corrective Action: Ensure policies are updated when needed to align with
changes to ODHS licensing rules for child-caring agencies.
Supplemental Information Provided by CCA Yes✓No[ ] The agency submitted update drafts. This
Additional Actions: Submit the following written policies and procedures, or licensor reviewed and provided edits for the
information, meeting requirements pursuant to each OAR, for review. agency to update before finalizing.
- 419-400-0110(b): documenting, reporting, and saving information about
critical events and other types of incidents. Corrective Action:
- 419-400-0200(1): agency transporting children in care. - The agency shall update and re-submit
- 419-400-0200(2): searches on children in care or visitors. for review before finalization.
- 419-400-0200(4): addressing potentially harmful materials that are in areas
accessible to the children in care in the program of on the grounds of the
program.
- 419-400-0190: Information provided to children in care.
Residential Care Safety 419-470-0080(3)(a) Evacuation drill occurs monthly Yes[ ] No✓ Evacuation drill logs were observed, and
under varying conditions, is retained 2 years and contains: this requirement is met.
(A) identify of person conducting drill
(B) date & time - No further corrective action needed at
(C) notification method this time.
(D) staff participating
(E) # of children & staff evacuated
(F) special conditions simulated
(G) problems encountered
(H) time to complete
- Special conditions simulated (F) are blank on the fire drill logs.
Corrective Action: The agency shall ensure a variety of simulations are
practiced, i.e., kitchen fire, dorm room area, odor of Natural Gas, etc. and
appropriately documented.

Medication 419-470-0100(10) Written record of the administration of Yes[ ] No✓ Medication logs and possible adverse
medication includes: reaction documentation were observed, and
(a) name this requirement is met.
(b) description
(c) dates and times - No further corrective action needed at
(d) missed doses this time.
(e) medication disposed
(f) method of administration
(g) ID of person administering
(h) possible adverse reactions
(i) medication taken outside facility
Corrective Action:
(10)(h) The agency shall ensure that possible adverse reactions (side effects) are
listed for all medication types.
Recommendation: Add a notation on the medication administration record at
times when medications are not available. A notation should be made anytime a
medication is not administered at a prescribed time for any reason.
Personnel Files 419-400-0120(3)(d) Annual performance evaluations Yes[ ] No[ ] N/A✓ Performance appraisals for 2023 will occur
Performance appraisals were not completed for the year 2021. January 2024; therefore, nothing to review
at this time.
Corrective Action: The agency shall ensure performance appraisals occur
annually and are appropriately documented.
Authorizations 419-470-0160(3) Disclose or exchange information with Yes✓No[ ] This requirement remains challenging to
others. obtain from guardians. The agency provided
an example letter for review, and this
Corrective action: The agency shall make extra efforts to obtain authorizations licensor will provide edits and
from guardians to disclose or exchange information with others. recommendations.
- This is a repeat violation.
- Corrective Action: Once finalized, the
agency shall ensure this requirement is
met.
Service Planning 419-470-0170(2)(e) (A)&(B) Service plan within 60 days Yes[ ] No✓ Two service plans were observed, and this
(parent, guardian and child actively involved). Describes how child's issues requirement is met.
will be addressed, anticipated outcomes, and reviewed by child and
guardian/parent. - The agency shall continue their efforts
for service plans to more individualized
Service Plans had generic child information, and there were some records as well as involving the child in the
missing documentation of the child's involvement and review. creation and review of the plan and
document accordingly.
Corrective Action:
- The agency shall ensure each child in care's service plan is individualized - No further corrective action needed at
describing how the child's issues will be addressed and anticipated outcomes. this time.

- The agency shall ensure the creation of the service plan involves the child in
care and that it's reviewed by the child in care and documented appropriately.
Case Management 419-470-0170(3)(b)-(d) discharge planning and Yes[ ] No✓ One file was reviewed where discharge
instructions. Discharge planning had minimal or no information. planning was noted.
Corrective Action: The agency shall ensure discharge planning and instructions - The agency shall continue their efforts
are included in case management documentation. to document discharge planning.
- No further corrective action needed at
this time.
Records Relating to Restraint & Involuntary Seclusion Yes✓No[ ] This requirement remains unmet.
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 Corrective Action: The agency shall
in care in the program. The child caring agency shall provide the notice ensure this notice is provided and document
upon the child in care's admission and at least two times each year having provided it.
thereafter. - This licensor will provide examples
and/or discuss areas to implement in
Corrective Action: The agency shall ensure this notice is provided, as outlined in already established documents.
rule, upon admission and at least two times each year thereafter, and document
having provided it.
Records Relating to Restraint & Involuntary Seclusion Yes✓No[ ] This requirement remains unmet.
419-400-0190(1) Information provided to children in care relating to
Restraint & Involuntary Seclusion Corrective Action: The agency shall
ensure this notice is provided and document
Corrective Action: The agency shall ensure this notice is provided, as outlined in having provided it.
rule, upon admission and at least two times each year thereafter, and document - This licensor will provide examples
having provided it. and/or discuss areas to implement in
already established documents.
New Findings from Site Visit Corrective Actions
419-470-0170(2)(a)(C) The service plan must be reviewed at least quarterly. The requirement to update service plans quarterly is unmet.
- Corrective Action: The agency shall ensure all service plans are
updated and implement a system to ensure service plans are
reviewed and updated quarterly.

Interview Summary
Two youth were individually interviewed, ages 13 and 16, with stays in the program of 2 years and 6 months, respectively. Both gave examples of how the
program is helping them, that they feel safe, and staff are trusting. Their peer community is fine, peers could be kinder to each other, food is good and plentiful,
and there's been no issues getting medications as prescribed. They report the agency does well at their approach of teaching, vs. "being bossy", and talking
about life skills. When asked if they could change anything about the program, they reported that the agency could be stricter with the rules around swearing
language, intervene with youth to be kinder, to allow youth to have their electronics more, and more staff to accommodate transportation to various activities,
i.e., school games. They described recreation and activities on-and-off site. They have regular phone calls with approved contact people, and there are two
specific areas to have those calls in privacy.
Observations
Upon entrance, the living and dining room, and kitchen were clean, tidy, and decorated for the holidays. Youth were doing a variety of activities in the conference
and dining rooms. Downstairs, the youths' individual bedrooms, two dorm room areas, both bathrooms, and the laundry room were observed to be clean, odor
free, and in good repair. There's a fist sized hole in the wall at one youth's beds from being punched, and it's scheduled to be repaired. The recreation center
was observed to be clean, tidy, and odor free. The agency reported that the heater had just went out, and a new one is ordered for replacement.

excerpt:
419-400-0130.
- Personnel in OAR


summary: Unannounced - 11 findings

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Residential Care
Licensee: Affect Youth Services, Inc Date of Unannounced: March 21, 2024
Executive Director: Mandy Augsburger Licensing Coordinator: Robin DuVal
Other Regulatory or Accrediting Agencies: Oregon Department of Human Services (ODHS) Child Welfare Treatment Services.
Purpose: Per OAR 419-400-0240 (1)(b) Children’s Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Repeat Findings
Previous Findings
Further Action Comments
Unannounced Site Visit 12/15/2023
Needed
Supplemental Information Provided by CCA. All required policies and Yes☐ No✓ All policies and procedures have been updated
procedures as identified in the Umbrella Rules. meeting licensing requirements. There’s no further
corrective action at this time.
The agency submitted update drafts. This licensor reviewed and provided
edits for the agency to update before finalizing.
Corrective Action: The agency shall update and re-submit for review
before finalization.
Supplemental Information Provided by CCA: All required policies and Yes☐ No✓ All policies and procedures have been updated
procedures as identified in Residential Care Specific Rules. meeting licensing requirements. There’s no further
corrective action at this time.
The agency submitted update drafts. This licensor reviewed and provided
edits for the agency to update before finalizing.
Corrective Action: The agency shall update and re-submit for review
before finalization.
Form Rev. 11/14/2023 P age 1 | 4
Supplemental Information Provided by CCA. Additional Actions: Yes☐ No✓ All policies and procedures have been updated
Submit the following written policies and procedures, or information, meeting licensing requirements. There’s no further
meeting requirements pursuant to each OAR, for review. corrective action at this time.
419-400-0110(b): documenting, reporting, and saving information about
critical events and other types of incidents.
419-400-0200(1): agency transporting children in care.
419-400-0200(2): searches on children in care or visitors.
419-400-0200(4): addressing potentially harmful materials that are in areas
accessible to the children in care in the program of on the grounds of the
program.
419-400-0190: Information provided to children in care.
The agency submitted update drafts. This licensor reviewed and provided
edits for the agency to update before finalizing.
Corrective Action: The agency shall update and re-submit for review
before finalization.
Authorizations 419-470-0160(3) Disclose or exchange information with Yes☐ No✓ This requirement is met. There’s no further
others. corrective action needed at this time.
This requirement remains challenging to obtain from guardians. The agency
provided an example letter for review, and this licensor will provide edits
and recommendations.
Corrective Action: Once finalized, the agency shall ensure this
requirement is met.
Records Relating to Restraint & Involuntary Seclusion Yes☐ No✓ This requirement is met. There’s no further
419-400-0180(13)(e) Each child caring agency shall provide notice corrective action needed as this time.
regarding how to access the quarterly reports to the parents or guardians of
children in care in the program. The child caring agency shall provide the
notice upon the child in care’s admission and at least two times each year
thereafter.
This requirement remains unmet.
Corrective Action: The agency shall ensure this notice is provided and
document having provided it.
• This licensor will provide examples and/or discuss areas to implement in
already established documents.
Form Rev. 11/14/2023 P age 2 | 4
Records Relating to Restraint & Involuntary Seclusion Yes☐ No☐ N/A✓ This finding from the 12/15/2023 report was
419-400-0190(1) Information provided to children in care relating to amended on 1/25/2024. This agency serves
Restraint & Involuntary Seclusion children placed by ODHS, and it is ODHS’s
responsibility to provide this information to the
This requirement remains unmet. children ODHS places with Affect Youth Services.
Corrective Action: The agency shall ensure this notice is provided and
document having provided it.
• This licensor will provide examples and/or discuss areas to implement in
already established documents.
• Amended. This report has been amended on 1.25.2024. This agency
serves children placed by ODHS, and it is ODHD’s responsibility to provide
this information to the children ODHS places with Affect Youth Services.
419-470-0170(2)(a)(C) The service plan must be reviewed at least Yes☐ No✓ This requirement is met. There’s no further
quarterly. corrective action at this time.
The requirement to update service plans quarterly is unmet.
Corrective Action: The agency shall ensure all service plans are updated
and implement a system to ensure service plans are reviewed and updated
quarterly.
New Findings from Site Visit Corrective Actions
419-470-0020(2)(c) Physical Plant Requirements. All areas of buildings The fist sized hole in the wall at one bed (bunk #10) remains un-repaired from
where children in care are present must be kept clean and in good repair. the last unannounced visit on 12/15/2023. Currently, that bed is unoccupied.
• Corrective Action: The agency shall repair as soon as possible
considering this area is in the dorm area where other children in care
are present.
419-470-0030(4)(c) When impervious mats are used, they must be The shower mat in the bathroom on the bigger dorm room side was on the floor.
disinfected and dried at least once per day, be in good condition, and free
of mold. • Corrective Action: The agency shall ensure mats are dried daily.
Form Rev. 11/14/2023 P age 3 | 4
Interview Summary
Three youth were individually interviewed, ages 17, 16, and 16, who have been in the program for approximately 18 months, 12 months, and 3 months,
respectively. They report feeling safe in this program, described ways the program is helping them, and indicated staff are trusting. The food is good and
plentiful. They described activities and recreation available at the program and outings, such as the park, and they described outings that occur more during the
summer months and school breaks. For those receiving medications, they report no issues getting medications as prescribed. Their peer community is going
fine, and the bedroom sharing is fine. They have regular phone calls with approved contacts, a minimum of 3 times per week, and there are specific areas to
have those calls in privacy. They report the agency does well at “changing kids’ behaviors”, routine, and structure; and could improve on active listening and
having more community time. If they could change anything about the program, they report having more community and friend time, and the ability to have a
job to gain that experience and learn money management.
**See below regarding shower schedule. The interviewed youth report they’re used to it now, it works to get through the amount of youth, and they think it’s
enough time; however, the short timeframe may not be enough time for some to complete a thorough hygiene process. They report exceptions have been
provided when youth are injured or have other situations.
Observations
Five youth and one staff person were present while other youth and staff were out of program for various appointments. Note: this was a no school day. The
youth were in the conference room area watching a show on TV. The physical plant of this agency is in a residential home, not a traditional facility-like structure.
The living room, dining room, kitchen, and conference room were clean and tidy and were within normal temperatures. Food was observed in the refrigerators,
freezer, and pantry. The agency has two dogs that are inside/outside and are very friendly. Downstairs, the youths’ individual bedrooms, two dorm room areas,
and both bathrooms were observed to be clean, odor free, and in good repair, with the exception of where noted above in “new findings”. The recreation center
was observed to be clean, tidy, and odor free.
**A posted shower schedule was observed describing time from entering and exiting the bathroom for an approximate 7-8 minutes, which included time for
undressing, shower, dry off, put clothes on, and take dirty laundry out.)
Corrective Actions and Timeframes: Please submit the following to verify compliance.
Within 45 days of receipt of this report Affect Youth Services, Inc. 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 are to be emailed directly to Robin
DuVal at robin.m.duval@odhsoha.oregon.gov.
Licensing Coordinator’s Signature: ________________________ Date: _3_/2__5_/2_0_2_4___________
Manager Review: ______________________________________ Date: _3_-2_5_-_2_0_2_4__________
Form Rev. 11/14/2023 P age 4 | 4

purpose:
Per OAR 419-400-0240 (1)(b) Children's Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Repeat Findings
Previous Findings
Further Action Comments
Unannounced Site Visit 12/15/2023
Needed
Supplemental Information Provided by CCA. All required policies and Yes[ ] No✓ All policies and procedures have been updated
procedures as identified in the Umbrella Rules. meeting licensing requirements. There's no further
corrective action at this time.
The agency submitted update drafts. This licensor reviewed and provided
edits for the agency to update before finalizing.
Corrective Action: The agency shall update and re-submit for review
before finalization.
Supplemental Information Provided by CCA: All required policies and Yes[ ] No✓ All policies and procedures have been updated
procedures as identified in Residential Care Specific Rules. meeting licensing requirements. There's no further
corrective action at this time.
The agency submitted update drafts. This licensor reviewed and provided
edits for the agency to update before finalizing.
Corrective Action: The agency shall update and re-submit for review
before finalization.

Supplemental Information Provided by CCA. Additional Actions: Yes[ ] No✓ All policies and procedures have been updated
Submit the following written policies and procedures, or information, meeting licensing requirements. There's no further
meeting requirements pursuant to each OAR, for review. corrective action at this time.
419-400-0110(b): documenting, reporting, and saving information about
critical events and other types of incidents.
419-400-0200(1): agency transporting children in care.
419-400-0200(2): searches on children in care or visitors.
419-400-0200(4): addressing potentially harmful materials that are in areas
accessible to the children in care in the program of on the grounds of the
program.
419-400-0190: Information provided to children in care.
The agency submitted update drafts. This licensor reviewed and provided
edits for the agency to update before finalizing.
Corrective Action: The agency shall update and re-submit for review
before finalization.
Authorizations 419-470-0160(3) Disclose or exchange information with Yes[ ] No✓ This requirement is met. There's no further
others. corrective action needed at this time.
This requirement remains challenging to obtain from guardians. The agency
provided an example letter for review, and this licensor will provide edits
and recommendations.
Corrective Action: Once finalized, the agency shall ensure this
requirement is met.
Records Relating to Restraint & Involuntary Seclusion Yes[ ] No✓ This requirement is met. There's no further
419-400-0180(13)(e) Each child caring agency shall provide notice corrective action needed as this time.
regarding how to access the quarterly reports to the parents or guardians of
children in care in the program. The child caring agency shall provide the
notice upon the child in care's admission and at least two times each year
thereafter.
This requirement remains unmet.
Corrective Action: The agency shall ensure this notice is provided and
document having provided it.
- This licensor will provide examples and/or discuss areas to implement in
already established documents.

Records Relating to Restraint & Involuntary Seclusion Yes[ ] No[ ] N/A✓ This finding from the 12/15/2023 report was
419-400-0190(1) Information provided to children in care relating to amended on 1/25/2024. This agency serves
Restraint & Involuntary Seclusion children placed by ODHS, and it is ODHS's
responsibility to provide this information to the
This requirement remains unmet. children ODHS places with Affect Youth Services.
Corrective Action: The agency shall ensure this notice is provided and
document having provided it.
- This licensor will provide examples and/or discuss areas to implement in
already established documents.
- Amended. This report has been amended on 1.25.2024. This agency
serves children placed by ODHS, and it is ODHD's responsibility to provide
this information to the children ODHS places with Affect Youth Services.
419-470-0170(2)(a)(C) The service plan must be reviewed at least Yes[ ] No✓ This requirement is met. There's no further
quarterly. corrective action at this time.
The requirement to update service plans quarterly is unmet.
Corrective Action: The agency shall ensure all service plans are updated
and implement a system to ensure service plans are reviewed and updated
quarterly.
New Findings from Site Visit Corrective Actions
419-470-0020(2)(c) Physical Plant Requirements. All areas of buildings The fist sized hole in the wall at one bed (bunk #10) remains un-repaired from
where children in care are present must be kept clean and in good repair. the last unannounced visit on 12/15/2023. Currently, that bed is unoccupied.
- Corrective Action: The agency shall repair as soon as possible
considering this area is in the dorm area where other children in care
are present.
419-470-0030(4)(c) When impervious mats are used, they must be The shower mat in the bathroom on the bigger dorm room side was on the floor.
disinfected and dried at least once per day, be in good condition, and free
of mold. - Corrective Action: The agency shall ensure mats are dried daily.

Interview Summary
Three youth were individually interviewed, ages 17, 16, and 16, who have been in the program for approximately 18 months, 12 months, and 3 months,
respectively. They report feeling safe in this program, described ways the program is helping them, and indicated staff are trusting. The food is good and
plentiful. They described activities and recreation available at the program and outings, such as the park, and they described outings that occur more during the
summer months and school breaks. For those receiving medications, they report no issues getting medications as prescribed. Their peer community is going
fine, and the bedroom sharing is fine. They have regular phone calls with approved contacts, a minimum of 3 times per week, and there are specific areas to
have those calls in privacy. They report the agency does well at "changing kids' behaviors", routine, and structure; and could improve on active listening and
having more community time. If they could change anything about the program, they report having more community and friend time, and the ability to have a
job to gain that experience and learn money management.
**See below regarding shower schedule. The interviewed youth report they're used to it now, it works to get through the amount of youth, and they think it's
enough time; however, the short timeframe may not be enough time for some to complete a thorough hygiene process. They report exceptions have been
provided when youth are injured or have other situations.
Observations
Five youth and one staff person were present while other youth and staff were out of program for various appointments. Note: this was a no school day. The
youth were in the conference room area watching a show on TV. The physical plant of this agency is in a residential home, not a traditional facility-like structure.
The living room, dining room, kitchen, and conference room were clean and tidy and were within normal temperatures. Food was observed in the refrigerators,
freezer, and pantry. The agency has two dogs that are inside/outside and are very friendly. Downstairs, the youths' individual bedrooms, two dorm room areas,
and both bathrooms were observed to be clean, odor free, and in good repair, with the exception of where noted above in "new findings". The recreation center
was observed to be clean, tidy, and odor free.
**A posted shower schedule was observed describing time from entering and exiting the bathroom for an approximate 7-8 minutes, which included time for
undressing, shower, dry off, put clothes on, and take dirty laundry out.)