summary: License Renewals - 9 findings

raw_content:
Licensed Child Caring Agency Site Visit Report
Residential Care
Licensee: Marion County GAP Program Date of site visit: May 12, 2022
Executive Director: Troy Gregg Licensing Coordinator: Holly Ivey
Program Director: Jose Miranda
Program Compliance: The program was found to be compliant or will be compliant with OAR 413-215-0001 to 413-215-0131, Licensing Umbrella
Rules, and OAR 413-215-0501 to 413-215-0586, Licensing Residential Care Agencies Rules. Personnel records were reviewed and compliance
with required background checks was documented for employees in all programs.
Program Description(s): Marion County Juvenile Department Guaranteed Attendance Program (GAP) is a voluntary shelter program for court
involved youth ages 12-17. Youth are referred if they need additional structure as they transition out of detention or if they are at risk for being
placed in detention. Youth generally attend school or are involved in work programs during the daytime hours and return at night. The program
serves both male and female with specific Behavioral Rehabilitation Services (BRS) programing. The average length of stay is approximately 90
days.
Program type and services: Residential Services
Capacity and Age Range: 25, male and female ages 12-17
Funding sources: BRS Contracts, General Funds, and Diversion Funds
Contracts and sources for referrals: Contracts with the Oregon Youth Authority; referrals are made through the Marion County Probation
Officers.
Average length of stay: 90 days
Average daily population served: 10-15 youth
Number of children served annually: 60-70 youth
(rev. 03/25/2021)
Use of seclusion or restraint: Seclusion N/A, NCI Trained in case of emergency for restraints.
Interviews, Observations:
Interviews: During the review Jose Miranda, Program Director, and Cynthia Navarro, Case Manager, were informally interviewed, as they assisted
with the walk through of the facility. At the time of the review the youth where at school and not available to be interviewed. Three youth were
privately interviewed on the phone on May 17, 2022, by Holly Ivey, Licensing Coordinator. When asked what they appreciated most about the GAP
Program the youth reported:” The staff are teaching me skills, the activities and outings are pretty fun, hanging out with people in the program,
playing basketball, and football, everyone is respectful, staff help us out if we need anything.” All youth reported getting enough food at the program
and daily snacks. All youth reported having daily private phone contact with their approved contacts. The youth reported the following recreational
activities: “Playing basketball, and soccer, going to the clubhouse (an area in the program that has a video gaming system, fuse ball and other
games), going on outings, going to parks as a group.” Two of the three youth reported hygiene products were provided by the program if they
needed them. One youth stated, “Hygiene products had to be earned.” (The DHS Licensing Coordinator spoke with Jose Miranda, Program
Director, after the youth interview, he stated, “Hygiene products are available if youth have a need for them, and it is not a requirement to earn
them.” He stated, “This would be something he would speak to staff about being clearer with youth about.”) When the youth were asked what they
would change about the program, they reported: “Everyone can have more outings, different varieties of food we mostly get the same stuff, to have
better food even though the food is good, more choices.” All youth reported feeling respected by staff and safe at the program.
Observations: A walk through tour was conducted of the program in all areas where youth are allowed access. The program was well kept and
observed to be clean and in good repair. Youth have a daily chore assigned to assist with the cleaning of the program. A contracted agency in the
Marion County Detention Facility is responsible for all meals, which are prepared in the detention facilities kitchen. Meals are brought from
detention to the GAP Program. The DHS Licensing Coordinator did not observe the detention’s kitchen. The GAP Program has a kitchen that staff
uses to make snacks and teach life skills with the youth. The kitchen at the GAP Program was clean and in good repair. The DHS Licensing
Coordinator observed food in the refrigerator, and snacks in the cupboards for the youth. The DHS Licensing Coordinator observed two vans that
staff use to transport youth in the program. There were no deficiencies observed with the vehicles.
Program Strengths:
The following strengths were identified by the Program Director at the time of the review:
 DBT based skills groups to help youth identify ways to make lasting change in their lives.
 A tenured staff that is skilled in building rapport with youth
 Program offers many outings to youth
 Supported by partnering Juvenile Department programs such as: Education Services; Probation Services; and Mental Health counseling.
Program Challenges:
The following strengths were identified by the Program Director at the time of the review:
 Creating successful aftercare once youth is discharged from the program.
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 Adapting to the increasing needs of the youth (Mental Health issues, drug and alcohol dependency; and trauma informed care) to best serve
them while running a structured program.
 Covid-19 related issues and protocols.
 Decreased relief staff pool.
Changes that have occurred in the last 2 years:
The following changes were identified by the Program Director at the time of the review:
 Covid-19 pandemic related issues and protocol.
 Revising how youth and families orient to the program.
 Looking for more activities to fill out the daily schedule.
Lawsuits: N/A
Grievances and complaints filed in the last two years: N/A
Corrective Actions and Timeframes: Please submit the following to verify compliance.
Within 45 days of receipt of this report Marion County GAP Program, must submit a letter of verification indicating the agency is in compliance with
the specific rules cited above and describing how compliance will be maintained going forward. Along with the letter of verification, the agency must
submit any and all specific documentation requested in the body of this report. The letter of verification and any additional requested documents can
be emailed directly to Holly Ivey, Licensing Coordinator. Her email address is: Holly.r.ivey@state.or.us
Exceptions: Two exceptions were requested and approved during the Licensing Renewal Process.
1. OAR 413-215-0566(1)(b) a residential care agency must obtain written approval from the parent or legal guardian and the licensing
coordinator before two children in care may share a room when one of the children in care is 18 years of age or older.
 Information provided to Licensing: Prior to entering the program, all youth and families were informed about the possibility of their child
sleeping in the same dorm with a non-minor child. They all consented with written approval.
DHS Licensing approved the exception until June 30, 2024.
2. OAR 413-215-0516 (3)(e) Have a minimum of 60 square feet per bed. (i)(A) There must be at least three feet between beds.
 Information provided to Licensing: The program has a dorm setting with bunk beds set up for optimal viewing of staff. The youth have
more than enough living space outside of the dorm to move around the program freely during waking hours.
DHS Licensing approved the exception until June 30, 2024.
Changes in License: No changes
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Summary of Review
Program and Services Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0011(2) Completed
Program and services are in scope of license X
Governance of the Agency Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0021 Completed
(1)(a) Minimum of 5 board members X
(2)(f) Formally evaluate the exec. Director’s X
performance annually
(2)(g) Approves annual budget X
(2)(h) Obtain and review an annual X
independent financial review or audit of
financial records.
(2)(k) Written quality improvement program X
(2)(l) Meeting minutes X
Executive Director or Program Director Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0021 Completed
(3)(a) knowledge of requirements for X
providing care and treatment appropriate to
programs
(3)(g) Approval from BCU X
Discipline, Behavior Management, and Corrective Action
Yes No N/A Corrective Actions/Comments
Suicide Prevention 413-215-0076 Completed
(3) Agency uses appropriate and positive
methods of behavior management and
X
nationally recognized non-violent crisis
intervention
(3)(b)(C) Agency does not use chemical and
mechanical restraint (excluding medically X
necessary devices/prescriptions)
(3)(c) Agency uses appropriate time-out
rooms (adequate space, heat, light and
ventilation and is not capable of locking) and X
documents use in child’s record when
applicable
(3)(e) Agency uses seclusion
X
appropriately/consistent with policy
(4) Agency has adequate plan in place to
X
respond to suicidal behavior/warning signs
Contractors (if applicable) Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0061(6) Completed
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(a) Agency ensures the contractor meets the
requirements of this rule and Chapter 413 X
division 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 X
(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
Supplemental Information Provided by Corrective Action
Yes No N/A Corrective Actions/Comments
CCA Completed
Documents as indicated on the form titled
X
“Renewal Licensing Required Documents”
Documents as indicated on form titled
“Required Financial Documents and X
Information”
All required policies and procedures as Supplemental Information Provided by CCA All required
identified in the “Umbrella Rules” policies and procedures as identified in the “Umbrella Rules”
X  *Required policy revisions are stated in detail at the
end of the report.
All required policies and procedures as Supplemental Information Provided by CCA All required
identified in “Agency Type Specific Rules” policies and procedures as identified in “Agency Type
Specific Rules”
X
 *Required policy revisions are stated in detail at the
end of the report.
Physical Plant Corrective Action
Yes No N/A Corrective Actions/Comments
Completed
413-215-0046(3)(a) Foster Rights Posted (if X
children in DHS custody)
413-215-0051(1) Sufficient safe space, X
equipment, and office equipment
413-215-0091(12) License is posted in X
common area at each facility
413-215-0001(5)(d), 0516(4(a)(I) & 0521(1) X
Adequate furnishings and personal items
413-215-0511(2)(a) &(c) Buildings are X
smoke free, clean and in good repair
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413-215-0511(2)(d) Rooms are free of X
harmful drafts, odors, and excessive noise
413-215-0511(2)(e) Rooms are adequate in X
size and arrangement
413-215-0511(2)(f) System provides a X
continuous supply of hot and cold water to
taps located throughout the facility
413-215-0511(2)(h) Building is well X
ventilated and room temperature is within a
normal comfort range
413-215-0516(1) All parts of the facility X
ensure the safety of children
Room and Space Requirements Corrective Action
Yes No N/A Corrective Actions/Comments
Bedrooms 413-215-0516(3) Completed
(a) Adequate furnishings and personal items X Room and Space Requirements Bedrooms 413-215-
(b) Separate from rooms used for dining, X 0516(3) (d) Ceiling at least 90 inches(i) Beds are 3 feet apart
living, laundry, kitchen, and storage and maintained to ensure safety
(c) Outside room with window allowing X  An exception was granted by DHS Licensing,
egress from building regarding the above stated rule and will be in effect
(d) Ceiling at least 90 inches X until June 30, 2024. See above in the exception
(e) Minimum 60 SF per bed X section for more detail. There is nothing further that
(f) No more than 25 if dorm style X needs to be sent to Licensing regarding the findings.
(g) Permanently wired fixtures X
(h) Window covering X
(i) Beds are 3 feet apart and maintained to X
ensure safety
Room and Space Requirements Corrective Action
Yes No N/A Corrective Actions/Comments
Bathrooms 413-215-0516(4) Completed
(a)(A)&(B) 1:8 ratio for toilets and sinks X
(a)(D) Hot and cold running water, soap, and X
approved hand drying options
(a)(E) 1:10 ratio for shower or bathtub X
(a)(E) Individual privacy X
(a)(F) Window covering X
(a)(G) Permanently wired fixtures X
(a)(H) Adequate ventilation X
(b)&(c) Wooden racks on floors are X
prohibited and impervious shower mats are
disinfected & dried daily
Room and Space Requirements Corrective Action
Yes No N/A Corrective Actions/Comments
Kitchen 413-215-0516(6) Completed
(a) Used exclusively for storage, food X (The Licensing Coordinator viewed the GAP Program’s
preparation, dish washing, and activities kitchen, which is not where meals are prepared for the youth.
related to eating
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(b) Walls, floors are easily cleanable X Meals are prepared in the detention building’s kitchen and
(c) Equipment and utensils are easily X brought to the GAP Program.)
cleanable, durable, nontoxic, and kept clean
(e) Equipment is easy to clean beneath, X
between and behind
Room and Space Requirements Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0516 Completed
(2) There is a separate living room or lounge X
area – 15 SF minimum per child
(5) There is a separate dining room with X
capacity for ½ of children in care and 15 SF
per child in care
(7) Laundry is separate from living areas, X
kitchen and dining
(8) Separate storage areas are provided for X
food, kitchen supplies, utensils, clean linens,
soiled linens and clothing, cleaning supplies
and equip, poisons, chemicals, outdoor
recreational and maintenance equipment
(9) Outdoor activity area is protected from X
vehicles and other hazards and of a size and
availability appropriate to the age and needs
of children in care
(11) & 413-215-0076(3)(c)(C) Time out X
rooms have adequate space, heat, light and
ventilation and is not capable of locking
Furnishings and Personal Items Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0521 Completed
(1) There is a bed with frame, clean mattress X
and pillow and personal storage (dresser,
closet)
(2) Linens are in good repair. There is a X
waterproof mattress cover or mattress.
Linens are appropriate and towels and
washcloths are provided
(3) Bedding is changed weekly or when X
soiled
(4)&(5) Personal hygiene supplies and X
appropriate clothing are provided
Food Services Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0536(1)&(2) Completed
(1)(a) Meals are arranged daily, consistent X Food is cooked and brought over to the program from Marion
with normal mealtimes that occur during the County’s Detention Facility. The DHS Licensing Coordinator
hours of operation did not inspect the kitchen of the detention facility.
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(1)(b) Menus are prepared in advance in X
accordance with USDA guidelines, provide a
variety of foods and are adjusted for
seasonal changes.
(1)(b) Menus are kept for at least 6 months X
(1)(c) Drinking water is freely available X
(2)(a) Food is stored, prepared & served in a X
sanitary manner
(2)(c) & (d) Food products are obtained from X
commercial suppliers (exception of fruits &
vegetables), unpasteurized juice is
prohibited, and only Grade A pasteurized
and fortified milk in appropriate container.
Safety Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0541 Completed
(2)(a) Written emergency plan X
(2)(b) Telephone numbers for local police X
and fire are posted near all telephones
(2)(c) Operative flashlights sufficient in X
number are readily available to staff
(3)(a) Evacuation drill occurs monthly under X
varying conditions, is retained 2 yrs and
contains;
(A) identify of person conducting drill
(B) date & time
(C) notification method
(D) staff participating
(E) # of children & staff evacuated
(F) special conditions simulated
(G) problems encountered
(H) time to complete
Safety – Transportation Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0541 Completed
(5)(b) Vehicle has insurance policy, is smoke X
free, safe operating condition, and has first
aid kit and fire extinguisher 2-A:10-BC
Medication Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0551 Completed
(3)&(7)(e) Medications have a prescription X Medication 413-215-0551 (9) Written record of the disposal
and are stored in the original container with of medications is maintained and includes: (d) method
prescription label  At the time of the review, nursing staff were utilizing
(4)&(5) Herbal supplements and remedies, X an old disposal form that did not have the above
medical treatments, special diets, physical required information.
therapy, physical aides or limitations have a
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written order signed by a physician or  On 6.7.2022, Jose Miranda, Program Director, sent
qualified medical professional. an email to Holly Ivey, Licensing Coordinator, stating
(7)(c) Medications are inaccessible to X that he added a footer to the disposal log to ensure
children that staff utilize the most recent disposal form, and
(8) Medications are disposed in accordance X he disposed of the old form. Jose Miranda sent a
with state and federal law disposal log to the Licensing Coordinator that will be
(9) Written record of the disposal of X utilized that meets all the required Licensing Rules.
medications is maintained and includes: There is nothing further that needs to be sent to
(a) description and amount Licensing regarding this finding. DHS Licensing will
(b) name monitor ongoing compliance at the 2022,
(c) reason Unannounced Site Inspection.
(d) method
(e) staff & witness signature
(10) Written record of the administration of X
medication includes:
(a) name
(b) description
(c) dates and times
(d) missed doses
(e) medication disposed
(f) method of administration
(g) ID of person administering
(h) possible adverse reactions
(i) medication taken outside facility
Extracurricular, Enrichment, Cultural &
Corrective Action
Social Activities Yes No N/A Corrective Actions/Comments
Completed
413-215-0554
(2) Children have ongoing opportunities to X
participate in at least one age-appropriate or
developmentally appropriate activity
Minimum Staffing Requirements Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0561 Completed
(1)&(2) Supervision is adequate for the type X
of program, location, age and type of
children, ability of supervisor to respond,
electronic back-up systems.
Minimum ratios are maintained:
Under 30 months of age: 1:4
30 months to ˃ 6 yrs or non-ambulatory: 1:6
Ages 6 and older: 1:7
Overnight (staff awake)
1:10
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(4)(a) When one staff on duty, there is X
additional staff immediately available with
max response time of 30 minutes
(5) There is at least one on-site employee X
authorized to apply the reasonable and
prudent parent standard
Separation of Residents Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0566 Completed
(1) Children are in separate bedrooms than X
adults, unless parent and child, or there is
written approval from guardian/parent and
licensing coordinator
(2) There is adequate supervision of children X
if both males and females are served by the
program
Personnel Files Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0061 Completed
Staff Name/Position X
(3)(g) Date of Hire X
(3)(a) record of education, training and X
previous employment
(1)(b) & (3)(b) reference checks completed X
and documented
(1)(a) & (3)(c) Background check completed X
and documented
(3)(d) Annual performance evaluations X
(3)(f) Record of personnel actions X
(3)(g) Termination date, reason for
X
termination
(3)(h) Current job description (1)(c)
Employee meets minimum qualifications X
stated in current job description
New Employee Orientation – Umbrella
Corrective Action
Requirements (30 days) Yes No N/A Corrective Actions/Comments
Completed
413-215-0061(4)
(a) Agency policies and procedures X
(b) Ethical and professional guidelines X
(c) Organizational lines of authority X
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(d) Attributes of population served X
(e) & (5)(a) to (c) Mandatory reporting that X
includes:
(a) legal definition of child abuse ORS
419B.005, Oregon Laws 2016, chapter 106,
section 36
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to
the employee
(f) Privacy laws X
(g) Emergency procedures X
New Employee Orientation – Residential
Corrective Action
(30 days) Yes No N/A Corrective Actions/Comments
Completed
413-215-0556
(1)(a) Discipline and behavior management X
including de-escalation, crisis prevention,
positive behavior management, and
disciplinary techniques that are non-punitive
in nature
(1)(b) Restraint and seclusion (if applicable) X
Ongoing Training Corrective Action
Yes No N/A Corrective Actions/Comments
Completed
413-215-0536(2)(b) Employees who handle X
food served to children have a valid food
handler’s card
413-215-0541(5)(a) Employees transporting X
children have: current driver’s license,
insurance, trained in emergency procedures
and behavior management, and training for
15+ passenger vans if applicable)
Ongoing Training 413-215-0556(4) Designated staff
413-215-0556(2)(a) Environmental X
authorized to apply reasonable and prudent parent standard
emergencies
are trained in application of the standard.
413-215-0556(2)(b) Universal Precautions X  Verification of the above required training was
413-215-0556(2)(c) Discipline and Behavior X missing in some of the personnel files reviewed.
Management  On June 8, 2022, Jose Miranda, Program Manager,
sent an email to Holly Ivey, Licensing Coordinator,
413-215-0556(3) Staff providing direct care X
confirming that staff had received the required
must maintain current CPR/First Aid
Prudent Parent Training. (One relief staff will be
certification
trained later as she is taking several months off.)
413-215-0556(4) Designated staff authorized There is nothing further that needs to be sent to
to apply reasonable and prudent parent Licensing regarding this finding. DHS will monitor
X
standard are trained in application of the ongoing compliance at the 2022, Unannounced Site
standard Inspection.
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413-215-0061(5) Mandatory reporting X
(annually) that includes:
(a) legal definition of child abuse ORS
419B.005, Oregon Laws 2016, chapter 106,
section 36
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to
the employee
Comments:
Children’s Records Corrective Action
Yes No N/A Corrective Actions/Comments
Completed
Health Services
413-215-0546
(2) Medical history obtained within 30 days X
(significant findings, current immunizations,
history of surgical procedures-health issues-
injuries, allergies, dental, vision, hearing,
behavioral health, and physician orders)
(2)(e) Documentation of age-appropriate X
instruction – pregnancy prevention, nutrition,
prevention of HIV & AIDS, and prevention
and treatment of sexually transmitted
disease
(4)(a) to (f) Medical exams (3 in first year of
life, 2,4,6,9,14) X
Consents Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0576(1) Completed
(a) Provide routine and emergency medical
X Consents 413-215-0576(1) (c) Use restraint or seclusion
care
Must specify the reasons for the intervention and how staff
(b) Use the discipline and behavior are trained and supervised
X
management system  The consents being utilized were missing the above
(c) Use restraint or seclusion (if applicable). required information.
Must specify the reasons for the intervention X  On May 25, 2022, Jose Miranda, Program Manager,
and how staff are trained and supervised sent Holly Ivey, Licensing Coordinator, a revised
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(d) Restrict contact with persons outside of GAP Voluntary Placement Agreement. The
X
the agency Placement Agreement included a consent that was
modified to include all the above required
(e) Allow access as defined in 413-215-0091
X information. The consent meets the Licensing Rule
& 0101
requirement. There is nothing further that needs to
(f) Impose a dress code X be sent to Licensing regarding this finding. DHS will
monitor ongoing compliance at the 2022,
(g) Apply the reasonable and prudent parent Unannounced Site Inspection.
X
standard
Disclosures
Corrective Action
413-215-0576(2) Parent/guardian has Yes No N/A Corrective Actions/Comments
Completed
acknowledged in writing:
(a) Information regarding personal or room X
searches and protocols for confiscation of
contraband
(b) Statement of Rights of Children and X
Parents/Guardians
(c) Any policies and procedures upon X
request
Authorizations Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0576(3) Completed
(a) Disclose or exchange information with X Authorizations 413-215-0576(3) (c) Visitation resources
others are pre-approved
 Authorizations reviewed lacked verification of
(b) Child specific visitors X
approval by the guardians for visitation resources.
(c) Visitation resources are pre-approved X
 On May 19, Jose Miranda, Program Manager sent
X Holly Ivey, Licensing Coordinator, a revised GAP
Screening Form that had a line for guardian approval
(d) Activity specific authorizations are pre-
of visitor contacts. This meets the Licensing Rule
approved to allow children to participate in
requirements. There is nothing further that needs to
potentially hazardous activities, including but
be sent to Licensing regarding this finding. DHS will
not limited to using motorized yard
monitor ongoing compliance at the 2022,
equipment, swimming, and horseback riding.
Unannounced Site Inspection.
Information about Children in Care
Corrective Action
413-215-0581(1) Summary sheet contains Yes No N/A Corrective Actions/Comments
Completed
the following:
(a)The name, gender, date of birth, religious X
preference, and previous address
(b) Name and location of previous and X
current school
(c) Date of admission X
(d) Legal custody X
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(e) The name, address, and telephone
number of:
(A) The child in care's parents.
(B) The child in care's legal guardian, if
different than the parents, and a copy of
X
the document that provides for his or her
authority over the child in care.
(C) Other persons significant to child
(D) Other professionals to be involved in
service planning (if applicable)
Service Planning Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0581(2) Completed
(b) Intake document is completed the date X
child accepted into care (emergency
placement 48 hours)
(d) Assessment is completed within 30 days X
and contains relevant historical info., current
behavioral observations, identified need for
services, and how agency will provide
services
(e) (A)&(B) Service plan within 60 days X
(parent, guardian and child actively
involved). Describes how child’s issues will
be addressed, anticipated outcomes and
reviewed by child and guardian/parent.
(e)(C)&(D) Service plan is reviewed quarterly
and revised when information indicates other X
services should be provided
Case Management Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0581(3) Completed
(a) Services are documented, progress X
toward achieving goals is tracked
(b)-(d) discharge planning and instructions X
(f) Incident Reports X
Financial Records Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0581(4) Completed
Financial Records 413-215-0581(4) Records contain…
source, purpose
Records contain date, amount, source,
X  The financial records forms being utilized did not
purpose, signatures
have the above required information.
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Personal Possessions Records Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0581(5) Completed
Individual written inventory of all personal
possessions is maintained and updated as X
needed
Records and Documentation Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0071 Completed
(1) Stored safely X
(2) Permanent, legible, dated, and signed X
(3)&(4) Uniform in organization, readily X
identifiable and accessible, current, and
complete, containing all required info. No
eraser tape or white out.
(7) Permanent registry for each child X
includes:
Name
Gender
Birth date
Names, addresses of parents or guardians
Dates of admission
Placement upon discharge
Comments:
*Supplemental information provided by the CCA as stated above (page 5). Required Policy Revisions:
413-215-0036 Licensing Umbrella Rules: Conflict of Interest (Amended 12/01/19) A child-caring agency must have a conflict-of-interest policy that
prohibits preferential treatment of board members, employees, volunteers, and contributors. The policy must outline safeguards when the child-caring agency
allows dual relationships, such as employees serving as proctor foster parents, including the requirement that all material facts of the conflicted transaction and the
direct or indirect interest of the board member, employee, volunteer, or contributor are disclosed or known to the board approving the conflicted transaction. If
circumstances do not permit board approval of the conflicted transaction, a non-profit child-caring agency may obtain the approval of the Attorney General or the
Department prior to entering into the transaction.
 The above required information was missing in the policies submitted.
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413-215-0046 Licensing Umbrella Rules: Children and Families Rights Policy and Grievance Procedures (Amended 1/1/19) (1) Rights of children
in care and families served by the child-caring agency. (a) Except as provided in paragraph (B) of this subsection, the child in care's right to uncensored
communication with legal guardians, caseworkers, legal representatives, and other persons approved for communication by the legal guardian or as provided in a
court order. (A) This right cannot be waived, including voluntarily. Restriction on communication between a child in care and his or her legal guardian may not be
a condition of participation in the program. (B) A child-caring agency may place reasonable limits on communication, but only as provided in the child-caring
agency's policy. Reasonable limits include, but are not limited to, having set time periods during the day for visitation and phone calls and imposing moderate
limits on the duration of calls or visits. However, a limitation is not considered reasonable if it prevents the ability to meaningfully communicate, such as not
allowing contact with a child in care's attorney during regular business hours. (e) The child in care's right to file a grievance (as provided in section (2) of this rule)
if the child in care or family feels that they are treated unfairly or if they are not in agreement with the services provided. (f) The child in care's right to have
adequate (The policy was missing “adequate clothing”) and personally exclusive clothing. (g) The child in care's right to personal belongings. (h) The child in
care's right to an appropriate education.
 The above required information was missing from the polices submitted.
(2) Grievance Procedures. (a) A child-caring agency must enact and adhere to written procedures for the children in care and families the child-caring agency
serves to submit a grievance. The child-caring agency must provide the procedures to each child in care and family. The procedures must include all of the
following: (A) A process likely to result in a fair and expeditious resolution of a grievance. (B) A prohibition of reprisal or retaliation against any individual who
files a grievance. (C) A procedure to follow, in the event the grievance is filed against the executive director, that ensures that the executive director does not make
the final decision on the grievance. (D) The name, address, and phone number of: (i) A Department licensing coordinator; and (ii) Any other governmental entities
with oversight responsibilities. (b) Grievances and complaints filed with the child-caring agency and all information obtained in their resolution must be
maintained for a minimum of two years and provided to the Department upon request. (3) A child-caring agency serving children in care who are also in the care
or custody of the Department must: (a) Post and adhere to the Oregon Foster Children’s Bill of Rights in accordance with the requirements of OAR 413-010-0180
and comply with ORS 418.200 to 418.202; and (b) Have and adhere to a process for children in care in Department care or custody to make complaints consistent
with ORS 418.201(1). (c) Comply with the Oregon Foster Children's Sibling Bill of Rights in accordance with the requirements of OAR 413-010-0180 and comply
with ORS 418.607
 The above required information was missing from the polices submitted.
413-215-0056 Licensing Umbrella Rules: Policies and Procedures (Amended 1/1/19) (2) In addition to other policies and procedures required by these
rules, the policies and procedures in section (1) of this rule must include: (a) A written policy on mandatory child abuse reporting, consistent with ORS 418.257,
418.258, 419B.005, 419B.010, and 419B.015 that includes requirements that child-caring agency employees, staff, contractors, agents, and proctor foster parents
do all of the following: (A) Immediately report suspected child abuse directly to the Department via the child abuse reporting hotline. (C) Receive child-caring
agency-provided training on the definitions of child abuse in ORS 418.257 and 419B.005 that apply in child-caring agencies.
 The above required information must be added to the Mandatory Reporting of Child Abuse Policy.
 Additional edits to the policy needed:
o The Mandatory Reporting of Child Abuse policy on page 2 under Policy states,” In particular, Oregon statute requires employees of certain public
agencies to report situations where employees have reasonable cause to believe abuse has occurred. Reasonable cause could allow an employee
to make the determination of what is “reasonable or not.” The verbiage in the sentence should be replaced with “suspect abuse has occurred.”
o On Page 2 it is recommended that the Oregon Child Abuse State Hotline phone number should be added 1-855-503-7233. On page 5 B.2 states,
“The reporter will make an oral report to the local law enforcement agency or to DHS -CPS within the county where the reporter is located.” The
Oregon Child Abuse State Hotline phone number should be added 1-855-503-7233 to the policy. Currently, child abuse is reported to Child
Welfare through the 24-hour state hotline.
16
o Page 4 Number 3. States, “Failure to report suspected incidents of abuse, neglect or sexual assault may result in disciplinary action and or legal
consequences.” It is recommended to change the verbiage, “Mandatory Reporters failure to report child abuse could result in a class A Violation.”
413-215-0066 Privacy (Amended 06/29/18) (2) Except as provided in section (4) of this rule, a child-caring agency may not disclose any identifying
information of a child in care, including a picture, without first obtaining the written consent from the child's parents or legal guardians.
(3) A child-caring agency must ensure the privacy of all information that identifies a child in care or family the child-caring agency serves. A child-caring agency
may not disclose such information without proper written consent or as otherwise allowed by law.
 The Confidential Client Information Policy 1 E, stated the following “Client information was not confidential and may be released. 1. The date and time
and place of any juvenile court proceeding in which the juvenile is involved. 2. The juveniles address and names and address of juvenile’s parent or
guardian. 3. The name of the investigating and arresting agency. 4. The offense for which the juvenile was taken into custody. F. Any information
released to the media may only be released with the approval of the Director or Deputy Director.”
o The privacy policy must be changed to be in compliance with the above stated Licensing Rule.
413-215-0076 Licensing Umbrella Rules: Discipline, Behavior Management & Training, and Suicide Prevention (Excluding Adoption
Agencies) (Amended 02/01/2022)
(1) (b) The discipline and behavior management policies and procedures must prohibit the following: (B) Committing an act designed to…. degrade a child in care
or undermine the self-respect of a child in care. (H) Using any other kind of harsh punishment. (I) Denying a …. sibling the right to visit or communicate with a
child in care solely as a disciplinary measure against the child in care. (2) Discipline Policy. A child-caring agency must incorporate into the program’s care-giving
practices positive nonpunitive discipline and ways of helping a child in care build….self-esteem. (3) Behavior Management. (d) Training. (A) Only child-caring
agency staff who have been trained in a nationally recognized nonviolent crisis-intervention system consistent with OAR 413-215-0077 may use restraint or
involuntary seclusion and only, when necessary, as a last resort to prevent a child in care from inflicting harm to self or others. (e) Review. The policies of the
child-caring agency must require that whenever a restraint is used on a child in care more than two times in seven days, there is a review by the executive director,
the director's designee, or a management team to determine the suitability of the program for the child in care, whether modifications to the child in care's plan are
warranted, and whether staff need additional training in alternative therapeutic behavior management techniques. The child-caring agency must take appropriate
action indicated by the review.
 The above required information was missing from the polices submitted.
\
(4) Suicide Prevention. The policy must include the following: (b) Warning signs of suicide; (d) Training requirements for staff, including suicide prevention
training and suicide risk assessment tool training; (h) A process for tracking suicide behavioral patterns.
 The above required information was missing from the polices submitted.
413-215-0077 Licensing Umbrella Rules: Restraints and Involuntary Seclusion (Adopted 02/01/2022) (1) A child-caring agency may only place child
in care in a restraint or involuntary seclusion if the child in care’s behavior poses a reasonable risk of imminent serious bodily injury to the child in care or others
and less restrictive interventions would not effectively reduce the risk. (2) A child-caring agency may not place a child in care in a restraint or involuntary
seclusion as a form of discipline, punishment, or retaliation or for the convenience of staff, contractors or volunteers of the child-caring agency. (3) If the child-
caring agency utilizes restraints or involuntary seclusion as part of its practices, its use of restraints and involuntary seclusion must be in compliance with all
applicable federal and state laws, regulations and rules. (4) A child in care placed in a restraint or involuntary seclusion must be continuously monitored by staff of
the child-caring agency for the duration of the restraint or involuntary seclusion. (5) Any restraint or involuntary seclusion used on a child in care must be
performed in a manner that is safe, proportionate and appropriate, taking into consideration the child in care’s chronological and developmental age, size, gender
identity, physical, medical and psychiatric condition and personal history, including any history of physical or sexual abuse. `(6) If any restraint or involuntary
seclusion lasts for more than 10 minutes, the child-caring must provide adequate access to the bathroom and water at least every thirty minutes to the child in care.
17
(7) For any restraint or involuntary seclusion lasting more than 10 minutes a supervisor, trained in the non-violent crisis intervention system used by the child-
caring agency must provide written authorization for the continuation of the restraint or involuntary seclusion every five minutes. (a) If the supervisor is not on-site
at the time the restraint is used, the supervisor may provide the written authorization electronically. (b) The written authorization must document why the restraint
or involuntary seclusion continues to be the least restrictive intervention to reduce the risk of imminent serious bodily injury in the given circumstances. (8)
Restraint. (a) The following types of restraint of a child in care are prohibited: (C) Prone restraint. (D) Supine restraint, (E) Any restraint that includes the
nonincidental use of a solid object, including the ground, a wall or the floor, to impede a child in care’s movement, except: (i) This type of restraint may be used if
the restraint is necessary to gain control of a weapon or; (F) Any restraint that places or creates a risk of placing pressure on a child in care’s neck or throat. (G)
Any restraint that places or creates a risk of placing, pressure on a child in care’s mouth, except: (i)This type of restraint may be used if the restraint is necessary
for the purpose of extracting a body part from a bite. (H) Any restraint that impedes, or creates a risk of impeding, a child in care’s breathing. (I) Any restraint that
involves the intentional placement of hands, feet, elbows, knees or any object on a child in care’s neck, throat, genitals or other intimate parts. (J) Any restraint that
causes pressure to be placed or creates a risk of causing pressure to be placed, on a child in care’s stomach, chest, joints, throat or back by a knee, foot or elbow.
(K) Any other restraint which the primary purpose is to inflict pain. (b) Permissible use of restraint. A restraint may be used on a child in care in the following
situations: (A) Holding a child in care’s hand or arm to escort the child in care safely and without the use of force from one area to another; (B) Assisting the child
in care to complete a task if the child in care does not resist the physical contact; or (C) Using a physical intervention if: (i) The intervention is necessary to break
up a physical fight or to effectively protect a person from an assault, serious bodily injury or sexual contact; (ii) The intervention uses the least amount of physical
force and contact possible: and (iii) The intervention is not a prohibited restraint identified in OAR 413-215-0077(8)(a) (c) Only child-caring agency staff and
proctor foster parents who have been trained in a nationally recognized nonviolent crisis-intervention system may use restraint and only when necessary as a last
resort to prevent a child in care from inflicting harm to self or others. The restraint must be conducted within the parameters of the nationally recognized system in
which the staff or proctor foster parent is trained. (d) Any use of restraint by a staff member of the child-caring agency, if the member is not trained in a nationally
recognized nonviolent crisis intervention system, must also be reported to a Department licensing coordinator within one business day of occurrence. (10) Records
(a) A program shall maintain a record of each incident in which a reportable injury arises from the use of a restraint or involuntary seclusion. The record must
include any audio or video recording immediately preceding, during and following the incident. (b) If a program places a child in care in a restraint, except as
described in OAR 413-215-0077(8)(b)(A) or 413-215-0077(8)(b)(B) or involuntary seclusion, the program shall provide the child in care’s case manager, attorney,
court appointed special advocate and parent or guardian with: (A) Verbal or electronic notice that the restraint or involuntary seclusion was used as soon as
practicable following the incident but not later than the end of the next business day; and (B) Written notice in compliance with OAR 413-215-0077(10)(c) that the
restraint or involuntary seclusion was used as soon as practicable following the incident but not later than the end of the next business day. (c) The written notice
must include:(A) A description of the restraint or involuntary seclusion, the date of the restraint or involuntary seclusion, the times when the restraint or
involuntary seclusion began and ended and the location of the restraint or involuntary seclusion; (B) A description of the child in care’s activity that necessitated
the use of restraint or involuntary seclusion; (C) The efforts the program used to de-escalate the situation and the alternatives to restraint or involuntary seclusion
the program attempted before placing the child in care in the restraint or involuntary seclusion; (D) The names of each of individual who placed the child in care in
the restraint or involuntary seclusion or who monitored or approved the placement of the child in care in the restraint or involuntary seclusion; (i) For each
individual identified whether the individual was trained, as required by the Department of Human Services by rule, in the use of the type of restraint or involuntary
seclusion used, the date of the individual’s most recent training and a description of the types of restraint the individual is trained to use, if any. (ii) If an individual
identified was not trained in the type of restraint or involuntary seclusion used, or if the individual’s training was not current, a description of the individual’s
training deficiency and the reason an individual without the proper training was involved in the restraint or involuntary seclusion. (d) If an incident requires notice
under 413-215-0077(b), not later than two business days following the date of the restraint or involuntary seclusion, the program shall hold a debriefing meeting
with each individual who was involved in the incident and with any other appropriate program staff, shall take written notes of the debriefing meeting and shall
provide copies of the written notes to the child in care’s case manager, attorney, court appointed special advocate and parents or guardians. (e) If a program places
a child in care in a restraint or involuntary seclusion and the child in care suffers a reportable injury arising from the restraint or involuntary seclusion, the program
shall immediately provide the department and the child in care’s attorney, court appointed special advocate and parents or guardians with written notification of the
incident and access to and, upon request, copies of all records related to the restraint or involuntary seclusion, including any photographs and audio or video
18
recordings.(f) If serious bodily injury or the death of staff occurs in connection to the use of the restraint or involuntary seclusion, the program shall provide the
department with written notification of the incident not later than 24 hours following the incident. (11) Reporting Requirements (a) A child caring agency must
submit a report to the Department on a quarterly basis that includes at a minimum: (A) The total number of incidents involving restraint. (B) The total number of
incidents involving involuntary seclusion. (C) The total number of involuntary seclusions in a locked room. (D) The total number of rooms available for use by the
program for involuntary seclusion and a description of the dimensions and design of the rooms. (E) The total number of children in care placed in restraint. (F) The
total number of children in care placed in involuntary seclusion. (G) The total number of incidents under paragraph (A) or (B) of this subsection that resulted in
reportable injuries. (H) The number of children in care who were placed in restraint or involuntary seclusion more than three times during the preceding three-
month period and a description of the steps the program has taken to decrease the use of restraint and involuntary seclusion. (I) The number of incidents in which
an individual who placed a child in care in a restraint or involuntary seclusion was not trained, as required by the department by rule, in the use of the type of
restraint or involuntary seclusion used. (J) The demographic characteristics of the children in care who the program placed in a restraint or involuntary seclusion,
including race, ethnicity, gender, disability status, migrant status, English proficiency and status as economically disadvantaged, unless the demographic
information would reveal personally identifiable information about an individual child in care. (b) If a child caring agency provides services in more than one
location, the reports required under subsection 413-215-0077(11)(a) must separate the data for each location that serves five or more children in care. (c) If a child
caring agency provides services to four or fewer children in care at a location, the location specific data must include a notation indicating the aggregate number of
children in care served by the child caring agency across all of its locations and the reporting requirements continue to apply to any of the child care agency’s other
locations serving five or more children in care. (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 Child Caring Agency’s main office and on the child caring agency’s website if applicable. (e) Each child caring agency shall provide
notice regarding how to access the quarterly reports to the parents or guardians of children in care in the program. The child caring agency shall provide the notice
upon the child in care’s admission and at least two times each year thereafter.
 The above required information was missing from the polices submitted.
413-215-0546 Health Services (Technical Amended 01/13/20) (5) A residential care agency must have written procedures for accessing routine and urgent
medical care for children in care, including obtaining necessary consents.
 The Administration of Medication and Medical Care policy was missing how the agency would obtain necessary consents.
413-215-0551 Medication (Technical Amended 01/13/20) A residential care agency must meet all of the following requirements: (1) Policy and procedures.
The residential care agency must have policies and procedures that cover all prescription and non-prescription medications that address all of the following: (c)
How the staff of the residential care agency who administer medication will be trained. (f) How unused medication will be disposed of.
(g) The process that ensures that each child in care's prescription and non-prescription medications are reviewed, unless the medications are all provided through a
single pharmacy. As used in this rule, "non-prescription medication" means any medication that does not require a written prescription for purchase or dispensing
and includes the use of any herbal remedies or supplements.
 The above required information was missing from the polices submitted.
413-215-0541 Residential Care Agencies: Safety (Amended 1/1/19) A residential care agency must meet all of the following requirements related to safety:
(2) Emergency plan. (a) The residential care agency must have, for each facility it operates, a written emergency plan that includes: (A) Instructions for evacuation
of children in care and employees in the event of fire, explosion, accident, or other emergency.
(B) Instructions for response in the event of a natural disaster, external safety threat, or other emergency.
 The above required information was missing from the polices submitted.
19
413-215-0576 Consents, Disclosures, and Authorizations (Amended 02/01/2022) (a) To provide routine and emergency medical care. However, if the
parent or legal guardian relies on prayer or spiritual means for healing in accordance with the creed or tenets of a well-recognized religion or denomination, the
residential care agency is not required to use medical, psychological or rehabilitative procedures, unless the child in care is old enough to consent to these
procedures and does so. The residential care agency must have policies and procedures for this practice, which are reviewed and approved by the child in care's
parent or legal guardian.
 The above required information was missing from the polices submitted.
Licensing Coordinator’s Signature: ________________________ Date: _6_/2_8_/_2_0_2_2_ __________
Manager Review: ______________________________________ Date: _6_/2_1_/_2_0_2_2_ _________
20

facility_type: Residential Care

program_services: Residential Services

capacity_age_range: 25, male and female ages 12-17

average_length_of_stay: 90 days

average_daily_population_served: 10-15 youth

number_of_children_served_annually: 60-70 youth

interviews_observations:
Interviews: During the review Jose Miranda, Program Director, and Cynthia Navarro, Case Manager, were informally interviewed, as they assisted
with the walk through of the facility. At the time of the review the youth where at school and not available to be interviewed. Three youth were
privately interviewed on the phone on May 17, 2022, by Holly Ivey, Licensing Coordinator. When asked what they appreciated most about the GAP
Program the youth reported:" The staff are teaching me skills, the activities and outings are pretty fun, hanging out with people in the program,
playing basketball, and football, everyone is respectful, staff help us out if we need anything." All youth reported getting enough food at the program
and daily snacks. All youth reported having daily private phone contact with their approved contacts. The youth reported the following recreational
activities: "Playing basketball, and soccer, going to the clubhouse (an area in the program that has a video gaming system, fuse ball and other
games), going on outings, going to parks as a group." Two of the three youth reported hygiene products were provided by the program if they
needed them. One youth stated, "Hygiene products had to be earned." (The DHS Licensing Coordinator spoke with Jose Miranda, Program
Director, after the youth interview, he stated, "Hygiene products are available if youth have a need for them, and it is not a requirement to earn
them." He stated, "This would be something he would speak to staff about being clearer with youth about.") When the youth were asked what they
would change about the program, they reported: "Everyone can have more outings, different varieties of food we mostly get the same stuff, to have
better food even though the food is good, more choices." All youth reported feeling respected by staff and safe at the program.
Observations: A walk through tour was conducted of the program in all areas where youth are allowed access. The program was well kept and
observed to be clean and in good repair. Youth have a daily chore assigned to assist with the cleaning of the program. A contracted agency in the
Marion County Detention Facility is responsible for all meals, which are prepared in the detention facilities kitchen. Meals are brought from
detention to the GAP Program. The DHS Licensing Coordinator did not observe the detention's kitchen. The GAP Program has a kitchen that staff
uses to make snacks and teach life skills with the youth. The kitchen at the GAP Program was clean and in good repair. The DHS Licensing
Coordinator observed food in the refrigerator, and snacks in the cupboards for the youth. The DHS Licensing Coordinator observed two vans that
staff use to transport youth in the program. There were no deficiencies observed with the vehicles.

program_strengths:
The following strengths were identified by the Program Director at the time of the review:
- DBT based skills groups to help youth identify ways to make lasting change in their lives.
- A tenured staff that is skilled in building rapport with youth
- Program offers many outings to youth
- Supported by partnering Juvenile Department programs such as: Education Services; Probation Services; and Mental Health counseling.

program_challenges:
The following strengths were identified by the Program Director at the time of the review:
- Creating successful aftercare once youth is discharged from the program.
2
- Adapting to the increasing needs of the youth (Mental Health issues, drug and alcohol dependency; and trauma informed care) to best serve
them while running a structured program.
- Covid-19 related issues and protocols.
- Decreased relief staff pool.

changes_in_last_two_years:
The following changes were identified by the Program Director at the time of the review:
- Covid-19 pandemic related issues and protocol.
- Revising how youth and families orient to the program.
- Looking for more activities to fill out the daily schedule.

exceptions:
Two exceptions were requested and approved during the Licensing Renewal Process.
1. OAR 413-215-0566(1)(b) a residential care agency must obtain written approval from the parent or legal guardian and the licensing
coordinator before two children in care may share a room when one of the children in care is 18 years of age or older.
- Information provided to Licensing: Prior to entering the program, all youth and families were informed about the possibility of their child
sleeping in the same dorm with a non-minor child. They all consented with written approval.
DHS Licensing approved the exception until June 30, 2024.
2. OAR 413-215-0516 (3)(e) Have a minimum of 60 square feet per bed. (i)(A) There must be at least three feet between beds.
- Information provided to Licensing: The program has a dorm setting with bunk beds set up for optimal viewing of staff. The youth have
more than enough living space outside of the dorm to move around the program freely during waking hours.
DHS Licensing approved the exception until June 30, 2024.

changes_in_license:
No changes
3

excerpt:
All required policies and procedures as
identified in the “Umbrella Rules” Supplemental Information Provided by CCA All required
policies and procedures as identified in the “Umbrella Rules”
 *Required policy revisions are stated in detail at the
end of the report.

excerpt:
All required policies and procedures as
identified in “Agency Type Specific Rules” Supplemental Information Provided by CCA All required
policies and procedures as identified in “Agency Type
Specific Rules”
 *Required policy revisions are stated in detail at the
end of the report.

excerpt: (e) Minimum 60 SF per bed

excerpt:
(i) Beds are 3 feet apart and maintained to
ensure safety

excerpt:
(9) Written record of the disposal of
medications is maintained and includes:
(a) description and amount
(b) name
(c) reason
(d) method
(e) staff & witness signature

excerpt:
Designated staff authorized
to apply reasonable and prudent parent
standard are trained in application of the
standard Consents 413-215-0576(1) (c) Use restraint or seclusion
Must specify the reasons for the intervention and how staff
are trained and supervised
 The consents being utilized were missing the above
required information.
 On May 25, 2022, Jose Miranda, Program Manager,
sent Holly Ivey, Licensing Coordinator, a revised

excerpt:
(c) Use restraint or seclusion (if applicable).
Must specify the reasons for the intervention
and how staff are trained and supervised

excerpt:
Records contain date, amount, source,
purpose, signatures Financial Records 413-215-0581(4) Records contain…
source, purpose
 The financial records forms being utilized did not
have the above required information.


state: OR

facility_name: Marion County GAP Program

summary: Unannounced - 12 findings

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Licensee: Marion County GAP Program
Executive Director: Troy Gregg
Program Director(s): Jose Miranda
Date of Unannounced: November 7, 2022
Licensing Coordinator: Holly Ivey
Other Regulatory or Accrediting Agencies: Oregon Youth Authority
Purpose: Per OAR 413-215-0101 (1) (b) Children’s Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Comments
Findings
Further Action
Needed
Supplemental Information Provided by Yes☐ No Supplemental Information Provided by CCA All required policies and procedures as
CCA All required policies and procedures as identified in the “Umbrella Rules”
identified in the “Umbrella Rules”  *Required policy revisions are stated in detail at the end of the report.
 *Required policy revisions are stated Policy revisions were approved by Holly Ivey, Licensing Coordinator with the
in detail at the end of the report. Plan of Correction from the March 12, 2022, Licensing Review.
Supplemental Information Provided by Yes☐ No Supplemental Information Provided by CCA All required policies and procedures as
CCA All required policies and procedures as identified in “Agency Type Specific Rules”
identified in “Agency Type Specific Rules”  *Required policy revisions are stated in detail at the end of the report.
 *Required policy revisions are stated Policy revisions were approved by the Licensing Coordinator with the Plan
in detail at the end of the report. of Correction from the March 12, 2022, Licensing Review.
Room and Space Requirements Bedrooms Yes☐ No Room and Space Requirements Bedrooms 413-215-0516(3) (d) Ceiling at least 90
413-215-0516(3) (d) Ceiling at least 90 inches(i) Beds are 3 feet apart and maintained to ensure safety
inches(i) Beds are 3 feet apart and maintained An exception was granted by DHS Licensing, regarding the above stated rule and
to ensure safety will be in effect until June 30, 2024.
1
(rev. 07/21/2022)
An exception was granted by DHS Licensing,
regarding the above stated rule and will be in
effect until June 30, 2024. See above in the
exception section for more detail. There is
nothing further that needs to be sent to
Licensing regarding the findings.
Medication 413-215-0551 (9) Written record Yes☐ No Medication 413-215-0551 (9) Written record of the disposal of medications is maintained
of the disposal of medications is maintained and includes: (d) method
and includes: (d) method  At the time of the review, nursing staff were utilizing an old disposal form that did
 At the time of the review, nursing staff not have the above required information.
were utilizing an old disposal form  On 6.7.2022, Jose Miranda, Program Director, sent an email to Holly Ivey,
that did not have the above required Licensing Coordinator, stating that he added a footer to the disposal log to ensure
information. that staff utilize the most recent disposal form, and he disposed of the old form.
 On 6.7.2022, Jose Miranda, Program Jose Miranda sent a disposal log to the Licensing Coordinator that will be utilized
Director, sent an email to Holly Ivey, that meets all the required Licensing Rules. There is nothing further that needs to
Licensing Coordinator, stating that he be sent to Licensing regarding this finding. DHS Licensing will monitor ongoing
added a footer to the disposal log to compliance at the 2022, Unannounced Site Inspection.
ensure that staff utilize the most At the Unannounced Licensing Inspection on November 7, 2022, the
recent disposal form, and he disposed Licensing Coordinator, observed the medication disposal log being utilized
of the old form. Jose Miranda sent a and verified that it met the above stated rule requirement.
disposal log to the Licensing
Coordinator that will be utilized that
meets all the required Licensing
Rules. There is nothing further that
needs to be sent to Licensing
regarding this finding. DHS Licensing
will monitor ongoing compliance at
the 2022, Unannounced Site
Inspection.
REPEAT FINDING FROM JUNE 2,
2021
Ongoing Training 413-215-0556(4) Yes☐ No Ongoing Training 413-215-0556(4) Designated staff authorized to apply reasonable and
Designated staff authorized to apply prudent parent standard are trained in application of the standard.
reasonable and prudent parent standard are  Verification of the above required training was missing in some of the personnel
trained in application of the standard. files reviewed.
 Verification of the above required On June 8, 2022, Jose Miranda, Program Manager, sent an email to Holly Ivey,
training was missing in some of the Licensing Coordinator, confirming that staff had received the required Prudent
personnel files reviewed. Parent Training. (One relief staff will be trained later as she is taking several
 On June 8, 2022, Jose Miranda, months off.) There is nothing further that needs to be sent to Licensing regarding
Program Manager, sent an email to this finding. DHS will monitor ongoing compliance at the 2022, Unannounced Site
Holly Ivey, Licensing Coordinator, Inspection.
confirming that staff had received the The Licensing Coordinator received verification on November 8, 2022, via
required Prudent Parent Training. email from Jose Miranda, Program Supervisor, that all the program staff
(One relief staff will be trained later as
2
she is taking several months off.) (including the above-mentioned staff whose training was 7.11.22) received
There is nothing further that needs to the required annual training.
be sent to Licensing regarding this
finding. DHS will monitor ongoing
compliance at the 2022,
Unannounced Site Inspection.
Consents 413-215-0576(1) (c) Use restraint Yes☐ No Consents 413-215-0576(1) (c) Use restraint or seclusion Must specify the reasons for the
or seclusion Must specify the reasons for the intervention and how staff are trained and supervised
intervention and how staff are trained and  The consents being utilized were missing the above required information.
supervised On May 25, 2022, Jose Miranda, Program Manager, sent Holly Ivey, Licensing
 The consents being utilized were Coordinator, a revised GAP Voluntary Placement Agreement. The Placement
missing the above required Agreement included a consent that was modified to include all the above required
information. information. The consent meets the Licensing Rule requirement. There is nothing
 On May 25, 2022, Jose Miranda, further that needs to be sent to Licensing regarding this finding. DHS will monitor
Program Manager, sent Holly Ivey, ongoing compliance at the 2022, Unannounced Site Inspection.
Licensing Coordinator, a revised GAP At the Unannounced Licensing Inspection on November 7, 2022, the
Voluntary Placement Agreement. Licensing Coordinator observed the consents being utilized and verified the
The Placement Agreement included a above stated rule requirement was being met.
consent that was modified to include
all the above required information.
The consent meets the Licensing
Rule requirement. There is nothing
further that needs to be sent to
Licensing regarding this finding. DHS
will monitor ongoing compliance at
the 2022, Unannounced Site
Inspection.
Authorizations 413-215-0576(3) (c) Yes☐ No Authorizations 413-215-0576(3) (c) Visitation resources are pre-approved
Visitation resources are pre-approved  Authorizations reviewed lacked verification of approval by the guardians for
 Authorizations reviewed lacked visitation resources.
verification of approval by the On May 19, Jose Miranda, Program Manager sent Holly Ivey, Licensing
guardians for visitation resources. Coordinator, a revised GAP Screening Form that had a line for guardian approval
 On May 19, Jose Miranda, Program of visitor contacts. This meets the Licensing Rule requirements. There is nothing
Manager sent Holly Ivey, Licensing further that needs to be sent to Licensing regarding this finding. DHS will monitor
Coordinator, a revised GAP ongoing compliance at the 2022, Unannounced Site Inspection.
Screening Form that had a line for At the Unannounced Licensing Inspection on November 7, 2022, the
guardian approval of visitor contacts. Licensing Coordinator observed the authorization being utilized and verified
This meets the Licensing Rule the above stated rule requirement was being met.
requirements. There is nothing
further that needs to be sent to
Licensing regarding this finding. DHS
will monitor ongoing compliance at
3
the 2022, Unannounced Site
Inspection.
Financial Records 413-215-0581(4) Yes☐ No Financial Records 413-215-0581(4) Records contain… source, purpose
Records contain… source, purpose The financial records forms being utilized did not have the above required
 The financial records forms being information.
utilized did not have the above At the Unannounced Licensing Inspection on November 7, 2022, the
required information. Licensing Coordinator observed the financial records being utilized and
verified the above stated rule requirement was being met.
New Findings from Site Visit Comments
N/A
Interview Summary
During the unannounced inspection Jose Miranda, Program Director, was informally interviewed, as he assisted with the walk through of the
facility. At the time of the inspection the youth where at school and not available to be interviewed. Two youth were privately interviewed on the
phone on November 8, 2022, by Holly Ivey, Licensing Coordinator. When asked what they appreciated most about the GAP Program the youth
reported: “The kind staff, they’re pretty nice, they help. They give us everything we need, food and everything.” Both of the youth shared that
they get enough food at the program and are provided daily snacks. Both of the youth shared having daily private phone contact with their
approved contacts. The youth reported the following recreational activities: “Playing basketball, and cards, kickball and little games, going to a
church to play in their gym, playing on the computer, and going on outings.” The youth shared that hygiene products were provided by the
program if they needed them. When the youth were asked what they would change about the program, they reported: “Probably better food,
they would let us watch YouTube, the other kids being respectful to each other.” Both youth shared that they felt safe at the program. When
asked if they felt respected by staff at the program, one youth stated, “Yes of course.” One youth shared a disrespectful comment that he had
heard that a staff member had said to two other youth in the program, which the Licensing Coordinator called into the Child Abuse Hotline on
November 8, 2022. The DHS Licensing Coordinator spoke with Jose Miranda, Program Director, after the youth interview, and told him that she
called the information into the hotline. OTIS Screening did not assign the concern. After the screening decision was made Jose Miranda,
addressed the concern with the staff, and retrained staff on the Departments Code of Conduct.
4
Observations
A walk-through inspection was conducted of the program in all areas where youth were allowed access. The program was well kept and
observed to be clean and in good repair. A contracted agency that works in the Marion County Detention Facility is responsible for all meals for
the GAP Program, which are prepared in the detention facilities kitchen. Meals are brought from the detention center to the GAP Program. The
DHS Licensing Coordinator walked through and observed the Marion County Detention Center’s Kitchen where food is stored and prepared for
the youth at the GAP Program. The DHS Licensing Coordinator observed food in the refrigerator, and pantry. The DHS Licensing Coordinator
observed two vans that staff use to transport youth in the program. There were no deficiencies observed with the vehicles.
Corrective Actions and Timeframes:
Please submit the following to verify compliance.
Within 45 days of receipt of this report Marion County GAP Program, must submit a letter of verification indicating the agency is in compliance
with the specific rules cited above and describing how compliance will be maintained going forward. Along with the letter of verification, the agency
must submit any and all specific documentation requested in the body of this report. The letter of verification and any additional requested
documents can be emailed directly to the Licensing Coordinator, Holly Ivey: Hollyr.ivey@dhsoha.state.or.us
Licensing Coordinator’s Signature: ________________________ Date: _1_2_-_2_-2_0__2_2__________
Manager Review: ______________________________________ Date: _1_2_-_2_-2__0_2_2_ ________
5

agency_name: Marion County Juvenile Department (MARIONCJD)

program_name: GAP

program_type: (RC) Residential Care Programs

report_type: Unannounced

view_code: RC

licensee: Marion County GAP Program

executive_director: Troy Gregg

program_director: Jose Miranda

visit_date: November 7, 2022

licensing_coordinator: Holly Ivey

other_regulatory_agencies: Oregon Youth Authority

purpose:
Per OAR 413-215-0101 (1) (b) Children's Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Comments
Findings
Further Action
Needed
Supplemental Information Provided by Yes[ ] No Supplemental Information Provided by CCA All required policies and procedures as
CCA All required policies and procedures as identified in the "Umbrella Rules"
identified in the "Umbrella Rules" - *Required policy revisions are stated in detail at the end of the report.
- *Required policy revisions are stated Policy revisions were approved by Holly Ivey, Licensing Coordinator with the
in detail at the end of the report. Plan of Correction from the March 12, 2022, Licensing Review.
Supplemental Information Provided by Yes[ ] No Supplemental Information Provided by CCA All required policies and procedures as
CCA All required policies and procedures as identified in "Agency Type Specific Rules"
identified in "Agency Type Specific Rules" - *Required policy revisions are stated in detail at the end of the report.
- *Required policy revisions are stated Policy revisions were approved by the Licensing Coordinator with the Plan
in detail at the end of the report. of Correction from the March 12, 2022, Licensing Review.
Room and Space Requirements Bedrooms Yes[ ] No Room and Space Requirements Bedrooms 413-215-0516(3) (d) Ceiling at least 90
413-215-0516(3) (d) Ceiling at least 90 inches(i) Beds are 3 feet apart and maintained to ensure safety
inches(i) Beds are 3 feet apart and maintained An exception was granted by DHS Licensing, regarding the above stated rule and
to ensure safety will be in effect until June 30, 2024.
1

An exception was granted by DHS Licensing,
regarding the above stated rule and will be in
effect until June 30, 2024. See above in the
exception section for more detail. There is
nothing further that needs to be sent to
Licensing regarding the findings.
Medication 413-215-0551 (9) Written record Yes[ ] No Medication 413-215-0551 (9) Written record of the disposal of medications is maintained
of the disposal of medications is maintained and includes: (d) method
and includes: (d) method - At the time of the review, nursing staff were utilizing an old disposal form that did
- At the time of the review, nursing staff not have the above required information.
were utilizing an old disposal form - On 6.7.2022, Jose Miranda, Program Director, sent an email to Holly Ivey,
that did not have the above required Licensing Coordinator, stating that he added a footer to the disposal log to ensure
information. that staff utilize the most recent disposal form, and he disposed of the old form.
- On 6.7.2022, Jose Miranda, Program Jose Miranda sent a disposal log to the Licensing Coordinator that will be utilized
Director, sent an email to Holly Ivey, that meets all the required Licensing Rules. There is nothing further that needs to

interview_summary:
During the unannounced inspection Jose Miranda, Program Director, was informally interviewed, as he assisted with the walk through of the
facility. At the time of the inspection the youth where at school and not available to be interviewed. Two youth were privately interviewed on the
phone on November 8, 2022, by Holly Ivey, Licensing Coordinator. When asked what they appreciated most about the GAP Program the youth
reported: "The kind staff, they're pretty nice, they help. They give us everything we need, food and everything." Both of the youth shared that
they get enough food at the program and are provided daily snacks. Both of the youth shared having daily private phone contact with their
approved contacts. The youth reported the following recreational activities: "Playing basketball, and cards, kickball and little games, going to a
church to play in their gym, playing on the computer, and going on outings." The youth shared that hygiene products were provided by the
program if they needed them. When the youth were asked what they would change about the program, they reported: "Probably better food,
they would let us watch YouTube, the other kids being respectful to each other." Both youth shared that they felt safe at the program. When
asked if they felt respected by staff at the program, one youth stated, "Yes of course." One youth shared a disrespectful comment that he had
heard that a staff member had said to two other youth in the program, which the Licensing Coordinator called into the Child Abuse Hotline on
November 8, 2022. The DHS Licensing Coordinator spoke with Jose Miranda, Program Director, after the youth interview, and told him that she
called the information into the hotline. OTIS Screening did not assign the concern. After the screening decision was made Jose Miranda,
addressed the concern with the staff, and retrained staff on the Departments Code of Conduct.
4

observations:
A walk-through inspection was conducted of the program in all areas where youth were allowed access. The program was well kept and
observed to be clean and in good repair. A contracted agency that works in the Marion County Detention Facility is responsible for all meals for
the GAP Program, which are prepared in the detention facilities kitchen. Meals are brought from the detention center to the GAP Program. The
DHS Licensing Coordinator walked through and observed the Marion County Detention Center's Kitchen where food is stored and prepared for
the youth at the GAP Program. The DHS Licensing Coordinator observed food in the refrigerator, and pantry. The DHS Licensing Coordinator
observed two vans that staff use to transport youth in the program. There were no deficiencies observed with the vehicles.

previous_findings:
Repeat Comments
Findings
Further Action
Needed
Supplemental Information Provided by Yes[ ] No Supplemental Information Provided by CCA All required policies and procedures as
CCA All required policies and procedures as identified in the "Umbrella Rules"
identified in the "Umbrella Rules" - *Required policy revisions are stated in detail at the end of the report.
- *Required policy revisions are stated Policy revisions were approved by Holly Ivey, Licensing Coordinator with the
in detail at the end of the report. Plan of Correction from the March 12, 2022, Licensing Review.
Supplemental Information Provided by Yes[ ] No Supplemental Information Provided by CCA All required policies and procedures as
CCA All required policies and procedures as identified in "Agency Type Specific Rules"
identified in "Agency Type Specific Rules" - *Required policy revisions are stated in detail at the end of the report.
- *Required policy revisions are stated Policy revisions were approved by the Licensing Coordinator with the Plan
in detail at the end of the report. of Correction from the March 12, 2022, Licensing Review.
Room and Space Requirements Bedrooms Yes[ ] No Room and Space Requirements Bedrooms 413-215-0516(3) (d) Ceiling at least 90
413-215-0516(3) (d) Ceiling at least 90 inches(i) Beds are 3 feet apart and maintained to ensure safety
inches(i) Beds are 3 feet apart and maintained An exception was granted by DHS Licensing, regarding the above stated rule and
to ensure safety will be in effect until June 30, 2024.
1

An exception was granted by DHS Licensing,
regarding the above stated rule and will be in
effect until June 30, 2024. See above in the
exception section for more detail. There is
nothing further that needs to be sent to
Licensing regarding the findings.
Medication 413-215-0551 (9) Written record Yes[ ] No Medication 413-215-0551 (9) Written record of the disposal of medications is maintained
of the disposal of medications is maintained and includes: (d) method
and includes: (d) method - At the time of the review, nursing staff were utilizing an old disposal form that did
- At the time of the review, nursing staff not have the above required information.
were utilizing an old disposal form - On 6.7.2022, Jose Miranda, Program Director, sent an email to Holly Ivey,
that did not have the above required Licensing Coordinator, stating that he added a footer to the disposal log to ensure
information. that staff utilize the most recent disposal form, and he disposed of the old form.
- On 6.7.2022, Jose Miranda, Program Jose Miranda sent a disposal log to the Licensing Coordinator that will be utilized
Director, sent an email to Holly Ivey, that meets all the required Licensing Rules. There is nothing further that needs to
Licensing Coordinator, stating that he be sent to Licensing regarding this finding. DHS Licensing will monitor ongoing
added a footer to the disposal log to compliance at the 2022, Unannounced Site Inspection.
ensure that staff utilize the most At the Unannounced Licensing Inspection on November 7, 2022, the
recent disposal form, and he disposed Licensing Coordinator, observed the medication disposal log being utilized
of the old form. Jose Miranda sent a and verified that it met the above stated rule requirement.
disposal log to the Licensing
Coordinator that will be utilized that
meets all the required Licensing
Rules. There is nothing further that
needs to be sent to Licensing
regarding this finding. DHS Licensing
will monitor ongoing compliance at
the 2022, Unannounced Site
Inspection.
REPEAT FINDING FROM JUNE 2,
2021
Ongoing Training 413-215-0556(4) Yes[ ] No Ongoing Training 413-215-0556(4) Designated staff authorized to apply reasonable and
Designated staff authorized to apply prudent parent standard are trained in application of the standard.
reasonable and prudent parent standard are - Verification of the above required training was missing in some of the personnel
trained in application of the standard. files reviewed.
- Verification of the above required On June 8, 2022, Jose Miranda, Program Manager, sent an email to Holly Ivey,
training was missing in some of the Licensing Coordinator, confirming that staff had received the required Prudent
personnel files reviewed. Parent Training. (One relief staff will be trained later as she is taking several
- On June 8, 2022, Jose Miranda, months off.) There is nothing further that needs to be sent to Licensing regarding
Program Manager, sent an email to this finding. DHS will monitor ongoing compliance at the 2022, Unannounced Site
Holly Ivey, Licensing Coordinator, Inspection.
confirming that staff had received the The Licensing Coordinator received verification on November 8, 2022, via
required Prudent Parent Training. email from Jose Miranda, Program Supervisor, that all the program staff
(One relief staff will be trained later as
2
she is taking several months off.) (including the above-mentioned staff whose training was 7.11.22) received
There is nothing further that needs to the required annual training.
be sent to Licensing regarding this
finding. DHS will monitor ongoing
compliance at the 2022,
Unannounced Site Inspection.
Consents 413-215-0576(1) (c) Use restraint Yes[ ] No Consents 413-215-0576(1) (c) Use restraint or seclusion Must specify the reasons for the
or seclusion Must specify the reasons for the intervention and how staff are trained and supervised
intervention and how staff are trained and - The consents being utilized were missing the above required information.
supervised On May 25, 2022, Jose Miranda, Program Manager, sent Holly Ivey, Licensing
- The consents being utilized were Coordinator, a revised GAP Voluntary Placement Agreement. The Placement
missing the above required Agreement included a consent that was modified to include all the above required
information. information. The consent meets the Licensing Rule requirement. There is nothing
- On May 25, 2022, Jose Miranda, further that needs to be sent to Licensing regarding this finding. DHS will monitor
Program Manager, sent Holly Ivey, ongoing compliance at the 2022, Unannounced Site Inspection.
Licensing Coordinator, a revised GAP At the Unannounced Licensing Inspection on November 7, 2022, the
Voluntary Placement Agreement. Licensing Coordinator observed the consents being utilized and verified the
The Placement Agreement included a above stated rule requirement was being met.
consent that was modified to include
all the above required information.
The consent meets the Licensing
Rule requirement. There is nothing
further that needs to be sent to
Licensing regarding this finding. DHS
will monitor ongoing compliance at
the 2022, Unannounced Site
Inspection.
Authorizations 413-215-0576(3) (c) Yes[ ] No Authorizations 413-215-0576(3) (c) Visitation resources are pre-approved
Visitation resources are pre-approved - Authorizations reviewed lacked verification of approval by the guardians for
- Authorizations reviewed lacked visitation resources.
verification of approval by the On May 19, Jose Miranda, Program Manager sent Holly Ivey, Licensing
guardians for visitation resources. Coordinator, a revised GAP Screening Form that had a line for guardian approval
- On May 19, Jose Miranda, Program of visitor contacts. This meets the Licensing Rule requirements. There is nothing
Manager sent Holly Ivey, Licensing further that needs to be sent to Licensing regarding this finding. DHS will monitor
Coordinator, a revised GAP ongoing compliance at the 2022, Unannounced Site Inspection.
Screening Form that had a line for At the Unannounced Licensing Inspection on November 7, 2022, the
guardian approval of visitor contacts. Licensing Coordinator observed the authorization being utilized and verified
This meets the Licensing Rule the above stated rule requirement was being met.
requirements. There is nothing
further that needs to be sent to
Licensing regarding this finding. DHS
will monitor ongoing compliance at
3
the 2022, Unannounced Site
Inspection.
Financial Records 413-215-0581(4) Yes[ ] No Financial Records 413-215-0581(4) Records contain… source, purpose
Records contain… source, purpose The financial records forms being utilized did not have the above required
- The financial records forms being information.
utilized did not have the above At the Unannounced Licensing Inspection on November 7, 2022, the
required information. Licensing Coordinator observed the financial records being utilized and
verified the above stated rule requirement was being met.
New Findings from Site Visit Comments
N/A

excerpt:
413-215-0581(4) Records contain… source, purpose
Records contain… source, purpose The financial records forms being utilized did not have the above required
- The financial records forms being information.
utilized did not have the above At the Unannounced Licensing Inspection on November 7, 2022, the
required information. Licensing Coordinator observed the financial records being utilized and
verified the above stated rule requirement was being met.
New Findings from Site Visit Comments
N/A
N/A


summary: Unannounced - 05/09/2023

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Residential Program
Licensee: Marion County GAP Program
Executive Director: Troy Gregg
Program Director(s): Jose Miranda
Date of Unannounced: May 9, 2023
Licensing Coordinator: Holly Ivey
Other Regulatory or Accrediting Agencies: Oregon Youth Authority
Purpose: Per OAR 419-400-0240 (1)(b) Children’s Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Comments
Unannounced Site Visit 11/07/2023 – no Findings
findings Further Action
Needed
N/A There were no violations recorded at the time of the previous unannounced site visit
in 2022
New Findings from Site Visit Comments
N/A No violations were noted during this recent unannounced visit.
1 |P ag e
Form Rev. 01/23/2023
Interview Summary
Youth were in school during the Unannounced Inspection and unavailable to be interviewed. A phone call occurred with Holly Ivey, ODHS
Licensing Coordinator, and two youth on May 15, 2023. The two private interviews of youth consisted of the following information obtained:
 Both youth stated things were going well for them while residing at the program, and one youth stated they liked it there.
 When asked what they appreciated most about the program the youth stated: “I like the structure, I have the same schedule every day,
and I know what’s coming.” “Outings they take us on. “
 Fun activities reported by the youth: going to a church gym, playing basketball in the backyard, playing sports.
 Both youth mentioned that they receive three meals a day, and snacks are provided to them.
 The youth all stated they can call people on their approved contact list and talk privately daily twice a day.
 Both youth reported that the program provides hygiene products.
 Both youth reported that they could talk to staff if they had a concern or a need, and that they felt respected by staff.
 When asked what changes they would make to the program the youth stated: “Probably better tasting food and quality because its
detention food”
 Both youth reported feeling safe at the program.
 There were no concerns stated to the Licensing Coordinator in the interviews conducted.
Observations
At the Unannounced Inspection, the Program Director, Jose Miranda, and Assistant Program Director, Cynthia Ramos-Navarro, assisted with a
walk through with Holly Ivey, ODHS Licensing Coordinator. All areas of the programs (inside and outside) where youth had access were
observed to be well kept, clean and in good repair. The agency vehicles that the youth ride in were observed and met the requirements per
Licensing Rules. Both kitchen’s (in the Residential Program, and the Marion County Detention Center- where food is prepared and brought to
the youth) were observed to be clean and have food in the refrigerator and pantries. Medication was observed to be in a locked medication cart
which was inaccessible to youth. Youth were in school during the walk-through inspection and were not observed at the program.
Corrective Actions and Timeframes:
N/A there were no compliance issues or concerns found while conducting the Unannounced Inspection. There is nothing the agency needs to send
to ODHS Licensing regarding this inspection.
Licensing Coordinator’s Signature: ________________________ Date: _6_-_7_-2_3______________
Manager Review: ______________________________________ Date: _6_-_7_-2_0__2_3_ _________
2 | P a g e
Form Rev. 01/23/2023

facility_type: Residential Program

purpose:
Per OAR 419-400-0240 (1)(b) Children's Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Comments
Unannounced Site Visit 11/07/2023 - no Findings
findings Further Action
Needed
N/A There were no violations recorded at the time of the previous unannounced site visit
in 2022
New Findings from Site Visit Comments
N/A No violations were noted during this recent unannounced visit.

Interview Summary
Youth were in school during the Unannounced Inspection and unavailable to be interviewed. A phone call occurred with Holly Ivey, ODHS

interview_summary:
Youth were in school during the Unannounced Inspection and unavailable to be interviewed. A phone call occurred with Holly Ivey, ODHS
Licensing Coordinator, and two youth on May 15, 2023. The two private interviews of youth consisted of the following information obtained:
- Both youth stated things were going well for them while residing at the program, and one youth stated they liked it there.
- When asked what they appreciated most about the program the youth stated: "I like the structure, I have the same schedule every day,
and I know what's coming." "Outings they take us on. "
- Fun activities reported by the youth: going to a church gym, playing basketball in the backyard, playing sports.
- Both youth mentioned that they receive three meals a day, and snacks are provided to them.
- The youth all stated they can call people on their approved contact list and talk privately daily twice a day.
- Both youth reported that the program provides hygiene products.
- Both youth reported that they could talk to staff if they had a concern or a need, and that they felt respected by staff.
- When asked what changes they would make to the program the youth stated: "Probably better tasting food and quality because its
detention food"
- Both youth reported feeling safe at the program.
- There were no concerns stated to the Licensing Coordinator in the interviews conducted.

observations:
At the Unannounced Inspection, the Program Director, Jose Miranda, and Assistant Program Director, Cynthia Ramos-Navarro, assisted with a
walk through with Holly Ivey, ODHS Licensing Coordinator. All areas of the programs (inside and outside) where youth had access were
observed to be well kept, clean and in good repair. The agency vehicles that the youth ride in were observed and met the requirements per
Licensing Rules. Both kitchen's (in the Residential Program, and the Marion County Detention Center- where food is prepared and brought to
the youth) were observed to be clean and have food in the refrigerator and pantries. Medication was observed to be in a locked medication cart
which was inaccessible to youth. Youth were in school during the walk-through inspection and were not observed at the program.