state: OR

facility_name: Trillium Family Services - Parry Center (Portland Date of site visit: May 6th, 2025 Campus)

summary: Unannounced - 1 finding

raw_content:
Licensed Child Caring Agency Unannounced Site Visits Report
Licensee: Trillium Family Services- Children’s Farm Home campus
Executive Director: Jamie Vandergon
Date of Unannounced: 11-16-2023 and 11-29-2023
Licensing Coordinator: Aubrey Kelly (Licensing Coordinator Mary Torres also participated in the visit on 11/16/2023) Regulatory Manager Harry
Gilmore wrote this report using interview notes from the visits and other available information.
Other Regulatory or Accrediting Agencies: Oregon Health Authority, Health Systems Division (OHA Operations & Policy Analyst Carrie Wouda
participated in the visit on 11/29/2023)
Purpose: Per OAR 419-400-0240 (1)(b) Children’s Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Comments
September 2023 license renewal review Findings
Further Action
Needed
419-400-0100 (2) Licensing Umbrella Rules: Yes✓No☐ Excerpt from September 2023 license renewal report:
Resources Required. (2) A child-caring agency During staff interviews and subsequent record review, it was discovered one client was
must employ or contract for a sufficient unable to take a shower on two separate occasions in a two-week period due to an
number of competent and qualified insufficient number of staff. There were numerous notes that the client smelled and was
employees to perform the functions not clean. Furthermore, there was an incident in which a staff was in a physical
regulated by these rules and to provide altercation with a client in the backyard of a unit and called for staff support three times.
adequate care, safety, protection, and There were not enough staff on campus to respond to the call. It was reported by staff
supervision of the children in care and that low staffing is a constant issue. The program shall ensure a sufficient number of staff
families the child-caring agency serves. are on campus to provide adequate care, safety, protection and supervision of the clients
in care.
------------
Numerous interviews with children in care, care-giver personnel and supervisory
personnel were conducted during unannounced visits on November 16 and November 29.
Interviews are summarized below in the Interview Summary section of this report.
Interviewees reported a lack of staff to meet every child’s needs and experiencing
situations when a child or children are in crisis and there are not enough staff on campus
to respond to the crisis, despite requests for assistance and backup from other units.
Additionally, staff reported a child who is on “high risk” designation for shower
Form Rev. 11/14/2023 P age 1| 6
supervision had been denied showers multiple times due to lack of available staff to
support the supervision requirement.
Interviewees reported inconsistent availability outdoor recreation and off-campus
activities and an inability to provide prescribed treatment groups, and this was attributed
to not having sufficient personnel to provide these activities while also managing
residents’ behaviors, managing the milieu in general and providing 1:1 supervision to the
youth who require it.
On November 10, 2023, a child in Trillium’s Sequoia unit engaged in behavior that
required accountability and reflection. Sequoia staff on shift that evening were unable to
work with the child as needed due to lack of staffing and inexperienced staff. Evening
staff passed that task on to day staff, so the child was held accountable in the morning of
November 11, 2023. The child became extremely escalated, lodging homicidal threats,
kicking doors, windows, and people, and ultimately dysregulating other children in the
milieu alongside them. This resulted in the children overtaking the milieu and
sequestering staff in an observation booth. Staff called a local law enforcement agency for
assistance, but they declined to respond. Staff ultimately called 911 and officers
responded, allowing Trillium staff to regain control of the milieu.
----------
Trillium must create a plan and take steps to ensure that the number of trained staff
present at all times at the Farm Home is enough to manage youths’ behaviors, including
having staff available to reliably respond timely to calls for back-up support in a crisis.
The program must create a plan and take steps to ensure that treatment groups reliably
occur, that youth can reliably have access to outside recreation and the cafeteria, that
youth who are approved for off-campus activities have access to these activities, and that
all youth can reliably take showers, have scheduled snacks, make phone calls, and use the
bathroom without undue delay and have other needs reliably met without undue delay.
If there is not an existing method of measuring and tracking the things listed above, a
method must be developed to do so with a reasonable amount of specificity and
accuracy, including a method of tracking individual calls for back-up support, the response
to such calls and the timeliness of the response.
The program must include measures of employee morale, satisfaction and retention in
the program’s on-going quality improvement plan, if these are not already part of the QI
plan.
Form Rev. 11/14/2023 P age 2| 6
Other previous findings from the license Yes☐ No☐
renewal review in September 2023 will be
checked during later visits.
New Findings from Site Visit Comments
N/A
Interview Summary
Multiple youth in care and multiple Trillium employees were interviewed either in the course of the two separate site visits on 11/16 and 11/28 or via
subsequent phone calls.
Campus Operations Employee: Staffing on the weekends is difficult. Having 6 staff of swing feels like a solid team.
Employee at Sequoia: There aren’t enough staff, particularly on swing shift and weekends, and it’s stressful. A newer employee who was hired a month ago
is quitting.
Employee at Sequoia: Although not the job she was hired for, she’s been filling in as a skills trainer due to staff shortages. People are pulled from regular
duties to assist with youths’ behaviors. The staffing situation is the worst it’s been in three years. Management has stated there isn’t anything they can do
about the staffing shortage. She is concerned for her safety. On two occasions, when she called for support, no-one responded.
Program Supervisor: Staff to youth supervision ratio requirements are being met. There is staff turnover. They don’t have knowledge of circumstances that
had been reported prior to the unannounced visit, including employees not having breaks, no-one responding to employees’ requests for back-up to assist
with managing youth behaviors, youth not receiving meals and snacks or youth not having access to showers. The pass-along emails, which are a means of
summarizing important information and sharing it between shifts, are consistently occurring.
Employee at Sequoia: When youth are designated for heightened supervision, other work doesn’t get done. There are safety issues when there are not
enough personnel. When requesting staff support, it’s not always available. Staff have communicated their concerns about staffing levels to management
verbally and by email. Scheduled treatment groups don’t always happen, and this is due to not having enough staff. When they previously had contracted
temporary staff on site, staff could rely on back-up support when needed to manage youths’ behaviors, staff were able to reliably take scheduled breaks and
treatment groups were reliably occurring.
Campus Operations Employee: Feels more staff are needed in the Secure Adolescent Inpatient (SAIP) units. Youth are not always able to take showers.
Staff recruitment and retention needs improvement.
Employee at Sequoia: Feels there are not enough staff, and swing shift, in particular, has had staffing problems for months. The situation has been
exacerbated by the discontinuation of contracting for temporary personnel. Staff are burning out. Staff are able to take scheduled breaks approximately 50%
of the time on the shifts he works. Treatment groups are occurring on his shifts. He believes site supervisors understand the staffing concerns and have been
trying to address them. “Campus Ops” personnel are in the role that contracted temporary personnel used to occupy.
Form Rev. 11/14/2023 P age 3| 6
Employee at Redwood: Staffing is a problem. Things work well with 6 staff on duty, but they’ve been making do with 5. There was an instance of staff
responsible to 1:1 supervision of a youth having to leave to assist other staff. Staff are receiving scheduled breaks on the shifts he works. Back-up crisis
support isn’t reliably available when needed. It often not possible for youth to have time outside the facility due to insufficient staff levels. The situation was
better, and things were manageable when contracted temporary personnel were on site. Staff retention is a big problem.
Employee at Redwood: Used to enjoy the work, but doesn’t anymore due to staffing shortages, so is seeking other employment. Staff are being injured, and
a staff suffered a broken leg in a situation in which having additional staff available could have prevented it. The program has taken steps to improve
employee morale and retention, but these have been insufficient. High rates of turnover have resulted in employees with less experience occupying roles with
greater responsibility when compared to the level of experience that was required for similar roles in the past. Staff are receiving their scheduled breaks. Calls
for crisis support are not reliably answered. Staff retention is the biggest problem at the Farm Home.
Employee at Redwood: There are not enough staff to supervise the youth. On 2 recent occasions there was a request to end 1:1 supervision requirement for
two youth to free up staff, but this was not possible due to the ongoing needs of the youth receiving the heightened supervision. Calls for crisis support are
frequently unanswered when staff and youth are being attacked. Staffing levels were sufficient when contracted temporary staff were on site, but this has
been discontinued.
Employee at Sequoia: Has worked at Farm Home for between 4 and 5 months. Staffing is a problem. She is quitting, and one of her co-workers is quitting.
She believes staffing issues contributed to the recent incident in which staff lost control of the program and had to lock themselves in the observation booth
while waiting for law enforcement to respond. She feels a staffing-related delay in initiating a consequence for a particular youth’s behavior caused an
extreme reaction by the youth and the escalation of other youths in care. She feels Trillium’s recruitment efforts need improvement and that contracted staff,
who were previously brough in to assist, should be brought back. Staff are not getting breaks, and treatment groups aren’t happening reliably. Youth are
waiting a long time for snacks. Showers for a youth on high-risk aren’t happening. Outings have been curtailed. Sometimes no-one comes when there all
calls for support. Youth are not getting outside, and staff aren’t available to walk with youth to the cafeteria.
Employee at Redwood: Feels there are not enough staff to ensure safety of youth in care since contracted temporary staff were discontinued. The employe
stated they have been vocal about their concerns about low staffing. Youth are sometimes not getting showers. The previous week a particular youth had
requested a shower every day, but it couldn’t happen due to insufficient staff. Injuries to employees and youth have happened that could have been
prevented with adequate staff levels. On the Sunday preceding the day of the unannounced visit, staffing levels were low on all units. The employee
described an incident in which a physical restraint couldn’t be controlled due not having enough staff available. They talked about having suffered
concussions, and indicated this is not uncommon. Youth are not getting out of the facility due to low staffing. Calls for backup go unanswered, and physical
interventions can’t be implemented when circumstances warrant. Snacks and beverages are delayed or missed due to low staffing. Feels concerns
expressed at “red flag meetings” are not being heard or addressed. The staffing situation is an ongoing problem, and there doesn’t appear to be any plan to
address it.
Program Supervisor: There is a divide between staff and leadership. Staffing levels in the facility meet the state requirements in terms of the ratio of
employees to youth in care, but level is insufficient to meet resident’s needs. Youth are not able to leave the facility for walks or other outings. Scheduled
treatment groups don’t happen consistently. Staff are not reliably getting breaks. Several days per week there is a crisis related to finding enough staff to
work a given shift. Supervisors are being asked to work all the time and are being pulled out of their assigned units to provide campus-wide coverage.
Supervisors’ access to the staff scheduling system has been restricted. Supervisors are seeking other employment. Staff morale is low, and they perceive a
disconnect between their feelings and leadership.
Employee at Sequoia: Since contracted temporary personnel were discontinued, there are never enough staff. They’ve been in crisis mode for 3 months. It’s
unsafe. Leadership/ management are in chaos, and there is infighting. None of the programs on campus are fully staffed. Leadership makes empty
promises.
Form Rev. 11/14/2023 P age 4| 6
Program Supervisor: More shifts are understaffed than not. Major changes are needed but not happening. Treatment groups aren’t reliably occurring. Staff
who normally occupy the observation booth are regularly pulled. Had to help with a physical hold while restricted to light duty. Staff have been told by a VP to
“stop talking about their feelings”. Looking for other employment.
Youth in Care at Sequoia: Upset about the departure of a preferred staff person. She has usually been able to take showers, but sometimes not. Treatment
groups aren’t occurring due to staffing issues. She doesn’t always get a snack. She doesn’t always feel safe and would like there to be cameras in
bedrooms. She had a mark on her head which she attributed to head-banging.
Youth in Care at Sequoia: She’s been at the Farm Home since August. She was recently able to access laundry detergent and ingest it. She feels the
program is short-staffed. There were 3 times when she was not able to take a shower due to staffing. Treatment groups are not happening reliably.
Recreational activities and access to the outdoors have been curtailed. When this youth was interviewed again on 11/28, she reported she had been able to
shower when she wanted. She feels safe at the program.
Youth in Care at Sequoia: She has been at the Farm Home for 5 months in 2 different campus facilities. She characterized the program as “pretty good”, but
more staff are needed. Snacks and bathroom access have been delayed due to staffing. Treatment groups don’t always happen due to staff being occupied
managing youths’ behaviors. She likes her peers and staff and feels safe.
Youth in Care at Sequoia: He has been at Farm Home for almost 1 year. He feels the program is fine but needs more staff. Treatment groups don’t happen
as often as they should. He described a particular swing shift employee as mean and disrespectful towards him. He said his jacket had been taken from him
and he is cold. His phone calls are via speakerphone. He feels the “restorative services” youth are treated differently. Outings were discontinued 4 months
ago. His wireless earbuds were taken away and his shoes and his diamond ring have been lost.
Youth in Care at Sequoia: She has been at the program for almost 2 months and was at the Farm home Previously. She is on “medium risk” and believes
it’s unwarranted. She recently became aware that youths were going into each other’s rooms, and she reported it. Sometimes she needs to wait for her needs
to be met. She feels safe at the program.
Campus Operations Employee: Feels the program is understaffed and management has been dismissive when concerns about staffing are voiced.
Frequently works double shifts. There were 3 or 4 occasions when calls for support were not answered. On one occasion she called for support 4 times with
no answer. Management must be consulted before law enforcement is called.
Youth in Care at Sequoia: She has been at program for 2 months. Feels the program is OK, but she wishes she could do more. She gets along with staff
and peers. There are times when she can’t go outside, and phone calls are sometimes delayed or don’t happen due to staffing issues. Treatment groups
have been happening.
Youth in Care at Sequoia: He’s been there a couple weeks. The food is OK. He feels safe. He doesn’t get to take walks due to staffing issues. Would like to
be able to go off campus.
Youth in Care at Sequoia: She’s been at Farm Home for 7 months. She reported an employee touched her sexually. (CCLP confirmed this had been
reported to the hotline by Trillium). Youth are expected to wait patiently for needs to be met and for snacks. Her favorite staff are Chris and Alli.
Corrective Actions and Timeframes:
Please submit the following to verify compliance.
Form Rev. 11/14/2023 P age 5| 6
Within 45 days of receipt of this report Trillium Family Services must submit a letter of verification indicating the agency is in compliance with the
specific rules cited above and describing how compliance will be maintained going forward. Along with the letter of verification, the agency must
submit any and all specific documentation requested in the body of this report. The letter of verification and any additional requested documents
can be emailed directly to Ed Wyller by email at Edward.Wyller@odhsoha.oregon.gov.
______________________________________ _O_D__H_S__ R_e__g_u_la_t_o_r_y_ M__n_g_r_. _2_ ___ _1_2_-_2_1_-_2_0_2_3_ ________
Signature Title Date
Form Rev. 11/14/2023 P age 6| 6

agency_name: Trillium Family Services (TFS)

program_type: (RC) Residential Care Programs

report_type: Unannounced

view_code: RC

licensee: Trillium Family Services- Children's Farm Home campus

executive_director: Jamie Vandergon

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
September 2023 license renewal review Findings
Further Action
Needed
419-400-0100 (2) Licensing Umbrella Rules: Yes✓No[ ] Excerpt from September 2023 license renewal report:
Resources Required. (2) A child-caring agency During staff interviews and subsequent record review, it was discovered one client was
must employ or contract for a sufficient unable to take a shower on two separate occasions in a two-week period due to an
number of competent and qualified insufficient number of staff. There were numerous notes that the client smelled and was
employees to perform the functions not clean. Furthermore, there was an incident in which a staff was in a physical
regulated by these rules and to provide altercation with a client in the backyard of a unit and called for staff support three times.
adequate care, safety, protection, and There were not enough staff on campus to respond to the call. It was reported by staff
supervision of the children in care and that low staffing is a constant issue. The program shall ensure a sufficient number of staff
families the child-caring agency serves. are on campus to provide adequate care, safety, protection and supervision of the clients
in care.
------------
Numerous interviews with children in care, care-giver personnel and supervisory
personnel were conducted during unannounced visits on November 16 and November 29.
Interviews are summarized below in the Interview Summary section of this report.
Interviewees reported a lack of staff to meet every child's needs and experiencing
situations when a child or children are in crisis and there are not enough staff on campus
to respond to the crisis, despite requests for assistance and backup from other units.
Additionally, staff reported a child who is on "high risk" designation for shower

supervision had been denied showers multiple times due to lack of available staff to
support the supervision requirement.
Interviewees reported inconsistent availability outdoor recreation and off-campus
activities and an inability to provide prescribed treatment groups, and this was attributed
to not having sufficient personnel to provide these activities while also managing
residents' behaviors, managing the milieu in general and providing 1:1 supervision to the
youth who require it.
On November 10, 2023, a child in Trillium's Sequoia unit engaged in behavior that
required accountability and reflection. Sequoia staff on shift that evening were unable to
work with the child as needed due to lack of staffing and inexperienced staff. Evening
staff passed that task on to day staff, so the child was held accountable in the morning of
November 11, 2023. The child became extremely escalated, lodging homicidal threats,
kicking doors, windows, and people, and ultimately dysregulating other children in the
milieu alongside them. This resulted in the children overtaking the milieu and
sequestering staff in an observation booth. Staff called a local law enforcement agency for
assistance, but they declined to respond. Staff ultimately called 911 and officers
responded, allowing Trillium staff to regain control of the milieu.
----------
Trillium must create a plan and take steps to ensure that the number of trained staff
present at all times at the Farm Home is enough to manage youths' behaviors, including
having staff available to reliably respond timely to calls for back-up support in a crisis.
The program must create a plan and take steps to ensure that treatment groups reliably
occur, that youth can reliably have access to outside recreation and the cafeteria, that
youth who are approved for off-campus activities have access to these activities, and that
all youth can reliably take showers, have scheduled snacks, make phone calls, and use the
bathroom without undue delay and have other needs reliably met without undue delay.
If there is not an existing method of measuring and tracking the things listed above, a
method must be developed to do so with a reasonable amount of specificity and
accuracy, including a method of tracking individual calls for back-up support, the response
to such calls and the timeliness of the response.
The program must include measures of employee morale, satisfaction and retention in
the program's on-going quality improvement plan, if these are not already part of the QI
plan.

Other previous findings from the license Yes[ ] No[ ]
renewal review in September 2023 will be
checked during later visits.
New Findings from Site Visit Comments
N/A
Interview Summary
Multiple youth in care and multiple Trillium employees were interviewed either in the course of the two separate site visits on 11/16 and 11/28 or via
subsequent phone calls.
Campus Operations Employee: Staffing on the weekends is difficult. Having 6 staff of swing feels like a solid team.
Employee at Sequoia: There aren't enough staff, particularly on swing shift and weekends, and it's stressful. A newer employee who was hired a month ago
is quitting.
Employee at Sequoia: Although not the job she was hired for, she's been filling in as a skills trainer due to staff shortages. People are pulled from regular
duties to assist with youths' behaviors. The staffing situation is the worst it's been in three years. Management has stated there isn't anything they can do
about the staffing shortage. She is concerned for her safety. On two occasions, when she called for support, no-one responded.
Program Supervisor: Staff to youth supervision ratio requirements are being met. There is staff turnover. They don't have knowledge of circumstances that
had been reported prior to the unannounced visit, including employees not having breaks, no-one responding to employees' requests for back-up to assist
with managing youth behaviors, youth not receiving meals and snacks or youth not having access to showers. The pass-along emails, which are a means of
summarizing important information and sharing it between shifts, are consistently occurring.
Employee at Sequoia: When youth are designated for heightened supervision, other work doesn't get done. There are safety issues when there are not
enough personnel. When requesting staff support, it's not always available. Staff have communicated their concerns about staffing levels to management
verbally and by email. Scheduled treatment groups don't always happen, and this is due to not having enough staff. When they previously had contracted
temporary staff on site, staff could rely on back-up support when needed to manage youths' behaviors, staff were able to reliably take scheduled breaks and
treatment groups were reliably occurring.
Campus Operations Employee: Feels more staff are needed in the Secure Adolescent Inpatient (SAIP) units. Youth are not always able to take showers.
Staff recruitment and retention needs improvement.
Employee at Sequoia: Feels there are not enough staff, and swing shift, in particular, has had staffing problems for months. The situation has been
exacerbated by the discontinuation of contracting for temporary personnel. Staff are burning out. Staff are able to take scheduled breaks approximately 50%
of the time on the shifts he works. Treatment groups are occurring on his shifts. He believes site supervisors understand the staffing concerns and have been
trying to address them. "Campus Ops" personnel are in the role that contracted temporary personnel used to occupy.

Employee at Redwood: Staffing is a problem. Things work well with 6 staff on duty, but they've been making do with 5. There was an instance of staff
responsible to 1:1 supervision of a youth having to leave to assist other staff. Staff are receiving scheduled breaks on the shifts he works. Back-up crisis
support isn't reliably available when needed. It often not possible for youth to have time outside the facility due to insufficient staff levels. The situation was
better, and things were manageable when contracted temporary personnel were on site. Staff retention is a big problem.
Employee at Redwood: Used to enjoy the work, but doesn't anymore due to staffing shortages, so is seeking other employment. Staff are being injured, and
a staff suffered a broken leg in a situation in which having additional staff available could have prevented it. The program has taken steps to improve
employee morale and retention, but these have been insufficient. High rates of turnover have resulted in employees with less experience occupying roles with
greater responsibility when compared to the level of experience that was required for similar roles in the past. Staff are receiving their scheduled breaks. Calls
for crisis support are not reliably answered. Staff retention is the biggest problem at the Farm Home.
Employee at Redwood: There are not enough staff to supervise the youth. On 2 recent occasions there was a request to end 1:1 supervision requirement for
two youth to free up staff, but this was not possible due to the ongoing needs of the youth receiving the heightened supervision. Calls for crisis support are
frequently unanswered when staff and youth are being attacked. Staffing levels were sufficient when contracted temporary staff were on site, but this has
been discontinued.
Employee at Sequoia: Has worked at Farm Home for between 4 and 5 months. Staffing is a problem. She is quitting, and one of her co-workers is quitting.
She believes staffing issues contributed to the recent incident in which staff lost control of the program and had to lock themselves in the observation booth
while waiting for law enforcement to respond. She feels a staffing-related delay in initiating a consequence for a particular youth's behavior caused an
extreme reaction by the youth and the escalation of other youths in care. She feels Trillium's recruitment efforts need improvement and that contracted staff,
who were previously brough in to assist, should be brought back. Staff are not getting breaks, and treatment groups aren't happening reliably. Youth are
waiting a long time for snacks. Showers for a youth on high-risk aren't happening. Outings have been curtailed. Sometimes no-one comes when there all
calls for support. Youth are not getting outside, and staff aren't available to walk with youth to the cafeteria.
Employee at Redwood: Feels there are not enough staff to ensure safety of youth in care since contracted temporary staff were discontinued. The employe
stated they have been vocal about their concerns about low staffing. Youth are sometimes not getting showers. The previous week a particular youth had
requested a shower every day, but it couldn't happen due to insufficient staff. Injuries to employees and youth have happened that could have been
prevented with adequate staff levels. On the Sunday preceding the day of the unannounced visit, staffing levels were low on all units. The employee
described an incident in which a physical restraint couldn't be controlled due not having enough staff available. They talked about having suffered
concussions, and indicated this is not uncommon. Youth are not getting out of the facility due to low staffing. Calls for backup go unanswered, and physical
interventions can't be implemented when circumstances warrant. Snacks and beverages are delayed or missed due to low staffing. Feels concerns
expressed at "red flag meetings" are not being heard or addressed. The staffing situation is an ongoing problem, and there doesn't appear to be any plan to
address it.
Program Supervisor: There is a divide between staff and leadership. Staffing levels in the facility meet the state requirements in terms of the ratio of
employees to youth in care, but level is insufficient to meet resident's needs. Youth are not able to leave the facility for walks or other outings. Scheduled
treatment groups don't happen consistently. Staff are not reliably getting breaks. Several days per week there is a crisis related to finding enough staff to
work a given shift. Supervisors are being asked to work all the time and are being pulled out of their assigned units to provide campus-wide coverage.
Supervisors' access to the staff scheduling system has been restricted. Supervisors are seeking other employment. Staff morale is low, and they perceive a
disconnect between their feelings and leadership.
Employee at Sequoia: Since contracted temporary personnel were discontinued, there are never enough staff. They've been in crisis mode for 3 months. It's
unsafe. Leadership/ management are in chaos, and there is infighting. None of the programs on campus are fully staffed. Leadership makes empty
promises.

Program Supervisor: More shifts are understaffed than not. Major changes are needed but not happening. Treatment groups aren't reliably occurring. Staff
who normally occupy the observation booth are regularly pulled. Had to help with a physical hold while restricted to light duty. Staff have been told by a VP to
"stop talking about their feelings". Looking for other employment.
Youth in Care at Sequoia: Upset about the departure of a preferred staff person. She has usually been able to take showers, but sometimes not. Treatment
groups aren't occurring due to staffing issues. She doesn't always get a snack. She doesn't always feel safe and would like there to be cameras in
bedrooms. She had a mark on her head which she attributed to head-banging.
Youth in Care at Sequoia: She's been at the Farm Home since August. She was recently able to access laundry detergent and ingest it. She feels the
program is short-staffed. There were 3 times when she was not able to take a shower due to staffing. Treatment groups are not happening reliably.
Recreational activities and access to the outdoors have been curtailed. When this youth was interviewed again on 11/28, she reported she had been able to
shower when she wanted. She feels safe at the program.
Youth in Care at Sequoia: She has been at the Farm Home for 5 months in 2 different campus facilities. She characterized the program as "pretty good", but
more staff are needed. Snacks and bathroom access have been delayed due to staffing. Treatment groups don't always happen due to staff being occupied
managing youths' behaviors. She likes her peers and staff and feels safe.
Youth in Care at Sequoia: He has been at Farm Home for almost 1 year. He feels the program is fine but needs more staff. Treatment groups don't happen
as often as they should. He described a particular swing shift employee as mean and disrespectful towards him. He said his jacket had been taken from him
and he is cold. His phone calls are via speakerphone. He feels the "restorative services" youth are treated differently. Outings were discontinued 4 months
ago. His wireless earbuds were taken away and his shoes and his diamond ring have been lost.
Youth in Care at Sequoia: She has been at the program for almost 2 months and was at the Farm home Previously. She is on "medium risk" and believes
it's unwarranted. She recently became aware that youths were going into each other's rooms, and she reported it. Sometimes she needs to wait for her needs
to be met. She feels safe at the program.
Campus Operations Employee: Feels the program is understaffed and management has been dismissive when concerns about staffing are voiced.
Frequently works double shifts. There were 3 or 4 occasions when calls for support were not answered. On one occasion she called for support 4 times with
no answer. Management must be consulted before law enforcement is called.
Youth in Care at Sequoia: She has been at program for 2 months. Feels the program is OK, but she wishes she could do more. She gets along with staff
and peers. There are times when she can't go outside, and phone calls are sometimes delayed or don't happen due to staffing issues. Treatment groups
have been happening.
Youth in Care at Sequoia: He's been there a couple weeks. The food is OK. He feels safe. He doesn't get to take walks due to staffing issues. Would like to
be able to go off campus.
Youth in Care at Sequoia: She's been at Farm Home for 7 months. She reported an employee touched her sexually. (CCLP confirmed this had been
reported to the hotline by Trillium). Youth are expected to wait patiently for needs to be met and for snacks. Her favorite staff are Chris and Alli.

excerpt:
419-400-0100 (2) Licensing Umbrella Rules: Yes✓No[ ] Excerpt from September 2023 license renewal report:
Resources Required. (2) A child-caring agency During staff interviews and subsequent record review, it was discovered one client was
must employ or contract for a sufficient unable to take a shower on two separate occasions in a two-week period due to an
number of competent and qualified insufficient number of staff. There were numerous notes that the client smelled and was
employees to perform the functions not clean. Furthermore, there was an incident in which a staff was in a physical
regulated by these rules and to provide altercation with a client in the backyard of a unit and called for staff support three times.
adequate care, safety, protection, and There were not enough staff on campus to respond to the call. It was reported by staff
supervision of the children in care and that low staffing is a constant issue. The program shall ensure a sufficient number of staff
families the child-caring agency serves. are on campus to provide adequate care, safety, protection and supervision of the clients
in care.
------------
Numerous interviews with children in care, care-giver personnel and supervisory
personnel were conducted during unannounced visits on November 16 and November 29.
Interviews are summarized below in the Interview Summary section of this report.
Interviewees reported a lack of staff to meet every child's needs and experiencing
situations when a child or children are in crisis and there are not enough staff on campus
to respond to the crisis, despite requests for assistance and backup from other units.
Additionally, staff reported a child who is on "high risk" designation for shower
supervision had been denied showers multiple times due to lack of available staff to
support the supervision requirement.
Interviewees reported inconsistent availability outdoor recreation and off-campus
activities and an inability to provide prescribed treatment groups, and this was attributed
to not having sufficient personnel to provide these activities while also managing
residents' behaviors, managing the milieu in general and providing 1:1 supervision to the
youth who require it.
On November 10, 2023, a child in Trillium's Sequoia unit engaged in behavior that
required accountability and reflection. Sequoia staff on shift that evening were unable to
work with the child as needed due to lack of staffing and inexperienced staff. Evening
staff passed that task on to day staff, so the child was held accountable in the morning of
November 11, 2023. The child became extremely escalated, lodging homicidal threats,
kicking doors, windows, and people, and ultimately dysregulating other children in the
milieu alongside them. This resulted in the children overtaking the milieu and
sequestering staff in an observation booth. Staff called a local law enforcement agency for
assistance, but they declined to respond. Staff ultimately called 911 and officers
responded, allowing Trillium staff to regain control of the milieu.
----------
Trillium must create a plan and take steps to ensure that the number of trained staff
present at all times at the Farm Home is enough to manage youths' behaviors, including
having staff available to reliably respond timely to calls for back-up support in a crisis.
The program must create a plan and take steps to ensure that treatment groups reliably
occur, that youth can reliably have access to outside recreation and the cafeteria, that
youth who are approved for off-campus activities have access to these activities, and that
all youth can reliably take showers, have scheduled snacks, make phone calls, and use the
bathroom without undue delay and have other needs reliably met without undue delay.
If there is not an existing method of measuring and tracking the things listed above, a
method must be developed to do so with a reasonable amount of specificity and
accuracy, including a method of tracking individual calls for back-up support, the response
to such calls and the timeliness of the response.
The program must include measures of employee morale, satisfaction and retention in
the program's on-going quality improvement plan, if these are not already part of the QI
plan.
Other previous findings from the license Yes[ ] No[ ]
renewal review in September 2023 will be
checked during later visits.
New Findings from Site Visit Comments
N/A
N/A


summary: Unannounced - 8 findings

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Residential Care
Licensee: Trillium Family Services- Parry Center
Executive Director: Jamie Vandergon
Program Director(s): Brian Schilling
Date of Unannounced: February 27th, 2024
Licensing Coordinator: Ed Wyller, assisted by Harry Gilmore
Other Regulatory or Accrediting Agencies: Oregon Health Authority
Purpose: Per OAR 419-400-0240 (1)(b) Children’s Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Comments
License Renewal July 25th-26th, 2023 and Findings
August 29th-31st, 2023 Further Action
Needed
Supplemental Information Provided by Yes☐ No✓
CCA Trillium provided the required documentation on 11-14-2023.
Documents as indicated on form titled
“Required Financial Documents and
Information”
• The program has not submitted their
tax compliance certificate. The
program is actively working to obtain
the certificate. The program shall
ensure their tax compliance certificate
is obtained and submitted to
Licensing.
Physical Plant Yes✓ No☐ • Repeated Finding: Both North 1 and North 2 bedrooms were messy with child
419-470-0020(2)(a) &(c) Buildings are smoke belongings scattered throughout their bedrooms. These rooms had too many
free, clean and in good repair items that would make conducting an area search very time consuming and
• Parry Center difficult to perform or be effective. North 1 and North 2 bathrooms were found not
North 1: One client’s bedroom was messy and clean and needing caulk replaced in the seam between the floor and the shower
had water on the floor. Room A5 and the pans. During youth interviews youth from west programs reported experiencing
sensory room were messy and had client dirty bathrooms as well.
belongings all over the floor. The program
shall ensure all buildings are clean.
Form Rev. 11/14/2023 P age 1 | 5
New Employee Orientation – Umbrella Yes✓ No☐ • Repeated Finding: Reviewers reviewed 4 new employees since last renewal
Requirements (30 days) review. Reviewers found documentation of just 1 out of 4 staff receiving this
419-400-0120(4) training in the required 30-day requirement. Two of the employees did receive the
(a) Agency policies and procedures training. However, it was two weeks late. The other employee has not received
• Parry Center: Staff did not complete the training and is outside of the required 30-day period.
orientation training on agency policies
and procedures within 30 days of hire.
The program shall ensure all staff
complete all orientation trainings
within 30 days of hire.
New Employee Orientation – Umbrella Yes✓ No☐ • Repeated Finding: Reviewers reviewed 4 new employees since last renewal
Requirements (30 days) review. Reviewers found documentation of just 1 out of 4 staff receiving this
419-400-0120(4) training in the required 30-day requirement. Two of the employees did receive the
(e) & (5)(a) to (c) Mandatory reporting that training, however, it was two weeks late. The other employee has not received the
includes: training and is outside of the required 30-day period.
(a) legal definition of child abuse in ORS
418.257 and 419B.005
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to
the employee
• Parry Center: Staff did not complete
orientation training on mandatory
reporting within 30 days of hire. The
program shall ensure all staff
complete all orientation trainings
within 30 days of hire.
New Employee Orientation – Umbrella Yes✓ No☐ • Repeated Finding: Reviewers reviewed 4 new employees since last renewal
Requirements (30 days) review. Reviewers found documentation of just 1 out of 4 staff receiving this
419-400-0120(4) training in the required 30-day requirement. Two of the employees did receive the
(f) Privacy laws training, however, it was two weeks late. The other employee has not received the
• Parry Center: Staff did not complete training and is outside of the required 30-day period.
orientation training on privacy laws
within 30 days of hire. The program
shall ensure all staff complete all
orientation trainings within 30 days of
hire.
New Employee Orientation – Umbrella Yes✓ No☐ • Repeated Finding: Reviewers reviewed 4 new employees since last renewal
Requirements (30 days) review. Reviewers found documentation of just 1 out of 4 staff receiving this
419-400-0120(4) training in the required 30-day requirement. Two of the employees did receive the
(g) Emergency procedures training, however, it was two weeks late. The other employee has not received the
• Parry Center: Staff did not complete training and is outside of the required 30-day period.
orientation training on emergency
procedures within 30 days of hire.
The program shall ensure all staff
Form Rev. 11/14/2023 P age 2 | 5
complete all orientation trainings
within 30 days of hire.
Ongoing Training Yes☐ No✓ • This is no longer a finding
419-400-0120(5) Mandatory reporting
(annually) that includes:
(a) legal definition of child abuse in ORS
418.257 and 419B.005
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to
the employee
• Parry Center: One staff did not
complete mandatory reporting training
within 30 days of hire. The program
shall ensure all staff complete
mandatory reporting training within 30
days of hire.
Records Relating to Restraint & Yes☐ No✓ • Trillium Parry Center provided additional records after unannounced site visit of
Involuntary Seclusion requested child files and those records show compliance with this requirement.
419-400-0180(13)(e) Each child caring
agency shall provide notice regarding how to
access the quarterly reports to the parents or
guardians of children in care in the program.
The child caring agency shall provide the
notice upon the child in care’s admission and
at least two times each year thereafter.
• The programs do not provide notice
regarding how to access the quarterly
reports to the parents or guardians of
children in care. The program shall
ensure the parents or guardians of
children in care are provided notice
regarding how to access the quarterly
reports.
Records Relating to Restraint & Yes☐ No✓ • Trillium Parry Center provided additional records after unannounced site visit of
Involuntary Seclusion requested child files and those records show compliance with this requirement.
419-400-0190(1) Information provided to
children in care relating to Restraint &
Involuntary Seclusion
• The programs do not provide
information to children in care relating
to restraint and involuntary seclusion.
The program shall ensure the
information described in OAR 419-
Form Rev. 11/14/2023 P age 3 | 5
400-190 is provided to children in
care relating to restraint and
involuntary seclusion.
New Findings from Site Visit Comments
N/A N/A
Interview Summary
DHS CCLP interviewed four clients during the unannounced site inspection. One client was interviewed in his room while clients were in a transition time
between school and lunch. The other three clients were interviewed at the administrative building in their Library one at a time with no staff present. All
interviews took place in a private manner to ensure the clients ability to speak freely.
On a scale from 0-10 (0=worst program, 10=best program) client’s reported Trillium – Parry Center to be a 5, 7.5, 8, and a 10 on that scale. All client’s
reported feeling safe at Parry Center. Clients described staff as, “cool and respectful;”, “respectful and like them”, “staff are really great, give you options, kind,
funny and they take sarcasm”, “like the staff”. Food was described as: “10 out of 10!”, “Recently had a stomachache from mac and cheese”, “pretty good – 9
out of 10”, and “good”. All clients reported getting enough food to eat and that they receive snacks. Reported snacks included: fruit, vegetables, yogurt, and
crackers. All clients reported having visits and phone calls and showers. One client reported enjoying the school program as they are getting caught up and
they enjoy the length of time in school and the break schedule works well for them.
All clients were able to discuss what they have learned in their respective groups. A younger client was able to discuss the concept of “stop and think” and
they enjoyed groups. Other clients spoke about DBT skills, breathing skills, and life skills learned at the Parry Center. Clients reported fun: play basketball,
play video games, reading, journaling, get to go outside the fence and ride bikes. Clients also spoke about how the staff manage the environment well when
another client is being disruptive to the milieu. Removing other clients from the disruption, offering noise cancelling headphones for youth to use, and
separating clients.
When asked if given a magic wand and could improve the program within reason, client’s reported: “Wish the bathroom was cleaner, address dirty showers”,
Another client reported a desire for cleaner bathrooms as well. Another client reported wanting more staff so they could have more frequent basketball time
and their wish to not have ants in the building. Another client reported a desire for more consistency amongst staff from “front end week staff to back end
week staff”.
I spoke with one staff member while they were in the laundry room asking how they like working at Parry Center. They reported they have just started working
and have liked working there. I met the education team during their lunch break and they shared some of their curriculum and teaching approaches used in
their respective classrooms.
Form Rev. 11/14/2023 P age 4 | 5
Observations
During the inspection I observed the school building having work performed on it due to a burst pipe from the January Ice storm. The West building was
having mold remediation work performed in the crawl space. I observed clients and staff interacting in a prosocial positive manner. I observed a staff member
watching a client that was on one-on-one supervision status.
Corrective Actions and Timeframes:
Please submit the following to verify compliance.
Within 45 days of receipt of this report Trillium Family Services-Parry Center 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 Ed Wyller edward.wyller@odhsoha.oregon.gov.
Licensing Coordinator’s Signature: ________________________ Date: _3_-_8_-2_4______________
Manager Review: ______________________________________ Date: _3_-8_-_2_0_2_4___________
Form Rev. 11/14/2023 P age 5 | 5

facility_type: Residential Care

licensee: Trillium Family Services- Parry Center

program_director: Brian Schilling

visit_date: February 27th, 2024

licensing_coordinator: Ed Wyller, assisted by Harry Gilmore

other_regulatory_agencies: Oregon Health Authority

purpose:
Per OAR 419-400-0240 (1)(b) Children's Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Comments
License Renewal July 25th-26th, 2023 and Findings
August 29th-31st, 2023 Further Action
Needed
Supplemental Information Provided by Yes[ ] No✓
CCA Trillium provided the required documentation on 11-14-2023.
Documents as indicated on form titled
"Required Financial Documents and
Information"
- The program has not submitted their
tax compliance certificate. The
program is actively working to obtain
the certificate. The program shall
ensure their tax compliance certificate
is obtained and submitted to
Licensing.
Physical Plant Yes✓ No[ ] - Repeated Finding: Both North 1 and North 2 bedrooms were messy with child
419-470-0020(2)(a) &(c) Buildings are smoke belongings scattered throughout their bedrooms. These rooms had too many
free, clean and in good repair items that would make conducting an area search very time consuming and
- Parry Center difficult to perform or be effective. North 1 and North 2 bathrooms were found not
North 1: One client's bedroom was messy and clean and needing caulk replaced in the seam between the floor and the shower
had water on the floor. Room A5 and the pans. During youth interviews youth from west programs reported experiencing
sensory room were messy and had client dirty bathrooms as well.
belongings all over the floor. The program
shall ensure all buildings are clean.

New Employee Orientation - Umbrella Yes✓ No[ ] - Repeated Finding: Reviewers reviewed 4 new employees since last renewal
Requirements (30 days) review. Reviewers found documentation of just 1 out of 4 staff receiving this
419-400-0120(4) training in the required 30-day requirement. Two of the employees did receive the
(a) Agency policies and procedures training. However, it was two weeks late. The other employee has not received
- Parry Center: Staff did not complete the training and is outside of the required 30-day period.
orientation training on agency policies
and procedures within 30 days of hire.
The program shall ensure all staff
complete all orientation trainings
within 30 days of hire.
New Employee Orientation - Umbrella Yes✓ No[ ] - Repeated Finding: Reviewers reviewed 4 new employees since last renewal
Requirements (30 days) review. Reviewers found documentation of just 1 out of 4 staff receiving this
419-400-0120(4) training in the required 30-day requirement. Two of the employees did receive the
(e) & (5)(a) to (c) Mandatory reporting that training, however, it was two weeks late. The other employee has not received the
includes: training and is outside of the required 30-day period.
(a) legal definition of child abuse in ORS
418.257 and 419B.005
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to
the employee
- Parry Center: Staff did not complete
orientation training on mandatory
reporting within 30 days of hire. The
program shall ensure all staff
complete all orientation trainings
within 30 days of hire.
New Employee Orientation - Umbrella Yes✓ No[ ] - Repeated Finding: Reviewers reviewed 4 new employees since last renewal
Requirements (30 days) review. Reviewers found documentation of just 1 out of 4 staff receiving this
419-400-0120(4) training in the required 30-day requirement. Two of the employees did receive the
(f) Privacy laws training, however, it was two weeks late. The other employee has not received the
- Parry Center: Staff did not complete training and is outside of the required 30-day period.
orientation training on privacy laws
within 30 days of hire. The program
shall ensure all staff complete all
orientation trainings within 30 days of
hire.
New Employee Orientation - Umbrella Yes✓ No[ ] - Repeated Finding: Reviewers reviewed 4 new employees since last renewal
Requirements (30 days) review. Reviewers found documentation of just 1 out of 4 staff receiving this
419-400-0120(4) training in the required 30-day requirement. Two of the employees did receive the
(g) Emergency procedures training, however, it was two weeks late. The other employee has not received the
- Parry Center: Staff did not complete training and is outside of the required 30-day period.
orientation training on emergency
procedures within 30 days of hire.
The program shall ensure all staff

complete all orientation trainings
within 30 days of hire.
Ongoing Training Yes[ ] No✓ - This is no longer a finding
419-400-0120(5) Mandatory reporting
(annually) that includes:
(a) legal definition of child abuse in ORS
418.257 and 419B.005
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to
the employee
- Parry Center: One staff did not
complete mandatory reporting training
within 30 days of hire. The program
shall ensure all staff complete
mandatory reporting training within 30
days of hire.
Records Relating to Restraint & Yes[ ] No✓ - Trillium Parry Center provided additional records after unannounced site visit of
Involuntary Seclusion requested child files and those records show compliance with this requirement.
419-400-0180(13)(e) Each child caring
agency shall provide notice regarding how to
access the quarterly reports to the parents or
guardians of children in care in the program.
The child caring agency shall provide the
notice upon the child in care's admission and
at least two times each year thereafter.
- The programs do not provide notice
regarding how to access the quarterly
reports to the parents or guardians of
children in care. The program shall
ensure the parents or guardians of
children in care are provided notice
regarding how to access the quarterly
reports.
Records Relating to Restraint & Yes[ ] No✓ - Trillium Parry Center provided additional records after unannounced site visit of
Involuntary Seclusion requested child files and those records show compliance with this requirement.
419-400-0190(1) Information provided to
children in care relating to Restraint &
Involuntary Seclusion
- The programs do not provide
information to children in care relating
to restraint and involuntary seclusion.
The program shall ensure the
information described in OAR 419-

400-190 is provided to children in
care relating to restraint and
involuntary seclusion.
New Findings from Site Visit Comments
N/A N/A
Interview Summary
DHS CCLP interviewed four clients during the unannounced site inspection. One client was interviewed in his room while clients were in a transition time
between school and lunch. The other three clients were interviewed at the administrative building in their Library one at a time with no staff present. All
interviews took place in a private manner to ensure the clients ability to speak freely.
On a scale from 0-10 (0=worst program, 10=best program) client's reported Trillium - Parry Center to be a 5, 7.5, 8, and a 10 on that scale. All client's
reported feeling safe at Parry Center. Clients described staff as, "cool and respectful;", "respectful and like them", "staff are really great, give you options, kind,
funny and they take sarcasm", "like the staff". Food was described as: "10 out of 10!", "Recently had a stomachache from mac and cheese", "pretty good - 9
out of 10", and "good". All clients reported getting enough food to eat and that they receive snacks. Reported snacks included: fruit, vegetables, yogurt, and
crackers. All clients reported having visits and phone calls and showers. One client reported enjoying the school program as they are getting caught up and
they enjoy the length of time in school and the break schedule works well for them.
All clients were able to discuss what they have learned in their respective groups. A younger client was able to discuss the concept of "stop and think" and
they enjoyed groups. Other clients spoke about DBT skills, breathing skills, and life skills learned at the Parry Center. Clients reported fun: play basketball,
play video games, reading, journaling, get to go outside the fence and ride bikes. Clients also spoke about how the staff manage the environment well when
another client is being disruptive to the milieu. Removing other clients from the disruption, offering noise cancelling headphones for youth to use, and
separating clients.
When asked if given a magic wand and could improve the program within reason, client's reported: "Wish the bathroom was cleaner, address dirty showers",
Another client reported a desire for cleaner bathrooms as well. Another client reported wanting more staff so they could have more frequent basketball time
and their wish to not have ants in the building. Another client reported a desire for more consistency amongst staff from "front end week staff to back end
week staff".
I spoke with one staff member while they were in the laundry room asking how they like working at Parry Center. They reported they have just started working
and have liked working there. I met the education team during their lunch break and they shared some of their curriculum and teaching approaches used in
their respective classrooms.

Observations
During the inspection I observed the school building having work performed on it due to a burst pipe from the January Ice storm. The West building was
having mold remediation work performed in the crawl space. I observed clients and staff interacting in a prosocial positive manner. I observed a staff member
watching a client that was on one-on-one supervision status.

new_findings: N/A N/A

excerpt:
419-400-0190(1) Information provided to
children in care relating to Restraint &
Involuntary Seclusion
- The programs do not provide
information to children in care relating
to restraint and involuntary seclusion.
The program shall ensure the
information described in OAR 419-
400-190 is provided to children in
care relating to restraint and
involuntary seclusion.
New Findings from Site Visit Comments
N/A N/A
N/A N/A


summary: Unannounced - 2 findings

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Residential Care
Licensee: Trillium Family Services – Sender House
Executive Director: Jamie Vandergon
Program Director: Rafael Larios
Date of Unannounced: May 14th, 2024
Licensing Coordinator: Ed Wyller
Other Regulatory or Accrediting Agencies: OHA
Purpose: Per OAR 419-400-0240 (1)(b) Children’s Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Comments
License Renewal Site Visit 07/25/2023 & Findings
08/29/2023 Further Action
Needed
Supplemental Information Provided by Yes☐ No✓ • Trillium provided the required documentation on November 14th, 2023. In
CCA Compliance
Documents as indicated on form titled
“Required Financial Documents and
Information”
• The program has not submitted their
tax compliance certificate. The
program is actively working to obtain
the certificate. The program shall
ensure their tax compliance certificate
is obtained and submitted to
Licensing.
Records Relating to Restraint & Yes✓ No☐ • Repeated Finding: Sender House was missing the notice regarding how to access
Involuntary Seclusion quarterly reports that must be provided to the parents or guardians of the children in
419-400-0180(13)(e) Each child caring care.
agency shall provide notice regarding how to
1 | P age
Form Rev. 01/23/2023
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 programs do not provide notice
regarding how to access the quarterly
reports to the parents or guardians of
children in care. The program shall
ensure the parents or guardians of
children in care are provided notice
regarding how to access the quarterly
reports.
Records Relating to Restraint & Yes✓ No☐ • Repeated Finding: Sender House will need to formalize a process of providing
Involuntary Seclusion information to children in care relating to restraint and seclusion.
419-400-0190(1) Information provided to
children in care relating to Restraint &
Involuntary Seclusion
• The programs do not provide
information to children in care relating
to restraint and involuntary seclusion.
The program shall ensure the
information described in OAR 419-
400-190 is provided to children in
care relating to restraint and
involuntary seclusion.
New Findings from Site Visit Comments
N/A Good work!!
2 | P age
Form Rev. 01/23/2023
Interview Summary
Sender House currently has 4 residents in care. During my unannounced site visit two were in the community and one resident was sleeping. One resident
was on site. I interviewed the one awake resident away from staff to be able to have a private conversation. This resident reported Sender House to be an
8.5 on a scale from 0-10 (0=worst program, 10=best program). Resident reported feeling safe at Sender House and that the food is good. Food was reported
to be good as “cook for yourself”. It was reported there is enough food and that residents go shopping weekly. In addition, program does BBQ’s and potluck
meals for the whole program. Staff were described as, “people who support you and trust”, “treat with respect”, and “feel genuine”. Staff also were reported to
help with making sure medications are taken and encouragement to do things. For fun, resident reported enjoying riding their long board in the community.
Resident reported enjoying music production, playing games, and laptop on-site at Sender House. A recent community outing that resident did not take part in
was going to the Oregon Zoo. Resident was proud that they are employed and maintaining that employment in the community. When asked what they would
change if given a magic wand to improve the program, resident reported “really good and no issues”. They did state they “wished peers could be better but
nothing on the staff end.”
Staff reported they enjoy working at Sender House. All staff had worked many years at Sender House and reported enjoying working with the residents and
seeing growth.
Observations
When I arrived, I observed a Sender House staff washing the agency van. It was a nice warm day. I observed Sender House to be clean and orderly.
Bathrooms and kitchen were clean. This was my first time at Sender House, and I found the space and staff to be welcoming. During the site inspection I
discussed the adjacent recreation room that will be converted into storage, recreation room, and an additional transition bedroom for residents ready for more
independence. The space will be able to accommodate those plans. I shared with program leadership the necessary steps for the program to take to
increase the program’s licensed capacity from four to five .
3 | P age
Form Rev. 01/23/2023
Corrective Actions and Timeframes:
Please submit the following to verify compliance.
Within 45 days of receipt of this report Trillium Family Services must submit a letter of verification indicating the agency is in compliance with the
specific rules cited above and describing how compliance will be maintained going forward. Along with the letter of verification, the agency must
submit any and all specific documentation requested in the body of this report. The letter of verification and any additional requested documents can
be emailed directly to Ed Wyller edward.wyller@dhsoha.state.or.us
Licensing Coordinator’s Signature: ________________________ Date: _5_/2__3_/2_4_____________
Manager Review: ______________________________________ Date: _5_-2_2_-_2_0_2_4__________
4 | P age
Form Rev. 01/23/2023

licensee: Trillium Family Services - Sender House

program_director: Rafael Larios

licensing_coordinator: Ed Wyller

other_regulatory_agencies: OHA

purpose:
Per OAR 419-400-0240 (1)(b) Children's Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Comments
License Renewal Site Visit 07/25/2023 & Findings
08/29/2023 Further Action
Needed
Supplemental Information Provided by Yes[ ] No✓ - Trillium provided the required documentation on November 14th, 2023. In
CCA Compliance
Documents as indicated on form titled
"Required Financial Documents and
Information"
- The program has not submitted their
tax compliance certificate. The
program is actively working to obtain
the certificate. The program shall
ensure their tax compliance certificate
is obtained and submitted to
Licensing.
Records Relating to Restraint & Yes✓ No[ ] - Repeated Finding: Sender House was missing the notice regarding how to access
Involuntary Seclusion quarterly reports that must be provided to the parents or guardians of the children in
419-400-0180(13)(e) Each child caring care.
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 programs do not provide notice
regarding how to access the quarterly
reports to the parents or guardians of
children in care. The program shall
ensure the parents or guardians of
children in care are provided notice
regarding how to access the quarterly
reports.
Records Relating to Restraint & Yes✓ No[ ] - Repeated Finding: Sender House will need to formalize a process of providing
Involuntary Seclusion information to children in care relating to restraint and seclusion.
419-400-0190(1) Information provided to
children in care relating to Restraint &
Involuntary Seclusion
- The programs do not provide
information to children in care relating
to restraint and involuntary seclusion.
The program shall ensure the
information described in OAR 419-
400-190 is provided to children in
care relating to restraint and
involuntary seclusion.
New Findings from Site Visit Comments
N/A Good work!!

Interview Summary
Sender House currently has 4 residents in care. During my unannounced site visit two were in the community and one resident was sleeping. One resident
was on site. I interviewed the one awake resident away from staff to be able to have a private conversation. This resident reported Sender House to be an
8.5 on a scale from 0-10 (0=worst program, 10=best program). Resident reported feeling safe at Sender House and that the food is good. Food was reported
to be good as "cook for yourself". It was reported there is enough food and that residents go shopping weekly. In addition, program does BBQ's and potluck
meals for the whole program. Staff were described as, "people who support you and trust", "treat with respect", and "feel genuine". Staff also were reported to
help with making sure medications are taken and encouragement to do things. For fun, resident reported enjoying riding their long board in the community.
Resident reported enjoying music production, playing games, and laptop on-site at Sender House. A recent community outing that resident did not take part in
was going to the Oregon Zoo. Resident was proud that they are employed and maintaining that employment in the community. When asked what they would
change if given a magic wand to improve the program, resident reported "really good and no issues". They did state they "wished peers could be better but
nothing on the staff end."
Staff reported they enjoy working at Sender House. All staff had worked many years at Sender House and reported enjoying working with the residents and
seeing growth.
Observations
When I arrived, I observed a Sender House staff washing the agency van. It was a nice warm day. I observed Sender House to be clean and orderly.
Bathrooms and kitchen were clean. This was my first time at Sender House, and I found the space and staff to be welcoming. During the site inspection I
discussed the adjacent recreation room that will be converted into storage, recreation room, and an additional transition bedroom for residents ready for more
independence. The space will be able to accommodate those plans. I shared with program leadership the necessary steps for the program to take to
increase the program's licensed capacity from four to five .

new_findings: N/A Good work!!

excerpt:
419-400-0190(1) Information provided to
children in care relating to Restraint &
Involuntary Seclusion
- The programs do not provide
information to children in care relating
to restraint and involuntary seclusion.
The program shall ensure the
information described in OAR 419-
400-190 is provided to children in
care relating to restraint and
involuntary seclusion.
New Findings from Site Visit Comments
N/A Good work!!
N/A Good work!!


summary: Unannounced - 2 findings

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Residential Care
Licensee: Trillium Family Services
Executive Director: Jamie Vandergon
Program Director(s): Chiharu (Malone) Blatt
Date of Unannounced: January 29th, 2025
Licensing Coordinator: Ed Wyller
Other Regulatory or Accrediting Agencies: Oregon Health Authority
Purpose: Per OAR 419-400-0240 (1)(b) Children’s Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Findings Comments
Unannounced Site Visit – 5/14/2024 Further Action
Needed
Records Relating to Restraint & Involuntary Seclusion Yes☐ No✓ • I reviewed 3 resident charts and all 3 had the appropriate notice.
419-400-0180(13)€ Each child caring agency shall provide (In-compliance)
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.
• Repeated Finding: Sender House was missing the notice
regarding how to access quarterly reports that must be
provided to the parents or guardians of the children in care.
Records Relating to Restraint & Involuntary Seclusion Yes☐ No✓ • I reviewed 3 resident charts and all 3 had the required
419-400-0190(1) Information provided to children in care information provided to residents regarding restraint and
relating to Restraint & Involuntary Seclusion involuntary seclusion. (In-compliance)
• Repeated Finding: Sender House will need to formalize a
process of providing information to children in care relating
to restraint and seclusion.
Form Rev. 11/14/2023 P age 1 | 3
New Findings from Site Visit Comments
N/A • No findings good work!
Interview Summary
Sender House has a capacity of four residents. One resident was on-site and available to be interviewed. I met with the resident in the adjacent recreation
room in a separate building to ensure privacy. This resident has been at many programs and rated this program as the best. She ranked it an 8-9 on a scale
from 0-10 (0=worst program and 10 =best program). She reported she has learned life skills while at Sender House. “Staff help with skills, If I wasn’t here, I
would struggle with life skills and mental health”. Resident reported feeling safe. Food was reported to be “good”. The residents go out weekly with staff to
purchase groceries for the week. Reported outings included going to a Christmas event in Corvallis and visiting a pumpkin patch. If given a magic wand to
improve the program, resident reported more scheduled group outings. She reported the current group of residents are not interested in group outings.
Observations
During my tour I found the staff to be welcoming. All staff enjoyed working at Sender House and had no intentions of looking elsewhere. The downstairs
basement had been remodeled and laundry room is receiving new locking cabinets. Staff office is to receive lockers for staff. The outside foundation had
major repairs regarding drainage issues. No issues in home or mold. Foundation work was done with an engineer. I found the recreation room to be
reorganized and useable. Last visit it was mainly a storage area and considerable work has been made to make it a great space for Residents away from the
main house. Staff discussed how they work with the residents on how to shop for groceries and take them to a variety of stores to give them experience on
how to shop for both quality and price.
All areas were clean and organized.
Corrective Actions and Timeframes:
Please submit the following to verify compliance.
Form Rev. 11/14/2023 P age 2 | 3
Within 45 days of receipt of this report Trillium Family Services – Sender House 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 Ed Wyller at Edward.Wyller@odhsoha.oregon.gov.
Licensing Coordinator’s Signature: ________________________ Date: _2_.1_2_._2_5_____________
2-11-2025
Manager Review: ______________________________________ Date: __________________
Form Rev. 11/14/2023 P age 3 | 3

licensee: Trillium Family Services

program_director: Chiharu (Malone) Blatt

visit_date: January 29th, 2025

purpose:
Per OAR 419-400-0240 (1)(b) Children's Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Findings Comments
Unannounced Site Visit - 5/14/2024 Further Action
Needed
Records Relating to Restraint & Involuntary Seclusion Yes[ ] No✓ - I reviewed 3 resident charts and all 3 had the appropriate notice.
419-400-0180(13)€ Each child caring agency shall provide (In-compliance)
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.
- Repeated Finding: Sender House was missing the notice
regarding how to access quarterly reports that must be
provided to the parents or guardians of the children in care.
Records Relating to Restraint & Involuntary Seclusion Yes[ ] No✓ - I reviewed 3 resident charts and all 3 had the required
419-400-0190(1) Information provided to children in care information provided to residents regarding restraint and
relating to Restraint & Involuntary Seclusion involuntary seclusion. (In-compliance)
- Repeated Finding: Sender House will need to formalize a
process of providing information to children in care relating
to restraint and seclusion.

New Findings from Site Visit Comments
N/A - No findings good work!
Interview Summary
Sender House has a capacity of four residents. One resident was on-site and available to be interviewed. I met with the resident in the adjacent recreation
room in a separate building to ensure privacy. This resident has been at many programs and rated this program as the best. She ranked it an 8-9 on a scale
from 0-10 (0=worst program and 10 =best program). She reported she has learned life skills while at Sender House. "Staff help with skills, If I wasn't here, I
would struggle with life skills and mental health". Resident reported feeling safe. Food was reported to be "good". The residents go out weekly with staff to
purchase groceries for the week. Reported outings included going to a Christmas event in Corvallis and visiting a pumpkin patch. If given a magic wand to
improve the program, resident reported more scheduled group outings. She reported the current group of residents are not interested in group outings.
Observations
During my tour I found the staff to be welcoming. All staff enjoyed working at Sender House and had no intentions of looking elsewhere. The downstairs
basement had been remodeled and laundry room is receiving new locking cabinets. Staff office is to receive lockers for staff. The outside foundation had
major repairs regarding drainage issues. No issues in home or mold. Foundation work was done with an engineer. I found the recreation room to be
reorganized and useable. Last visit it was mainly a storage area and considerable work has been made to make it a great space for Residents away from the
main house. Staff discussed how they work with the residents on how to shop for groceries and take them to a variety of stores to give them experience on
how to shop for both quality and price.
All areas were clean and organized.

new_findings: N/A - No findings good work!

excerpt:
419-400-0190(1) Information provided to children in care information provided to residents regarding restraint and
relating to Restraint & Involuntary Seclusion involuntary seclusion. (In-compliance)
- Repeated Finding: Sender House will need to formalize a
process of providing information to children in care relating
to restraint and seclusion.
New Findings from Site Visit Comments
N/A - No findings good work!
N/A - No findings good work!


summary: Unannounced - 5 findings

raw_content:
Licensed Child Caring Agency Site Visit Report
Residential Care - Unannounced
Licensee: Trillium Family Services – Parry Center (Portland Date of site visit: May 6th, 2025
Campus)
Executive Director: Jamie Vandergon Licensing Coordinator: Ed Wyller with assistance from Jorge
Pelinski
Program Director: Brain Schilling
Other regulatory or accrediting agencies: Oregon Health Authority
Purpose: Per OAR 419-400-0240 (1)(b) Children’s Care Licensing is required to perform at least one unannounced site visit a year
where children in care reside.
Previous findings Repeat findings Comments
Unannounced Site Visit – 02/27/2024 further action
needed
Physical Plant
419-470-0020(2)(a) &(c) Buildings are smoke
free, clean and in good repair
• Repeated Finding: for bedrooms being messy in
North 1 and North 2.
• Repeated Finding: Both North 1 and North
2 bedrooms were messy with child belongings
Yes • All bathrooms were found to be clean and were in
scattered throughout their bedrooms. These
compliance. Please note overall bedrooms look
rooms had too many items that would make
much improved with amount of personal belongings
conducting an area search very time
in room and items such as food in bedrooms.
consuming and difficult to perform or be
effective. North 1 and North 2 bathrooms
were found not clean and needing caulk
Form Rev. 3/12/2025 P a g e 1 | 6
Previous findings Repeat findings Comments
Unannounced Site Visit – 02/27/2024 further action
needed
replaced in the seam between the floor and
the shower pans. During youth interviews
youth from west programs reported
experiencing dirty bathrooms as well.
New Employee Orientation – Umbrella
Requirements (30 days) 419-400-0120(4)
(a) Agency policies and procedures
• Repeated Finding: Reviewers reviewed 4
• I reviewed three recently hired employees from late
new employees since last renewal review.
2024 and early 2025 and all employees had this
Reviewers found documentation of just 1 out No
required training within the 30-day period from date
of 4 staff receiving this training in the required
of hire. (In-Compliance)
30-day requirement. Two of the employees
did receive the training. However, it was two
weeks late. The other employee has not
received the training and is outside of the
required 30-day period.
New Employee Orientation – Umbrella
Requirements (30 days)
419-400-0120(4)(e) & (5)(a) to (c) Mandatory
reporting that includes:
(a) legal definition of child abuse in ORS
418.257 and 419B.005 • I reviewed three recently hired employees from late
(b) legal responsibility to immediately report 2024 and early 2025 and all employees had this
No
(c) legal responsibility to report is personal to required training within the 30-day period from date
the employee of hire. (In-Compliance)
• Repeated Finding: Reviewers reviewed 4
new employees since last renewal review.
Reviewers found documentation of just 1 out
of 4 staff receiving this training in the required
Form Rev. 3/12/2025 P a g e 2 | 6
Previous findings Repeat findings Comments
Unannounced Site Visit – 02/27/2024 further action
needed
30-day requirement. Two of the employees
did receive the training, however, it was two
weeks late. The other employee has not
received the training and is outside of the
required 30-day period.
New Employee Orientation – Umbrella
Requirements (30 days)
419-400-0120(4)(f) Privacy laws
• Repeated Finding: Reviewers reviewed 4
• I reviewed three recently hired employees from late
new employees since last renewal review.
2024 and early 2025 and all employees had this
Reviewers found documentation of just 1 out No
required training within the 30-day period from date
of 4 staff receiving this training in the required
of hire. (In-Compliance)
30-day requirement. Two of the employees
did receive the training, however, it was two
weeks late. The other employee has not
received the training and is outside of the
required 30-day period.
New Employee Orientation – Umbrella
Requirements (30 days)
419-400-0120(4)(g) Emergency procedures
• Repeated Finding: Reviewers reviewed 4
• I reviewed three recently hired employees from late
new employees since last renewal review.
2024 and early 2025 and all employees had this
Reviewers found documentation of just 1 out No
required training within the 30-day period from date
of 4 staff receiving this training in the required
of hire. (In-Compliance)
30-day requirement. Two of the employees
did receive the training, however, it was two
weeks late. The other employee has not
received the training and is outside of the
required 30-day period.
Form Rev. 3/12/2025 P a g e 3 | 6
New findings from site visit Comments
No new findings • No new findings
Interview summary
DHS CCLP interviewed seven clients (2 from West-1), (2 from West-2), (1 from North-1), and (2 from North-2) during the
unannounced site inspection. Most clients were interviewed outside the cafeteria courtyard to ensure privacy. One client was
interviewed on unit in the private family room and another client was interviewed in the large conference room in the
administrative building. All interviews took place in a private manner to ensure the clients ability to speak freely.
On a scale from 0-10 (0=worst program, 10=best program) client’s reported Trillium – Parry Center to be an average rating of
6.1 on that scale (3, 5, 5, 5,7, 7.5, and 10). All client’s reported feeling safe at Parry Center. The client reporting program as a
3 reported the “food is bad, and they receive only one hour of outside time a day.” Other’s described food as “pretty good”,
“fine”, “mostly good”, and “okay”. All client’s reported having enough food to eat and receiving snacks. Reported favorite
foods include mac and cheese, chicken strips, tacos, enchiladas, pizza, nachos, and the orange cream cheese muffins. Other
clients reported enjoying the option to drink different juices throughout the day. Clients reported vegetarian options are
available, as this had been a recent concern. None of the clients reported this as a concern now.
Clients reported attending groups, going weekly to counseling and family therapy. Clients reported having phone calls and
having visits both on and off site with family members. Other clients reported acronyms from their treatment groups from
Dialectical Behavioral Therapy (DBT). Most clients were able to identify what it takes to discharge and where their possible
discharge placement would be. For fun clients reported the following: draw, skateboard, bike, rollerblade, four square, go
outside, work in the garden, screen time, and today some clients were excited to play in water as it is a warm / hot day. Client
reported a slip n slide will be set up and water balloons and soaker toys. This client was very animated about this activity after
school today. Another client reports they enjoy the tub in the bathroom and the bath toys and finds this time relaxing.
Clients were asked if given a magic wand to improve the program within reason what would you do? “Staff need to be more
supportive.” “Make bedrooms bigger.” “Hire more emotionally mature staff.” “To be moved to the more mature unit.” “To have
a pool on site, and if not that, tree houses.”
Form Rev. 3/12/2025 P a g e 4 | 6
Interview summary
One client brought up a previous reported concern. That concern has been reported to the Safe line, and OTIS is involved. I
confirmed this during my debrief with Trillium Administrative team at conclusion / debrief at end of unannounced site visit.
I followed up with head of the Kitchen regarding a previous concern. The concern was related to emergency food during
inclement weather and/or if staff do not report to work. It was also reported the main concern was regarding not having
vegetarian options. Program has a salad bar in cafeteria and provides vegetarian snacks as well. Emergency food is on site,
both hot and easy to serve options that are vegetarian. Gluten free options are available, including gluten free bread that is in
freezer. In addition, the Culinary Department has made an effort to have various juices available to encourage clients to stay
hydrated. Clients reported they like the different drink options. Staff reported they enjoy their work at Parry Center. Spoke
with one school associated worker that does not work for Trillium but is employed with Portland Public Schools. They reported
concerns about Portland Public Schools hiring more administrative staff while cutting positions for those delivering direct
services to students.
Observations
During the inspection I saw areas of the building where the roof is being worked on. All buildings were clean except a few
client bedrooms. When I spoke with clients, they reported there are expectations to have clean bedrooms. I observed staff
interacting with clients in a positive and helpful manner.
Corrective actions and timeframes: Please submit the following to verify compliance.
Within 45 days of receipt of this report Trillium Family Services – Parry Center 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 Ed Wyller at
Edward.Wyller@odhsoha.oregon.gov.
Form Rev. 3/12/2025 P a g e 5 | 6
X
5.14.25 5-14-2025
Ed Wyller Harry Gilmore
Licensing Coordinator Manager Review
Form Rev. 3/12/2025 P a g e 6 | 6

facility_type: Residential Care - Unannounced

licensee: Trillium Family Services - Parry Center (Portland Date of site visit: May 6th, 2025 Campus)

program_director: Brain Schilling

visit_date: May 6th, 2025 Campus)

purpose:
Per OAR 419-400-0240 (1)(b) Children's Care Licensing is required to perform at least one unannounced site visit a year
where children in care reside.
Previous findings Repeat findings Comments
Unannounced Site Visit - 02/27/2024 further action
needed
Physical Plant
419-470-0020(2)(a) &(c) Buildings are smoke
free, clean and in good repair
- Repeated Finding: for bedrooms being messy in
North 1 and North 2.
- Repeated Finding: Both North 1 and North
2 bedrooms were messy with child belongings
Yes - All bathrooms were found to be clean and were in
scattered throughout their bedrooms. These
compliance. Please note overall bedrooms look
rooms had too many items that would make
much improved with amount of personal belongings
conducting an area search very time
in room and items such as food in bedrooms.
consuming and difficult to perform or be
effective. North 1 and North 2 bathrooms
were found not clean and needing caulk

Previous findings Repeat findings Comments
Unannounced Site Visit - 02/27/2024 further action
needed
replaced in the seam between the floor and
the shower pans. During youth interviews
youth from west programs reported
experiencing dirty bathrooms as well.
New Employee Orientation - Umbrella
Requirements (30 days) 419-400-0120(4)
(a) Agency policies and procedures
- Repeated Finding: Reviewers reviewed 4
- I reviewed three recently hired employees from late
new employees since last renewal review.
2024 and early 2025 and all employees had this
Reviewers found documentation of just 1 out No
required training within the 30-day period from date
of 4 staff receiving this training in the required
of hire. (In-Compliance)
30-day requirement. Two of the employees
did receive the training. However, it was two
weeks late. The other employee has not
received the training and is outside of the
required 30-day period.
New Employee Orientation - Umbrella
Requirements (30 days)
419-400-0120(4)(e) & (5)(a) to (c) Mandatory
reporting that includes:
(a) legal definition of child abuse in ORS
418.257 and 419B.005 - I reviewed three recently hired employees from late
(b) legal responsibility to immediately report 2024 and early 2025 and all employees had this
No
(c) legal responsibility to report is personal to required training within the 30-day period from date
the employee of hire. (In-Compliance)
- Repeated Finding: Reviewers reviewed 4
new employees since last renewal review.
Reviewers found documentation of just 1 out
of 4 staff receiving this training in the required

Previous findings Repeat findings Comments
Unannounced Site Visit - 02/27/2024 further action
needed
30-day requirement. Two of the employees
did receive the training, however, it was two
weeks late. The other employee has not
received the training and is outside of the
required 30-day period.
New Employee Orientation - Umbrella
Requirements (30 days)
419-400-0120(4)(f) Privacy laws
- Repeated Finding: Reviewers reviewed 4
- I reviewed three recently hired employees from late
new employees since last renewal review.
2024 and early 2025 and all employees had this
Reviewers found documentation of just 1 out No
required training within the 30-day period from date
of 4 staff receiving this training in the required
of hire. (In-Compliance)
30-day requirement. Two of the employees
did receive the training, however, it was two
weeks late. The other employee has not
received the training and is outside of the
required 30-day period.
New Employee Orientation - Umbrella
Requirements (30 days)
419-400-0120(4)(g) Emergency procedures
- Repeated Finding: Reviewers reviewed 4
- I reviewed three recently hired employees from late
new employees since last renewal review.
2024 and early 2025 and all employees had this
Reviewers found documentation of just 1 out No
required training within the 30-day period from date
of 4 staff receiving this training in the required
of hire. (In-Compliance)
30-day requirement. Two of the employees
did receive the training, however, it was two
weeks late. The other employee has not
received the training and is outside of the
required 30-day period.

New findings from site visit Comments
No new findings - No new findings
Interview summary
DHS CCLP interviewed seven clients (2 from West-1), (2 from West-2), (1 from North-1), and (2 from North-2) during the
unannounced site inspection. Most clients were interviewed outside the cafeteria courtyard to ensure privacy. One client was
interviewed on unit in the private family room and another client was interviewed in the large conference room in the
administrative building. All interviews took place in a private manner to ensure the clients ability to speak freely.
On a scale from 0-10 (0=worst program, 10=best program) client's reported Trillium - Parry Center to be an average rating of
6.1 on that scale (3, 5, 5, 5,7, 7.5, and 10). All client's reported feeling safe at Parry Center. The client reporting program as a
3 reported the "food is bad, and they receive only one hour of outside time a day." Other's described food as "pretty good",
"fine", "mostly good", and "okay". All client's reported having enough food to eat and receiving snacks. Reported favorite
foods include mac and cheese, chicken strips, tacos, enchiladas, pizza, nachos, and the orange cream cheese muffins. Other
clients reported enjoying the option to drink different juices throughout the day. Clients reported vegetarian options are
available, as this had been a recent concern. None of the clients reported this as a concern now.
Clients reported attending groups, going weekly to counseling and family therapy. Clients reported having phone calls and
having visits both on and off site with family members. Other clients reported acronyms from their treatment groups from
Dialectical Behavioral Therapy (DBT). Most clients were able to identify what it takes to discharge and where their possible
discharge placement would be. For fun clients reported the following: draw, skateboard, bike, rollerblade, four square, go
outside, work in the garden, screen time, and today some clients were excited to play in water as it is a warm / hot day. Client
reported a slip n slide will be set up and water balloons and soaker toys. This client was very animated about this activity after
school today. Another client reports they enjoy the tub in the bathroom and the bath toys and finds this time relaxing.
Clients were asked if given a magic wand to improve the program within reason what would you do? "Staff need to be more
supportive." "Make bedrooms bigger." "Hire more emotionally mature staff." "To be moved to the more mature unit." "To have
a pool on site, and if not that, tree houses."

Interview summary
One client brought up a previous reported concern. That concern has been reported to the Safe line, and OTIS is involved. I
confirmed this during my debrief with Trillium Administrative team at conclusion / debrief at end of unannounced site visit.
I followed up with head of the Kitchen regarding a previous concern. The concern was related to emergency food during
inclement weather and/or if staff do not report to work. It was also reported the main concern was regarding not having
vegetarian options. Program has a salad bar in cafeteria and provides vegetarian snacks as well. Emergency food is on site,
both hot and easy to serve options that are vegetarian. Gluten free options are available, including gluten free bread that is in
freezer. In addition, the Culinary Department has made an effort to have various juices available to encourage clients to stay
hydrated. Clients reported they like the different drink options. Staff reported they enjoy their work at Parry Center. Spoke
with one school associated worker that does not work for Trillium but is employed with Portland Public Schools. They reported
concerns about Portland Public Schools hiring more administrative staff while cutting positions for those delivering direct
services to students.
Observations
During the inspection I saw areas of the building where the roof is being worked on. All buildings were clean except a few
client bedrooms. When I spoke with clients, they reported there are expectations to have clean bedrooms. I observed staff
interacting with clients in a positive and helpful manner.

new_findings: No new findings - No new findings

excerpt:
419-400-0120(4)(g) Emergency procedures
- Repeated Finding: Reviewers reviewed 4
- I reviewed three recently hired employees from late
new employees since last renewal review.
2024 and early 2025 and all employees had this
Reviewers found documentation of just 1 out No
required training within the 30-day period from date
of 4 staff receiving this training in the required
of hire. (In-Compliance)
30-day requirement. Two of the employees
did receive the training, however, it was two
weeks late. The other employee has not
received the training and is outside of the
required 30-day period.
New findings from site visit Comments
No new findings - No new findings
No new findings - No new findings