summary: 6-month - 62 findings

raw_content:
Licensed Child Caring Agency Site Visit Report
Residential Care - 6-Month
Licensee: Klamath Basin Behavioral Health (KBBH) Board Chairperson: Edward Horvath
Residential Programs: Sage and Yarrow Date of site visit: 4/7/25
Executive Director: Kendall Alexander Licensing Coordinator: Mary Torres
Other Regulatory or Accrediting Agencies: Oregon Department of Human Services (ODHS) - Treatment Services, Child Welfare
Program compliance: The program was found to be compliant or will be compliant with OAR 419-400-0005 to 419-400-0310,
Licensing Umbrella Rules, and OAR 419-470-0010 to 419-470-0180, Licensing Residential Care Agencies Rules. Personnel records
were reviewed and compliance with required background checks was documented for employees in all programs.
Program description(s): As per the CCA's website; The youth residential facilities provide behavioral rehabilitation services to youth in
DHS custody who are experiencing a severe behavioral health episode. Services are provided to male and female adolescents ages
10-17 years.
Program type and services: As per the CCA's website; Services provided include 24/7 supervision, intensive weekly skills building,
medication management, and care coordination. Temporary crisis respite services are available for non-qualifying youth who need
mental health supervision while waiting for less restrictive services.
Capacity and age range: 10 youth total, 4 youth at Yarrow, 6 youth at Sage, ages 10 - 17 years
Funding sources: Oregon Department of Human Services (ODHS)
Contracts and sources for referrals: Oregon Department of Human Services (ODHS)
Average length of stay: To be determined over the upcoming 2-year licensing period.
Form revised 3/12/2025 Page 1 of 32
Average daily population served: To be determined over the upcoming 2-year licensing period.
Number of children served annually: To be determined over the upcoming 2-year licensing period.
Use of seclusion or restraint: The CCA does not currently utilize seclusion nor restraint. Although the program expresses a strong
desire to refrain from the use of restraints, a recent decision to train staff in safety holds through Crisis Prevention Institute (CPI) has
been made. This will provide staff with the tools needed to safely and effectively implement a hold should circumstances warrant a
physical intervention by staff to lower risk and maximize safety.
Interviews/observations: Licensing completed a tour of the building and conducted both staff and youth interviews. At the time of this
6 month review, the program was servicing two youth with a third expected to arrive the same evening. Since the program's opening in
November of 2024, the program has served 15 youth total. Both buildings were clean and showed no signs of previous damage done
only a few weeks prior by a prevoius milieu. The agency's maintenance team was quick to repair walls, doors, doorframes, etc.
Three direct care staff were interviewed. All staff were able to identify essential training topics covered in during their new employee
orientation. One staff suggested breaking up the three week training course as it was difficult to retain so much new information.
Strengths identified by staff include the Program Manager's "good communication" with staff, quick responses to questions and
situations and their "open door policy." The teams cohesiveness was also appreciated. Areas where staff would like to see
improvement are having all staff trained to administer medication to youth and finding "a balance" when intaking youth to prevent the
need for discharging youth on an emergency basis due to an inbalance of needs within the milieu. The program will soon implement a
12 hour work schedule, allowing staff to have three consecutive days to recharge. Those inteviewed are excited about this change and
feel it will reap positive results.
One youth was open to being interviewed. Youth reports feeling safe within the program and feels that staff are adequately trained to
provide care and supervision of youth. The current miliue is diverse and although the youth is experiencing issues with a peer, there is
opportunity to create space from the peer and staff are able to provide individual support. A program positive, in the youth's
perspective, is the amount of free time allowed and there are not too many required groups that youth must attend. A change to the TV
and video game use was recommended. Currently, screen time is only allowed after 4:00 pm or later, depending on what is happening
Form revised 3/12/2025 Page 2 of 32
in the milieu. Outings regularly occur and include trips to the park, swimming at the Y, and library. With summer approaching, the
program is planning on more outside activities. The youth has met with the program's therapist and treatment goals have been
established. The in house therapist has offered this youth with support and the youth verbalizes a commitment to stay in program.
Program strengths: A common strength identified by staff is the support and positive communication provided by the Program
Manager. Staff report that the Program Manager is quick to respond and encourages staff to utilize critical thinking when dealing with
difficult youth behaviors.
Program challenges: Staff identify program challenges as difficult youth behaviors that result in emergency discharges and the lack of
medication adminstration for all staff. Enrolling new youth into school within a timely manner has proven to be difficult. School
administrators have been apprehensive in accepting newly placed youth without requested school history and documentation, delaying
enrollment by weeks. Youth behaviors within the milieu and in the community coming to the attention of law enforcement are creating
tension with local police. The program is assessing their reporting practices and making changes as needed to avoid taxing police
resources.
Changes that have occurred in the last two years: None reported by the program.
Lawsuits: None reported by the program.
Grievances and complaints filed in the last two years: None reported by the program.
Corrective actions and timeframes: Please submit the following to verify compliance.
Within 45 days of receipt of this report Klamath Basin Behavioral Health (KBBH) 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 Mary Torres at mary.torres@odhsoha.oregon.gov.
Exceptions: None
Form revised 3/12/2025 Page 3 of 32
Changes in license: The residential programs were added to the CCA's 2-year license on November 19. 2024. A review for the CCA
is scheduled to occur before the license's expiration on September 30, 2025.
Summary of review
Program and services Yes/No Corrective actions/comments
419-400-0020 (2) or N/A
Program and services are in scope of Yes
license
Governance of the agency Yes/No Corrective actions/comments
419-400-0040 or N/A
(1)(a) Minimum of 5 board members Yes
(2)(f) Formally evaluate the Executive N/A Item to be audited at the upcoming license renewal.
Director’s performance annually
(2)(g) Approves annual budget N/A Item to be audited at the upcoming license renewal.
(2)(h) Obtain and review an annual N/A Item to be audited at the upcoming license renewal.
independent financial review or audit
of financial records.
(2)(k) Written quality improvement No A quality improvement plan was not submitted.
program
CORRECTIVE ACTION: Submit a written quality improvement plan to
Licensing for review.
(2)(l) Meeting minutes N/A Item to be audited at the upcoming license renewal.
Form revised 3/12/2025 Page 4 of 32
Executive Director or Program Yes/No Corrective actions/comments
Director or N/A
419-400-0040
(3)(a) knowledge of requirements for Yes
providing care and treatment
appropriate to programs
(3)(g) Approval from BCU Yes Approved background check from 2023 license renewal on file with
Licensing. This background check will be renewed for the next licensing
period due fall of 2025.
Installation and use of video Yes/No Corrective actions/comments
equipment used to monitor or or N/A
record children in care
419-400-0145
(1) If a child-caring agency installs Yes
video equipment to monitor or record
a child in care, all employees,
volunteers, parents or guardians and
children in care must be informed
about the intended use and locations
of the equipment.
Discipline, behavior management Yes/No Corrective actions/comments
and suicide prevention or N/A
419-400-0150
(3) Agency uses appropriate and Yes The program utlizes Dialectical Behavior Therapy (DBT) and Cognitive
positive methods of behavior Behavioral Therapy (CBT) when assisting youth regulate. There was a
management and nationally recent decision to extend CPI training to include training on safety holds.
recognized non-violent crisis Once this occurs, the program will need to revise their current behavior
intervention mamagement policy to reflect these changes.
(3)(b)(C) Agency does not use N/A The program does not utilize chemical or mechanical restraints.
chemical and mechanical restraint
Form revised 3/12/2025 Page 5 of 32
Discipline, behavior management Yes/No Corrective actions/comments
and suicide prevention or N/A
419-400-0150
(excluding medically necessary
devices/prescriptions)
(3)(c) Agency uses appropriate time- N/A The program does not utilize the use of time out rooms.
out rooms (adequate space, heat,
light and ventilation and is not capable
of locking) and documents use in
child’s record when applicable
(3)(e) Agency uses seclusion N/A The program does not utilize seclusion.
appropriately/consistent with policy
(4) Agency has adequate plan in Yes
place to respond to suicidal
behavior/warning signs
Contractors (if applicable) Yes/No Corrective actions/comments
419-400-0120(6) or N/A
(a) Agency ensures the contractor N/A Item to be audited at the upcoming license renewal
meets the requirements of this rule
and Chapter 413 division 215
(b)(B) Contract includes the following: N/A Item to be audited at the upcoming license renewal
(i) Services provided
(ii) Contractor fees
(iii) Disclosure of information from
contractor to agency
(iv) Lines of authority
(v) Adherence to rules, including
background check
(vi) Any liability of the agency for acts
of the contractor, rights of indemnity
and limitations on liability
Form revised 3/12/2025 Page 6 of 32
Restraints and Involuntary Yes/No Corrective actions/comments
Seclusion or N/A
419-400-0180
(13)(d) Each child caring agency that No Although the program has submitted a copy of the program's most recent
submits a report under this section quarterly report to Licensing for public posting, a copy of the report has not
shall make its quarterly report been uploaded to the CCA's own website.
available to the public upon request at
the child caring agency’s main office CORRECTIVE ACTION: Upload most recent and future quarterly reports
and on the child caring agency’s onto the CCA's own website for public review.
website if applicable.
Supplemental information provided Yes/No Corrective actions/comments
by CCA or N/A
Documents as indicated on the form Yes These items were checked prior to the program receiving its' license and
titled “Renewal Licensing Required was not audited during this 6-month review.
Documents”
Documents as indicated on form titled Yes These items were checked prior to the program receiving its' license and
“Required Financial Documents and was not audited during this 6-month review
Information”
All required policies and procedures Yes These items were checked prior to the program receiving its' license and
as identified in the “Umbrella Rules” was not audited during this 6-month review
All required policies and procedures Yes These items were checked prior to the program receiving its' license and
as identified in “Agency Type Specific was not audited during this 6-month review
Rules”
Physical plant Yes/No Corrective actions/comments
or N/A
419-400-0090(3)(a) Foster Rights No Foster Rights was not posted.
Posted (if children in ODHS custody)
Form revised 3/12/2025 Page 7 of 32
Physical plant Yes/No Corrective actions/comments
or N/A
CORRECTIVE ACTION: Post youth Foster Rights in the common area of
each facility. Send a picure to Licensing showing the posted page as proof.
419-400-0100(1) Sufficient safe Yes
space, equipment and office
equipment
419-400-0230(12) License is posted No License was not posted.
in common area at each facility
CORRECTIVE ACTION: Post a copy of the CCA's license in each facility in
the common area. Send a picture to Licensing showing the posted license
as proof.
419-470-0020(2)(a) and (c) Buildings Yes
are smoke free, clean and in good
repair
419-470-0020 (2)(d) Rooms are free Yes
of harmful drafts, odors and excessive
noise
419-470-0020 (2)(e) Rooms are Yes
adequate in size and arrangement
419-470-0020 (2)(f) System provides Yes
a continuous supply of hot and cold
water to taps located throughout the
facility
419-470-0020 (2)(h) Building is well Yes
ventilated, and room temperature is
within a normal comfort range
419-470-0030 (1) All parts of the Yes
facility ensure the safety of children
Form revised 3/12/2025 Page 8 of 32
Room and space requirements Yes/No Corrective actions/comments
419-470-0030 or N/A
(2) There is a separate living room or Yes
lounge area – 15 SF minimum per
child
(5) There is a separate dining room Yes
with capacity for ½ of children in care
and 15 SF per child in care
(7) Laundry is separate from living, Yes
kitchen and dining areas
(8) Separate storage areas are Yes
provided for food, kitchen supplies,
utensils, clean linens, soiled linens
and clothing, cleaning supplies and
equipment, poisons, chemicals,
outdoor recreational and maintenance
equipment. (Hazardous materials are
properly labeled, in original container
and locked)
(9) Outdoor activity area is protected Yes
from vehicles and other hazards and
of a size and availability appropriate to
the age and needs of children in care
(11) Time-out rooms: Rooms used for N/A The program does not use time out rooms.
time out or quiet time must have
adequate space, heat, light and
ventilation and must not be capable of
locking.
Form revised 3/12/2025 Page 9 of 32
Room and space requirements - Yes/No Corrective actions/comments
bedrooms or N/A
419-470-0030(3)
(a) Adequate furnishings and personal Yes
items
(b) Separate from rooms used for Yes
dining, living, laundry, kitchen and
storage
(c) Meet Oregon Fire Code Yes
Requirements
(d) Be an outside room, with a window Yes
that operates as designed. If the
window is modified from its original
design, the fire marshal must approve
the modification and indicate this
room still meets applicable Oregon
Fire Code.
(d) Ceiling at least 90 inches Yes
(e) Minimum 60 SF per occupant Yes
(f) No more than 25 if dorm style N/A The program provides youth with single room occupancy.
(g) Permanently wired fixtures Yes
(h) Window covering Yes
Room and space requirements - Yes/No Corrective actions/comments
bathrooms or N/A
419-470-0030(4)
(a)(A) and (B) 1:8 ratio for toilets and Yes
sinks
(a)(D) Hot and cold running water, Yes
soap and approved hand drying
options
(a)(E) 1:10 ratio for shower or bathtub Yes
Form revised 3/12/2025 Page 10 of 32
Room and space requirements - Yes/No Corrective actions/comments
bathrooms or N/A
419-470-0030(4)
(a)(E) Individual privacy Yes
(a)(F) Window covering Yes
(a)(G) Permanently wired fixtures Yes
(a)(H) Adequate ventilation Yes
(b) and (c) Wooden racks on floors are Yes The program will be using an impervious shower mat in each shower. The
prohibited and impervious shower development of a procedure, ensuring the mats are disinfected and dried
mats are disinfected and dried daily be on a daily basis is being requested by Licensing. ***Please note, this is not
in good condition and free of mold a corrective action.***
Room and space requirements - Yes/No Corrective actions/comments
kitchen or N/A
419-470-0030(6)
(a) Used exclusively for storage, food Yes
preparation, dishwashing and
activities related to eating and food
preparation activities
(b) Walls, floors are easily cleanable Yes
(c) Equipment and utensils are easily Yes
cleanable, durable, nontoxic and kept
clean
(e) Equipment is easy to clean Yes
beneath, between and behind
Furnishings and personal items Yes/No Corrective actions/comments
419-470-0040 or N/A
(1) There is a bed with frame Yes
Form revised 3/12/2025 Page 11 of 32
Furnishings and personal items Yes/No Corrective actions/comments
419-470-0040 or N/A
(1)(b) clean mattress in good Yes
condition, with a minimum thickness
of five inches
(1)(c) a pillow in good condition Yes
(1)(d) a private dresser, closet, or Yes
similar storage area for personal
belongings that is readily accessible
(2) Linens are in good repair. There is Yes
a waterproof mattress cover or
mattress. Linens are appropriate and
towels and washcloths are provided
(3) Bedding is changed weekly or Yes
when soiled
(4) and (5) Personal hygiene supplies Yes
and appropriate clothing are provided
Food services Yes/No Corrective actions/comments
419-470-0070 or N/A
(1)(a) Meals are arranged daily, Yes
consistent with normal mealtimes that
occur during the hours of operation
and provide snacks between
mealtimes
(1)(b) Menus are prepared in advance Yes Snacks are to be listed on each monthly menu. Snacks options can be listed
in accordance with USDA guidelines, for each day or listed for each week. ***Please note, this is not a finding.***
provide a variety of foods and are
adjusted for seasonal changes
including snacks
(1)(b) Menus are kept for at least 6 Yes
months
Form revised 3/12/2025 Page 12 of 32
Food services Yes/No Corrective actions/comments
419-470-0070 or N/A
(1)(c) Drinking water is freely available Yes
(2)(a) Food is stored, prepared and Yes
served in a sanitary manner
(2)(c) and (d) Food products are Yes
obtained from commercial suppliers
(exception of fruits and vegetables),
unpasteurized juice is prohibited, and
only Grade A pasteurized and fortified
milk in appropriate container.
Residential care safety Yes/No Corrective actions/comments
419-470-0080 or N/A
(2) Written emergency plan that Yes
includes
(a) Identifying the types of Yes
emergencies most likely to happen
where the residential care agency is
located
(b) Identifying a place to meet for Yes
each type of emergency identified
(c) Identifying an alternate shelter if Yes
necessary
(d) Ensuring access to necessary Yes
medications or medical equipment
(e) How to help each child in care Yes
recover after a disaster
(3) Telephone numbers for local Yes
police, fire department, poison control,
after hours medical advice and other
Form revised 3/12/2025 Page 13 of 32
Residential care safety Yes/No Corrective actions/comments
419-470-0080 or N/A
appropriate emergency numbers must
be posted near all telephones.
(4) Operative flashlights sufficient in Yes
number are readily available to staff
(5)(a) Evacuation drill occurs monthly No Although evacuations have occurred monthly since the program's opening,
under varying conditions, is retained 2 the documentation for these drills do not reflect the required information as
years and contains: listed to the side of this narrative.
(A) identify of person conducting drill
(B) date and time CORRECTIVE ACTION: Revise the existing evacuation sheet to include the
(C) notification method required information and implement the use of the revised form moving
(D) staff participating forward. If further assistance is needed, the program will reach out to the
(E) number of children and staff Licensing Coordinator.
evacuated
(F) special conditions simulated
(G) problems encountered
(H) time to complete
Umbrella safety Yes/No Corrective actions/comments
419-400-0200 or N/A
(5)(b) Vehicle has insurance policy, is Yes
smoke free, safe operating condition,
and has first aid kit and fire
extinguisher 2-A:10-BC
(1)(b)(A) Each vehicle used to Yes A copy of the vehicle's current registration issued by the DMV is requested
transport a child in care must be: to be kept in the vehicle moving forward. ***Please note, this is not a
properly registered, finding.***
covered by an insurance policy in full
force and effect, maintained in safe
operating condition and smoke-free.
Form revised 3/12/2025 Page 14 of 32
Umbrella safety Yes/No Corrective actions/comments
419-400-0200 or N/A
(3) If a child-caring agency has a N/A The program does not have a pool on site. If the program has plans to have
swimming pool on the premises that is youth engage in swimming off site, then a policy addressing disclosures and
accessible to children in care or if a obtaiing consents as well as assessing the swimming ability of each chilld in
child-caring agency plans to have care will need to be submitted to Licensing. ***Please note, this is not a
children in care engage in swimming, finding.***
the child-caring agency must have
and adhere to policies and procedures
that address, at a minimum, providing
disclosures and obtaining consents,
assessing swimming ability of children
in care and ensuring the safety of pool
access.
(4)(a) The program protects children Yes
from potentially harmful items and
materials.
(4)(b) Direct supervision of children Yes
who do not have the ability to adjust
and control water temperature
(4)(c) Light fixtures have protective Yes
covers unless designed to be used
without one
Medication Yes/No Corrective actions/comments
419-470-0100 or N/A
(3) and (7)(e) Medications have a Yes
prescription and are stored in the
original container with prescription
label
(4) and (5) Herbal supplements and Yes
remedies, medical treatments, special
Form revised 3/12/2025 Page 15 of 32
Medication Yes/No Corrective actions/comments
419-470-0100 or N/A
diets, physical therapy, physical aides
or limitations have a written order
signed by a physician or qualified
medical professional. A written order,
signed by a physician or qualified
medical professional, is also required
before a restriction on diet or physical
activity is imposed.
(7)(c) Medications are inaccessible to Yes
children and stored behind at least
two locking mechanisms. This does
not apply to Naloxone.
(8) Medications are disposed in Yes
accordance with state and federal law
(9) Written record of the disposal of No Disposal log is missing two staff signatures.
medications is maintained and
includes: CORRECTIVE ACTION: Ensure that all required informaition is noted on the
(a) description and amount disposal log to include two staff signatures. Submit revised document to
(b) name Licensing.
(c) reason
(d) method
(e) staff and witness signature
(10) Written record of the Yes
administration of medication includes:
(a) name
(b) description
(c) dates and times
(d) missed doses
(e) medication disposed
(f) method of administration
(g) ID of person administering
Form revised 3/12/2025 Page 16 of 32
Medication Yes/No Corrective actions/comments
419-470-0100 or N/A
(h) possible adverse reactions
(i) medication taken outside facility
Extracurricular, enrichment, Yes/No Corrective actions/comments
cultural and social activities or N/A
419-470-0110
(2) Children have ongoing Yes
opportunities to participate in at least
one age-appropriate or
developmentally appropriate activity
Minimum staffing requirements Yes/No Corrective actions/comments
419-470-0130 or N/A
(1) and (2) Supervision is adequate Yes
for the type of program, location, age
and type of children, ability of
supervisor to respond, electronic
back-up systems.
Minimum ratios are maintained:
Under 30 months of age: 1:4
30 months to ˃ 6 years or non-
ambulatory: 1:6
Ages 6 and older: 1:7
Overnight (staff awake)
1:10
(4)(a) When one staff on duty, there is Yes
additional staff immediately available
with max response time of 30 minutes
Form revised 3/12/2025 Page 17 of 32
Minimum staffing requirements Yes/No Corrective actions/comments
419-470-0130 or N/A
(5) There is at least one on-site No A review of staff files does not reflect reasonable and prudent parent
employee authorized to apply the standard training being offered to residential staff.
reasonable and prudent parent
standard CORRECTIVE ACTION: Train all staff in this area and submit proof in
writing to Licensing.
Sleeping arrangements Yes/No Corrective actions/comments
419-470-0140 or N/A
(1) Children are in separate bedrooms N/A The program's age range is 10 - 17 years.
than adults, unless parent and child,
or there is written approval from
guardian/parent and licensing
coordinator
(2) There is adequate supervision of Yes
children when sleeping
(3) When assigning bedrooms a Yes
residential care agency must consider
all of the following:
(a) Chronological age
(b) Developmental age
(c) Gender identity
(d) Personal history, including
medical, mental health, behavioral
health and past adverse experiences
including any physical or sexual
abuse
Form revised 3/12/2025 Page 18 of 32
Personnel files Yes/No Corrective actions/comments
419-400-0120 or N/A
Staff name/position Yes
(3)(g) Date of hire Yes
(3)(a) record of education, training Yes
and previous employment
(1)(b) and (3)(b) reference checks Yes
completed and documented
(1)(a) and (3)(c) Background check Yes
completed and documented
(3)(d) Annual performance N/A Evaluations for residential staff are scheduled for June 2025. Item to be
evaluations audited at the upcoming license renewal.
(3)(f) Record of personnel actions Yes
(3)(g) Termination date, reason for Yes
termination
(3)(h) Current job description (1)(c) Yes
Employee meets minimum
qualifications stated in current job
description
New employee orientation – Yes/No Corrective actions/comments
Umbrella Requirements (30 days) or N/A
419-400-0120(4)
(a) Agency policies and procedures Yes
(b) Ethical and professional Yes
guidelines
(c) Suicide prevention and No One personnel file reviewed reflected partial training in this area.
intervention
CORRECTIVE ACTION: Ensure that the staff member completes this
training. Submit proof that this training was completed to Licensing.
Licensing is able to identify the staff member to the program upon request.
Form revised 3/12/2025 Page 19 of 32
New employee orientation – Yes/No Corrective actions/comments
Umbrella Requirements (30 days) or N/A
419-400-0120(4)
(d) Attributes of population served Yes
(e) and (5)(a) to (c) Mandatory Yes
reporting 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
(f) Privacy laws Yes
(g) Emergency procedures Yes
New employee orientation Yes/No Corrective actions/comments
residential (prior to working alone or N/A
and within 30 days)
419-470-0120(1)
(a) Discipline and behavior Yes
management including de-escalation,
crisis prevention, positive behavior
management and disciplinary
techniques that are non-punitive in
nature
(b) CPR and First Aid sufficient to Yes
retain a current certification
(c) Universal precautions and hygiene Yes
(d) Application of the reasonable and No Reasonable and prudent parent standard training is not being offered to
prudent parent standard residential staff.
Form revised 3/12/2025 Page 20 of 32
New employee orientation Yes/No Corrective actions/comments
residential (prior to working alone or N/A
and within 30 days)
419-470-0120(1)
CORRECTIVE ACTION: Implement a process where this required training
is a part of the new employee onboarding process and existing staff are
trained in this area. Submit completion of this training to Licensing.
(e) Training on the agency’s policy on No Although the program provides training in suicide prevention and
suicide prevention and suicide risk intervention to staff, it is unclear how and which staff are trained to
assessment tool administer a suicide risk assessment.
CORRECTIVE ACTION: Clarify what suicide risk assessment tool is used,
which staff are trained to administer the assessment and how staff are
trained in the use of this tool.
Crisis intervention training Yes/No Corrective actions/comments
standards and certification or N/A
419-400-0160(4) (as applicable)
(a)Complete a minimum of 12 hours N/A The program does not currently utilize physical restraint as a behavior
of initial training in person from a intervention
certified instructor, including but not
limited to a minimum of six hours of
training focused on positive behavior
support, nonviolent crisis intervention
and other methods of nonphysical
intervention to support children in
care during a crisis
(d) Receive a certificate that states: N/A The program does not currently utilize physical restraint as a behavior
(A) The dates during which the intervention
certification is current
Form revised 3/12/2025 Page 21 of 32
Crisis intervention training Yes/No Corrective actions/comments
standards and certification or N/A
419-400-0160(4) (as applicable)
(B) The type of restraint which the
individual is certified to perform if
applicable
(C) The type of training the individual
is certified to conduct if applicable
(D) Any special endorsements earned
by the individual
(E) The level of training
(F) The name of the certified
instructor who conducted the training
and administered the assessment of
proficiency.
(e) A certification issued: N/A The program does not currently utilize physical restraint as a behavior
(A) Must be personal to the individual intervention
certified by the training provider
(B) May be valid for no more than two
years with recertification
Ongoing training Yes/No Corrective actions/comments
or N/A
419-470-0070(2)(b) Employees who N/A The program is less than a year in existence.
handle food served to children have a
valid food handler’s card
419-400-0200 (1) Employees N/A The program is less than a year in existence.
transporting children have: current
driver’s license, insurance, trained in
emergency procedures and behavior
Form revised 3/12/2025 Page 22 of 32
Ongoing training Yes/No Corrective actions/comments
or N/A
management and training for 15+
passenger vans if applicable)
419-470-0120 (2)(a) Environmental N/A The program is less than a year in existence.
emergencies
419-470-0120 (2)(b) Universal N/A The program is less than a year in existence.
precautions
419-470-0120 (2)(c) Discipline and N/A The program is less than a year in existence.
behavior management
419-470-0120 (2)(d) Agency’s policy N/A The program is less than a year in existence.
on suicide prevention and risk
assessment tool
419-470-0120 (3) Staff providing N/A The program is less than a year in existence.
direct care must maintain current
CPR/First Aid certification
419-470-0120 (4) Designated staff N/A The program is less than a year in existence.
authorized to apply reasonable and
prudent parent standard are trained in
application of the standard
419-400-0120(5) Mandatory reporting N/A The program is less than a year in existence.
(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
419-400-0160(4)(b) Receive N/A The program is less than a year in existence.
continuing education (as applicable
Form revised 3/12/2025 Page 23 of 32
Ongoing training Yes/No Corrective actions/comments
or N/A
on crisis intervention training) from a
certified instructor on an annual basis
Children’s records Yes/No Corrective actions/comments
health services or N/A
419-470-0090
(2) Medical history obtained within 30 Yes Currently the program utilizes the Child Welfare referral packet (1055)
days (significant findings, current submitted for each child the program considers and takes into care. For
immunizations, history of surgical now, the information captured in this packet adequately addresses a
procedures-health issues-injuries, youth's medical history. Licensing will offer technical assistance in this area
allergies, dental, vision, hearing, should the program decide to independently obtain and document a youth's
behavioral health and physician medical history in additon to the referral packet.
orders)
(4)(a) to (f) Medical exams (3 in first Yes
year of life, 2,4,6,9,14)
(g) Have a physical examination within Yes The program is establishing partnerships within the medical community and
the first 60 days after admission of a is striving to have all youth fast tracked through Sky Lakes for a well child
child in care. Documentation of a check within 2 weeks of their arrival. Vision and dental appointments are
physical examination having occurred taking longer to schedule than 2 weeks.
within the calendar year will meet this
requirement.
Consents Yes/No Corrective actions/comments
419-470-0160(1) or N/A
(a) Provide routine and emergency Yes
medical care
(b) Use the discipline and behavior Yes
management system
Form revised 3/12/2025 Page 24 of 32
Consents Yes/No Corrective actions/comments
419-470-0160(1) or N/A
(c) Use restraint or seclusion (if N/A The program does not practice restraint or seculsion. This may change
applicable). Must specify the reasons once staff are fully trained in safety holds through CPI.
for the intervention and how staff are
trained and supervised
(d) Restrict contact with persons Yes
outside of the agency
(e) Allow access as defined in 419- No This required consent is missing from the program's intake packet.
400-0230 and 0240
CORRECTIVE ACTION: Create and implement the use of this consent that
allows the following:
419-400-0230 Licensing Umbrella Rules: Responsibilities of Licensees
A Licensee is responsible to do all of the following:
(10) Permit immediate access to a child in care and access to any area of
the premises in which the child in care receives care or services to the
following:
(a) Employees and representatives of the Department;
(b) The child in care's attorney;
(c) The child in care's court-appointed special advocate;
(d) The parent or legal guardian of the child in care if the child in care has
not been committed to the custody of the Department or the Oregon Youth
Authority;
(e) Any governmental agency or unit that has a contract with the child-
caring agency to provide care or services to the child in care; and
(f) Any other person authorized by the Department
(f) Impose a dress code Yes
(g) Apply the reasonable and prudent No This required consent is missing from the program's intake packet.
parent standard
CORRECTIVE ACTION: Create and implement the use of this consent that
allows the program to apply the reasonable and prudent parent standard to
determine whether the child in care is allowed to participate in age-
Form revised 3/12/2025 Page 25 of 32
Consents Yes/No Corrective actions/comments
419-470-0160(1) or N/A
appropriate or developmentally appropriate activities including
extracurricular, enrichment, cultural, and social activities.
Disclosures Yes/No Corrective actions/comments
419-470-0160(2) or N/A
Parent/guardian has acknowledged in
writing:
(a) Information regarding personal or Yes
room searches and protocols for
confiscation of contraband
(b) Statement of Rights of Children Yes
and Parents/Guardians
(c) Any policies and procedures upon No This required disclosure is missing from the program's intake packet.
request
CORRECTIVE ACTION: Create and implement the use of this disclosure
stating that a parent/guardian will be provided any of the program's policies
and/or procedures upon request.
Authorizations Yes/No Corrective actions/comments
419-470-0160(3) or N/A
(a) Disclose or exchange information Yes
with others
(b) Child specific visitors Yes
(c) Visitation resources are pre- Yes
approved
(d) Activity specific authorizations are Yes
pre-approved to allow children to
participate in potentially hazardous
activities, including but not limited to
Form revised 3/12/2025 Page 26 of 32
Authorizations Yes/No Corrective actions/comments
419-470-0160(3) or N/A
using motorized yard equipment,
swimming and horseback riding.
Information about children in care Yes/No Corrective actions/comments
419-400-0190(1) or N/A
Summary sheet contains the
following:
(a)The name, gender, date of birth, Yes The program will make an active effort to document a youth's most recent
religious preference and previous placement and address, if known, as part of the intake process for new
address youth moving forward. This may warrant a revision to the program's
existing intake packet. ***Please note, this is not a finding.***
(b) Name and location of previous and No The program's existing intake packet does not have a dedicated space to
current school document a youth's previous and current school setting.
CORRECTIVE ACTION: Revise the existing intake packet to include a
youth's previous and current school name and address.
(c) Date of admission Yes
(d) Legal custody Yes
(e) The name, address and telephone Yes
number of:
(A) The child in care's parents.
(B) The child in care's legal
guardian, if different than the
parents and a copy of the
document that provides for his or
her authority over the child in care.
(C) Other persons significant to
child
(D) Other professionals to be involved
in service planning (if applicable)
Form revised 3/12/2025 Page 27 of 32
Service planning Yes/No Corrective actions/comments
419-470-0170(2) or N/A
(b) Intake document is completed the Yes
date child accepted into care
(emergency placement 48 hours)
(d) Assessment is completed within 30 No Youth assessments have not been completed as the program did not have
days and contains relevant historical an active mental health therapist available until one was hired on 3/3/25.
information, current behavioral
observations, identified need for CORRECTIVE ACTION: Submit a plan as to how the newly hired therapist
services and how agency will provide will meet this 30 day requirement moving forward.
services
(e) (A) and (B) Service plan within 60 No Service plans have not been completed as the program did not have an
days (parent, guardian and child active mental health therapist available until one was hired on 3/3/25.
actively involved). Describes how
child’s issues will be addressed, CORRECTIVE ACTION: Submit a plan as to how the newly hired therapist
anticipated outcomes and reviewed by will meet this 60 day requirement moving forward.
child and guardian/parent.
(e)(C) and (D) Service plan is No It is unknown how often the program plans to review service plans.
reviewed quarterly and revised when
information indicates other services CORRECTIVE ACTION: Submit a plan as to how often service plans are to
should be provided be reviewed and by who.
Case management Yes/No Corrective actions/comments
419-470-0170(3) or N/A
(a) Services are documented, No Services nor progress toward achieving goals are not documented.
progress toward achieving goals is
tracked CORRECTIVE ACTION: Submit a plan as to how services are documented
and how progress toward achieving goals is tracked.
(c) Discharge summary must include: No The program has yet to develop a discharge summary that captures the
(A)Current medications required information located to the side of this narrative.
Form revised 3/12/2025 Page 28 of 32
Case management Yes/No Corrective actions/comments
419-470-0170(3) or N/A
(B)Name of the physician or qualified
medical professional who prescribed CORRECTIVE ACTION: Create and implement a discharge summary that
each medication addresses the required information. Submit a copy of this document to
(C)Any outstanding medical or other Licensing for review.
appointments
(D)Summary of the child’s
participation in the program and
progress achieved
(E)Results of evaluations
(F)Recommendations regarding
services
(G)Discharge destination
(e) Follow up services No Youth that have exited the program thus far, have been discharged under
emergency circumstances. Examples of a planned discharge with
identified follow up services are nonexistent.
CORRECTIVE ACTION: Provide a summary as to how the program plans
to offer and provide transitional or aftercare service coordination to youth
upon their discharge from the program.
(f) Incident reports Yes Licensing will continue to offer support in this area to ensure that all
pertinent information is appropriately documented in these incident reports.
Records relating to Restraint and Yes/No Corrective actions/comments
Involuntary Seclusion or N/A
419-400-0180 (12) Records N/A The program does not utilize restraint or seclusion.
419-400-0180(13)(e) Each child No It is unknown how this notice is provided to parents/guardians at the time of
caring agency shall provide notice admission.
regarding how to access the quarterly
reports to the parents or guardians of CORRECTIVE ACTION: Submit how this information is provided to
children in care in the program. The Licening.
Form revised 3/12/2025 Page 29 of 32
Records relating to Restraint and Yes/No Corrective actions/comments
Involuntary Seclusion or N/A
child caring agency shall provide the
notice upon the child in care’s
admission and at least two times each
year thereafter.
419-400-0190(1) Information provided No The program accepts youth from ODHS - Child Welfare. Although it is the
to children in care relating to Restraint responsibility of ODHS to provide children in care with this required
and Involuntary Seclusion information, the program also provides crisis respite services to the county
youth who must also be provided the same informaiton.
CORRECTIVE ACTION: Create and implement a plan as to how non
ODHS youth will receive the following informaiton as required through rule:
(1) Each child in care receiving services from a child-caring agency must
be given the following:
(a) Instruction regarding how a child in care may report suspected
inappropriate use of restraint or involuntary seclusion;
(b) Assurance that the child in care will not experience retaliation for
reporting suspected inappropriate uses of restraint or involuntary seclusion
and;
(c) The telephone number for the toll-free child abuse hotline (855-503-
7233) described in ORS 417.805 and the telephone numbers and
electronic mail addresses for the program’s Licensing Agency (Mary Torres
503-798-5300, mary.torres@odhsoha.oregon.gov, the child in care’s
caseworker and attorney, the child in care’s court appointed special
advocate and Disability Rights Oregon (503-243-2081).
(2) The information must be provided by:
(a) The Oregon Department of Human Services if the department placed
the child in care in the child-caring agency;
(b) The Oregon Youth Authority if the child in care has been committed to
the custody of the authority; or
(c) The child-caring agency for all other children in care.
Form revised 3/12/2025 Page 30 of 32
Financial records Yes/No Corrective actions/comments
419-470-0170(4) or N/A
Records contain date, amount, N/A Any monetary items (cash, gift cards) that the youth arrive with are locked
source, purpose, signatures up and given to the caseworker upon discharge. There is no need for youth
to access their money during their stay. The program is encouraged to
document the amount of money that is secured at the time of arrival as well
as the amount upon discharge to include staff and youth signatures at both
times. ***Please note, this is not a finding.***
Personal possessions records Yes/No Corrective actions/comments
419-470-0170 (5) or N/A
Individual written inventory of all Yes Although the files reviewed had written inventories, the lists were
personal possessions is maintained inconsistent with the information documented (i.e., not updated, not dated,
and updated as needed not signed, not specific). The program is encouraged to develop a uniform
way for staff to document a youth's belongings and set the expection that
all fields in the document are addressed.
Records and documentation Yes/No Corrective actions/comments
419-400-0140 or N/A
(1) Stored safely Yes
(2) Permanent, legible, dated and Yes
signed
(3) and (4) Uniform in organization, No The program is currently utilizing a drop file system.
readily identifiable and accessible,
current and complete, containing all CORRECTIVE ACTION: The program will develop and implement a filing
required info. No eraser tape or white system that enhances organization, accessibility and ensures that all
out. required information is in each respective file. A checklist or a standard
table of contents has proven helpful for the CCAs in reaching this goal.
(7) Permanent registry for each child Yes
includes:
Name
Form revised 3/12/2025 Page 31 of 32
Records and documentation Yes/No Corrective actions/comments
419-400-0140 or N/A
Gender
Birth date
Names, addresses of parents or
guardians
Dates of admission
Placement upon discharge
5-19-2025 5-19-2025
Mary Torres Tom van der Veen
Licensing Coordinator's signature Manager Review
Form revised 3/12/2025 Page 32 of 32

report_title: Licensed Child Caring Agency Site Visit Report

facility_type: Residential Care - 6-Month

licensee: Klamath Basin Behavioral Health (KBBH)

executive_director: Kendall Alexander

board_chairperson: Edward Horvath Residential Programs: Sage and Yarrow

licensing_coordinator: Mary Torres

other_regulatory_agencies: Oregon Department of Human Services (ODHS) - Treatment Services, Child Welfare

capacity_age_range: 10 youth total, 4 youth at Yarrow, 6 youth at Sage, ages 10 - 17 years

funding_sources: Oregon Department of Human Services (ODHS)

contracts_and_referrals: Oregon Department of Human Services (ODHS)

average_length_of_stay: To be determined over the upcoming 2-year licensing period. Form revised 3/12/2025 Page 1 of 32

average_daily_population_served: To be determined over the upcoming 2-year licensing period.

number_of_children_served_annually: To be determined over the upcoming 2-year licensing period.

program_challenges: Staff identify

changes_in_last_two_years: None reported by the program.

lawsuits: None reported by the program.

grievances_and_complaints: None reported by the program.

exceptions:
None
Form revised 3/12/2025 Page 3 of 32

observations:
, identified need for CORRECTIVE ACTION: Submit a plan as to how the newly hired therapist
services and how agency will provide will meet this 30 day requirement moving forward.
services
(e) (A) and (B) Service plan within 60 No Service plans have not been completed as the program did not have an
days (parent, guardian and child active mental health therapist available until one was hired on 3/3/25.
actively involved). Describes how
child's issues will be addressed, CORRECTIVE ACTION: Submit a plan as to how the newly hired therapist
anticipated outcomes and reviewed by will meet this 60 day requirement moving forward.
child and guardian/parent.
(e)(C) and (D) Service plan is No It is unknown how often the program plans to review service plans.
reviewed quarterly and revised when
information indicates other services CORRECTIVE ACTION: Submit a plan as to how often service plans are to
should be provided be reviewed and by who.
Case management Yes/No Corrective actions/comments
419-470-0170(3) or N/A
(a) Services are documented, No Services nor progress toward achieving goals are not documented.
progress toward achieving goals is
tracked CORRECTIVE ACTION: Submit a plan as to how services are documented
and how progress toward achieving goals is tracked.
(c) Discharge summary must include: No The program has yet to develop a discharge summary that captures the
(A)Current medications required information located to the side of this narrative.
Form revised 3/12/2025 Page 28 of 32
Case management Yes/No Corrective actions/comments
419-470-0170(3) or N/A
(B)Name of the physician or qualified
medical professional who prescribed CORRECTIVE ACTION: Create and implement a discharge summary that
each medication addresses the required information. Submit a copy of this document to
(C)Any outstanding medical or other Licensing for review.
appointments
(D)Summary of the child's
participation in the program and
progress achieved
(E)Results of evaluations
(F)Recommendations regarding
services
(G)Discharge destination
(e) Follow up services No Youth that have exited the program thus far, have been discharged under
emergency circumstances. Examples of a planned discharge with
identified follow up services are nonexistent.
CORRECTIVE ACTION: Provide a summary as to how the program plans
to offer and provide transitional or aftercare service coordination to youth
upon their discharge from the program.
(f) Incident reports Yes Licensing will continue to offer support in this area to ensure that all
pertinent information is appropriately documented in these incident reports.
Records relating to Restraint and Yes/No Corrective actions/comments
Involuntary Seclusion or N/A
419-400-0180 (12) Records N/A The program does not utilize restraint or seclusion.
419-400-0180(13)(e) Each child No It is unknown how this notice is provided to parents/guardians at the time of
caring agency shall provide notice admission.
regarding how to access the quarterly
reports to the parents or guardians of CORRECTIVE ACTION: Submit how this information is provided to
children in care in the program. The Licening.
Form revised 3/12/2025 Page 29 of 32
Records relating to Restraint and Yes/No Corrective actions/comments
Involuntary Seclusion or N/A
child caring agency shall provide the
notice upon the child in care's
admission and at least two times each
year thereafter.
419-400-0190(1) Information provided No The program accepts youth from ODHS - Child Welfare. Although it is the
to children in care relating to Restraint responsibility of ODHS to provide children in care with this required
and Involuntary Seclusion information, the program also provides crisis respite services to the county
youth who must also be provided the same informaiton.
CORRECTIVE ACTION: Create and implement a plan as to how non
ODHS youth will receive the following informaiton as required through rule:
(1) Each child in care receiving services from a child-caring agency must
be given the following:
(a) Instruction regarding how a child in care may report suspected
inappropriate use of restraint or involuntary seclusion;
(b) Assurance that the child in care will not experience retaliation for
reporting suspected inappropriate uses of restraint or involuntary seclusion
and;
(c) The telephone number for the toll-free child abuse hotline (855-503-
7233) described in ORS 417.805 and the telephone numbers and
electronic mail addresses for the program's Licensing Agency (Mary Torres
503-798-5300, mary.torres@odhsoha.oregon.gov, the child in care's
caseworker and attorney, the child in care's court appointed special
advocate and Disability Rights Oregon (503-243-2081).
(2) The information must be provided by:
(a) The Oregon Department of Human Services if the department placed
the child in care in the child-caring agency;
(b) The Oregon Youth Authority if the child in care has been committed to
the custody of the authority; or
(c) The child-caring agency for all other children in care.
Form revised 3/12/2025 Page 30 of 32
Financial records Yes/No Corrective actions/comments
419-470-0170(4) or N/A
Records contain date, amount, N/A Any monetary items (cash, gift cards) that the youth arrive with are locked
source, purpose, signatures up and given to the caseworker upon discharge. There is no need for youth
to access their money during their stay. The program is encouraged to
document the amount of money that is secured at the time of arrival as well
as the amount upon discharge to include staff and youth signatures at both
times. ***Please note, this is not a finding.***
Personal possessions records Yes/No Corrective actions/comments
419-470-0170 (5) or N/A
Individual written inventory of all Yes Although the files reviewed had written inventories, the lists were
personal possessions is maintained inconsistent with the information documented (i.e., not updated, not dated,
and updated as needed not signed, not specific). The program is encouraged to develop a uniform
way for staff to document a youth's belongings and set the expection that
all fields in the document are addressed.
Records and documentation Yes/No Corrective actions/comments
419-400-0140 or N/A
(1) Stored safely Yes
(2) Permanent, legible, dated and Yes
signed
(3) and (4) Uniform in organization, No The program is currently utilizing a drop file system.
readily identifiable and accessible,
current and complete, containing all CORRECTIVE ACTION: The program will develop and implement a filing
required info. No eraser tape or white system that enhances organization, accessibility and ensures that all
out. required information is in each respective file. A checklist or a standard
table of contents has proven helpful for the CCAs in reaching this goal.
(7) Permanent registry for each child Yes
includes:
Name
Form revised 3/12/2025 Page 31 of 32
Records and documentation Yes/No Corrective actions/comments
419-400-0140 or N/A
Gender
Birth date
Names, addresses of parents or
guardians
Dates of admission
Placement upon discharge
5-19-2025 5-19-2025
Mary Torres Tom van der Veen

excerpt:
419-400-0040 or N/A
(1)(a) Minimum of 5 board members Yes
(2)(f) Formally evaluate the Executive N/A Item to be audited at the upcoming license renewal.
Director's performance annually
(2)(g) Approves annual budget N/A Item to be audited at the upcoming license renewal.
(2)(h) Obtain and review an annual N/A Item to be audited at the upcoming license renewal.
independent financial review or audit
of financial records.
(2)(k) Written quality improvement No A quality improvement plan was not submitted.
program
CORRECTIVE ACTION: Submit a written quality improvement plan to
Licensing for review.
(2)(l) Meeting minutes N/A Item to be audited at the upcoming license renewal.
Form revised 3/12/2025 Page 4 of 32
Executive Director or Program Yes/No Corrective actions/comments
Director or N/A

rule: 419-400-0150 (excluding medically necessary devices/prescriptions) (3)(c)

excerpt:
419-400-0150
(excluding medically necessary
devices/prescriptions)
(3)(c) Agency uses appropriate time- N/A The program does not utilize the use of time out rooms.
out rooms (adequate space, heat,
light and ventilation and is not capable
of locking) and documents use in
child's record when applicable
(3)(e) Agency uses seclusion N/A The program does not utilize seclusion.
appropriately/consistent with policy
(4) Agency has adequate plan in Yes
place to respond to suicidal
behavior/warning signs
Contractors (if applicable) Yes/No Corrective actions/comments

excerpt:
419-400-0180
(13)(d) Each child caring agency that No Although the program has submitted a copy of the program's most recent
submits a report under this section quarterly report to Licensing for public posting, a copy of the report has not
shall make its quarterly report been uploaded to the CCA's own website.
available to the public upon request at
the child caring agency's main office CORRECTIVE ACTION: Upload most recent and future quarterly reports
and on the child caring agency's onto the CCA's own website for public review.
website if applicable.
Supplemental information provided Yes/No Corrective actions/comments
by CCA or N/A
Documents as indicated on the form Yes These items were checked prior to the program receiving its' license and
titled "Renewal Licensing Required was not audited during this 6-month review.
Documents"
Documents as indicated on form titled Yes These items were checked prior to the program receiving its' license and
"Required Financial Documents and was not audited during this 6-month review
Information"
All required policies and procedures Yes These items were checked prior to the program receiving its' license and
as identified in the "Umbrella Rules" was not audited during this 6-month review
All required policies and procedures Yes These items were checked prior to the program receiving its' license and
as identified in "Agency Type Specific was not audited during this 6-month review
Rules"
Physical plant Yes/No Corrective actions/comments
or N/A

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

excerpt:
419-470-0020(2)(a) and (c) Buildings Yes
are smoke free, clean and in good
repair

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

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

excerpt:
419-470-0030 or N/A
(2) There is a separate living room or Yes
lounge area - 15 SF minimum per
child
(5) There is a separate dining room Yes
with capacity for ½ of children in care
and 15 SF per child in care
(7) Laundry is separate from living, Yes
kitchen and dining areas
(8) Separate storage areas are Yes
provided for food, kitchen supplies,
utensils, clean linens, soiled linens
and clothing, cleaning supplies and
equipment, poisons, chemicals,
outdoor recreational and maintenance
equipment. (Hazardous materials are
properly labeled, in original container
and locked)
(9) Outdoor activity area is protected Yes
from vehicles and other hazards and
of a size and availability appropriate to
the age and needs of children in care
(11) Time-out rooms: Rooms used for N/A The program does not use time out rooms.
time out or quiet time must have
adequate space, heat, light and
ventilation and must not be capable of
locking.
Form revised 3/12/2025 Page 9 of 32
Room and space requirements - Yes/No Corrective actions/comments
bedrooms or N/A

excerpt:
419-400-0120 or N/A
Staff name/position Yes
(3)(g) Date of hire Yes
(3)(a) record of education, training Yes
and previous employment
(1)(b) and (3)(b) reference checks Yes
completed and documented
(1)(a) and (3)(c) Background check Yes
completed and documented
(3)(d) Annual performance N/A Evaluations for residential staff are scheduled for June 2025. Item to be
evaluations audited at the upcoming license renewal.
(3)(f) Record of personnel actions Yes
(3)(g) Termination date, reason for Yes
termination
(3)(h) Current job description (1)(c) Yes
Employee meets minimum
qualifications stated in current job
description
New employee orientation - Yes/No Corrective actions/comments
Umbrella Requirements (30 days) or N/A

excerpt:
419-400-0120(4)
(a) Agency policies and procedures Yes
(b) Ethical and professional Yes
guidelines
(c) Suicide prevention and No One personnel file reviewed reflected partial training in this area.
intervention
CORRECTIVE ACTION: Ensure that the staff member completes this
training. Submit proof that this training was completed to Licensing.
Licensing is able to identify the staff member to the program upon request.
Form revised 3/12/2025 Page 19 of 32
New employee orientation - Yes/No Corrective actions/comments
Umbrella Requirements (30 days) or N/A

excerpt:
419-470-0120(1)
CORRECTIVE ACTION: Implement a process where this required training
is a part of the new employee onboarding process and existing staff are
trained in this area. Submit completion of this training to Licensing.
(e) Training on the agency's policy on No Although the program provides training in suicide prevention and
suicide prevention and suicide risk intervention to staff, it is unclear how and which staff are trained to
assessment tool administer a suicide risk assessment.
CORRECTIVE ACTION: Clarify what suicide risk assessment tool is used,
which staff are trained to administer the assessment and how staff are
trained in the use of this tool.
Crisis intervention training Yes/No Corrective actions/comments
standards and certification or N/A

excerpt:
419-470-0070(2)(b) Employees who N/A The program is less than a year in existence.
handle food served to children have a
valid food handler's card

excerpt:
419-400-0200 (1) Employees N/A The program is less than a year in existence.
transporting children have: current
driver's license, insurance, trained in
emergency procedures and behavior
Form revised 3/12/2025 Page 22 of 32
Ongoing training Yes/No Corrective actions/comments
or N/A
management and training for 15+
passenger vans if applicable)

excerpt:
419-470-0120 (2)(a) Environmental N/A The program is less than a year in existence.
emergencies

excerpt:
419-470-0120 (2)(b) Universal N/A The program is less than a year in existence.
precautions

excerpt:
419-470-0120 (2)(d) Agency's policy N/A The program is less than a year in existence.
on suicide prevention and risk
assessment tool

excerpt:
419-400-0160(4)(b) Receive N/A The program is less than a year in existence.
continuing education (as applicable
Form revised 3/12/2025 Page 23 of 32
Ongoing training Yes/No Corrective actions/comments
or N/A
on crisis intervention training) from a
certified instructor on an annual basis
Children's records Yes/No Corrective actions/comments
health services or N/A


state: OR

facility_name: Crimson Rose

summary: Unannounced - 06/24/2021

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Licensee: Klamath County Juvenile Department / Crimson Rose
Executive Director: Dan Golden
Date of Unannounced: June 24th, 2021
Licensing Coordinator: Ed Wyller
Other Regulatory or Accrediting Agencies: Oregon Youth Authority
Purpose: Per OAR 413-215-0101 (1) (b) Children’s Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings: Repeat Comments
Unannounced Site Visit 05-20-2020 Findings
Further Action
Needed
Klamath Crimson Rose currently is serving a Yes☐ No On May 21st, 2020 Dan Golden Klamath County Juvenile Director requested by letter to
youth that is 13 years old and falls outside of change DHS CCLP license to 12-20 years old. On May 26th, 2020 Klamath Crimson Rose
current license age range of 14-20. Klamath License had been amended to this new age range.
Crimson Rose had just changed from their
previous age range of 13-17 at their recent
license renewal.
“Debriefed with both Dan Golden and Steve
Quick regarding either an individual exception
for the new 13-year-old in program or
changing their age range on license. Crimson
Rose reported they will file paperwork with
their licensor Ed Wyller.”
New Findings from Site Visit Comments
N/A No new findings. Great Job!!!
1
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 200115)
Interview Summary
I met with three of the four youth currently at Crimson Rose in the gym off the classroom (independently to ensure their privacy). One youth chose not to
speak with me due to prior interactions with DHS that were not positive for her. On a scale from 0-10 where (0=worst program, 10=best program) youth
ranked Crimson Rose a 5, 8, and 8.5. The youth ranking it a 5 reported if she could change anything about the program it would be for family visits. At this
time Oregon Youth Authority is not allowing family visits and youth reported she talks with her family daily via telephone. All youth indicated feeling safe at
Crimson Rose. All youth reported being in treatment groups three times a day during the week and two times a day on weekends. Youth reported learning
how to control anger, refusal skills for drugs or alcohol, and coping skills. Youth spoke highly of the education component of the program. One youth reports
she just passed her GED and that she thought this was not possible before coming to Crimson Rose. All three youth reported the food to be good. Youth
reported the following outings in the community: garden, park, Lake of the Woods, library, and various fast food and stores (Dairy Queen, Subway, Wendy’s,
Dominos, McDonald’s and Dutch Bros). Youth reported being active in the gym doing workouts with jump ropes, video’s, leg bands, and having fun working
out together. Youth also reported spending time watching tv, reading, and talking with each other. One youth reported the “days go fast here”. Another
reported “feel like is good to help you set goals”. Staff were described as respectful. One youth came back to talk to me. She wanted to let me know about a
grievance she is working on with the program. During my debrief with Crimson Rose management they reported they have been working with the youth and
the particular staff member and are monitoring to ensure it is addressed.
Observations
I started my tour with Dan Golden Klamath County Juvenile Department Director. During the tour it was noted the building to be clean and organized. Youth
and staff were all wearing masks and maintaining social distancing. I observed the newly built classroom. The classroom was just completed one month ago.
Lottery dollars were awarded to create a new classroom in what was previously unused storage space. Prior to the completion of the new classroom youth
would conduct class in the dayroom on unit. In the dayroom I observed the newly created GED wall. When youth attain their GED certificates, they can
choose to add their name to the GED wall. I observed teachers, direct care staff, and Crimson Rose Administrators interacting with the youth in a positive
caring manner. During my visit to the classroom the program highlighted a recent accomplishment of a youth just attaining her GED.
Corrective Actions and Timeframes:
Please submit the following to verify compliance.
Within 45 days of receipt of this report Klamath County Juvenile Department 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 or sent by regular mail to the following address:
Due to Covid-19 pandemic and working remotely the preferred method is to send directly to Ed Wyller at his email address.
Department of Human Services
Children’s Care Licensing Program
Attn: Ed Wyller
2
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 200115)
201 High St. SE Suite 500
Salem, OR 97301
6/30/2021
Licensing Coordinator’s Signature: ________________________ Date: ___________________
6-30-2021
Manager Review: ______________________________________ Date: __________________
3
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 200115)

agency_name: Klamath County Juvenile Department (KCJD)

program_name: Crimson Rose

program_type: (RC) Residential Care Programs

report_type: Unannounced

view_code: RC

executive_director: Dan Golden

licensing_coordinator: Ed Wyller

other_regulatory_agencies: Oregon Youth Authority

purpose:
Per OAR 413-215-0101 (1) (b) Children's Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings: Repeat Comments
Unannounced Site Visit 05-20-2020 Findings
Further Action
Needed
Klamath Crimson Rose currently is serving a Yes[ ] No On May 21st, 2020 Dan Golden Klamath County Juvenile Director requested by letter to
youth that is 13 years old and falls outside of change DHS CCLP license to 12-20 years old. On May 26th, 2020 Klamath Crimson Rose
current license age range of 14-20. Klamath License had been amended to this new age range.
Crimson Rose had just changed from their
previous age range of 13-17 at their recent
license renewal.
"Debriefed with both Dan Golden and Steve
Quick regarding either an individual exception
for the new 13-year-old in program or
changing their age range on license. Crimson
Rose reported they will file paperwork with
their licensor Ed Wyller."
New Findings from Site Visit Comments
N/A No new findings. Great Job!!!
1

Interview Summary
I met with three of the four youth currently at Crimson Rose in the gym off the classroom (independently to ensure their privacy). One youth chose not to
speak with me due to prior interactions with DHS that were not positive for her. On a scale from 0-10 where (0=worst program, 10=best program) youth
ranked Crimson Rose a 5, 8, and 8.5. The youth ranking it a 5 reported if she could change anything about the program it would be for family visits. At this
time Oregon Youth Authority is not allowing family visits and youth reported she talks with her family daily via telephone. All youth indicated feeling safe at
Crimson Rose. All youth reported being in treatment groups three times a day during the week and two times a day on weekends. Youth reported learning
how to control anger, refusal skills for drugs or alcohol, and coping skills. Youth spoke highly of the education component of the program. One youth reports
she just passed her GED and that she thought this was not possible before coming to Crimson Rose. All three youth reported the food to be good. Youth
reported the following outings in the community: garden, park, Lake of the Woods, library, and various fast food and stores (Dairy Queen, Subway, Wendy's,
Dominos, McDonald's and Dutch Bros). Youth reported being active in the gym doing workouts with jump ropes, video's, leg bands, and having fun working
out together. Youth also reported spending time watching tv, reading, and talking with each other. One youth reported the "days go fast here". Another
reported "feel like is good to help you set goals". Staff were described as respectful. One youth came back to talk to me. She wanted to let me know about a
grievance she is working on with the program. During my debrief with Crimson Rose management they reported they have been working with the youth and
the particular staff member and are monitoring to ensure it is addressed.
Observations
I started my tour with Dan Golden Klamath County Juvenile Department Director. During the tour it was noted the building to be clean and organized. Youth
and staff were all wearing masks and maintaining social distancing. I observed the newly built classroom. The classroom was just completed one month ago.
Lottery dollars were awarded to create a new classroom in what was previously unused storage space. Prior to the completion of the new classroom youth
would conduct class in the dayroom on unit. In the dayroom I observed the newly created GED wall. When youth attain their GED certificates, they can
choose to add their name to the GED wall. I observed teachers, direct care staff, and Crimson Rose Administrators interacting with the youth in a positive
caring manner. During my visit to the classroom the program highlighted a recent accomplishment of a youth just attaining her GED.

new_findings:
N/A No new findings. Great Job!!!
1