facility_name: Dragonfly Transitions

summary: Unannounced - 60 findings

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Licensee: Dragonfly Transitions
Executive Director: Michelle Hall
Program Director: Lindsey “Stormy” King
Date of Unannounced: 8/30/23
Licensing Coordinator: Mary Torres
Other Regulatory or Accrediting Agencies: Joint Commission, Clinical Laboratory Improvement Amendments (CLIA) on-site drug testing
certification, Oregon Health Authority (OHA) for Embark
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
Findings
Further Action
Needed
Governance of the Agency 419-400-0020 Yes☐ No✓ A favorable evaluation for the program’s newest Exec. Director was submitted to Licensing
(2)(f) Formally evaluate the Exec. on 6/6/23 via email.
Director’s performance annually.
The newly appointed Exec. Director (hire
date: 5/2/22) has yet to be evaluated. An
evaluation is expected to be completed in
June of 2023 at which all performance.
evaluations for staff are scheduled to be
completed.
CORRECTIVE ACTION: Forward a copy of
the newly appointed Exec. Director’s
evaluation to Licensing upon completion in
June of 2023.
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Governance of the Agency 419-400-0020 Yes☐ No✓ On 5/27/23, the program submitted a copy of a scorecard that is updated and reviewed at
(2)(k) Written quality improvement plan. the program’s weekly leadership meeting. Measured Goals include, but are not limited to,
admissions, safety, clinical, critical events, and staffing. This submitted scorecard reflects
The program submitted a Department and data gathered between May 2022 – May 2023.
Performance Improvement Policy that
monitors the various departments within the
program through monthly reviews.
CORRECTIVE ACTION: Specifics related to
this policy were not provided, the program is
being asked to submit a copy of the data
gathered for the last 12 months from these
departmental meetings for Licensing’s review.
Governance of the Agency 419-400-0020 Yes☐ No✓ Initially, the program submitted copies of their monthly Leadership L10 meeting notes in
(2)(l) Meeting minutes lieu of board meeting notes on 6/14/23. These meeting notes highlight campus issues and
result in a scorecard for the program to measure specific outcomes to include capacity,
Board meeting notes were not submitted at incidents, treatment, staffing, etc.
the time of the review.
CORRECTIVE ACTION: Submit boarding Board meeting notes from Embark were submitted to Licensing via email on 7/24/23.
meeting notes for the last 12 months to
Licensing for review.
Supplemental Information Provided by Yes☐ No✓ A revised program description meeting Licensing rule related to Dragonfly Transitions was
CCA Documents as indicated on the form updated in the program’s existing Policies and Procedures Manual Master 2023 (Dragonfly
titled “Renewal Licensing Required Transitions) (pages 12-18). A copy of this manual was submitted to Licensing via email on
Documents” 6/14/23.
The submitted Program Description related to
the Klamath Falls campus (Boarding and
Sunflower House) requires revision.
CORRECTIVE ACTION: Revise the Program
Description to meet Licensing criteria.
Supplemental Information Provided by Yes✓No☐ The program submitted a copy of the Required Financial Documents and Information via
CCA Documents as indicated on form email on 6/14/23.
titled “Required Financial Documents and
Information” Signatures from the Board approving the program’s budget was submitted via email to
Licensing on 8/3/23.
The following required financial documents
were not submitted at the time of the review The program has not obtained a Tax Compliance Certificate from the Department of
• Proof the board approved the budget Revenue. This item remains outstanding from the program’s review in March of 2023.
• Tax Compliance Certificate from the
Department of Revenue
• A completed and signed copy of the form
titled “Required Financial Documents and
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Information.” Licensing can make this form
available at the program’s request.
Supplemental Information Provided by Yes☐ No✓ A revised grievance policy meeting Licensing rule related to Dragonfly Transitions was
CCA All required policies and procedures updated in the program’s existing Policies and Procedures Manual Master 2023 (Dragonfly
as identified in the “Umbrella Rules” Transitions) (pages 94-95). A copy of this manual was submitted to Licensing via email on
6/14/23.
The submitted grievance procedure policy for
children in care and families requires
revision to meet Licensing Rule.
CORRECTIVE ACTION: Revise the
program’s Parent Rights and Grievance
Procedure
to include the highlighted information in the
following rule:
419-400-0090 Licensing Umbrella Rules:
Children and Families Rights Policy and
Grievance Procedures
(2) Grievance Procedures.
D) The name, address, and phone number of:
(i) A Department licensing coordinator; Mary
Torres 201 High St SE Suite 500 Salem, OR
97301, 503-978-5300 and
(ii) Any other governmental entities with
oversight responsibilities (Oregon Health
Authority at Embark)
Supplemental Information Provided by Yes☐ No✓ A revised mandatory child abuse reporting and training policy related to Dragonfly
CCA All required policies and procedures Transitions was updated in the program’s existing Policies and Procedures Manual Master
as identified in the “Umbrella Rules” 2023 (Dragonfly Transitions) and now meets Licensing Rule (pages 76-78). A copy of this
manual was submitted to Licensing via email on 6/14/23.
The submitted Mandatory Child Abuse
Reporting and Training Policy requires
revision to meet Licensing Rule.
CORRECTIVE ACTION: Revise the
program’s Child Abuse Prevention and
Reporting Requirements to include the
highlighted information in the following rule:
419-400-0110 Licensing Umbrella Rules:
Policies and Procedures
(2) In addition to other policies and
procedures required by these rules, the
policies, and procedures in section (1) of this
rule must include:
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(a) A written policy on mandatory child abuse
reporting, consistent with ORS 418.257,
418.258, 419B.005, 419B.010, and 419B.015
that includes requirements that child-caring
agency employees, staff, contractors, agents,
and proctor foster parents do all of the
following:
(A) Immediately report suspected child abuse
directly to the Department via the child
abuse reporting hotline.
- Remove wording that the student’s primary
therapist would be given the information
related to suspected abuse and/or neglect
and that the therapist would follow through
with making a report. The staff member who
initially learned of the reported abuse and/or
neglect is responsible for making the child
abuse report.
- Add Oregon Child Abuse Hotline (ORCAH)
number to the policy and remove Klamath
and Jackson County Dept of Child Welfare
phone numbers as those numbers are now
obsolete. ORCAH # 855-503-7233.
- The program may consider adding that an
additional phone call maybe required by staff
if the alleged report occurred in another state.
Staff is encouraged to follow direction from
Oregon’s hotline at the time a report is made
regarding alleged abuse and/or neglect that
occurred outside of Oregon.
(B) Receive child-caring agency-provided
training on mandatory abuse reporting
requirements as part of employee orientation
and at least annually thereafter as described
in OAR 419-400-0120.
(C) Receive child-caring agency-provided
training on the definitions of child abuse in
ORS 418.257 and 419B.005 that apply in
child-caring agencies.
- In addition, one bullet point in the policy
speaks to alleged inappropriate interactions or
relationships with staff could be addressed
through the program’s grievance process. The
program will add that a call to the hotline may
also be warranted.
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Supplemental Information Provided by Yes☐ No✓ The program submitted revised policies to reflect the two missing items related to this
CCA All required policies and procedures Licensing Rule in the program’s existing Policies and Procedures Manual Master 2023
as identified in the “Umbrella Rules” (Dragonfly Transitions). The sharing of critical events is captured under Incident Categories
(page 126) and how a report will be saved is under Incident Reporting (page 128). A copy
Submitted information related to the of this manual was submitted to Licensing via email on 6/14/23.
documentation of incident report writing
requires revision.
CORRECTIVE ACTION: Revise reporting
information captured at the end of the
program’s Child Abuse Prevention and
Reporting Requirements to include the
highlighted information from the following rule:
419-400-0110 Licensing Umbrella Rules:
Policies and Procedures
(b) A written policy and procedure on
documenting, reporting, and saving
information about critical events and other
types of incidents that includes, but is not
limited to:
(C) Whether and how a report will be shared.
Critical events must be shared with the
child-caring agency's assigned licensing
coordinator (see OAR 419-400-0230(11)(b))
but other types of reports may be shared with
other regulatory agencies or legal guardians.
(D) How a report will be saved. This must
include, but is not limited to, ensuring the
report is placed in the individual child in care's
record if applicable.
Supplemental Information Provided by CCA Yes☐ No✓ Information reflected in the personnel records policy related to termination dates and
All required policies and procedures as reason for termination was added to the program’s existing Policies and Procedures
identified in the “Umbrella Rules” Manual Master 2023 (Dragonfly Transitions) (page 158). A copy of this manual was
submitted to Licensing via email on 6/14/23. An addition, all employee files have a cover
Submitted Personnel Records policy requires sheet that reflects, as applicable, a termination date and reason for termination.
revision.
The program had in existence a written grievance procedure for staff under their Employee
CORRECTIVE ACTION: Revise Personnel Standards of Conduct Policy (page 171) in the program’s existing Policies and Procedures
Records policy to include the highlighted Manual Master 2023 (Dragonfly Transitions) meeting Licensing Rule. A copy of this manual
information from the following rule: was submitted to Licensing via email on 6/14/23.
419-400-120 Licensing Umbrella Rules:
Personnel Staff requirements and hiring. To
ensure that the child-caring agency uses only
staff and volunteers who do not jeopardize the
health, safety, or welfare of children, a child-
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caring agency and its contractors must meet
all of the following requirements:
(e) A written grievance procedure for staff.
(g) Starting and termination dates, and reason
for termination.
Supplemental Information Provided by CCA Yes☐ No✓ The program submitted a revised version of their milieu management policy in the
All required policies and procedures as program’s existing Policies and Procedures Manual Master 2023 (Dragonfly Transitions)
identified in the “Umbrella Rules” (page 68). A copy of this manual was submitted to Licensing via email on 6/14/23.
Submitted discipline and behavior
management policy entitled Milieu
Management Policies requires revision.
CORRECTIVE ACTION: Revise Milieu
Management Policies to include the
highlighted information from the following rule:
419-400-0150 Licensing Umbrella Rules:
Discipline, Behavior Management &
Training, and Suicide Prevention (Excluding
Adoption Agencies)
(1) A child-caring agency, except a child-
caring agency licensed only to provide
adoption services under OAR 419-420-0010
to 419-420-0160, must adopt and adhere to
written policies and procedures on discipline,
behavior management, and suicide prevention
that meet all of the requirements of this rule.
(b) The discipline and behavior management
policies and procedures must prohibit the
following:
(K) Removing or limiting the use of a mobility
aid or other assistive device for the purpose
of controlling a child in care’s behavior.
Supplemental Information Provided by CCA Yes☐ No✓ A revised copy of the program’s Suicide Prevention Plan meeting Licensing rule was
All required policies and procedures as submitted to Licensing via email on 7/31/23.
identified in the “Umbrella Rules”
Submitted Suicide Prevention Plan requires
revision.
CORRECTIVE ACTION: Revise suicide
policy to include the highlighted information
from the following rule:
419-400-0150 Licensing Umbrella Rules:
Discipline, Behavior Management &
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Training, and Suicide Prevention (Excluding
Adoption Agencies)
(4) Suicide Prevention. The policy must
include the following:
(c) Emergency protocol and contacts;
(d) Training requirements for staff, including
suicide prevention training and suicide risk
assessment tool training;
(e) Procedures for determining
implementation of additional supervision
precautions and for determining removal of
additional supervision precautions;
(f) Suicide risk assessment procedures on the
day of intake; Policy currently refers to an
assessment within the first 14 days from
intake. Rule requires suicide risk assessment
on the day of intake. Remove reference to 14
days and implement a plan as to how
incoming youth will be assessed the day of
intake.
(g) Documentation requirements for suicide
ideation, self-harm, and special observation
precautions to ensure immediate
communication to all staff;
(h) A process for tracking suicide behavioral
patterns; and
(i) A "post-intervention" plan with identified
resources.
Supplemental Information Provided by CCA Yes☐ No✓ The program submitted a revised version of their Driver and Fleet Safety Policy (pages
All required policies and procedures as 142-153) in the program’s existing Policies and Procedures Manual Master 2023
identified in the “Umbrella Rules” (Dragonfly Transitions) that now meets Licensing Rule. A copy of this manual was
submitted to Licensing via email on 6/14/23.
Submitted Driver and Fleet Safety requires
revision.
CORRECTIVE ACTION: Revise Driver and
Fleet Safety policy to include the highlighted
information from the following rule:
419-400-0200 Licensing Umbrella Rules:
Safety
(b) Vehicle requirements.
(A) Each vehicle used to transport a child in
care must be:
(i) Properly registered;
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(ii) Covered by an insurance policy in full force
and effect;
(iii) Maintained in safe operating condition;
and
(iv) Smoke-free.
Supplemental Information Provided by CCA Yes☐ No✓ The program submitted a revised version of their search policy (pages 122- 123) in the
All required policies and procedures as program’s existing Policies and Procedures Manual Master 2023 (Dragonfly Transitions)
identified in the “Umbrella Rules” that now meets Licensing Rule. A copy of this manual was submitted to Licensing via email
on 6/14/23.
Submitted Safety Committee policy related to
searches requires revision.
CORRECTIVE ACTION: Revise Safety
Committee policy to include the highlighted
information from the following rule:
419-400-0200 Licensing Umbrella Rules:
Safety
2) Searches. If a child-caring agency carries
out searches on children in care or visitors,
the child-caring agency must have written
policies and procedures that, at a minimum,
comply with all of the following:
(G) If the child in care refuses to comply, the
executive director or designee must be
notified immediately and be responsible to
resolve the matter; and
(H) All searches must be documented in
writing.
(g) Information regarding any personal or
room searches and protocols for confiscation
of contraband items, including the notification
of law enforcement if illegal contraband is
discovered.
Supplemental Information Provided by CCA Yes☐ No✓ The program submitted a Hazard Policy meeting Licensing rule via email on 7/31/23.
All required policies and procedures as
identified in the “Umbrella Rules”
A policy related to potential hazards was not
submitted to Licensing for review.
CORRECTIVE ACTION: Submit a policy
related to potential hazards or create a policy
that complies with the following rule:
419-400-0200 Licensing Umbrella Rules:
Safety
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(4) Hazards.
(a) A child-caring agency must protect
children in care it serves from guns, drugs,
sharps, paint, hazardous materials, bio-
hazardous materials, and other potentially
harmful items.
A child-caring agency must have a written
policy that addresses potentially harmful
materials that are in areas accessible to the
children in care in the program or on the
grounds of the program.
Supplemental Information Provided by CCA Yes☐ No✓ Projected Staffing Patterns are detailed in the program’s Policies and Procedures Manual
All required policies and procedures as Master 2023 (Dragonfly Transitions) on pages 14 – 15, meeting this Licensing requirement.
identified in “Agency Type Specific Rules” A copy of this manual was submitted to Licensing via email on 6/14/23.
Submitted staffing requirement policy located
in the program’s Workplace Safety policy
requires revision.
CORRECTIVE ACTION: Revise Workplace
Safety Policy to include the highlighted
information from the following rule:
419-450-0030 Homeless, Runaway, and
Transitional Living Shelters: Staffing
Requirements
(1) A child-caring agency must have and
follow written policies regarding minimum
staffing requirements, including a written
staffing plan that indicates the number of paid
and volunteer staff in each job category.
(2) During each shift, there must be at least
one staff member who has been trained in a
non-violent crisis intervention strategy. A
volunteer or intern may be used to meet this
requirement only if the volunteer or intern has
met the training requirements for staff in
OAR 413-215-0726.
Supplemental Information Provided by CCA Yes☐ No✓ The program added a newly created Health and Hygiene Policy (page 109) to the
All required policies and procedures as program’s existing Policies and Procedures Manual Master 2023 (Dragonfly Transitions)
identified in “Agency Type Specific Rules” that now meets Licensing Rule. A copy of this manual was submitted to Licensing via email
on 6/14/23.
A policy related to health and hygiene was not
submitted to Licensing for review.
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CORRECTIVE ACTION: Submit policy
related to health and hygiene to Licensing or
create a policy that complies with the following
rule:
419-450-0090 Homeless, Runaway, and
Transitional Living Shelters: Health and
Hygiene
(1) A child-caring agency must have and
follow policies that ensure the prompt and
accurate assessment and care of injuries,
illness, and physical complaints of children in
care.
Grouping 419-450-0100 Yes☐ No✓ The program added a newly created Grouping Policy (pages 64 – 67) to the program’s
(1) & (2) Has and follows policies for existing Policies and Procedures Manual Master 2023 (Dragonfly Transitions) that now
grouping children that meets requirements meets Licensing Rule. A copy of this manual was submitted to Licensing via email on
(age, developmental level, maturity, 6/14/23.
behavior, medical...)
No grouping policy was submitted to
Licensing at the time of the review.
CORRECTIVE ACTION: Submit copy of the
program’s Grouping policy. If this policy
needs to be created, please reference the
following rule for specifics required.
419-450-0100 Homeless, Runaway, and
Transitional Living Shelters: Grouping
(1) A child-caring agency must have and
follow written policies regarding the grouping
of children in care.
(2) Except as provided in section (3) of this
rule, an agency must place children in care in
groups based on the following factors:
(a) Age.
(b) Developmental level.
(c) Physical maturity.
(d) Social maturity.
(e) Behavioral functioning.
(f) Cognitive level.
(g) Medical concerns.
(h) Individual needs.
(3) A child in care with a diagnosed disability
may be served in the most integrated setting
appropriate to the needs of the child in care
within the context of the program. For
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purposes of this section:
(a) The child in care who can meet the
essential eligibility requirements for a group
with or without reasonable modification of
rules, policies or procedures, or the provision
of auxiliary aids and services may be served.
(b) "Integrated Setting" means a setting that
enables children in care with disabilities to
interact with non-disabled persons to the
fullest extent possible.
Grouping 419-450-0100 Yes☐ No✓ The program addresses emancipated children in their a newly created Grouping Policy
(4) Care was taken to assess and minimize (pages 64 – 67) found in the program’s existing Policies and Procedures Manual Master
risk for children placed with emancipated 2023 (Dragonfly Transitions) that now meets Licensing Rule. A copy of this manual was
children or adults submitted to Licensing via email on 6/14/23.
Information related to emancipated children or
adults was not submitted to Licensing at
the time of the review.
CORRECTIVE ACTION: Submit this
information to Licensing. If this information
needs to be created, please reference the
following rule for specifics required.
410-450-0100 Homeless, Runaway, and
Transitional Living Shelters: Grouping
(4) Placement with adults. A child-caring
agency may place children in care in the
same group as emancipated children in care
or adults only after taking special care to
assess and minimize the risk to the children in
care.
Umbrella Safety 419-400-0200 (1)(b)(A) Each Yes☐ No✓ On 6/9/23, proof of effective and current insurance coverage and valid registration for this
vehicle used to transport a child in care must vehicle was submitted via email to Licensing.
be: properly registered, covered by an
insurance policy in full force and effect,
maintained in safe operating
condition, and smoke-free.
Klamath Falls campus: White Ford van
(license plate # 907***) has outdated vehicle
registration and tags. The vehicle also does
not have a current insurance card to reflect
proof of insurance coverage.
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CORRECTIVE ACTION: Obtain current
vehicle registration and tags through DMV
and place in vehicle and on the vehicle’s
license plate. Obtain a copy of current
insurance coverage and place in vehicle.
Initial Training (Must be completed before Yes☐ No✓ On 6//9/23, the program submitted to Licensing, via email, a copy of training material
staff is alone with youth) 419-450-0040(1) developed related to First Aid kit contents and use. A signature and date at the end of this
(g) First aid kit contents and use training information will be proof the employee’s understanding and completion of this
training.
First Aid Kit training could not be verified
during the file review.
CORRECTIVE ACTION: Implement a
process where onboarding staff are trained in
the contents of First Aid kits and its use, and
this training is adequately documented.
Initial Training (Must be completed before Yes☐ No✓ All personnel files have been evaluated to ensure that all staff have a valid CPR/1st Aid
staff is alone with youth) 419-450-0040(1) certificate. To prevent a lapse in this training, the certificate number and expiration date are
(i) CPR and First Aid also recorded on each employee’s personnel file cover sheet and captured on a
spreadsheet to track approaching expiration dates.
Two out of the 5 personnel files did not reflect
current certification in CPR/1st Aid training.
CORRECTIVE ACTION: Ensure that required
training is completed and documented
moving forward.
Initial Training (Must be completed before Yes☐ No✓ The program is moving to a new crisis intervention training, Collaborative Problem Solving
staff is alone with youth) 419-450-0040(1) (CPS). An in-house staff member has been identified as a trainer. Once that trainer has
(j) Crisis intervention training been approved and qualified to provide instruction, all staff will complete this training and
record of their certification will be filed in their respective employee file.
Two out of the 5 personnel files did not reflect
current crisis intervention training at the time
of onboarding.
CORRECTIVE ACTION: Ensure that required
training is completed and documented
moving forward.
Child Records 419-450-0070(2) (d) Consent Yes☐ No✓ The program provided a written consent to reflect therapeutic interventions provided and
to treat the child with interventions in use used in the program via email on 7/31/23. This consent is located in Student Enrollment
at the program documents.
Files reviewed did not reflect the consent to
treat the child with interventions used by the
program.
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CORRECTIVE ACTION: Create and
implement a form or other means to document
this required consent. Reference the related
rule in the creation of this consent.
419-450-0070 Homeless, Runaway, and
Transitional Living Shelters: Client Files
(2) Child in care file requirements. A child-
caring agency must have a file on the
premises for each child in care currently
receiving services from the agency. To the
extent such information is reasonably
available to the agency, this file must be up to
date and include all of the following:
(d) A signed consent for the child-caring
agency to treat the child in care with the
interventions in use at the program.
Assessment 419-450-0050(3) Statement as Yes☐ No✓ A statement regarding eligibility requirements being met for admission has been added to
to whether child meets eligibility the program’s assessment document. The evaluating psychiatrist is tasked with making
requirements to be admitted to program. this final determination, signing off on this document and adding any necessary notes.
This plan was submitted to Licensing via email on 7/31/23.
Youth files reviewed did not reflect a clear
statement that the youth assessed meets
eligibility requirement to be admitted to
program.
CORRECTIVE ACTION: Collaborate with the
program’s psychiatrist to develop a
statement that reflects the eligibility of a youth
to be admitted to the program in a clear
and concise manner.
Records Relating to Restraint & Yes☐ No✓ The program revised their existing Parent and Student Manual to reflect how to access a
Involuntary Seclusion 419-400-0190(1) copy of the program’s quarterly restraint and involuntary seclusion reports (page 3). A
Information provided to children in care copy of the revised manual was submitted to Licensing via email on 6/9/23. In addition, this
relating to Restraint & Involuntary information has been added to the program’s monthly newsletters that both residents and
Seclusion guardians receive to meet the additional requirement of this information being shared twice
a year after intake.
Although copies of the program’s Quarterly
Restraint and Involuntary Seclusion are
posted on the program’s website the program
has not provided information to children or
guardian’s how to access this information.
CORRECTIVE ACTION: Develop and
implement a process where youth,
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guardians/parents are given information how
to access this information. Please see
related rule for reference.
419-400-0180 Licensing Umbrella Rules:
Restraints and Involuntary Seclusion
(13) Reporting Requirements
(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.
Additional Finding related to 419-400- Yes☐ No✓ The program has updated their existing Student Enrollment Packet to include information
0190(1) Information provided to children in as to reporting suspected inappropriate use or restraint or involuntary seclusion as well as
care written prohibition that a youth will experience retaliation if concerns are reported (page 3).
A copy of this updated Student Enrollment Packet was submitted to Licensing via email on
The review of youth files did not reflect 6/9/23.
instruction how a child in care may report
suspected inappropriate use of restraint or
involuntary seclusion and not
experience retaliation for reporting these
concerns.
CORRECTIVE ACTION: Create and
implement a process where a child in care is
given instruction how to report inappropriate
use of restraint or involuntary seclusion as
related to the following rule.
419-400-0190 Licensing Umbrella Rules:
Information Provided to Children in Care
(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 described in ORS 417.805
and the telephone numbers and electronic
mail addresses for the program’s licensing
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agency, the child in care’s caseworker and
attorney, the child in care’s court appointed
special advocate and Disability Rights
Oregon.
(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.
Food Services 419-470-0070 (1)(b) Menus Yes☐ No✓ Beginning in January of 2023, as requested by Licensing, the program began adding
are prepared in advance in accordance information regarding breakfast and lunch options on their monthly menus. A copy of
with USDA guidelines, provide a variety of menus beginning January of 2023 were submitted to Licensing via email on 6/9/23.
foods and are adjusted for seasonal
changes.
Continental breakfast and lunch options are
not captured in the program’s monthly
menus. Monthly menus document the group
meals planned by staff and the residents.
CORRECTIVE ACTION: Include breakfast
and lunch in the monthly menus that are in
accordance with the USDA guidelines.
Residential Care Safety 419-470-0080 Yes☐ No✓ A revised evacuation form was submitted to Licensing, via email, on 6/9/23 to reflect the
(3)(a) Evacuation drill occurs monthly addition of previously missing sections. To ensure drills are being conducted on a monthly
under varying conditions, is retained 2 basis, the Program Directors are in charge of making sure fire drills are completed monthly
years, and contains: prior to the 15th and reminders are documented on their calendars. The administrative
(A) identify of person conducting drill assistant audits fire drill documentation each month and if fire drills are not completed by
(B) date & time the 15th follow up will be held and a fire drill must be run in the next 72 hours. If fire drills
(C) notification method are not completed by the 15th of the month, the Executive Director will be notified.
(D) staff participating
(E) # of children & staff evacuated
(F) special conditions simulated
(G) problems encountered
(H) time to complete
The program submitted three monthly
documented evacuation drills. Submitted
evacuation drills are missing required sections
to include notification method, staff
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participating, special conditions simulated,
and problems encountered.
CORRECTIVE ACTION: Create a process
where monthly evacuation drills are routinely
conducted and documented. Update current
evacuation form to include the required
information outlined in rule.
Minimum Staffing Requirements Yes☐ No✓ On 6//9/23, the program submitted to Licensing, via email, a copy of training material
419-470-0130 (5) There is at least one on- developed related to Reasonable and Prudent Parent Standard. A signature and date at
site employee authorized to apply the the end of this training information will be proof the employee’s understanding and
reasonable and prudent parent standard completion of this training.
The program has yet to develop staff training
in this area.
CORRECTIVE ACTION: Establish staff
training based on information provided by
Licensing.
Personnel Files 419-400-0120 (1)(b) & (3)(b) Yes☐ No✓ The program’s newest Human Resource Director understands the importance of this
reference checks completed and requirement related to reference checks and is committed to completing this requirement
documented for all new or rehired employees. Completed reference checks will be placed in the
employee’s personnel files moving forward.
Documentation of reference checks, prior to
the new Human Resources Director, were
not consistently being completed and/or
documented. The program has made
significant improvements in this area
CORRECTIVE ACTION: Ensure that
personnel files consistently document
completed reference checks on all new
applicants moving forward.
Personnel Files 419-400-0120 (3)(d) Annual Yes☐ No✓ The program has implemented a new annual evaluation template that took effect April
performance evaluations 2023 and is scheduled to be completed annually for all staff in the months of May and
June. A copy of each employee’s evaluation will be submitted to HR for completion
Annual evaluations could not be located in the verification tracking and a physical copy will be filed in the employees’ respective files.
files reviewed.
CORRECTIVE ACTION: Develop a process
where employee evaluations are completed
and documented for all personnel.
New Employee Orientation – Umbrella Yes☐ No✓ The program advises that a section to capture the date this training was completed has
Requirements (30 days) 419-400-0120(4) been added to the quiz that staff must take and complete at the end of this training.
(g) Emergency procedures
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Training in this area was completed, but not
dated.
CORRECTIVE ACTION: Ensure that date of
completion is reflected in employee’s
training records moving forward.
Ongoing Training 419-470-0120 (4) Yes☐ No✓ On 6//9/23, the program submitted to Licensing, via email, a copy of training material
Designated staff developed related to Reasonable and Prudent Parent Standard. A signature and date at
authorized to apply reasonable and the end of this training information will be proof the employee’s understanding and
prudent parent standard are trained in completion of this training.
application of the standard
The program has yet to develop staff training
in this area.
CORRECTIVE ACTION: Establish staff
training based on information provided by
Licensing.
Ongoing Training 419-400-0120(5) Yes☐ No✓ The program advises that moving forward, Mandatory Child Abuse Reporting is to be
Mandatory reporting completed at the time of the employee’s annual work anniversary. A physical copy of all
(annually) that includes: annual training courses will be filed in each employee’s personnel file moving forward. All
(a) legal definition of child abuse in ORS staff employed for over a year are now up to date in this annual training requirement.
418.257 and 419B.005
(b) legal responsibility to immediately
report
(c) legal responsibility to report is personal
to the employee
Ongoing training in this area could not be
verified during file review.
CORRECTIVE ACTION: Ensure a process
where required, annual training is
documented in personnel files moving
forward.
Children’s Records Health Services Yes☐ No✓ Documentation of age-appropriate instruction has been added to the student enrollment
419-470-0090 (2)(e) Documentation of age- packet. A copy of the updated enrollment packet with this modification was provided to
appropriate instruction – pregnancy Licensing via email on 8/18/23.
prevention, nutrition, prevention of HIV &
AIDS, and prevention and treatment of
sexually transmitted disease
Documentation of age-appropriate instruction
was not reflected in the youth files reviewed.
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CORRECTIVE ACTION: Develop a process
where this instruction is documented in
youth files moving forward. Licensing would
be available to provide technical assistance
in this area upon the program’s request.
Consents 419-470-0160(1) (b) Use the Yes☐ No✓ The program has updated their existing Student Enrollment Packet to reflect the use of
discipline and behavior discipline and behavior management (pages 2-3). A copy of this updated Student
management system Enrollment Packet was submitted to Licensing via email on 6/9/23. The program added
their newest behavior management system, Collaborative Problem Solving (CPS).
A consent in this area could not be found in
the youth files reviewed.
CORRECTIVE ACTION: Generate this
required consent, obtain necessary signatures
and place in the youth’s files moving forward.
Consents 419-470-0160(1) (d) Restrict Yes☐ No✓ Consent regarding restricted contact with persons outside of the agency was added to
contact with persons outside of Student Enrollment Packet (pages 5-6) and submitted to Licensing on 7/31/23.
the agency
A consent in this area could not be found in
the youth files reviewed.
CORRECTIVE ACTION: Generate this
required consent, obtain necessary signatures
and place in the youth’s files moving forward.
Consents 419-470-0160(1) (e) Allow access Yes☐ No✓ The program has updated their existing Student Enrollment Packet to reflect that the
as defined in 419-400-0230 & 0240 program will allow access as defined in this related Licensing Rule (page 4). A copy of this
updated Student Enrollment Packet was submitted to Licensing via email on 6/9/23.
A consent in this area could not be found in
the youth files reviewed.
CORRECTIVE ACTION: Generate this
required consent, obtain necessary signatures
and place in the youth’s files moving forward.
Consents 419-470-0160(1) (f) Impose a Yes☐ No✓ The program has updated their existing Student Enrollment Packet to reflect dress code
dress code (page 11). A copy of this updated Student Enrollment Packet was submitted to Licensing
via email on 6/9/23.
Dress code is referenced in Client and Parent
Manual but requires revision.
CORRECTIVE ACTION: Develop consent
regarding imposing a dress code.
Consents 419-470-0160(1) (g) Apply the Yes☐ No✓ The program has updated their existing Student Enrollment Packet to reflect that the
reasonable and prudent parent program will apply the reasonable and prudent parent standard during the youth’s stay in
Standard
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A consent in this area could not be found in program (pages 4-5). A copy of this updated Student Enrollment Packet was submitted to
the youth files reviewed. Licensing via email on 6/9/23.
CORRECTIVE ACTION: Generate this
required consent, obtain necessary signatures
and place in the youth’s files moving forward.
Disclosures 419-470-0160(2) Yes☐ No✓ This disclosure regarding searches was added to the program’s existing Student
Parent/guardian has acknowledged in Enrollment Packet (page 20). A copy of this updated Student Enrollment Packet was
writing: (a) Information regarding personal submitted to Licensing via email on 6/9/12.
or room searches and protocols for
confiscation of contraband
A disclosure in this area could not be found in
the youth files reviewed.
CORRECTIVE ACTION: Generate this
required disclosure, obtain necessary
signatures and place in the youth’s files
moving forward.
Disclosures 419-470-0160(2) Yes☐ No✓ Statement of Rights referenced in Client and Parent Manual was revised and meets
Parent/guardian has acknowledged in Licensing rule. This revision was submitted via email on 7/31/23.
writing: (b) Statement of Rights of Children
and Parents/Guardians
Statement of Rights is referenced in Client
and Parent Manual but requires revision.
CORRECTIVE ACTION: Develop disclosure
regarding statement of rights to meet
Licensing rule.
Disclosures 419-470-0160(2) Yes☐ No✓ The program has updated their existing Student Enrollment Packet to reflect any policy and
Parent/guardian has acknowledged in procedure will be made available to either a parent/guardian or student upon request (page
writing: (c) Any policies and procedures 6). A copy of this updated Student Enrollment Packet was submitted to Licensing via email
upon request on 6/9/23.
A disclosure in this area could not be found in
the youth files reviewed.
CORRECTIVE ACTION: Generate this
required disclosure, obtain necessary
signatures and place in the youth’s files
moving forward.
Authorizations 419-470-0160(3) (b) Child Yes☐ No✓ Authorization regarding child specific visitors was added to the program’s existing Student
specific visitors Enrollment Packet (pages 6–7). A copy of this information was submitted to Licensing via
email on 6/9/23.
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An authorization in this area could not be
found in the youth files reviewed.
CORRECTIVE ACTION: Generate this
required authorization, obtain necessary
signatures and place in the youth’s files
moving forward.
Authorizations 419-470-0160(3) (c) Yes☐ No✓ Authorizations regarding visitation resources was added to the program’s existing Student
Visitation resources are pre-approved Enrollment Packet (pages 6–7). A copy of this information was submitted to Licensing via
email on 6/9/23.
An authorization in this area could not be
found in the youth files reviewed.
CORRECTIVE ACTION: Generate this
required authorization, obtain necessary
signatures and place in the youth’s files
moving forward.
Information about Children in Care Yes☐ No✓ A section to capture a youth’s religious preference was added to the program’s existing
419-400-0190(1) Summary sheet contains “Application for Enrollment.” A copy of this form was submitted to Licensing via email on
the following: (a)The name, gender, date of 6/9/23 for review.
birth, religious preference, and previous
address
Religious preference is not located in the
youth’s summary sheet.
CORRECITVE ACTION: Include religious
preference to the youth’s summary sheet.
Information about Children in Care Yes☐ No✓ A section to capture the youth’s educational history was added to the program’s existing
419-400-0190(1) Summary sheet contains “BN Parent App” (page 8). A copy of this form was submitted to Licensing via email on
the following: (b) Name and location of 6/9/23 for review.
previous and current school
Previous and current school environment is
not captured in the youth’s summary sheet.
CORRECTIVE ACTION: Develop a process
where a youth’s previous and current school
and education plan is capture in the youth’s
summary sheet.
Information about Children in Care Yes☐ No✓ A section to capture who has legal custody of the youth was added to the program’s
419-400-0190(1) Summary sheet contains existing “BN Parent App” (page 1). A copy of this form was submitted to Licensing via
the following: (d) Legal custody email on 6/9/23 for review.
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Legal custody of the youth is not documented
in the youth’s summary sheet.
CORRECTIVE ACTION: List who has legal
custody of the youth in the youth’s summary
sheet.
Records Relating to Restraint & Yes☐ No✓ The program has updated their existing Student Enrollment Packet to include information
Involuntary Seclusion 419-400-0190(1) as to reporting suspected inappropriate use or restraint or involuntary seclusion as well as
Information provided to children in care written prohibition that a youth will experience retaliation if concerns are reported (page 3).
relating to Restraint & Involuntary A copy of this updated Student Enrollment Packet was submitted to Licensing via email on
Seclusion 6/9/23.
Notice regarding how to access quarterly
reports to the parents or guardians of children
in care is not being provided at the time of
admission or at least twice a year.
CORRECTIVE ACTION: Establish a process
where information on how to access
quarterly reports is provided to parents at the
time of admission and at least twice a year
after that moving forward.
Records and Documentation 419-400-0140 Yes☐ No✓ Ongoing compliance in this area will be monitored by Licensing.
(3) & (4) Uniform in organization, readily
identifiable and accessible, current, and
complete, containing all required info. No
eraser tape or white out.
Although uniform, identifiable and accessible,
not all required information is captured.
Complying with all identified corrective actions
listed above will ensure that all missing
information will be captured in youth files
moving forward.
Yes☐ No☐
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New Findings from Site Visit Comments
419-450-0110 The Boarding House: Lower left bedroom has a hole in lower North wall.
Homeless, Runaway, and Transitional
Living Shelters: Safety CORRECTIVE ACTION: Patch hole and paint wall. Submit a photo of the repair as proof to Licensing.
B) All buildings where children in care are The Sunflower House: Lighting in both the bathroom and kitchen areas are not working.
present must be kept clean and in good
repair. CORRECTIVE ACTION: Repair lighting in these areas. Submit photos of repairs as proof to Licensing.
Interview Summary
Dragonfly’s Operations Manager led the tour of the program’s currently licensed buildings; the Boarding House, the Sunflower House and Embark. During the
tour and in conversation with various staff at each site, updates regarding the program were shared. Currently, the Boarding House remains empty. There
have been no residents in this building since December of 2022 around the time that renovation of this building began. New flooring, fresh paint and updated
lighting gives this building a more modern and brighter look as well as a more open feeling. This renovation reduces capacity to 12 residents. The program
has resubmitted paperwork with both the Oregon Health Authority (OHA) and with Licensing in hopes to make the Boarding House into a residential program,
serving residents 17 ½ years old and older. Historically, this building served males, but may soon become coed. The Sunflower House was also found in the
midst of transition, having been empty for almost a month. Youth previously in this setting transitioned to the program’s adult-only site called the Loft. Shortly
after the Sunflower House was vacated, staff began to re paint the interior of the home to provide an updated and open environment similar to the Boarding
House. This building will also become a residential program with a capacity of 10 residents. The program’s existing residential program, Embark, is the only
licensed program that has residents. There are currently two residents at Embark. The program is expecting the arrival of a 3rd resident tomorrow and a 4th
the following week. Embark’s Program Manager, who was appointed at the time of its’ reopening in August of 2022, recently left Dragonfly. The current
Program Manager for the Boarding House and Sunflower House is now overseeing Embark. Dragonfly has plans to hire a chef that will be preparing all
meals. In addition to hiring a chef, the program has plans to hire 12-14 mentors to staff all buildings.
During this unannounced visit, Licensing also completed tours of two additional buildings that the program is in the process of licensing. One property is
located in Ashland, OR. The plan is to have this property licensed as a Homeless/Runaway/Transitional Living Shelter. The second building is located in
Klamath Falls and is next door to The Boarding House. The plan is to have this building, currently known as the Loft, to be licensed as a residential program.
There are currently three residents in this building. Once licensed, the Loft will have a capacity of 6 residents. This would give Dragonfly a total of four
residential programs and one Homeless/Runaway/Transitional Living Shelter.
A resident from Embark was interviewed. The youth reports working with an Educational Consultant (EC) prior to arriving at Embark. The EC provided the
youth with four potential placement options and the youth vetted the choices, ultimately selecting Dragonfly. The resident reports feeling safe since arriving
two months ago. Staff are believed to be well trained and know how to appropriately respond to emergencies. A recent example was provided when a peer
required urgent medical care. Staff were quick to have the peer taken to the Emergency Room while other staff stayed back with the resident, offering verbal
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and emotional support throughout the night. Strengths of the program include the staff and weekend activities. An area of weakness for the program is a lack
of consistency by staff related to schedules and unplanned activities.
Observations
The renovation of the Boarding House was a nice update for the program and has sparked interest in having the Sunflower House look just as nice. The
Klamath Falls campus was uncharacteristically quiet due to the lack of residents. During previous site visits, youth were observed in various parts of their
respective buildings, meeting with mentors, conversing with peers, reading, preparing meals or in transition to or from work. Staff are anxious to get these
buildings reopened.
Corrective Actions and Timeframes:
Please submit the following to verify compliance.
Within 45 days of receipt of this report Dragonfly Transitions 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 Licensing Coordinator, Mary Torres at mary.torres@odhsoha.oregon.gov.
Licensing Coordinator’s Signature: ________________________ Date: _1_0_/_1_8_/2_3__ __________
Manager Review: ______________________________________ Date: _1_0_-1_7_-_2_0_2_3_ ________
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agency_name: Calo Programs of Missouri, Inc. dba Dragonfly Transitions (DT)

report_title: Licensed Child Caring Agency Unannounced Site Visit Report

licensee: Dragonfly Transitions

executive_director: Michelle Hall

program_director: Lindsey "Stormy" King

licensing_coordinator: Mary Torres

other_regulatory_agencies: Joint Commission, Clinical Laboratory Improvement Amendments (CLIA) on-site drug testing certification, Oregon Health Authority (OHA) for Embark

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
Findings
Further Action
Needed
Governance of the Agency 419-400-0020 Yes[ ] No✓ A favorable evaluation for the program's newest Exec. Director was submitted to Licensing
(2)(f) Formally evaluate the Exec. on 6/6/23 via email.
Director's performance annually.
The newly appointed Exec. Director (hire
date: 5/2/22) has yet to be evaluated. An
evaluation is expected to be completed in
June of 2023 at which all performance.
evaluations for staff are scheduled to be
completed.
CORRECTIVE ACTION: Forward a copy of
the newly appointed Exec. Director's
evaluation to Licensing upon completion in
June of 2023.

Governance of the Agency 419-400-0020 Yes[ ] No✓ On 5/27/23, the program submitted a copy of a scorecard that is updated and reviewed at
(2)(k) Written quality improvement plan. the program's weekly leadership meeting. Measured Goals include, but are not limited to,
admissions, safety, clinical, critical events, and staffing. This submitted scorecard reflects
The program submitted a Department and data gathered between May 2022 - May 2023.
Performance Improvement Policy that
monitors the various departments within the
program through monthly reviews.
CORRECTIVE ACTION: Specifics related to
this policy were not provided, the program is
being asked to submit a copy of the data
gathered for the last 12 months from these
departmental meetings for Licensing's review.
Governance of the Agency 419-400-0020 Yes[ ] No✓ Initially, the program submitted copies of their monthly Leadership L10 meeting notes in
(2)(l) Meeting minutes lieu of board meeting notes on 6/14/23. These meeting notes highlight campus issues and
result in a scorecard for the program to measure specific outcomes to include capacity,
Board meeting notes were not submitted at incidents, treatment, staffing, etc.
the time of the review.
CORRECTIVE ACTION: Submit boarding Board meeting notes from Embark were submitted to Licensing via email on 7/24/23.
meeting notes for the last 12 months to
Licensing for review.
Supplemental Information Provided by Yes[ ] No✓ A revised program description meeting Licensing rule related to Dragonfly Transitions was
CCA Documents as indicated on the form updated in the program's existing Policies and Procedures Manual Master 2023 (Dragonfly
titled "Renewal Licensing Required Transitions) (pages 12-18). A copy of this manual was submitted to Licensing via email on
Documents" 6/14/23.
The submitted Program Description related to
the Klamath Falls campus (Boarding and
Sunflower House) requires revision.
CORRECTIVE ACTION: Revise the Program
Description to meet Licensing criteria.
Supplemental Information Provided by Yes✓No[ ] The program submitted a copy of the Required Financial Documents and Information via
CCA Documents as indicated on form email on 6/14/23.
titled "Required Financial Documents and
Information" Signatures from the Board approving the program's budget was submitted via email to
Licensing on 8/3/23.
The following required financial documents
were not submitted at the time of the review The program has not obtained a Tax Compliance Certificate from the Department of
- Proof the board approved the budget Revenue. This item remains outstanding from the program's review in March of 2023.
- Tax Compliance Certificate from the
Department of Revenue
- A completed and signed copy of the form
titled "Required Financial Documents and

Information." Licensing can make this form
available at the program's request.
Supplemental Information Provided by Yes[ ] No✓ A revised grievance policy meeting Licensing rule related to Dragonfly Transitions was
CCA All required policies and procedures updated in the program's existing Policies and Procedures Manual Master 2023 (Dragonfly
as identified in the "Umbrella Rules" Transitions) (pages 94-95). A copy of this manual was submitted to Licensing via email on
6/14/23.
The submitted grievance procedure policy for
children in care and families requires
revision to meet Licensing Rule.
CORRECTIVE ACTION: Revise the
program's Parent Rights and Grievance
Procedure
to include the highlighted information in the
following rule:
419-400-0090 Licensing Umbrella Rules:
Children and Families Rights Policy and
Grievance Procedures
(2) Grievance Procedures.
D) The name, address, and phone number of:
(i) A Department licensing coordinator; Mary
Torres 201 High St SE Suite 500 Salem, OR
97301, 503-978-5300 and
(ii) Any other governmental entities with
oversight responsibilities (Oregon Health
Authority at Embark)
Supplemental Information Provided by Yes[ ] No✓ A revised mandatory child abuse reporting and training policy related to Dragonfly
CCA All required policies and procedures Transitions was updated in the program's existing Policies and Procedures Manual Master
as identified in the "Umbrella Rules" 2023 (Dragonfly Transitions) and now meets Licensing Rule (pages 76-78). A copy of this
manual was submitted to Licensing via email on 6/14/23.
The submitted Mandatory Child Abuse
Reporting and Training Policy requires
revision to meet Licensing Rule.
CORRECTIVE ACTION: Revise the
program's Child Abuse Prevention and
Reporting Requirements to include the
highlighted information in the following rule:
419-400-0110 Licensing Umbrella Rules:
Policies and Procedures
(2) In addition to other policies and
procedures required by these rules, the
policies, and procedures in section (1) of this
rule must include:

(a) A written policy on mandatory child abuse
reporting, consistent with ORS 418.257,
418.258, 419B.005, 419B.010, and 419B.015
that includes requirements that child-caring
agency employees, staff, contractors, agents,
and proctor foster parents do all of the
following:
(A) Immediately report suspected child abuse
directly to the Department via the child
abuse reporting hotline.
- Remove wording that the student's primary
therapist would be given the information
related to suspected abuse and/or neglect
and that the therapist would follow through
with making a report. The staff member who
initially learned of the reported abuse and/or
neglect is responsible for making the child
abuse report.
- Add Oregon Child Abuse Hotline (ORCAH)
number to the policy and remove Klamath
and Jackson County Dept of Child Welfare
phone numbers as those numbers are now
obsolete. ORCAH # 855-503-7233.
- The program may consider adding that an
additional phone call maybe required by staff
if the alleged report occurred in another state.
Staff is encouraged to follow direction from
Oregon's hotline at the time a report is made
regarding alleged abuse and/or neglect that
occurred outside of Oregon.
(B) Receive child-caring agency-provided
training on mandatory abuse reporting
requirements as part of employee orientation
and at least annually thereafter as described
in OAR 419-400-0120.
(C) Receive child-caring agency-provided
training on the definitions of child abuse in
ORS 418.257 and 419B.005 that apply in
child-caring agencies.
- In addition, one bullet point in the policy
speaks to alleged inappropriate interactions or
relationships with staff could be addressed
through the program's grievance process. The
program will add that a call to the hotline may
also be warranted.

Supplemental Information Provided by Yes[ ] No✓ The program submitted revised policies to reflect the two missing items related to this
CCA All required policies and procedures Licensing Rule in the program's existing Policies and Procedures Manual Master 2023
as identified in the "Umbrella Rules" (Dragonfly Transitions). The sharing of critical events is captured under Incident Categories
(page 126) and how a report will be saved is under Incident Reporting (page 128). A copy
Submitted information related to the of this manual was submitted to Licensing via email on 6/14/23.
documentation of incident report writing
requires revision.
CORRECTIVE ACTION: Revise reporting
information captured at the end of the
program's Child Abuse Prevention and
Reporting Requirements to include the
highlighted information from the following rule:
419-400-0110 Licensing Umbrella Rules:
Policies and Procedures
(b) A written policy and procedure on
documenting, reporting, and saving
information about critical events and other
types of incidents that includes, but is not
limited to:
(C) Whether and how a report will be shared.
Critical events must be shared with the
child-caring agency's assigned licensing
coordinator (see OAR 419-400-0230(11)(b))
but other types of reports may be shared with
other regulatory agencies or legal guardians.
(D) How a report will be saved. This must
include, but is not limited to, ensuring the
report is placed in the individual child in care's
record if applicable.
Supplemental Information Provided by CCA Yes[ ] No✓ Information reflected in the personnel records policy related to termination dates and
All required policies and procedures as reason for termination was added to the program's existing Policies and Procedures
identified in the "Umbrella Rules" Manual Master 2023 (Dragonfly Transitions) (page 158). A copy of this manual was
submitted to Licensing via email on 6/14/23. An addition, all employee files have a cover
Submitted Personnel Records policy requires sheet that reflects, as applicable, a termination date and reason for termination.
revision.
The program had in existence a written grievance procedure for staff under their Employee
CORRECTIVE ACTION: Revise Personnel Standards of Conduct Policy (page 171) in the program's existing Policies and Procedures
Records policy to include the highlighted Manual Master 2023 (Dragonfly Transitions) meeting Licensing Rule. A copy of this manual
information from the following rule: was submitted to Licensing via email on 6/14/23.
419-400-120 Licensing Umbrella Rules:
Personnel Staff requirements and hiring. To
ensure that the child-caring agency uses only
staff and volunteers who do not jeopardize the
health, safety, or welfare of children, a child-

caring agency and its contractors must meet
all of the following requirements:
(e) A written grievance procedure for staff.
(g) Starting and termination dates, and reason
for termination.
Supplemental Information Provided by CCA Yes[ ] No✓ The program submitted a revised version of their milieu management policy in the
All required policies and procedures as program's existing Policies and Procedures Manual Master 2023 (Dragonfly Transitions)
identified in the "Umbrella Rules" (page 68). A copy of this manual was submitted to Licensing via email on 6/14/23.
Submitted discipline and behavior
management policy entitled Milieu
Management Policies requires revision.
CORRECTIVE ACTION: Revise Milieu
Management Policies to include the
highlighted information from the following rule:
419-400-0150 Licensing Umbrella Rules:
Discipline, Behavior Management &
Training, and Suicide Prevention (Excluding
Adoption Agencies)
(1) A child-caring agency, except a child-
caring agency licensed only to provide
adoption services under OAR 419-420-0010
to 419-420-0160, must adopt and adhere to
written policies and procedures on discipline,
behavior management, and suicide prevention
that meet all of the requirements of this rule.
(b) The discipline and behavior management
policies and procedures must prohibit the
following:
(K) Removing or limiting the use of a mobility
aid or other assistive device for the purpose
of controlling a child in care's behavior.
Supplemental Information Provided by CCA Yes[ ] No✓ A revised copy of the program's Suicide Prevention Plan meeting Licensing rule was
All required policies and procedures as submitted to Licensing via email on 7/31/23.
identified in the "Umbrella Rules"
Submitted Suicide Prevention Plan requires
revision.
CORRECTIVE ACTION: Revise suicide
policy to include the highlighted information
from the following rule:
419-400-0150 Licensing Umbrella Rules:
Discipline, Behavior Management &

Training, and Suicide Prevention (Excluding
Adoption Agencies)
(4) Suicide Prevention. The policy must
include the following:
(c) Emergency protocol and contacts;
(d) Training requirements for staff, including
suicide prevention training and suicide risk
assessment tool training;
(e) Procedures for determining
implementation of additional supervision
precautions and for determining removal of
additional supervision precautions;
(f) Suicide risk assessment procedures on the
day of intake; Policy currently refers to an
assessment within the first 14 days from
intake. Rule requires suicide risk assessment
on the day of intake. Remove reference to 14
days and implement a plan as to how
incoming youth will be assessed the day of
intake.
(g) Documentation requirements for suicide
ideation, self-harm, and special observation
precautions to ensure immediate
communication to all staff;
(h) A process for tracking suicide behavioral
patterns; and
(i) A "post-intervention" plan with identified
resources.
Supplemental Information Provided by CCA Yes[ ] No✓ The program submitted a revised version of their Driver and Fleet Safety Policy (pages
All required policies and procedures as 142-153) in the program's existing Policies and Procedures Manual Master 2023
identified in the "Umbrella Rules" (Dragonfly Transitions) that now meets Licensing Rule. A copy of this manual was
submitted to Licensing via email on 6/14/23.
Submitted Driver and Fleet Safety requires
revision.
CORRECTIVE ACTION: Revise Driver and
Fleet Safety policy to include the highlighted
information from the following rule:
419-400-0200 Licensing Umbrella Rules:
Safety
(b) Vehicle requirements.
(A) Each vehicle used to transport a child in
care must be:
(i) Properly registered;

(ii) Covered by an insurance policy in full force
and effect;
(iii) Maintained in safe operating condition;
and
(iv) Smoke-free.
Supplemental Information Provided by CCA Yes[ ] No✓ The program submitted a revised version of their search policy (pages 122- 123) in the
All required policies and procedures as program's existing Policies and Procedures Manual Master 2023 (Dragonfly Transitions)
identified in the "Umbrella Rules" that now meets Licensing Rule. A copy of this manual was submitted to Licensing via email
on 6/14/23.
Submitted Safety Committee policy related to
searches requires revision.
CORRECTIVE ACTION: Revise Safety
Committee policy to include the highlighted
information from the following rule:
419-400-0200 Licensing Umbrella Rules:
Safety
2) Searches. If a child-caring agency carries
out searches on children in care or visitors,
the child-caring agency must have written
policies and procedures that, at a minimum,
comply with all of the following:
(G) If the child in care refuses to comply, the

interview_summary:
Dragonfly's Operations Manager led the tour of the program's currently licensed buildings; the Boarding House, the Sunflower House and Embark. During the
tour and in conversation with various staff at each site, updates regarding the program were shared. Currently, the Boarding House remains empty. There
have been no residents in this building since December of 2022 around the time that renovation of this building began. New flooring, fresh paint and updated
lighting gives this building a more modern and brighter look as well as a more open feeling. This renovation reduces capacity to 12 residents. The program
has resubmitted paperwork with both the Oregon Health Authority (OHA) and with Licensing in hopes to make the Boarding House into a residential program,
serving residents 17 ½ years old and older. Historically, this building served males, but may soon become coed. The Sunflower House was also found in the
midst of transition, having been empty for almost a month. Youth previously in this setting transitioned to the program's adult-only site called the Loft. Shortly
after the Sunflower House was vacated, staff began to re paint the interior of the home to provide an updated and open environment similar to the Boarding
House. This building will also become a residential program with a capacity of 10 residents. The program's existing residential program, Embark, is the only
licensed program that has residents. There are currently two residents at Embark. The program is expecting the arrival of a 3rd resident tomorrow and a 4th
the following week. Embark's Program Manager, who was appointed at the time of its' reopening in August of 2022, recently left Dragonfly. The current
Program Manager for the Boarding House and Sunflower House is now overseeing Embark. Dragonfly has plans to hire a chef that will be preparing all
meals. In addition to hiring a chef, the program has plans to hire 12-14 mentors to staff all buildings.
During this unannounced visit, Licensing also completed tours of two additional buildings that the program is in the process of licensing. One property is
located in Ashland, OR. The plan is to have this property licensed as a Homeless/Runaway/Transitional Living Shelter. The second building is located in
Klamath Falls and is next door to The Boarding House. The plan is to have this building, currently known as the Loft, to be licensed as a residential program.
There are currently three residents in this building. Once licensed, the Loft will have a capacity of 6 residents. This would give Dragonfly a total of four
residential programs and one Homeless/Runaway/Transitional Living Shelter.
A resident from Embark was interviewed. The youth reports working with an Educational Consultant (EC) prior to arriving at Embark. The EC provided the
youth with four potential placement options and the youth vetted the choices, ultimately selecting Dragonfly. The resident reports feeling safe since arriving
two months ago. Staff are believed to be well trained and know how to appropriately respond to emergencies. A recent example was provided when a peer
required urgent medical care. Staff were quick to have the peer taken to the Emergency Room while other staff stayed back with the resident, offering verbal

and emotional support throughout the night. Strengths of the program include the staff and weekend activities. An area of weakness for the program is a lack
of consistency by staff related to schedules and unplanned activities.

previous_findings:
Repeat Comments
Findings
Further Action
Needed
Governance of the Agency 419-400-0020 Yes[ ] No✓ A favorable evaluation for the program's newest Exec. Director was submitted to Licensing
(2)(f) Formally evaluate the Exec. on 6/6/23 via email.
Director's performance annually.
The newly appointed Exec. Director (hire
date: 5/2/22) has yet to be evaluated. An
evaluation is expected to be completed in
June of 2023 at which all performance.
evaluations for staff are scheduled to be
completed.
CORRECTIVE ACTION: Forward a copy of
the newly appointed Exec. Director's
evaluation to Licensing upon completion in
June of 2023.

Governance of the Agency 419-400-0020 Yes[ ] No✓ On 5/27/23, the program submitted a copy of a scorecard that is updated and reviewed at
(2)(k) Written quality improvement plan. the program's weekly leadership meeting. Measured Goals include, but are not limited to,
admissions, safety, clinical, critical events, and staffing. This submitted scorecard reflects
The program submitted a Department and data gathered between May 2022 - May 2023.
Performance Improvement Policy that
monitors the various departments within the
program through monthly reviews.
CORRECTIVE ACTION: Specifics related to
this policy were not provided, the program is
being asked to submit a copy of the data
gathered for the last 12 months from these
departmental meetings for Licensing's review.
Governance of the Agency 419-400-0020 Yes[ ] No✓ Initially, the program submitted copies of their monthly Leadership L10 meeting notes in
(2)(l) Meeting minutes lieu of board meeting notes on 6/14/23. These meeting notes highlight campus issues and
result in a scorecard for the program to measure specific outcomes to include capacity,
Board meeting notes were not submitted at incidents, treatment, staffing, etc.
the time of the review.
CORRECTIVE ACTION: Submit boarding Board meeting notes from Embark were submitted to Licensing via email on 7/24/23.
meeting notes for the last 12 months to
Licensing for review.
Supplemental Information Provided by Yes[ ] No✓ A revised program description meeting Licensing rule related to Dragonfly Transitions was
CCA Documents as indicated on the form updated in the program's existing Policies and Procedures Manual Master 2023 (Dragonfly
titled "Renewal Licensing Required Transitions) (pages 12-18). A copy of this manual was submitted to Licensing via email on
Documents" 6/14/23.
The submitted Program Description related to
the Klamath Falls campus (Boarding and
Sunflower House) requires revision.
CORRECTIVE ACTION: Revise the Program
Description to meet Licensing criteria.
Supplemental Information Provided by Yes✓No[ ] The program submitted a copy of the Required Financial Documents and Information via
CCA Documents as indicated on form email on 6/14/23.
titled "Required Financial Documents and
Information" Signatures from the Board approving the program's budget was submitted via email to
Licensing on 8/3/23.
The following required financial documents
were not submitted at the time of the review The program has not obtained a Tax Compliance Certificate from the Department of
- Proof the board approved the budget Revenue. This item remains outstanding from the program's review in March of 2023.
- Tax Compliance Certificate from the
Department of Revenue
- A completed and signed copy of the form
titled "Required Financial Documents and

Information." Licensing can make this form
available at the program's request.
Supplemental Information Provided by Yes[ ] No✓ A revised grievance policy meeting Licensing rule related to Dragonfly Transitions was
CCA All required policies and procedures updated in the program's existing Policies and Procedures Manual Master 2023 (Dragonfly
as identified in the "Umbrella Rules" Transitions) (pages 94-95). A copy of this manual was submitted to Licensing via email on
6/14/23.
The submitted grievance procedure policy for
children in care and families requires
revision to meet Licensing Rule.
CORRECTIVE ACTION: Revise the
program's Parent Rights and Grievance
Procedure
to include the highlighted information in the
following rule:
419-400-0090 Licensing Umbrella Rules:
Children and Families Rights Policy and
Grievance Procedures
(2) Grievance Procedures.
D) The name, address, and phone number of:
(i) A Department licensing coordinator; Mary
Torres 201 High St SE Suite 500 Salem, OR
97301, 503-978-5300 and
(ii) Any other governmental entities with
oversight responsibilities (Oregon Health
Authority at Embark)
Supplemental Information Provided by Yes[ ] No✓ A revised mandatory child abuse reporting and training policy related to Dragonfly
CCA All required policies and procedures Transitions was updated in the program's existing Policies and Procedures Manual Master
as identified in the "Umbrella Rules" 2023 (Dragonfly Transitions) and now meets Licensing Rule (pages 76-78). A copy of this
manual was submitted to Licensing via email on 6/14/23.
The submitted Mandatory Child Abuse
Reporting and Training Policy requires
revision to meet Licensing Rule.
CORRECTIVE ACTION: Revise the
program's Child Abuse Prevention and
Reporting Requirements to include the
highlighted information in the following rule:
419-400-0110 Licensing Umbrella Rules:
Policies and Procedures
(2) In addition to other policies and
procedures required by these rules, the
policies, and procedures in section (1) of this
rule must include:

(a) A written policy on mandatory child abuse
reporting, consistent with ORS 418.257,
418.258, 419B.005, 419B.010, and 419B.015
that includes requirements that child-caring
agency employees, staff, contractors, agents,
and proctor foster parents do all of the
following:
(A) Immediately report suspected child abuse
directly to the Department via the child
abuse reporting hotline.
- Remove wording that the student's primary
therapist would be given the information
related to suspected abuse and/or neglect
and that the therapist would follow through
with making a report. The staff member who
initially learned of the reported abuse and/or
neglect is responsible for making the child
abuse report.
- Add Oregon Child Abuse Hotline (ORCAH)
number to the policy and remove Klamath
and Jackson County Dept of Child Welfare
phone numbers as those numbers are now
obsolete. ORCAH # 855-503-7233.
- The program may consider adding that an
additional phone call maybe required by staff
if the alleged report occurred in another state.
Staff is encouraged to follow direction from
Oregon's hotline at the time a report is made
regarding alleged abuse and/or neglect that
occurred outside of Oregon.
(B) Receive child-caring agency-provided
training on mandatory abuse reporting
requirements as part of employee orientation
and at least annually thereafter as described
in OAR 419-400-0120.
(C) Receive child-caring agency-provided
training on the definitions of child abuse in
ORS 418.257 and 419B.005 that apply in
child-caring agencies.
- In addition, one bullet point in the policy
speaks to alleged inappropriate interactions or
relationships with staff could be addressed
through the program's grievance process. The
program will add that a call to the hotline may
also be warranted.

Supplemental Information Provided by Yes[ ] No✓ The program submitted revised policies to reflect the two missing items related to this
CCA All required policies and procedures Licensing Rule in the program's existing Policies and Procedures Manual Master 2023
as identified in the "Umbrella Rules" (Dragonfly Transitions). The sharing of critical events is captured under Incident Categories
(page 126) and how a report will be saved is under Incident Reporting (page 128). A copy
Submitted information related to the of this manual was submitted to Licensing via email on 6/14/23.
documentation of incident report writing
requires revision.
CORRECTIVE ACTION: Revise reporting
information captured at the end of the
program's Child Abuse Prevention and
Reporting Requirements to include the
highlighted information from the following rule:
419-400-0110 Licensing Umbrella Rules:
Policies and Procedures
(b) A written policy and procedure on
documenting, reporting, and saving
information about critical events and other
types of incidents that includes, but is not
limited to:
(C) Whether and how a report will be shared.
Critical events must be shared with the
child-caring agency's assigned licensing
coordinator (see OAR 419-400-0230(11)(b))
but other types of reports may be shared with
other regulatory agencies or legal guardians.
(D) How a report will be saved. This must
include, but is not limited to, ensuring the
report is placed in the individual child in care's
record if applicable.
Supplemental Information Provided by CCA Yes[ ] No✓ Information reflected in the personnel records policy related to termination dates and
All required policies and procedures as reason for termination was added to the program's existing Policies and Procedures
identified in the "Umbrella Rules" Manual Master 2023 (Dragonfly Transitions) (page 158). A copy of this manual was
submitted to Licensing via email on 6/14/23. An addition, all employee files have a cover
Submitted Personnel Records policy requires sheet that reflects, as applicable, a termination date and reason for termination.
revision.
The program had in existence a written grievance procedure for staff under their Employee
CORRECTIVE ACTION: Revise Personnel Standards of Conduct Policy (page 171) in the program's existing Policies and Procedures
Records policy to include the highlighted Manual Master 2023 (Dragonfly Transitions) meeting Licensing Rule. A copy of this manual
information from the following rule: was submitted to Licensing via email on 6/14/23.
419-400-120 Licensing Umbrella Rules:
Personnel Staff requirements and hiring. To
ensure that the child-caring agency uses only
staff and volunteers who do not jeopardize the
health, safety, or welfare of children, a child-

caring agency and its contractors must meet
all of the following requirements:
(e) A written grievance procedure for staff.
(g) Starting and termination dates, and reason
for termination.
Supplemental Information Provided by CCA Yes[ ] No✓ The program submitted a revised version of their milieu management policy in the
All required policies and procedures as program's existing Policies and Procedures Manual Master 2023 (Dragonfly Transitions)
identified in the "Umbrella Rules" (page 68). A copy of this manual was submitted to Licensing via email on 6/14/23.
Submitted discipline and behavior
management policy entitled Milieu
Management Policies requires revision.
CORRECTIVE ACTION: Revise Milieu
Management Policies to include the
highlighted information from the following rule:
419-400-0150 Licensing Umbrella Rules:
Discipline, Behavior Management &
Training, and Suicide Prevention (Excluding
Adoption Agencies)
(1) A child-caring agency, except a child-
caring agency licensed only to provide
adoption services under OAR 419-420-0010
to 419-420-0160, must adopt and adhere to
written policies and procedures on discipline,
behavior management, and suicide prevention
that meet all of the requirements of this rule.
(b) The discipline and behavior management
policies and procedures must prohibit the
following:
(K) Removing or limiting the use of a mobility
aid or other assistive device for the purpose
of controlling a child in care's behavior.
Supplemental Information Provided by CCA Yes[ ] No✓ A revised copy of the program's Suicide Prevention Plan meeting Licensing rule was
All required policies and procedures as submitted to Licensing via email on 7/31/23.
identified in the "Umbrella Rules"
Submitted Suicide Prevention Plan requires
revision.
CORRECTIVE ACTION: Revise suicide
policy to include the highlighted information
from the following rule:
419-400-0150 Licensing Umbrella Rules:
Discipline, Behavior Management &

Training, and Suicide Prevention (Excluding
Adoption Agencies)
(4) Suicide Prevention. The policy must
include the following:
(c) Emergency protocol and contacts;
(d) Training requirements for staff, including
suicide prevention training and suicide risk
assessment tool training;
(e) Procedures for determining
implementation of additional supervision
precautions and for determining removal of
additional supervision precautions;
(f) Suicide risk assessment procedures on the
day of intake; Policy currently refers to an
assessment within the first 14 days from
intake. Rule requires suicide risk assessment
on the day of intake. Remove reference to 14
days and implement a plan as to how
incoming youth will be assessed the day of
intake.
(g) Documentation requirements for suicide
ideation, self-harm, and special observation
precautions to ensure immediate
communication to all staff;
(h) A process for tracking suicide behavioral
patterns; and
(i) A "post-intervention" plan with identified
resources.
Supplemental Information Provided by CCA Yes[ ] No✓ The program submitted a revised version of their Driver and Fleet Safety Policy (pages
All required policies and procedures as 142-153) in the program's existing Policies and Procedures Manual Master 2023
identified in the "Umbrella Rules" (Dragonfly Transitions) that now meets Licensing Rule. A copy of this manual was
submitted to Licensing via email on 6/14/23.
Submitted Driver and Fleet Safety requires
revision.
CORRECTIVE ACTION: Revise Driver and
Fleet Safety policy to include the highlighted
information from the following rule:
419-400-0200 Licensing Umbrella Rules:
Safety
(b) Vehicle requirements.
(A) Each vehicle used to transport a child in
care must be:
(i) Properly registered;

(ii) Covered by an insurance policy in full force
and effect;
(iii) Maintained in safe operating condition;
and
(iv) Smoke-free.
Supplemental Information Provided by CCA Yes[ ] No✓ The program submitted a revised version of their search policy (pages 122- 123) in the
All required policies and procedures as program's existing Policies and Procedures Manual Master 2023 (Dragonfly Transitions)
identified in the "Umbrella Rules" that now meets Licensing Rule. A copy of this manual was submitted to Licensing via email
on 6/14/23.
Submitted Safety Committee policy related to
searches requires revision.
CORRECTIVE ACTION: Revise Safety
Committee policy to include the highlighted
information from the following rule:
419-400-0200 Licensing Umbrella Rules:
Safety
2) Searches. If a child-caring agency carries
out searches on children in care or visitors,
the child-caring agency must have written
policies and procedures that, at a minimum,
comply with all of the following:
(G) If the child in care refuses to comply, the
executive director or designee must be
notified immediately and be responsible to
resolve the matter; and
(H) All searches must be documented in
writing.
(g) Information regarding any personal or
room searches and protocols for confiscation
of contraband items, including the notification
of law enforcement if illegal contraband is
discovered.
Supplemental Information Provided by CCA Yes[ ] No✓ The program submitted a Hazard Policy meeting Licensing rule via email on 7/31/23.
All required policies and procedures as
identified in the "Umbrella Rules"
A policy related to potential hazards was not
submitted to Licensing for review.
CORRECTIVE ACTION: Submit a policy
related to potential hazards or create a policy
that complies with the following rule:
419-400-0200 Licensing Umbrella Rules:
Safety

(4) Hazards.
(a) A child-caring agency must protect
children in care it serves from guns, drugs,
sharps, paint, hazardous materials, bio-
hazardous materials, and other potentially
harmful items.
A child-caring agency must have a written
policy that addresses potentially harmful
materials that are in areas accessible to the
children in care in the program or on the
grounds of the program.
Supplemental Information Provided by CCA Yes[ ] No✓ Projected Staffing Patterns are detailed in the program's Policies and Procedures Manual
All required policies and procedures as Master 2023 (Dragonfly Transitions) on pages 14 - 15, meeting this Licensing requirement.
identified in "Agency Type Specific Rules" A copy of this manual was submitted to Licensing via email on 6/14/23.
Submitted staffing requirement policy located
in the program's Workplace Safety policy
requires revision.
CORRECTIVE ACTION: Revise Workplace
Safety Policy to include the highlighted
information from the following rule:
419-450-0030 Homeless, Runaway, and
Transitional Living Shelters: Staffing
Requirements
(1) A child-caring agency must have and
follow written policies regarding minimum
staffing requirements, including a written
staffing plan that indicates the number of paid
and volunteer staff in each job category.
(2) During each shift, there must be at least
one staff member who has been trained in a
non-violent crisis intervention strategy. A
volunteer or intern may be used to meet this
requirement only if the volunteer or intern has
met the training requirements for staff in
OAR 413-215-0726.
Supplemental Information Provided by CCA Yes[ ] No✓ The program added a newly created Health and Hygiene Policy (page 109) to the
All required policies and procedures as program's existing Policies and Procedures Manual Master 2023 (Dragonfly Transitions)
identified in "Agency Type Specific Rules" that now meets Licensing Rule. A copy of this manual was submitted to Licensing via email
on 6/14/23.
A policy related to health and hygiene was not
submitted to Licensing for review.

CORRECTIVE ACTION: Submit policy
related to health and hygiene to Licensing or
create a policy that complies with the following
rule:
419-450-0090 Homeless, Runaway, and
Transitional Living Shelters: Health and
Hygiene
(1) A child-caring agency must have and
follow policies that ensure the prompt and
accurate assessment and care of injuries,
illness, and physical complaints of children in
care.
Grouping 419-450-0100 Yes[ ] No✓ The program added a newly created Grouping Policy (pages 64 - 67) to the program's
(1) & (2) Has and follows policies for existing Policies and Procedures Manual Master 2023 (Dragonfly Transitions) that now
grouping children that meets requirements meets Licensing Rule. A copy of this manual was submitted to Licensing via email on
(age, developmental level, maturity, 6/14/23.
behavior, medical...)
No grouping policy was submitted to
Licensing at the time of the review.
CORRECTIVE ACTION: Submit copy of the
program's Grouping policy. If this policy
needs to be created, please reference the
following rule for specifics required.
419-450-0100 Homeless, Runaway, and
Transitional Living Shelters: Grouping
(1) A child-caring agency must have and
follow written policies regarding the grouping
of children in care.
(2) Except as provided in section (3) of this
rule, an agency must place children in care in
groups based on the following factors:
(a) Age.
(b) Developmental level.
(c) Physical maturity.
(d) Social maturity.
(e) Behavioral functioning.
(f) Cognitive level.
(g) Medical concerns.
(h) Individual needs.
(3) A child in care with a diagnosed disability
may be served in the most integrated setting
appropriate to the needs of the child in care
within the context of the program. For

purposes of this section:
(a) The child in care who can meet the
essential eligibility requirements for a group
with or without reasonable modification of
rules, policies or procedures, or the provision
of auxiliary aids and services may be served.
(b) "Integrated Setting" means a setting that
enables children in care with disabilities to
interact with non-disabled persons to the
fullest extent possible.
Grouping 419-450-0100 Yes[ ] No✓ The program addresses emancipated children in their a newly created Grouping Policy
(4) Care was taken to assess and minimize (pages 64 - 67) found in the program's existing Policies and Procedures Manual Master
risk for children placed with emancipated 2023 (Dragonfly Transitions) that now meets Licensing Rule. A copy of this manual was
children or adults submitted to Licensing via email on 6/14/23.
Information related to emancipated children or
adults was not submitted to Licensing at
the time of the review.
CORRECTIVE ACTION: Submit this
information to Licensing. If this information
needs to be created, please reference the
following rule for specifics required.
410-450-0100 Homeless, Runaway, and
Transitional Living Shelters: Grouping
(4) Placement with adults. A child-caring
agency may place children in care in the
same group as emancipated children in care
or adults only after taking special care to
assess and minimize the risk to the children in
care.
Umbrella Safety 419-400-0200 (1)(b)(A) Each Yes[ ] No✓ On 6/9/23, proof of effective and current insurance coverage and valid registration for this
vehicle used to transport a child in care must vehicle was submitted via email to Licensing.
be: properly registered, covered by an
insurance policy in full force and effect,
maintained in safe operating
condition, and smoke-free.
Klamath Falls campus: White Ford van
(license plate # 907***) has outdated vehicle
registration and tags. The vehicle also does
not have a current insurance card to reflect
proof of insurance coverage.

CORRECTIVE ACTION: Obtain current
vehicle registration and tags through DMV
and place in vehicle and on the vehicle's
license plate. Obtain a copy of current
insurance coverage and place in vehicle.
Initial Training (Must be completed before Yes[ ] No✓ On 6//9/23, the program submitted to Licensing, via email, a copy of training material
staff is alone with youth) 419-450-0040(1) developed related to First Aid kit contents and use. A signature and date at the end of this
(g) First aid kit contents and use training information will be proof the employee's understanding and completion of this
training.
First Aid Kit training could not be verified
during the file review.
CORRECTIVE ACTION: Implement a
process where onboarding staff are trained in
the contents of First Aid kits and its use, and
this training is adequately documented.
Initial Training (Must be completed before Yes[ ] No✓ All personnel files have been evaluated to ensure that all staff have a valid CPR/1st Aid
staff is alone with youth) 419-450-0040(1) certificate. To prevent a lapse in this training, the certificate number and expiration date are
(i) CPR and First Aid also recorded on each employee's personnel file cover sheet and captured on a
spreadsheet to track approaching expiration dates.
Two out of the 5 personnel files did not reflect
current certification in CPR/1st Aid training.
CORRECTIVE ACTION: Ensure that required
training is completed and documented
moving forward.
Initial Training (Must be completed before Yes[ ] No✓ The program is moving to a new crisis intervention training, Collaborative Problem Solving
staff is alone with youth) 419-450-0040(1) (CPS). An in-house staff member has been identified as a trainer. Once that trainer has
(j) Crisis intervention training been approved and qualified to provide instruction, all staff will complete this training and
record of their certification will be filed in their respective employee file.
Two out of the 5 personnel files did not reflect
current crisis intervention training at the time
of onboarding.
CORRECTIVE ACTION: Ensure that required
training is completed and documented
moving forward.
Child Records 419-450-0070(2) (d) Consent Yes[ ] No✓ The program provided a written consent to reflect therapeutic interventions provided and
to treat the child with interventions in use used in the program via email on 7/31/23. This consent is located in Student Enrollment
at the program documents.
Files reviewed did not reflect the consent to
treat the child with interventions used by the
program.

CORRECTIVE ACTION: Create and
implement a form or other means to document
this required consent. Reference the related
rule in the creation of this consent.
419-450-0070 Homeless, Runaway, and
Transitional Living Shelters: Client Files
(2) Child in care file requirements. A child-
caring agency must have a file on the
premises for each child in care currently
receiving services from the agency. To the
extent such information is reasonably
available to the agency, this file must be up to
date and include all of the following:
(d) A signed consent for the child-caring
agency to treat the child in care with the
interventions in use at the program.
Assessment 419-450-0050(3) Statement as Yes[ ] No✓ A statement regarding eligibility requirements being met for admission has been added to
to whether child meets eligibility the program's assessment document. The evaluating psychiatrist is tasked with making
requirements to be admitted to program. this final determination, signing off on this document and adding any necessary notes.
This plan was submitted to Licensing via email on 7/31/23.
Youth files reviewed did not reflect a clear
statement that the youth assessed meets
eligibility requirement to be admitted to
program.
CORRECTIVE ACTION: Collaborate with the
program's psychiatrist to develop a
statement that reflects the eligibility of a youth
to be admitted to the program in a clear
and concise manner.
Records Relating to Restraint & Yes[ ] No✓ The program revised their existing Parent and Student Manual to reflect how to access a
Involuntary Seclusion 419-400-0190(1) copy of the program's quarterly restraint and involuntary seclusion reports (page 3). A
Information provided to children in care copy of the revised manual was submitted to Licensing via email on 6/9/23. In addition, this
relating to Restraint & Involuntary information has been added to the program's monthly newsletters that both residents and
Seclusion guardians receive to meet the additional requirement of this information being shared twice
a year after intake.
Although copies of the program's Quarterly
Restraint and Involuntary Seclusion are
posted on the program's website the program
has not provided information to children or
guardian's how to access this information.
CORRECTIVE ACTION: Develop and
implement a process where youth,

guardians/parents are given information how
to access this information. Please see
related rule for reference.
419-400-0180 Licensing Umbrella Rules:
Restraints and Involuntary Seclusion
(13) Reporting Requirements
(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.
Additional Finding related to 419-400- Yes[ ] No✓ The program has updated their existing Student Enrollment Packet to include information
0190(1) Information provided to children in as to reporting suspected inappropriate use or restraint or involuntary seclusion as well as
care written prohibition that a youth will experience retaliation if concerns are reported (page 3).
A copy of this updated Student Enrollment Packet was submitted to Licensing via email on
The review of youth files did not reflect 6/9/23.
instruction how a child in care may report
suspected inappropriate use of restraint or
involuntary seclusion and not
experience retaliation for reporting these
concerns.
CORRECTIVE ACTION: Create and
implement a process where a child in care is
given instruction how to report inappropriate
use of restraint or involuntary seclusion as
related to the following rule.
419-400-0190 Licensing Umbrella Rules:
Information Provided to Children in Care
(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 described in ORS 417.805
and the telephone numbers and electronic
mail addresses for the program's licensing

agency, the child in care's caseworker and
attorney, the child in care's court appointed
special advocate and Disability Rights
Oregon.
(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.
Food Services 419-470-0070 (1)(b) Menus Yes[ ] No✓ Beginning in January of 2023, as requested by Licensing, the program began adding
are prepared in advance in accordance information regarding breakfast and lunch options on their monthly menus. A copy of
with USDA guidelines, provide a variety of menus beginning January of 2023 were submitted to Licensing via email on 6/9/23.
foods and are adjusted for seasonal
changes.
Continental breakfast and lunch options are
not captured in the program's monthly
menus. Monthly menus document the group
meals planned by staff and the residents.
CORRECTIVE ACTION: Include breakfast
and lunch in the monthly menus that are in
accordance with the USDA guidelines.
Residential Care Safety 419-470-0080 Yes[ ] No✓ A revised evacuation form was submitted to Licensing, via email, on 6/9/23 to reflect the
(3)(a) Evacuation drill occurs monthly addition of previously missing sections. To ensure drills are being conducted on a monthly
under varying conditions, is retained 2 basis, the Program Directors are in charge of making sure fire drills are completed monthly
years, and contains: prior to the 15th and reminders are documented on their calendars. The administrative
(A) identify of person conducting drill assistant audits fire drill documentation each month and if fire drills are not completed by
(B) date & time the 15th follow up will be held and a fire drill must be run in the next 72 hours. If fire drills
(C) notification method are not completed by the 15th of the month, the Executive Director will be notified.
(D) staff participating
(E) # of children & staff evacuated
(F) special conditions simulated
(G) problems encountered
(H) time to complete
The program submitted three monthly
documented evacuation drills. Submitted
evacuation drills are missing required sections
to include notification method, staff

participating, special conditions simulated,
and problems encountered.
CORRECTIVE ACTION: Create a process
where monthly evacuation drills are routinely
conducted and documented. Update current
evacuation form to include the required
information outlined in rule.
Minimum Staffing Requirements Yes[ ] No✓ On 6//9/23, the program submitted to Licensing, via email, a copy of training material
419-470-0130 (5) There is at least one on- developed related to Reasonable and Prudent Parent Standard. A signature and date at
site employee authorized to apply the the end of this training information will be proof the employee's understanding and
reasonable and prudent parent standard completion of this training.
The program has yet to develop staff training
in this area.
CORRECTIVE ACTION: Establish staff
training based on information provided by
Licensing.
Personnel Files 419-400-0120 (1)(b) & (3)(b) Yes[ ] No✓ The program's newest Human Resource Director understands the importance of this
reference checks completed and requirement related to reference checks and is committed to completing this requirement
documented for all new or rehired employees. Completed reference checks will be placed in the
employee's personnel files moving forward.
Documentation of reference checks, prior to
the new Human Resources Director, were
not consistently being completed and/or
documented. The program has made
significant improvements in this area
CORRECTIVE ACTION: Ensure that
personnel files consistently document
completed reference checks on all new
applicants moving forward.
Personnel Files 419-400-0120 (3)(d) Annual Yes[ ] No✓ The program has implemented a new annual evaluation template that took effect April
performance evaluations 2023 and is scheduled to be completed annually for all staff in the months of May and
June. A copy of each employee's evaluation will be submitted to HR for completion
Annual evaluations could not be located in the verification tracking and a physical copy will be filed in the employees' respective files.
files reviewed.
CORRECTIVE ACTION: Develop a process
where employee evaluations are completed
and documented for all personnel.
New Employee Orientation - Umbrella Yes[ ] No✓ The program advises that a section to capture the date this training was completed has
Requirements (30 days) 419-400-0120(4) been added to the quiz that staff must take and complete at the end of this training.
(g) Emergency procedures

Training in this area was completed, but not
dated.
CORRECTIVE ACTION: Ensure that date of
completion is reflected in employee's
training records moving forward.
Ongoing Training 419-470-0120 (4) Yes[ ] No✓ On 6//9/23, the program submitted to Licensing, via email, a copy of training material
Designated staff developed related to Reasonable and Prudent Parent Standard. A signature and date at
authorized to apply reasonable and the end of this training information will be proof the employee's understanding and
prudent parent standard are trained in completion of this training.
application of the standard
The program has yet to develop staff training
in this area.
CORRECTIVE ACTION: Establish staff
training based on information provided by
Licensing.
Ongoing Training 419-400-0120(5) Yes[ ] No✓ The program advises that moving forward, Mandatory Child Abuse Reporting is to be
Mandatory reporting completed at the time of the employee's annual work anniversary. A physical copy of all
(annually) that includes: annual training courses will be filed in each employee's personnel file moving forward. All
(a) legal definition of child abuse in ORS staff employed for over a year are now up to date in this annual training requirement.
418.257 and 419B.005
(b) legal responsibility to immediately
report
(c) legal responsibility to report is personal
to the employee
Ongoing training in this area could not be
verified during file review.
CORRECTIVE ACTION: Ensure a process
where required, annual training is
documented in personnel files moving
forward.
Children's Records Health Services Yes[ ] No✓ Documentation of age-appropriate instruction has been added to the student enrollment
419-470-0090 (2)(e) Documentation of age- packet. A copy of the updated enrollment packet with this modification was provided to
appropriate instruction - pregnancy Licensing via email on 8/18/23.
prevention, nutrition, prevention of HIV &
AIDS, and prevention and treatment of
sexually transmitted disease
Documentation of age-appropriate instruction
was not reflected in the youth files reviewed.

CORRECTIVE ACTION: Develop a process
where this instruction is documented in
youth files moving forward. Licensing would
be available to provide technical assistance
in this area upon the program's request.
Consents 419-470-0160(1) (b) Use the Yes[ ] No✓ The program has updated their existing Student Enrollment Packet to reflect the use of
discipline and behavior discipline and behavior management (pages 2-3). A copy of this updated Student
management system Enrollment Packet was submitted to Licensing via email on 6/9/23. The program added
their newest behavior management system, Collaborative Problem Solving (CPS).
A consent in this area could not be found in
the youth files reviewed.
CORRECTIVE ACTION: Generate this
required consent, obtain necessary signatures
and place in the youth's files moving forward.
Consents 419-470-0160(1) (d) Restrict Yes[ ] No✓ Consent regarding restricted contact with persons outside of the agency was added to
contact with persons outside of Student Enrollment Packet (pages 5-6) and submitted to Licensing on 7/31/23.
the agency
A consent in this area could not be found in
the youth files reviewed.
CORRECTIVE ACTION: Generate this
required consent, obtain necessary signatures
and place in the youth's files moving forward.
Consents 419-470-0160(1) (e) Allow access Yes[ ] No✓ The program has updated their existing Student Enrollment Packet to reflect that the
as defined in 419-400-0230 & 0240 program will allow access as defined in this related Licensing Rule (page 4). A copy of this
updated Student Enrollment Packet was submitted to Licensing via email on 6/9/23.
A consent in this area could not be found in
the youth files reviewed.
CORRECTIVE ACTION: Generate this
required consent, obtain necessary signatures
and place in the youth's files moving forward.
Consents 419-470-0160(1) (f) Impose a Yes[ ] No✓ The program has updated their existing Student Enrollment Packet to reflect dress code
dress code (page 11). A copy of this updated Student Enrollment Packet was submitted to Licensing
via email on 6/9/23.
Dress code is referenced in Client and Parent
Manual but requires revision.
CORRECTIVE ACTION: Develop consent
regarding imposing a dress code.
Consents 419-470-0160(1) (g) Apply the Yes[ ] No✓ The program has updated their existing Student Enrollment Packet to reflect that the
reasonable and prudent parent program will apply the reasonable and prudent parent standard during the youth's stay in
Standard

A consent in this area could not be found in program (pages 4-5). A copy of this updated Student Enrollment Packet was submitted to
the youth files reviewed. Licensing via email on 6/9/23.
CORRECTIVE ACTION: Generate this
required consent, obtain necessary signatures
and place in the youth's files moving forward.
Disclosures 419-470-0160(2) Yes[ ] No✓ This disclosure regarding searches was added to the program's existing Student
Parent/guardian has acknowledged in Enrollment Packet (page 20). A copy of this updated Student Enrollment Packet was
writing: (a) Information regarding personal submitted to Licensing via email on 6/9/12.
or room searches and protocols for
confiscation of contraband
A disclosure in this area could not be found in
the youth files reviewed.
CORRECTIVE ACTION: Generate this
required disclosure, obtain necessary
signatures and place in the youth's files
moving forward.
Disclosures 419-470-0160(2) Yes[ ] No✓ Statement of Rights referenced in Client and Parent Manual was revised and meets
Parent/guardian has acknowledged in Licensing rule. This revision was submitted via email on 7/31/23.
writing: (b) Statement of Rights of Children
and Parents/Guardians
Statement of Rights is referenced in Client
and Parent Manual but requires revision.
CORRECTIVE ACTION: Develop disclosure
regarding statement of rights to meet
Licensing rule.
Disclosures 419-470-0160(2) Yes[ ] No✓ The program has updated their existing Student Enrollment Packet to reflect any policy and
Parent/guardian has acknowledged in procedure will be made available to either a parent/guardian or student upon request (page
writing: (c) Any policies and procedures 6). A copy of this updated Student Enrollment Packet was submitted to Licensing via email
upon request on 6/9/23.
A disclosure in this area could not be found in
the youth files reviewed.
CORRECTIVE ACTION: Generate this
required disclosure, obtain necessary
signatures and place in the youth's files
moving forward.
Authorizations 419-470-0160(3) (b) Child Yes[ ] No✓ Authorization regarding child specific visitors was added to the program's existing Student
specific visitors Enrollment Packet (pages 6-7). A copy of this information was submitted to Licensing via
email on 6/9/23.

An authorization in this area could not be
found in the youth files reviewed.
CORRECTIVE ACTION: Generate this
required authorization, obtain necessary
signatures and place in the youth's files
moving forward.
Authorizations 419-470-0160(3) (c) Yes[ ] No✓ Authorizations regarding visitation resources was added to the program's existing Student
Visitation resources are pre-approved Enrollment Packet (pages 6-7). A copy of this information was submitted to Licensing via
email on 6/9/23.
An authorization in this area could not be
found in the youth files reviewed.
CORRECTIVE ACTION: Generate this
required authorization, obtain necessary
signatures and place in the youth's files
moving forward.
Information about Children in Care Yes[ ] No✓ A section to capture a youth's religious preference was added to the program's existing
419-400-0190(1) Summary sheet contains "Application for Enrollment." A copy of this form was submitted to Licensing via email on
the following: (a)The name, gender, date of 6/9/23 for review.
birth, religious preference, and previous
address
Religious preference is not located in the
youth's summary sheet.
CORRECITVE ACTION: Include religious
preference to the youth's summary sheet.
Information about Children in Care Yes[ ] No✓ A section to capture the youth's educational history was added to the program's existing
419-400-0190(1) Summary sheet contains "BN Parent App" (page 8). A copy of this form was submitted to Licensing via email on
the following: (b) Name and location of 6/9/23 for review.
previous and current school
Previous and current school environment is
not captured in the youth's summary sheet.
CORRECTIVE ACTION: Develop a process
where a youth's previous and current school
and education plan is capture in the youth's
summary sheet.
Information about Children in Care Yes[ ] No✓ A section to capture who has legal custody of the youth was added to the program's
419-400-0190(1) Summary sheet contains existing "BN Parent App" (page 1). A copy of this form was submitted to Licensing via
the following: (d) Legal custody email on 6/9/23 for review.

Legal custody of the youth is not documented
in the youth's summary sheet.
CORRECTIVE ACTION: List who has legal
custody of the youth in the youth's summary
sheet.
Records Relating to Restraint & Yes[ ] No✓ The program has updated their existing Student Enrollment Packet to include information
Involuntary Seclusion 419-400-0190(1) as to reporting suspected inappropriate use or restraint or involuntary seclusion as well as
Information provided to children in care written prohibition that a youth will experience retaliation if concerns are reported (page 3).
relating to Restraint & Involuntary A copy of this updated Student Enrollment Packet was submitted to Licensing via email on
Seclusion 6/9/23.
Notice regarding how to access quarterly
reports to the parents or guardians of children
in care is not being provided at the time of
admission or at least twice a year.
CORRECTIVE ACTION: Establish a process
where information on how to access
quarterly reports is provided to parents at the
time of admission and at least twice a year
after that moving forward.
Records and Documentation 419-400-0140 Yes[ ] No✓ Ongoing compliance in this area will be monitored by Licensing.
(3) & (4) Uniform in organization, readily
identifiable and accessible, current, and
complete, containing all required info. No
eraser tape or white out.
Although uniform, identifiable and accessible,
not all required information is captured.
Complying with all identified corrective actions
listed above will ensure that all missing
information will be captured in youth files
moving forward.
Yes[ ] No[ ]

New Findings from Site Visit Comments
419-450-0110 The Boarding House: Lower left bedroom has a hole in lower North wall.
Homeless, Runaway, and Transitional
Living Shelters: Safety CORRECTIVE ACTION: Patch hole and paint wall. Submit a photo of the repair as proof to Licensing.
B) All buildings where children in care are The Sunflower House: Lighting in both the bathroom and kitchen areas are not working.
present must be kept clean and in good
repair. CORRECTIVE ACTION: Repair lighting in these areas. Submit photos of repairs as proof to Licensing.

excerpt:
419-470-0160(1) (e) Allow access Yes[ ] No✓ The program has updated their existing Student Enrollment Packet to reflect that the
as defined in