summary: License Renewals - 66 findings

raw_content:
Licensed Child Caring Agency Site Visit Report
Residential Care - License Renewal
Licensee: Northwest Youth Discovery, Inc Date of site visit: March 12, 2025
Executive Director: Richard Streeter Licensing Coordinator: Todd Cooley
Board Chairperson: Jennifer Weeks
Other Regulatory or Accrediting Agencies: Oregon Youth Authority (OYA)
Program compliance: The program was found to be compliant or will be compliant with OAR 419-400-0005 to 419-400-0310,
Licensing Umbrella Rules, and OAR 419-470-0010 to 419-470-0180, Licensing Residential Care Agencies Rules. Personnel records
were reviewed and compliance with required background checks was documented for employees in all programs.
Program description(s): The following content provided by NW Youth Discovery: Located in Bend Oregon, Northwest Youth
Discovery (NWYD) serves adolescent females ages 12 to 21 within a therapeutic milieu supported by professionally trained staff. Most
of our clients have experienced some form of trauma in their lives which has contributed to school failure, drug and alcohol abuse,
emotional dysregulation, poor self-esteem, and the development of maladaptive coping strategies. NWYD serves youth who have not
met success within a less restrictive level of care and demonstrate a need for 24-hour supervision.
NWYD provides Behavior Rehabilitation Services (BRS) by utilizing evidence-based approaches to target those psychosocial,
emotional, and behavioral issues that have impeded our clients from achieving their full potential. Our high staff-to-youth ratio enables
us to meet success at providing physical, emotional, and psychological support while remediating our risk factors. NWYD’s services
include but are not limited to case management, treatment planning, goal development, aftercare services, individual and group
counseling, psychoeducation, therapeutic work experience, crisis support, therapeutic recreation, educational support, culinary
experience, cultural/spiritual involvement, milieu therapy, and independent living skills. NWYD employ interventions and strategies from
evidence-based models such as Dialectical Behavior Therapy and Therapeutic Crisis Intervention.
Program type and services: Residential with BRS
Capacity and age range: 10 clients ages 12-20
Form revised 3/12/2025 Page 1 of 26
Funding sources: OYA
Contracts and sources for referrals: OYA
Average length of stay: 180 days
Average daily population served: 8-9
Number of children served annually: 24
Use of seclusion or restraint: No seclusion or restraint.
Interviews/observations: During the onsite license renewal two youth were interviewed and all areas of the residence were observed.
Both youth interviewed had only been at the program for a short while, but one had been there previously. The following information
was obtained during the interviews:
- Program is safe, and youth had several staff they were comfortable bringing any concerns or issues to.
- Residents receive plenty of food and snacks. They have input into the menu, and one day a week they can request a preferred meal.
- Resident have lots of recreation opportunities in residence and out in the community. Provided examples of volleyball, Just Dance
(video game), walks, workouts. Summer provides additional outdoor activity opportunities.
- Stated during winter it is hard to get “outside” time. By the time they finish school and dinner it is already starting to get dark outside.
- Youth felt phone calls were minimally adequate and are provided 10 minutes 3 times a week minimum. The time limit is imposed in
order to give all youth opportunities to use the phone. Between school, recreation, chores, homework, etc., there is a small window in
which 10 clients use the phone. Youth said the calls are enough, but would prefer 15 minutes if given the opportunity. They did state
they can petition for additional calls and additional time on a case-by-case basis.
- Youth attend the local public school and said things were going well.
- Youth participate in both community and BRS groups, which they found repetitive but beneficial.
- Program is very structured, and they have found that helpful in staying on track.
- Youth stated some staff lack sympathy for their situation, and clarified this was only one or two staff (not named).
- Staff are really good at checking-in with youth and helping them achieve their goals.
Form revised 3/12/2025 Page 2 of 26
- Staff are consistent with the rules and keeping to the schedule.
- Staff are good at communicating and very understanding.
A walkthrough of the property and residence was conducted. Overall, the program is in good condition, and the program has00 been
making incremental improvements over time. There was new flooring in the bedrooms and alterations to the stairwell for safety. Youth
had hygiene products, bedding and other essential items. The pantry, fridge and multiple freezers contained adequate food and
snacks. Vehicles show some signs of age but are in safe operating condition.
Program strengths (per program): Northwest administrative staff qualifications far exceed contractual requirements and include an
executive director, clinical director, program director, and director of operations. We provide approximately two additional FTE in direct
care staff to maintain a 3:10 staff to client ratio between the hours of 3pm and 11pm, which is not required per contract. Northwest also
has an outpatient mental health clinic which can provide residential clients with an additional layer of mental health support if
necessary. Northwest continues to provide internship
opportunities for master’s level student seeking degrees in mental health counseling and/or social work. In addition to regular updates
to the physical plant, Northwest has incorporated a horticulture skills learning program which includes a greenhouse, orchard, and a
garden supervised by a bachelor’s level botanist.
Program challenges (per program): Northwest continues to experience some micromanagement from state officially to include being
required to complete tasks that would be more appropriate for state officials rather than program staff. In addition, Northwest has lost
approximately $32,235 in revenue since June 2024 due to a lack of prompt BRS authorization.
Changes that have occurred in the last two years (per program): Staff turnover has decreased after Northwest was able to
increase starting wages due to an increase in daily rates. Northwest has implemented a horticulture skills learning program by adding a
greenhouse, orchard/garden, and hired a botanist.
Lawsuits: None
Grievances and complaints filed in the last two years: None
Form revised 3/12/2025 Page 3 of 26
Corrective actions and timeframes: Please submit the following to verify compliance.
Within 45 days of receipt of this report Northwest Youth Discovery 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 Todd Cooley at Todd.Cooley@odhsoha.oregon.gov.
Recommendations: N/A
Exceptions: None
Changes in license: None
Summary of review
Program and services Yes/No or Corrective actions/comments
419-400-0020 (2) N/A
Program and services are in scope of license Yes
Governance of the agency Yes/No or Corrective actions/comments
419-400-0040 N/A
(1)(a) Minimum of 5 board members Yes
(2)(f) Formally evaluate the Executive Director’s
Yes
performance annually
(2)(g) Approves annual budget Yes
Form revised 3/12/2025 Page 4 of 26
Governance of the agency Yes/No or Corrective actions/comments
419-400-0040 N/A
(2)(h) Obtain and review an annual independent The financial audit is in progress and will be made available
financial review or audit of financial records. No to licensing upon completion (projected to be completed by
end of April 2025)
(2)(k) Written quality improvement program Yes
(2)(l) Meeting minutes Yes
Executive Director or Program Director Yes/No or Corrective actions/comments
419-400-0040 N/A
(3)(a) knowledge of requirements for providing
Yes
care and treatment appropriate to programs
(3)(g) Approval from BCU Yes
Installation and use of video equipment used Yes/No or Corrective actions/comments
to monitor or record children in care N/A
419-400-0145
(1) If a child-caring agency installs video
equipment to monitor or record a child in care, all
employees, volunteers, parents or guardians and Yes
children in care must be informed about the
intended use and locations of the equipment.
Discipline, behavior management and suicide Yes/No or Corrective actions/comments
prevention N/A
419-400-0150
(3) Agency uses appropriate and positive methods
of behavior management and nationally Yes
recognized non-violent crisis intervention
Form revised 3/12/2025 Page 5 of 26
Discipline, behavior management and suicide Yes/No or Corrective actions/comments
prevention N/A
419-400-0150
(3)(b)(C) Agency does not use chemical and
mechanical restraint (excluding medically Yes
necessary devices/prescriptions)
(3)(c) Agency uses appropriate time-out rooms
(adequate space, heat, light and ventilation and is
N/A Time-out rooms are not utilized at NWYD
not capable of locking) and documents use in
child’s record when applicable
(3)(e) Agency uses seclusion
N/A NWYD does not use restraint or seclusion.
appropriately/consistent with policy
(4) Agency has adequate plan in place to respond
Yes
to suicidal behavior/warning signs
Contractors (if applicable) Yes/No or Corrective actions/comments
419-400-0120(6) N/A
(a) Agency ensures the contractor meets the
requirements of this rule and Chapter 413 division N/A NWYD does not use any contractors.
215
(b)(B) Contract includes the following:
(i) Services provided
(ii) Contractor fees
(iii) Disclosure of information from contractor to
agency
(iv) Lines of authority N/A NWYD does not use any contractors.
(v) Adherence to rules, including background
check
(vi) Any liability of the agency for acts of the
contractor, rights of indemnity and limitations on
liability
Form revised 3/12/2025 Page 6 of 26
Restraints and Involuntary Seclusion Yes/No or Corrective actions/comments
419-400-0180 N/A
(13)(d) Each child caring agency that submits a
report under this section shall make its quarterly
report available to the public upon request at the Yes
child caring agency’s main office and on the child
caring agency’s website if applicable.
Supplemental information provided by CCA Yes/No or Corrective actions/comments
N/A
Documents as indicated on the form titled
Yes
“Renewal Licensing Required Documents”
Documents as indicated on form titled “Required
No Financial audit in progress.
Financial Documents and Information”
All required policies and procedures as identified
Yes
in the “Umbrella Rules”
All required policies and procedures as identified
Yes
in “Agency Type Specific Rules”
Physical plant Yes/No or Corrective actions/comments
N/A
419-400-0090(3)(a) Foster Rights Posted (if
N/A Only OYA clients.
children in ODHS custody)
419-400-0100(1) Sufficient safe space, equipment
Yes
and office equipment
419-400-0230(12) License is posted in common
Yes
area at each facility
419-470-0020(2)(a) and (c) Buildings are smoke
Yes
free, clean and in good repair
419-470-0020 (2)(d) Rooms are free of harmful
Yes
drafts, odors and excessive noise
Form revised 3/12/2025 Page 7 of 26
Physical plant Yes/No or Corrective actions/comments
N/A
419-470-0020 (2)(e) Rooms are adequate in size
Yes
and arrangement
419-470-0020 (2)(f) System provides a continuous
supply of hot and cold water to taps located Yes
throughout the facility
419-470-0020 (2)(h) Building is well ventilated and
room temperature is within a normal comfort Yes
range
419-470-0030 (1) All parts of the facility ensure
Yes
the safety of children
Room and space requirements Yes/No or Corrective actions/comments
419-470-0030 N/A
(2) There is a separate living room or lounge area
Yes
– 15 SF minimum per child
(5) There is a separate dining room with capacity
for ½ of children in care and 15 SF per child in Yes
care
(7) Laundry is separate from living, kitchen and
Yes
dining areas
(8) Separate storage areas are provided for food,
kitchen supplies, utensils, clean linens, soiled
linens and clothing, cleaning supplies and
equipment, poisons, chemicals, outdoor Yes
recreational and maintenance equipment.
(Hazardous materials are properly labeled, in
original container and locked)
(9) Outdoor activity area is protected from Yes
vehicles and other hazards and of a size and
Form revised 3/12/2025 Page 8 of 26
Room and space requirements Yes/No or Corrective actions/comments
419-470-0030 N/A
availability appropriate to the age and needs of
children in care
(11) Time-out rooms: Rooms used for time out or
quiet time must have adequate space, heat, light
N/A Time-out rooms are not used at NWYD
and ventilation and must not be capable of
locking.
Room and space requirements -bedrooms Yes/No or Corrective actions/comments
419-470-0030(3) N/A
(a) Adequate furnishings and personal items Yes
(b) Separate from rooms used for dining, living,
Yes
laundry, kitchen and storage
(c) Meet Oregon Fire Code Requirements Yes
(d) Be an outside room, with a window that
operates as designed. If the window is modified
from its original design, the fire marshal must Yes
approve the modification and indicate this room
still meets applicable Oregon Fire Code.
(d) Ceiling at least 90 inches Yes
(e) Minimum 60 SF per occupant Yes
(f) No more than 25 if dorm style N/A Not dorm style rooms.
(g) Permanently wired fixtures Yes
(h) Window covering Yes
Room and space requirements - bathrooms Yes/No or Corrective actions/comments
419-470-0030(4) N/A
(a)(A) and (B) 1:8 ratio for toilets and sinks Yes
(a)(D) Hot and cold running water, soap and
Yes
approved hand drying options
Form revised 3/12/2025 Page 9 of 26
Room and space requirements - bathrooms Yes/No or Corrective actions/comments
419-470-0030(4) N/A
(a)(E) 1:10 ratio for shower or bathtub Yes
(a)(E) Individual privacy Yes
(a)(F) Window covering Yes
(a)(G) Permanently wired fixtures Yes
(a)(H) Adequate ventilation Yes
(b) and (c) Wooden racks on floors are prohibited
and impervious shower mats are disinfected and N/A Wooden racks are not used in bathrooms.
dried daily be in good condition and free of mold
Room and space requirements - Yes/No or Corrective actions/comments
kitchen N/A
419-470-0030(6)
(a) Used exclusively for storage, food preparation,
dishwashing and activities related to eating and Yes
food preparation activities
(b) Walls, floors are easily cleanable Yes
(c) Equipment and utensils are easily cleanable,
Yes
durable, nontoxic and kept clean
(e) Equipment is easy to clean beneath, between
Yes
and behind
Furnishings and personal items Yes/No or Corrective actions/comments
419-470-0040 N/A
(1) There is a bed with frame Yes
(1)(b) clean mattress in good condition, with a
Yes
minimum thickness of five inches
(1)(c) a pillow in good condition Yes
Form revised 3/12/2025 Page 10 of 26
Furnishings and personal items Yes/No or Corrective actions/comments
419-470-0040 N/A
(1)(d) a private dresser, closet, or similar storage
area for personal belongings that is readily Yes
accessible
(2) Linens are in good repair. There is a
waterproof mattress cover or mattress. Linens are
Yes
appropriate and towels and washcloths are
provided
(3) Bedding is changed weekly or when soiled Yes
(4) and (5) Personal hygiene supplies and
Yes
appropriate clothing are provided
Food services Yes/No or Corrective actions/comments
419-470-0070 N/A
(1)(a) Meals are arranged daily, consistent with
normal mealtimes that occur during the hours of Yes
operation and provide snacks between mealtimes
(1)(b) Menus are prepared in advance in
accordance with USDA guidelines, provide a
Yes
variety of foods and are adjusted for seasonal
changes including snacks
(1)(b) Menus are kept for at least 6 months Yes
(1)(c) Drinking water is freely available Yes
(2)(a) Food is stored, prepared and served in a
Yes
sanitary manner
(2)(c) and (d) Food products are obtained from
commercial suppliers (exception of fruits and
vegetables), unpasteurized juice is prohibited, and Yes
only Grade A pasteurized and fortified milk in
appropriate container.
Form revised 3/12/2025 Page 11 of 26
Residential care safety Yes/No or Corrective actions/comments
419-470-0080 N/A
(2) Written emergency plan that includes Yes
(a) Identifying the types of emergencies most
likely to happen where the residential care agency Yes
is located
(b) Identifying a place to meet for each type of
Yes
emergency identified
(c) Identifying an alternate shelter if necessary Yes
(d) Ensuring access to necessary medications or
Yes
medical equipment
(e) How to help each child in care recover after a
Yes
disaster
(3) Telephone numbers for local police, fire
department, poison control, after hours medical
Yes
advice and other appropriate emergency numbers
must be posted near all telephones.
(4) Operative flashlights sufficient in number are
Yes
readily available to staff
(5)(a) Evacuation drill occurs monthly under
varying conditions, is retained 2 years and
contains:
(A) identify of person conducting drill
(B) date and time
(C) notification method Yes
(D) staff participating
(E) number of children and staff evacuated
(F) special conditions simulated
(G) problems encountered
(H) time to complete
Form revised 3/12/2025 Page 12 of 26
Umbrella safety Yes/No or Corrective actions/comments
419-400-0200 N/A
(5)(b) Vehicle has insurance policy, is smoke free,
safe operating condition, and has first aid kit and Yes
fire extinguisher 2-A:10-BC
(1)(b)(A) Each vehicle used to transport a child in
care must be: properly registered,
covered by an insurance policy in full force and Yes
effect, maintained in safe operating condition and
smoke-free.
(3) If a child-caring agency has a swimming pool
on the premises that is accessible to children in
care or if a child-caring agency plans to have
children in care engage in swimming, the child-
caring agency must have and adhere to policies N/A There is no onsite swimming pool.
and procedures that address, at a minimum,
providing disclosures and obtaining consents,
assessing swimming ability of children in care and
ensuring the safety of pool access.
(4)(a) The program protects children from
Yes
potentially harmful items and materials.
(4)(b) Direct supervision of children who do not
have the ability to adjust and control water Yes
temperature
(4)(c) Light fixtures have protective covers unless
Yes
designed to be used without one
Medication Yes/No or Corrective actions/comments
419-470-0100 N/A
(3) and (7)(e) Medications have a prescription and
are stored in the original container with Yes
prescription label
Form revised 3/12/2025 Page 13 of 26
Medication Yes/No or Corrective actions/comments
419-470-0100 N/A
(4) and (5) Herbal supplements and remedies,
medical treatments, special diets, physical
therapy, physical aides or limitations have a
written order signed by a physician or qualified
Yes
medical professional. A written order, signed by a
physician or qualified medical professional, is also
required before a restriction on diet or physical
activity is imposed.
(7)(c) Medications are inaccessible to children and
stored behind at least two locking mechanisms. Yes
This does not apply to Naloxone.
(8) Medications are disposed in accordance with
Yes
state and federal law
(9) Written record of the disposal of medications is
maintained and includes:
(a) description and amount
(b) name No Medication disposal log did not contain a witness signature.
(c) reason
(d) method
(e) staff and witness signature
(10) Written record of the administration of
medication includes:
(a) name
(b) description
(c) dates and times
(d) missed doses Yes
(e) medication disposed
(f) method of administration
(g) ID of person administering
(h) possible adverse reactions
(i) medication taken outside facility
Form revised 3/12/2025 Page 14 of 26
Extracurricular, enrichment, cultural and Yes/No or Corrective actions/comments
social activities N/A
419-470-0110
(2) Children have ongoing opportunities to
Yes
participate in at least one age-appropriate or
developmentally appropriate activity
Minimum staffing requirements Yes/No or Corrective actions/comments
419-470-0130 N/A
(1) and (2) Supervision is adequate for the type of
program, location, age and type of children, ability
of supervisor to respond, electronic back-up
systems.
Minimum ratios are maintained:
Yes
Under 30 months of age: 1:4
30 months to ˃ 6 years or non-ambulatory: 1:6
Ages 6 and older: 1:7
Overnight (staff awake)
1:10
(4)(a) When one staff on duty, there is additional
staff immediately available with max response Yes
time of 30 minutes
(5) There is at least one on-site employee
authorized to apply the reasonable and prudent Yes
parent standard
Sleeping arrangements Yes/No or Corrective actions/comments
419-470-0140 N/A
Form revised 3/12/2025 Page 15 of 26
(1) Children are in separate bedrooms than
adults, unless parent and child, or there is written
Yes
approval from guardian/parent and licensing
coordinator
(2) There is adequate supervision of children
Yes
when sleeping
(3) When assigning bedrooms a residential care
agency must consider all of the following:
(a) Chronological age
(b) Developmental age
(c) Gender identity Yes
(d) Personal history, including medical, mental
health, behavioral health and past adverse
experiences including any physical or sexual
abuse
Personnel files Yes/No or Corrective actions/comments
419-400-0120 N/A
Staff name/position Yes
(3)(g) Date of hire Yes
(3)(a) record of education, training and previous
Yes
employment
(1)(b) and (3)(b) reference checks completed and
Yes
documented
(1)(a) and (3)(c) Background check completed
Yes
and documented
(3)(d) Annual performance evaluations Yes
(3)(f) Record of personnel actions Yes
(3)(g) Termination date, reason for termination Yes
(3)(h) Current job description (1)(c) Employee
meets minimum qualifications stated in current job Yes
description
Form revised 3/12/2025 Page 16 of 26
New employee orientation – Umbrella Yes/No or Corrective actions/comments
Requirements (30 days) N/A
419-400-0120(4)
(a) Agency policies and procedures Yes
(b) Ethical and professional guidelines Yes
(c) Suicide prevention and intervention Yes
(d) Attributes of population served Yes
(e) and (5)(a) to (c) Mandatory reporting that
includes:
(a) legal definition of child abuse in ORS 418.257
and 419B.005 Yes
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to the
employee
(f) Privacy laws Yes
(g) Emergency procedures Yes
New employee orientation Yes/No or Corrective actions/comments
residential (prior to working alone and within N/A
30 days)
419-470-0120(1)
(a) Discipline and behavior management including
de-escalation, crisis prevention, positive behavior
Yes
management and disciplinary techniques that are
non-punitive in nature
(b) CPR and First Aid sufficient to retain a current
Yes
certification
(c) Universal precautions and hygiene Yes
(d) Application of the reasonable and prudent
Yes
parent standard
Form revised 3/12/2025 Page 17 of 26
New employee orientation Yes/No or Corrective actions/comments
residential (prior to working alone and within N/A
30 days)
419-470-0120(1)
(e) Training on the agency’s policy on suicide
Yes
prevention and suicide risk assessment tool
Crisis intervention training standards and Yes/No or Corrective actions/comments
certification N/A
419-400-0160(4) (as applicable)
(a)Complete a minimum of 12 hours of initial
training in person from a certified instructor,
including but not limited to a minimum of six hours
of training focused on positive behavior support, N/A NWYD does not utilize restraint so does not apply
nonviolent crisis intervention and other methods
of nonphysical intervention to support children in
care during a crisis
(d) Receive a certificate that states:
(A) The dates during which the certification is
current
(B) The type of restraint which the individual is
certified to perform if applicable
(C) The type of training the individual is certified
to conduct if applicable N/A NWYD does not utilize restraint so does not apply
(D) Any special endorsements earned by the
individual
(E) The level of training
(F) The name of the certified instructor who
conducted the training and administered the
assessment of proficiency.
Form revised 3/12/2025 Page 18 of 26
Crisis intervention training standards and Yes/No or Corrective actions/comments
certification N/A
419-400-0160(4) (as applicable)
(e) A certification issued:
(A) Must be personal to the individual certified by
the training provider N/A NWYD does not utilize restraint so does not apply
(B) May be valid for no more than two years with
recertification
Ongoing training Yes/No or Corrective actions/comments
N/A
419-470-0070(2)(b) Employees who handle food
served to children have a valid food handler’s Yes
card
419-400-0200 (1) Employees transporting
children have: current driver’s license, insurance,
trained in emergency procedures and behavior Yes
management and training for 15+ passenger vans
if applicable)
419-470-0120 (2)(a) Environmental emergencies Yes
419-470-0120 (2)(b) Universal precautions Yes
419-470-0120 (2)(c) Discipline and behavior
Yes
management
419-470-0120 (2)(d) Agency’s policy on suicide
Yes
prevention and risk assessment tool
419-470-0120 (3) Staff providing direct care must
Yes
maintain current CPR/First Aid certification
419-470-0120 (4) Designated staff authorized to
apply reasonable and prudent parent standard Yes
are trained in application of the standard
Form revised 3/12/2025 Page 19 of 26
Ongoing training Yes/No or Corrective actions/comments
N/A
419-400-0120(5) Mandatory reporting (annually)
that includes:
(a) legal definition of child abuse in ORS 418.257
and 419B.005 Yes
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to the
employee
419-400-0160(4)(b) Receive continuing education
(as applicable on crisis intervention training) from Yes
a certified instructor on an annual basis
Comments:
Children’s records Yes/No or Corrective actions/comments
health services N/A
419-470-0090
(2) Medical history obtained within 30 days
(significant findings, current immunizations,
history of surgical procedures-health issues- Yes
injuries, allergies, dental, vision, hearing,
behavioral health and physician orders)
(4)(a) to (f) Medical exams (3 in first year of life,
2,4,6,9,14) Yes
(g) Have a physical examination within the first 60
days after admission of a child in care. Yes
Documentation of a physical examination having
Form revised 3/12/2025 Page 20 of 26
Children’s records Yes/No or Corrective actions/comments
health services N/A
419-470-0090
occurred within the calendar year will meet this
requirement.
Consents Yes/No or Corrective actions/comments
419-470-0160(1) N/A
(a) Provide routine and emergency medical care Yes
(b) Use the discipline and behavior management
Yes
system
(c) Use restraint or seclusion (if applicable). Must
specify the reasons for the intervention and how Yes
staff are trained and supervised
(d) Restrict contact with persons outside of the
Yes
agency
(e) Allow access as defined in 419-400-0230 and Not addressed in the program’s consents.
0240
No
Correction Action: Add language to address allowing
access.
(f) Impose a dress code Not addressed in the program’s consents.
No
Correction Action: Add language to address imposing a
dress code.
(g) Apply the reasonable and prudent parent
Yes
standard
Form revised 3/12/2025 Page 21 of 26
Disclosures Yes/No or Corrective actions/comments
419-470-0160(2) N/A
Parent/guardian has acknowledged in writing:
(a) Information regarding personal or room
searches and protocols for confiscation of Yes
contraband
(b) Statement of Rights of Children and
Yes
Parents/Guardians
(c) Any policies and procedures upon request Yes
Authorizations Yes/No or Corrective actions/comments
419-470-0160(3) N/A
(a) Disclose or exchange information with others Yes
(b) Child specific visitors Yes
(c) Visitation resources are pre-approved Yes
(d) Activity specific authorizations are pre-
approved to allow children to participate in
potentially hazardous activities, including but not Yes
limited to using motorized yard equipment,
swimming and horseback riding.
Information about children in care Yes/No or Corrective actions/comments
419-400-0190(1) N/A
Summary sheet contains the following:
(a)The name, gender, date of birth, religious
Yes
preference and previous address
(b) Name and location of previous and current
Yes
school
(c) Date of admission Yes
(d) Legal custody Yes
(e) The name, address and telephone number of: Yes
Form revised 3/12/2025 Page 22 of 26
Information about children in care Yes/No or Corrective actions/comments
419-400-0190(1) N/A
Summary sheet contains the following:
(A) The child in care's parents.
(B) The child in care's legal guardian, if
different than the parents and a copy of the
document that provides for his or her authority
over the child in care.
(C) Other persons significant to child
(D) Other professionals to be involved in service
planning (if applicable)
Service planning Yes/No or Corrective actions/comments
419-470-0170(2) N/A
(b) Intake document is completed the date child
accepted into care (emergency placement 48 Yes
hours)
(d) Assessment is completed within 30 days and
contains relevant historical information, current
Yes
behavioral observations, identified need for
services and how agency will provide services
(e) (A) and (B) Service plan within 60 days
(parent, guardian and child actively involved).
Describes how child’s issues will be addressed, Yes
anticipated outcomes and reviewed by child and
guardian/parent.
(e)(C) and (D) Service plan is reviewed quarterly
and revised when information indicates other Yes
services should be provided
Form revised 3/12/2025 Page 23 of 26
Case management Yes/No or Corrective actions/comments
419-470-0170(3) N/A
(a) Services are documented, progress toward
Yes
achieving goals is tracked
(c) Discharge summary must include:
(A)Current medications
(B)Name of the physician or qualified medical
professional who prescribed each medication
(C)Any outstanding medical or other
appointments Yes
(D)Summary of the child’s participation in the
program and progress achieved
(E)Results of evaluations
(F)Recommendations regarding services
(G)Discharge destination
(e) Follow up services Yes
(f) Incident reports Yes
Records relating to Restraint and Involuntary Yes/No or Corrective actions/comments
Seclusion N/A
419-400-0180 (12) Records N/A NWYD does not utilize restraint or seclusion.
419-400-0180(13)(e) Each child caring agency
shall provide notice regarding how to access the
quarterly reports to the parents or guardians of
children in care in the program. The child caring Yes
agency shall provide the notice upon the child in
care’s admission and at least two times each year
thereafter.
419-400-0190(1) Information provided to children
Serves OYA youth. OYA responsible for providing this
in care relating to Restraint and Involuntary N/A
information.
Seclusion
Form revised 3/12/2025 Page 24 of 26
Financial records Yes/No or Corrective actions/comments
419-470-0170(4) N/A
Records contain date, amount, source, purpose,
Yes
signatures
Personal possessions records Yes/No or Corrective actions/comments
419-470-0170 (5) N/A
Individual written inventory of all personal
possessions is maintained and updated as Yes
needed
Records and documentation Yes/No or Corrective actions/comments
419-400-0140 N/A
(1) Stored safely Yes
(2) Permanent, legible, dated and signed Yes
(3) and (4) Uniform in organization, readily
identifiable and accessible, current and complete,
Yes
containing all required info. No eraser tape or
white out.
(7) Permanent registry for each child includes:
Name
Gender
Birth date Yes
Names, addresses of parents or guardians
Dates of admission
Placement upon discharge
Comments:
Form revised 3/12/2025 Page 25 of 26
Licensing Coordinator’s Signature: ________________________ Date: _4_-1_7_-_2_0_2_5__________
Manager Review: _____________________________________ Date: _4_-1_6_-_2_02_5___________
Form revised 3/12/2025 Page 26 of 26

report_title: Licensed Child Caring Agency Site Visit Report

facility_type: Residential Care - License Renewal

licensee: Northwest Youth Discovery, Inc Date of site visit: March 12, 2025

executive_director: Richard Streeter Licensing Coordinator: Todd Cooley

program_description:
The following content provided by NW Youth Discovery: Located in Bend Oregon, Northwest Youth
Discovery (NWYD) serves adolescent females ages 12 to 21 within a therapeutic milieu supported by professionally trained staff. Most
of our clients have experienced some form of trauma in their lives which has contributed to school failure, drug and alcohol abuse,
emotional dysregulation, poor self-esteem, and the development of maladaptive coping strategies. NWYD serves youth who have not
met success within a less restrictive level of care and demonstrate a need for 24-hour supervision.
NWYD provides Behavior Rehabilitation Services (BRS) by utilizing evidence-based approaches to target those psychosocial,
emotional, and behavioral issues that have impeded our clients from achieving their full potential. Our high staff-to-youth ratio enables
us to meet success at providing physical, emotional, and psychological support while remediating our risk factors. NWYD's services
include but are not limited to case management, treatment planning, goal development, aftercare services, individual and group
counseling, psychoeducation, therapeutic work experience, crisis support, therapeutic recreation, educational support, culinary
experience, cultural/spiritual involvement, milieu therapy, and independent living skills. NWYD employ interventions and strategies from
evidence-based models such as Dialectical Behavior Therapy and Therapeutic Crisis Intervention.

program_services: Residential with BRS

capacity_age_range: 10 clients ages 12-20 Form revised 3/12/2025 Page 1 of 26

funding_sources: OYA

contracts_and_referrals: OYA

average_length_of_stay: 180 days

use_of_seclusion_or_restraint: No seclusion or restraint. Interviews/observations: During the onsite license renewal two youth were interviewed and all areas of the residence were observed. Both youth interviewed had only been at the program for a short while, but one had been there previously. The following information was obtained during the interviews: - Program is safe, and youth had several staff they were comfortable bringing any concerns or issues to. - Residents receive plenty of food and snacks. They have input into the menu, and one day a week they can request a preferred meal. - Resident have lots of recreation opportunities in residence and out in the community. Provided examples of volleyball, Just Dance (video game), walks, workouts. Summer provides additional outdoor activity opportunities. - Stated during winter it is hard to get "outside" time. By the time they finish school and dinner it is already starting to get dark outside. - Youth felt phone calls were minimally adequate and are provided 10 minutes 3 times a week minimum. The time limit is imposed in order to give all youth opportunities to use the phone. Between school, recreation, chores, homework, etc., there is a small window in which 10 clients use the phone. Youth said the calls are enough, but would prefer 15 minutes if given the opportunity. They did state they can petition for additional calls and additional time on a case-by-case basis. - Youth attend the local public school and said things were going well. - Youth participate in both community and BRS groups, which they found repetitive but beneficial. - Program is very structured, and they have found that helpful in staying on track. - Youth stated some staff lack sympathy for their situation, and clarified this was only one or two staff (not named). - Staff are really good at checking-in with youth and helping them achieve their goals. Form revised 3/12/2025 Page 2 of 26 - Staff are consistent with the rules and keeping to the schedule. - Staff are good at communicating and very understanding. A walkthrough of the property and residence was conducted. Overall, the program is in good condition, and the program has00 been making incremental improvements over time. There was new flooring in the bedrooms and alterations to the stairwell for safety. Youth had hygiene products, bedding and other essential items. The pantry, fridge and multiple freezers contained adequate food and snacks. Vehicles show some signs of age but are in safe operating condition.

grievances_and_complaints:
None
Form revised 3/12/2025 Page 3 of 26

excerpt:
419-400-0040 N/A
(1)(a) Minimum of 5 board members Yes
(2)(f) Formally evaluate the Executive Director's
Yes
performance annually
(2)(g) Approves annual budget Yes
Form revised 3/12/2025 Page 4 of 26
Governance of the agency Yes/No or Corrective actions/comments

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

excerpt:
419-400-0180 N/A
(13)(d) Each child caring agency that submits a
report under this section shall make its quarterly
report available to the public upon request at the Yes
child caring agency's main office and on the child
caring agency's website if applicable.
Supplemental information provided by CCA Yes/No or Corrective actions/comments
N/A
Documents as indicated on the form titled
Yes
"Renewal Licensing Required Documents"
Documents as indicated on form titled "Required
No Financial audit in progress.
Financial Documents and Information"
All required policies and procedures as identified
Yes
in the "Umbrella Rules"
All required policies and procedures as identified
Yes
in "Agency Type Specific Rules"
Physical plant Yes/No or Corrective actions/comments
N/A

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

excerpt:
419-400-0230(12) License is posted in common
Yes
area at each facility

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

excerpt:
419-470-0030 N/A
(2) There is a separate living room or lounge area
Yes
- 15 SF minimum per child
(5) There is a separate dining room with capacity
for ½ of children in care and 15 SF per child in Yes
care
(7) Laundry is separate from living, kitchen and
Yes
dining areas
(8) Separate storage areas are provided for food,
kitchen supplies, utensils, clean linens, soiled
linens and clothing, cleaning supplies and
equipment, poisons, chemicals, outdoor Yes
recreational and maintenance equipment.
(Hazardous materials are properly labeled, in
original container and locked)
(9) Outdoor activity area is protected from Yes
vehicles and other hazards and of a size and
Form revised 3/12/2025 Page 8 of 26
Room and space requirements Yes/No or Corrective actions/comments

excerpt:
419-400-0120 N/A
Staff name/position Yes
(3)(g) Date of hire Yes
(3)(a) record of education, training and previous
Yes
employment
(1)(b) and (3)(b) reference checks completed and
Yes
documented
(1)(a) and (3)(c) Background check completed
Yes
and documented
(3)(d) Annual performance evaluations Yes
(3)(f) Record of personnel actions Yes
(3)(g) Termination date, reason for termination Yes
(3)(h) Current job description (1)(c) Employee
meets minimum qualifications stated in current job Yes
description
Form revised 3/12/2025 Page 16 of 26
New employee orientation - Umbrella Yes/No or Corrective actions/comments
Requirements (30 days) N/A

excerpt:
419-470-0120(1)
(e) Training on the agency's policy on suicide
Yes
prevention and suicide risk assessment tool
Crisis intervention training standards and Yes/No or Corrective actions/comments
certification N/A

excerpt:
419-470-0070(2)(b) Employees who handle food
served to children have a valid food handler's Yes
card

excerpt:
419-400-0200 (1) Employees transporting
children have: current driver's license, insurance,
trained in emergency procedures and behavior Yes
management and training for 15+ passenger vans
if applicable)

excerpt: 419-470-0120 (2)(a) Environmental emergencies Yes

excerpt: 419-470-0120 (2)(b) Universal precautions Yes

excerpt:
419-470-0120 (2)(c) Discipline and behavior
Yes
management

excerpt:
419-470-0120 (2)(d) Agency's policy on suicide
Yes
prevention and risk assessment tool

excerpt:
419-400-0160(4)(b) Receive continuing education
(as applicable on crisis intervention training) from Yes
a certified instructor on an annual basis
Comments:
Children's records Yes/No or Corrective actions/comments
health services N/A

excerpt:
419-470-0090
(2) Medical history obtained within 30 days
(significant findings, current immunizations,
history of surgical procedures-health issues- Yes
injuries, allergies, dental, vision, hearing,
behavioral health and physician orders)
(4)(a) to (f) Medical exams (3 in first year of life,
2,4,6,9,14) Yes
(g) Have a physical examination within the first 60
days after admission of a child in care. Yes
Documentation of a physical examination having
Form revised 3/12/2025 Page 20 of 26
Children's records Yes/No or Corrective actions/comments
health services N/A

excerpt:
419-400-0230 and Not addressed in the program's consents.
0240
No
Correction Action: Add language to address allowing
access.
(f) Impose a dress code Not addressed in the program's consents.
No
Correction Action: Add language to address imposing a
dress code.
(g) Apply the reasonable and prudent parent
Yes
standard
Form revised 3/12/2025 Page 21 of 26
Disclosures Yes/No or Corrective actions/comments

excerpt:
419-470-0170(2) N/A
(b) Intake document is completed the date child
accepted into care (emergency placement 48 Yes
hours)
(d) Assessment is completed within 30 days and
contains relevant historical information, current
Yes
behavioral observations, identified need for
services and how agency will provide services
(e) (A) and (B) Service plan within 60 days
(parent, guardian and child actively involved).
Describes how child's issues will be addressed, Yes
anticipated outcomes and reviewed by child and
guardian/parent.
(e)(C) and (D) Service plan is reviewed quarterly
and revised when information indicates other Yes
services should be provided
Form revised 3/12/2025 Page 23 of 26
Case management Yes/No or Corrective actions/comments

excerpt:
419-470-0170(3) N/A
(a) Services are documented, progress toward
Yes
achieving goals is tracked
(c) Discharge summary must include:
(A)Current medications
(B)Name of the physician or qualified medical
professional who prescribed each medication
(C)Any outstanding medical or other
appointments Yes
(D)Summary of the child's participation in the
program and progress achieved
(E)Results of evaluations
(F)Recommendations regarding services
(G)Discharge destination
(e) Follow up services Yes
(f) Incident reports Yes
Records relating to Restraint and Involuntary Yes/No or Corrective actions/comments
Seclusion N/A

excerpt:
419-400-0180(13)(e) Each child caring agency
shall provide notice regarding how to access the
quarterly reports to the parents or guardians of
children in care in the program. The child caring Yes
agency shall provide the notice upon the child in
care's admission and at least two times each year
thereafter.


state: OR

facility_name: The Next Door, Klahre House Residential Date of site visit: 5-27, 5-28 and 5-29-25

summary: 6-month - 15 findings

raw_content:
Licensed Child Caring Agency 6-Month Review Site Visit Report
Residential Care
Licensee: The Next Door, Klahre House Residential Board Chairperson: Ann Harris
Executive Director: Janet Hamada Date of site visit: 11-1-23
Program Director: Melanie Kelly Licensing Coordinator: Irvin Minten, M.S.W.
Other Regulatory or Accrediting Agencies: Oregon Youth Authority (OYA)
Program Compliance: As a part of this 6-month review, as noted OAR, Licensing Umbrella Rules, and Licensing Residential Care
Agency Rules were reviewed.
Program Description(s): The Next Door, Inc. provides services to children and families in the community, including foster care, day
treatment and residential care. The program provides a highly structured, therapeutic environment that emphasizes individual
treatment planning, experiential growth, academic progress and behavior change. The residential care program serves OYA youth. All
youth enrolled in the residential program attend The Next Door’s Day Treatment Program.
Program type and services: The program provides residential care services for youth in OYA custody. Any needed sex offender,
mental health, and drug and alcohol treatment services, as well as Independent Living Program (ILP) and mentoring services, are
provided on-site by staff employed through The Next Door. Educational services are provided on-site by staff employed through the
local school district.
Capacity and Age Range: The program serves males, ages 13-18. The program’s capacity is 5 youth.
Funding sources: OYA
Contracts and sources for referrals: Referrals come from OYA.
Average length of stay: The average length of stay in the program is between 9-18 months.
P age 1 | 24
Form Rev. 08/03/2023
Average daily population served: Since opening in May 2023, the program’s average daily population has been about 4 youth. The
program currently has 5 youth.
Number of children served annually: The program estimates it will serve 5 to 7 youth annually.
Use of seclusion or restraint: The program does not utilize seclusion or restraint.
Interviews, Observations: During the 6-month review, 1 program line staff and 2 youth currently enrolled at the program were
randomly selected and individually interviewed. A walkthrough of the facility and the facility’s outdoor area was also completed. During
the review, there was also a great deal of discussion with Asia VanHorn, Program Supervisor, and Dan Foster, Program Manager. The
program’s medication cabinet was also observed.
During individual interviews with the 2 youth, both reported they felt safe in the program, both during the day and at night. Both youth
also reported the program’s staff were sufficiently trained to assist them in meeting their goals and in caring for them. Both youth also
stated they got enough to eat and that they thought the food in the program was good. Both youth also indicated they could make
private calls to persons on their approved contact list, as they could use the program’s land-line phone in one of the program’s main
living areas, without other youth or staff present, and staff would watch them on silent video to ensure they did not make other calls.
Both youth also reported they would not change anything about the program and both stated they liked this program over others they
have been enrolled as this program allowed them the opportunity to go on community outings.
During an individual telephonic interview with 1 program staff, it was reported the program was a good place to work and that they felt
well trained, valued, and appreciated. It was also reported they received sufficient training to effectively do their work and that if an
issue arose, their program’s supervisor was very available to assist and answer questions. This staff also reported that the program’s
management supported continued learning and that if he wanted to learn more about an issue, the program’s management would do all
they could to see that they received training in the area. This staff also stated that since the program had only been in operation for
less than 6 months, the program continued to implement new routine and process, as unique circumstances arose. This staff also
seemed well versed on the program’s behavior management and suicide prevention protocols. This staff also reported that the
program did a great job of meeting each youth’s education and treatment needs and that the program provided good care to each of the
youth.
During walkthrough of the program, it was observed that the house was in a well-maintained middle-class neighborhood and that the
house was a well-constructed and designed, with main living and outdoor areas which were well maintained, welcoming, and in good
P age 2 | 24
Form Rev. 08/03/2023
repair. The bathrooms and kitchen also had very nice appliances and fixtures and most of the showers were nicely tiled. The areas
where youth congregated were also nicely painted and included comfortable and nice furniture.
Program Strengths: The program’s supervisor reports they are maintaining best practices in several areas, including having a 30-
minute overlap of staffing at shift change, which allows incoming and outgoing staff opportunity to discuss how each youth is doing. In
addition, the program’s supervisor reports she has frequent discussions with program staff on protocols, what is working well, and areas
in need of improvement. The program’s supervisor and the 1-line staff interviewed also report that program staff provide a high level of
care to the youth, that they want to make a difference in the lives of the youth, and that staff truly care about each of the youth and that
they want the youth to be successful and make needed changes. The program’s manager also reports they are creating a consistent
routine in the program, that the leadership in the program has been “phenomenal,” that the program’s supervisor is readily “available” to
staff, and that the staff in the program feel supported and are well trained.
Program Challenges: Although the program is currently fully staffed, in the first 6 months of operation, the program’s management
reports staffing has been an issue, as interview pools have not been strong and 2 staff quit shortly after hire after they realized the job
was not a good fit. In addition, the program’s management states they have had a couple youth in the program who have been
prematurely discharged due to the youth’s verbal and physical aggression toward staff and other youth.
Changes that have occurred since the program opened: NA
Lawsuits: NA
Grievances and complaints: NA
Corrective Actions and Timeframes: Please submit the following to verify compliance.
Within 45 days of receipt of this report The Next Door, Klahre House Residential 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 Irvin Minten at Irvin.minten@odhsoha.oregon.gov .
Recommendations: NA
Exceptions: NA
P age 3 | 24
Form Rev. 08/03/2023
Changes in License: NA
Summary of Review
Program and Services
Yes No N/A Corrective Actions/Comments
419-400-0020 (2)
Program and services are in scope of X
license
Governance of the Agency
Yes No N/A Corrective Actions/Comments
419-400-0040
(1)(a) Minimum of 5 board members o During this review, the governance of the program was not
X reviewed, as this was closely reviewed prior to the program’s
opening.
(2)(f) Formally evaluate the exec.
X
Director’s performance annually
(2)(g) Approves annual budget X
(2)(h) Obtain and review an annual
independent financial review or audit X
of financial records.
(2)(k) Written quality improvement
X
program
(2)(l) Meeting minutes X
Executive Director or Program
Director Yes No N/A Corrective Actions/Comments
419-400-0040
(3)(a) knowledge of requirements for
providing care and treatment X
appropriate to programs
(3)(g) Approval from BCU o This was reviewed at the time of the program’s opening but
X
was not reviewed again at the time of this review.
Discipline, Behavior Management,
and Suicide Prevention Yes No N/A Corrective Actions/Comments
419-400-0150
(3) Agency uses appropriate and
X
positive methods of behavior
P age 4 | 24
Form Rev. 08/03/2023
management and nationally
recognized non-violent crisis
intervention
(3)(b)(C) Agency does not use
chemical and mechanical restraint
X
(excluding medically necessary
devices/prescriptions)
(3)(c) Agency uses appropriate time-
out rooms (adequate space, heat,
light and ventilation and is not X o The program does not utilize time out.
capable of locking) and documents
use in child’s record when applicable
(3)(e) Agency uses seclusion
X o The program does not utilize seclusion or restraint.
appropriately/consistent with policy
(4) Agency has adequate plan in
place to respond to suicidal X
behavior/warning signs
Contractors (if applicable)
Yes No N/A Corrective Actions/Comments
419-400-0120(6)
(a) Agency ensures the contractor
meets the requirements of this rule X o The program does not utilize contractors.
and Chapter 413 division 215
(b)(B) Contract includes the following:
(i) Services provided
(ii) Contractor fees
(iii) Disclosure of information from
contractor to agency
(iv) Lines of authority X
(v) Adherence to rules, including
background check
(vi) Any liability of the agency for acts
of the contractor, rights of indemnity
and limitations on liability
Restraints and Involuntary
Seclusion Yes No N/A Corrective Actions/Comments
419-400-0180
(13)(d) Each child caring agency that
X
submits a report under this section
P age 5 | 24
Form Rev. 08/03/2023
shall make its quarterly report
available to the public upon request
at the Child Caring Agency’s main
office and on the child caring
agency’s website if applicable.
Supplemental Information
Yes No N/A Corrective Actions/Comments
Provided by CCA
Documents as indicated on the form
o These areas were reviewed at the time of the program’s
titled “Renewal Licensing Required X
opening but were not reviewed at the time of this review.
Documents”
Documents as indicated on form
titled “Required Financial Documents X
and Information”
All required policies and procedures
X
as identified in the “Umbrella Rules”
All required policies and procedures
as identified in “Agency Type Specific X
Rules”
Physical Plant
Yes No N/A Corrective Actions/Comments
419-400-0090(3)(a) Foster Rights
X o The program does not serve youth in ODHS custody.
Posted (if children in ODHS custody)
419-400-0100(1) Sufficient safe
space, equipment, and office X
equipment
419-400-0230(12) License is posted
X
in common area at each facility
419-470-0020(2)(a) &(c) Buildings • Although the program was found to be in good repair, well-kept
are smoke free, clean and in good and clean, there was some mold in one of the youth’s showers
X
repair where the youth’s shampoo was kept. The program must
ensure there is not any mold in the youth’s showers.
419-470-0020 (2)(d) Rooms are free
of harmful drafts, odors, and X
excessive noise
419-470-0020 (2)(e) Rooms are o 3 of the youth in the program have individual bedrooms and 2
adequate in size and arrangement of the youth share a bedroom. Each of the youth in individual
X
bedrooms have sex offense histories while the 2 youth who
share a bedroom do not have such histories.
P age 6 | 24
Form Rev. 08/03/2023
419-470-0020 (2)(f) System provides
a continuous supply of hot and cold
X
water to taps located throughout the
facility
419-470-0020 (2)(h) Building is well
ventilated and room temperature is X
within a normal comfort range
419-470-0030 (1) All parts of the
X
facility ensure the safety of children
Room and Space Requirements
Yes No N/A Corrective Actions/Comments
419-470-0030
(2) There is a separate living room or X
lounge area – 15 SF minimum per
child
(5) There is a separate dining room X
with capacity for ½ of children in care
and 15 SF per child in care
(7) Laundry is separate from living, X
kitchen, and dining areas
(8) Separate storage areas are X
provided for food, kitchen supplies,
utensils, clean linens, soiled linens
and clothing, cleaning supplies and
equip, poisons, chemicals, outdoor
recreational and maintenance
equipment. (Hazardous materials are
properly labeled, in original container
and locked)
(9) Outdoor activity area is protected X o The program’s front and back yards are well maintained.
from vehicles and other hazards and
of a size and availability appropriate
to the age and needs of children in
care
(11) Time-out rooms: Rooms used for X
time out or quiet time must have
adequate space, heat, light and
ventilation and must not be capable
of locking.
P age 7 | 24
Form Rev. 08/03/2023
Room and Space Requirements
Bedrooms Yes No N/A Corrective Actions/Comments
419-470-0030(3)
(a) Adequate furnishings and
X
personal items
(b) Separate from rooms used for
dining, living, laundry, kitchen, and X
storage
(c) Meet Oregon Fire Code
X
Requirements
(d) Be an outside room, with a
window that operates as designed. If
the window is modified from its
original design, the fire marshal must X
approve the modification and indicate
this room still meets applicable
Oregon Fire Code.
(d) Ceiling at least 90 inches X
(e) Minimum 60 SF per occupant X
(f) No more than 25 if dorm style X
(g) Permanently wired fixtures X
(h) Window covering X
Room and Space Requirements
Bathrooms Yes No N/A Corrective Actions/Comments
419-470-0030(4)
(a)(A)&(B) 1:8 ratio for toilets and
X
sinks
(a)(D) Hot and cold running water,
soap, and approved hand drying X
options
(a)(E) 1:10 ratio for shower or
X
bathtub
(a)(E) Individual privacy X
(a)(F) Window covering X
(a)(G) Permanently wired fixtures X
(a)(H) Adequate ventilation X
(b)&(c) Wooden racks on floors are
X
prohibited and impervious shower
P age 8 | 24
Form Rev. 08/03/2023
mats are disinfected & dried daily be
in good condition and free of mold
Room and Space Requirements
Kitchen Yes No N/A Corrective Actions/Comments
419-470-0030(6)
(a) Used exclusively for storage, food
preparation, dishwashing, and o The kitchen is a very nice area with nice appliances. It also
X
activities related to eating and food contains a large pantry.
preparation activities
(b) Walls, floors are easily cleanable X
(c) Equipment and utensils are easily
cleanable, durable, nontoxic, and X
kept clean
(e) Equipment is easy to clean
X
beneath, between and behind
Furnishings and Personal Items
Yes No N/A Corrective Actions/Comments
419-470-0040
(1) There is a bed with frame, X
(1)(b) clean mattress in good condition,
X
with a minimum thickness of five inches
(1)(c) a pillow in good condition X
(1)(d) a private dresser, closet, or similar
storage area for personal belongings that X
is readily accessible
(2) Linens are in good repair. There
is a waterproof mattress cover or
X
mattress. Linens are appropriate and
towels and washcloths are provided
(3) Bedding is changed weekly or
X
when soiled
(4)&(5) Personal hygiene supplies
X
and appropriate clothing are provided
Food Services
Yes No N/A Corrective Actions/Comments
419-470-0070
(1)(a) Meals are arranged daily,
consistent with normal mealtimes that X
occur during the hours of operation
P age 9 | 24
Form Rev. 08/03/2023
and provide snacks between
mealtimes
(1)(b) Menus are prepared in
advance in accordance with USDA
guidelines, provide a variety of foods X
and are adjusted for seasonal
changes including snacks
(1)(b) Menus are kept for at least 6
X
months
(1)(c) Drinking water is freely
X
available
(2)(a) Food is stored, prepared &
X
served in a sanitary manner
(2)(c) & (d) Food products are
obtained from commercial suppliers
(exception of fruits & vegetables),
X
unpasteurized juice is prohibited, and
only Grade A pasteurized and
fortified milk in appropriate container.
Residential Care Safety
Yes No N/A Corrective Actions/Comments
419-470-0080
(2) Written emergency plan that o The program’s emergency plan was reviewed prior to the
includes X program’s opening. It was not reviewed during this 6-month
review.
(a) Identifying the types of
emergencies most likely to happen
X
where the residential care agency is
located
(b) Identifying a place to meet for
X
each type of emergency identified
(c) Identifying an alternate shelter if
X
necessary
(d) Ensuring access to necessary
X
medications or medical equipment
(e) How to help each child in care
X
recover after a disaster
(3) Telephone numbers for local
X
police, fire department, poison
P age 10 | 24
Form Rev. 08/03/2023
control, after hours medical advice
and other appropriate emergency
numbers must be posted near all
telephones.
(4) Operative flashlights sufficient in
X
number are readily available to staff
(5)(a) Evacuation drill occurs monthly • Since the program opened, the program has not been having
under varying conditions, is retained monthly evacuation drills as, to date, the program has
2 years and contains: documented only 2 drills, in September and October 2023. In
(A) identify of person conducting drill addition, the program’s fire drill log does not contain all
(B) date & time required fields AND staff are sometimes not completing the
(C) notification method X required fields on the form. These fields include: (A) Identity of
(D) staff participating person conducting drill; (D) Staff participating; and (C)
(E) # of children & staff evacuated Problems encountered. The program must ensure that
(F) special conditions simulated monthly evacuation drills are occurring, that their evacuation
(G) problems encountered drill log contains all required fields, and that the evacuation
(H) time to complete drill log is being fully completed by staff.
Umbrella Safety
Yes No N/A Corrective Actions/Comments
419-400-0200
(5)(b) Vehicle has insurance policy, is X o The program’s vehicles were not observed during the 6-month
smoke free, safe operating condition, review, as the program’s transport vehicles were not present.
and has first aid kit and fire
extinguisher 2-A:10-BC
(1)(b)(A) Each vehicle used to X
transport a child in care must be:
properly registered,
covered by an insurance policy in full
force and effect, maintained in safe
operating condition, and smoke-free.
(3) If a child-caring agency has a X o The program does not have a swimming pool.
swimming pool on the premises that
is accessible to children in care or if a
child-caring agency plans to have
children in care engage in swimming,
the child-caring agency must have
and adhere to policies and
procedures that address, at a
minimum, providing disclosures and
P age 11 | 24
Form Rev. 08/03/2023
obtaining consents, assessing
swimming ability of children in care,
and ensuring the safety of pool
access.
(4)(a) The program protects children X
from potentially harmful items and
materials.
(4)(b) Direct supervision of children X
who do not have the ability to adjust
and control water temperature
(4)(c) Light fixtures have protective X
covers unless designed to be used
without one
Medication
Yes No N/A Corrective Actions/Comments
419-470-0100
(3)&(7)(e) Medications have a
prescription and are stored in the o The program’s medication cabinet and 2 children’s MARs were
X
original container with prescription reviewed during this review.
label
(4)&(5) Herbal supplements and
remedies, medical treatments,
special diets, physical therapy,
physical aides or limitations have a
written order signed by a physician or
X
qualified medical professional. A
written order, signed by a physician
or qualified medical professional, is
also required before a restriction on
diet or physical activity is imposed.
(7)(c) Medications are inaccessible to • The children’s medications are currently kept in a locked metal
children and stored behind at least storage cabinet and the metal storage cabinet is in one of the
two locking mechanisms. This does X main living areas of the house. The program must ensure that
not apply to Naloxone. medications are stored behind at least two locking
mechanisms.
(8) Medications are disposed in
o The program will be taking medications to their local pharmacy
accordance with state and federal X
for disposal.
law
P age 12 | 24
Form Rev. 08/03/2023
(9) Written record of the disposal of
medications is maintained and
includes:
(a) description and amount
X
(b) name
(c) reason
(d) method
(e) staff & witness signature
(10) Written record of the
administration of medication includes:
(a) name
(b) description • The program’s MAR contains all required fields. However, all
(c) dates and times required fields are not being completed. These fields include:
(d) missed doses X (b) description of the medication; and (h) possible adverse
(e) medication disposed reactions. The program must ensure that staff are fully
(f) method of administration completing each child’s MAR.
(g) ID of person administering
(h) possible adverse reactions
(i) medication taken outside facility
Extracurricular, Enrichment,
Cultural & Social Activities Yes No N/A Corrective Actions/Comments
419-470-0110
(2) Children have ongoing X
opportunities to participate in at least
one age-appropriate or
developmentally appropriate activity
Minimum Staffing Requirements
Yes No N/A Corrective Actions/Comments
419-470-0130
(1)&(2) Supervision is adequate for X
the type of program, location, age
and type of children, ability of
supervisor to respond, electronic
back-up systems.
Minimum ratios are maintained:
Under 30 months of age: 1:4
30 months to ˃ 6 years or non-
ambulatory: 1:6
P age 13 | 24
Form Rev. 08/03/2023
Ages 6 and older: 1:7
Overnight (staff awake)
1:10
(4)(a) When one staff is on duty, X
there is additional staff immediately
available with max response time of
30 minutes
(5) There is at least one on-site X
employee authorized to apply the
reasonable and prudent parent
standard
Sleeping Arrangements
Yes No N/A Corrective Actions/Comments
419-470-0140
(1) Children are in separate X
bedrooms than adults, unless parent
and child, or there is written approval
from guardian/parent and licensing
coordinator
(2) There is adequate supervision of X
children when sleeping
(3) When assigning bedrooms a X
residential care agency must
consider all of the following:
(a) Chronological age
(b) Developmental age
(c) Gender identity
(d) Personal history, including
medical, mental health, behavioral
health, and past adverse experiences
including any physical or sexual
abuse
Personnel Files
Yes No N/A Corrective Actions/Comments
419-400-0120
Staff Name/Position X o Personnel files were not reviewed during this 6-month review.
(3)(g) Date of Hire X
P age 14 | 24
Form Rev. 08/03/2023
(3)(a) record of education, training,
X
and previous employment
(1)(b) & (3)(b) reference checks
X
completed and documented
(1)(a) & (3)(c) Background check
X
completed and documented
(3)(d) Annual performance
X
evaluations
(3)(f) Record of personnel actions X
(3)(g) Termination date, reason for
X
termination
(3)(h) Current job description (1)(c)
Employee meets minimum
X
qualifications stated in current job
description
New Employee Orientation –
Umbrella Requirements (30 days) Yes No N/A Corrective Actions/Comments
419-400-0120(4)
o Employee training records were not reviewed during this 6-
month review. However, the program’s form to track required
(a) Agency policies and procedures X trainings was discussed and there was a great deal of
discussion about how program staff are trained and supported
in their learning.
(b) Ethical and professional
X
guidelines
(c) Suicide prevention and
X
intervention
(d) Attributes of population served X
(e) & (5)(a) to (c) Mandatory
reporting that includes:
(a) legal definition of child abuse in
ORS 418.257 and 419B.005
X
(b) legal responsibility to immediately
report
(c) legal responsibility to report is
personal to the employee
(f) Privacy laws X
P age 15 | 24
Form Rev. 08/03/2023
(g) Emergency procedures X
New Employee Orientation
Residential (Prior to working alone
Yes No N/A Corrective Actions/Comments
and within 30 days)
419-470-0120(1)
(a) Discipline and behavior
management including de-
escalation, crisis prevention, positive
X
behavior management, and
disciplinary techniques that are non-
punitive in nature
(b) CPR and First Aid sufficient to
X
retain a current certification
(c) Universal precautions and
X
hygiene
(d) Application of the reasonable and
X
prudent parent standard
(e) Training on the agency’s policy
on suicide prevention and suicide X
risk assessment tool
Crisis Intervention Training
Standards and Certification Yes No N/A Corrective Actions/Comments
419-400-0160(4) (as applicable)
(a)Complete a minimum of 12 hours
of initial training in person from a
certified instructor, including but not
limited to a minimum of six hours of
training focused on positive behavior X
support, nonviolent crisis intervention
and other methods of nonphysical
intervention to support children in
care during a crisis
(d) Receive a certificate that states:
(A) The dates during which the X
certification is current
P age 16 | 24
Form Rev. 08/03/2023
(B) The type of restraint which the
individual is certified to perform if
applicable
(C) The type of training the individual
is certified to conduct if applicable
(D) Any special endorsements
earned by the individual
(E) The level of training
(F) The name of the certified
instructor who conducted the training
and administered the assessment of
proficiency.
(e) A certification issued:
(A) Must be personal to the individual
certified by the training provider X
(B) May be valid for no more than
two years with recertification
Ongoing Training Yes No N/A Corrective Actions/Comments
419-470-0070(2)(b) Employees who
handle food served to children have X
a valid food handler’s card
419-400-0200 (1) Employees
transporting children have: current
driver’s license, insurance, trained in
X
emergency procedures and behavior
management, and training for 15+
passenger vans if applicable)
419-470-0120 (2)(a) Environmental
X
emergencies
419-470-0120 (2)(b) Universal
X
Precautions
419-470-0120 (2)(c) Discipline and
X
Behavior Management
P age 17 | 24
Form Rev. 08/03/2023
419-470-0120 (2)(d) Agency’s policy
on suicide prevention and risk X
assessment tool
419-470-0120 (3) Staff providing
direct care must maintain current X
CPR/First Aid certification
419-470-0120 (4) Designated staff
authorized to apply reasonable and
X
prudent parent standard are trained
in application of the standard
419-400-0120(5) Mandatory
reporting (annually) that includes:
(a) legal definition of child abuse in
ORS 418.257 and 419B.005
X
(b) legal responsibility to immediately
report
(c) legal responsibility to report is
personal to the employee
419-400-0160(4)(b) Receive
continuing education (as applicable
on crisis intervention training) from a X
certified instructor on an annual
basis
Comments:
Children’s Records Yes No N/A Corrective Actions/Comments
Health Services
419-470-0090
P age 18 | 24
Form Rev. 08/03/2023
(2) Medical history obtained within 30
days (significant findings, current
immunizations, history of surgical
procedures-health issues-injuries, X
allergies, dental, vision, hearing,
behavioral health, and physician
orders)
(4)(a) to (f) Medical exams (3 in first
year of life, 2,4,6,9,14) X
(g) Have a physical examination
within the first 60 days after
admission of a child in care.
Documentation of a physical X
examination having occurred within
the calendar year will meet this
requirement.
Consents
Yes No N/A Corrective Actions/Comments
419-470-0160(1)
(a) Provide routine and emergency
X
medical care
(b) Use the discipline and behavior
X
management system
(c) Use restraint or seclusion (if
applicable). Must specify the reasons
X
for the intervention and how staff are
trained and supervised
(d) Restrict contact with persons
X
outside of the agency
• The program does not have a consent stating that the program
(e) Allow access as defined in 419- will allow access as defined in 419-400-0230 and 0240. The
X
400-0230 & 0240 program must have a consent stating that the program will
allow access as defined in 419-400-0230 and 0240.
(f) Impose a dress code X
• The program does not have a consent that it will apply the
(g) Apply the reasonable and prudent reasonable and prudent parent standard. The program must
X
parent standard have a consent that it will apply the reasonable and prudent
parent standard.
P age 19 | 24
Form Rev. 08/03/2023
Disclosures
419-470-0160(2)
Yes No N/A Corrective Actions/Comments
Parent/guardian has acknowledged in
writing:
• The program does not have a disclosure regarding personal or
(a) Information regarding personal or
room searches and protocols for confiscation of contraband.
room searches and protocols for X
The program must have a disclosure regarding personal or
confiscation of contraband
room searches and protocols for confiscation of contraband.
(b) Statement of Rights of Children
X
and Parents/Guardians
(c) Any policies and procedures upon
X
request
Authorizations
Yes No N/A Corrective Actions/Comments
419-470-0160(3)
(a) Disclose or exchange information
X
with others
(b) Child specific visitors X
• Although the program is documenting approved visitation
resources for each youth in the program, the program does
(c) Visitation resources are pre- not have an authorization that all visitation resources must be
X
approved pre-approved. The program must ensure that they have an
authorization that all visitation resources must be pre-
approved.
• The program does not have a pre-approved authorization to
(d) Activity specific authorizations are
allow children to participate in potentially hazardous activities,
pre-approved to allow children to
including but not limited to hiking or using motorized yard
participate in potentially hazardous
X equipment such as lawnmowers. The program must have a
activities, including but not limited to
pre-approved authorization to allow children to participate in
using motorized yard equipment,
potentially hazardous activities including but not limited to
swimming, and horseback riding.
hiking or using a motorized lawn mower.
Information about Children in Care
419-400-0190(1)
Yes No N/A Corrective Actions/Comments
Summary sheet contains the
following:
• The program’s summary sheet does not include an area to list
(a)The name, gender, date of birth,
the previous address for the child. Also, although the
religious preference, and previous X
program’s summary sheet includes an area to document a
address
child’s religious preference, the program’s staff are not
P age 20 | 24
Form Rev. 08/03/2023
providing documentation in the allowed area. The program’s
summary sheet must include an area to indicate the child’s
previous address and the program’s staff must complete all
required fields on the program’s summary sheet, including the
child’s religious preference, if applicable.
(b) Name and location of previous
X
and current school
(c) Date of admission X
(d) Legal custody X
(e) The name, address, and
telephone number of:
(A) The child in care's parents.
(B) The child in care's legal
• The program’s summary sheet does not include an area to list
guardian, if different than the
(c) Other professionals to be involved in service planning (if
parents, and a copy of the
X applicable). The program’s summary sheet must include an
document that provides for his or
area to list other professionals to be involved in service
her authority over the child in care.
planning (if applicable).
(C) Other persons significant to
child
(D) Other professionals to be involved
in service planning (if applicable)
Service Planning
Yes No N/A Corrective Actions/Comments
419-470-0170(2)
o The program’s intake, assessment, and service plans were
(b) Intake document is completed the reviewed. All documents were completed within required
date child accepted into care X timelines, and they also contained required information. The
(emergency placement 48 hours) program also documented efforts to engage the child and the
child’s parents/guardians in the creation of the plan.
(d) Assessment is completed within
30 days and contains relevant
historical info., current behavioral
X
observations, identified need for
services, and how agency will provide
services
(e) (A)&(B) Service plan within 60
days (parent, guardian and child
X
actively involved). Describes how
child’s issues will be addressed,
P age 21 | 24
Form Rev. 08/03/2023
anticipated outcomes, and reviewed
by child and guardian/parent.
(e)(C)&(D) Service plan is reviewed
quarterly and revised when
X
information indicates other services
should be provided
Case Management
Yes No N/A Corrective Actions/Comments
419-470-0170(3)
(a) Services are documented,
progress toward achieving goals is X
tracked
(c) Discharge summary must include:
(A)Current medications
(B)Name of the physician or qualified
medical professional who prescribed
• The program’s discharge summaries do not include all
each medication
required information. The program’s discharge summaries do
(C)Any outstanding medical or other
not include (A) Current medications of child; (B) Name of the
appointments
X physician or qualified medical professional who prescribed
(D)Summary of the child’s
each medication; (C) Any outstanding medical or other
participation in the program and
appointments; and (E) Results of evaluations. The program’s
progress achieved
discharge summaries must include all required information.
(E)Results of evaluations
(F)Recommendations regarding
services
(G)Discharge destination
(e) Follow up services X
(f) Incident Reports X
Records Relating to Restraint &
Yes No N/A Corrective Actions/Comments
Involuntary Seclusion
419-400-0180 (12) Records X
419-400-0180(13)(e) Each child
• The program is not providing notice regarding how to access
caring agency shall provide notice
the quarterly restraint reports to the parents or guardians of
regarding how to access the quarterly
children in the program. The program must ensure they are
reports to the parents or guardians of X
providing notice regarding how to access the quarterly
children in care in the program. The
restraint report to the parents or guardians of children in the
child caring agency shall provide the
program. The program shall provide the notice upon the child
notice upon the child in care’s
P age 22 | 24
Form Rev. 08/03/2023
admission and at least two times in care’s admission and at least two times each year
each year thereafter. thereafter.
419-400-0190(1) Information o All the children in the program are committed to OYA. As a
provided to children in care relating to X result, the OYA caseworker provides the children with
Restraint & Involuntary Seclusion information regarding 419-400-0190(1).
Financial Records
Yes No N/A Corrective Actions/Comments
419-470-0170(4)
• The program is not maintaining an updated financial record for
each youth in the program. The program’s financial record
form also does not include all required fields, or the financial
Records contain date, amount, record form is not being fully completed. The program must
X
source, purpose, signatures ensure that each youth in the program has an updated
financial record and that the program’s financial record form
contains all required fields and that all required fields are
being fully completed by program staff.
Personal Possessions Records
Yes No N/A Corrective Actions/Comments
419-470-0170 (5)
• The program is not maintaining an updated written inventory
Individual written inventory of all
of each child’s personal possessions. The program must
personal possessions is maintained X
ensure they are maintaining an updated personal possessions
and updated as needed
inventory for each child in the program.
Records and Documentation
Yes No N/A Corrective Actions/Comments
419-400-0140
(1) Stored safely X
(2) Permanent, legible, dated, and
X
signed
(3)&(4) Uniform in organization,
readily identifiable and accessible,
current, and complete, containing all X
required info. No eraser tape or white
out.
(7) Permanent registry for each child
includes:
Name
Gender X
Birth date
Names, addresses of parents or
guardians
P age 23 | 24
Form Rev. 08/03/2023
Dates of admission
Placement upon discharge
Comments:
Licensing Coordinator’s Signature: ________________________ Date: ____1_1_/_1_4_/2_0_2_3_______
Manager Review: ______________________________________ Date: _1_1_-1_3_-_2_0_2_3_________
P age 24 | 24
Form Rev. 08/03/2023

agency_name: The Next Door (TND)

program_type: (RC) Residential Care Programs

view_code: RC

facility_type: Residential Care

board_chairperson: Ann Harris

licensing_coordinator: Irvin Minten, M.S.W.

other_regulatory_agencies: Oregon Youth Authority (OYA)

program_description:
The Next Door, Inc. provides services to children and families in the community, including foster care, day
treatment and residential care. The program provides a highly structured, therapeutic environment that emphasizes individual
treatment planning, experiential growth, academic progress and behavior change. The residential care program serves OYA youth. All
youth enrolled in the residential program attend The Next Door's Day Treatment Program.

capacity_age_range: The program serves males, ages 13-18. The program's capacity is 5 youth.

contracts_and_referrals: Referrals come from OYA.

average_daily_population_served: Since opening in May 2023, the program's average daily population has been about 4 youth. The program currently has 5 youth.

interviews_observations:
During the 6-month review, 1 program line staff and 2 youth currently enrolled at the program were
randomly selected and individually interviewed. A walkthrough of the facility and the facility's outdoor area was also completed. During
the review, there was also a great deal of discussion with Asia VanHorn, Program Supervisor, and Dan Foster, Program Manager. The
program's medication cabinet was also observed.
During individual interviews with the 2 youth, both reported they felt safe in the program, both during the day and at night. Both youth
also reported the program's staff were sufficiently trained to assist them in meeting their goals and in caring for them. Both youth also
stated they got enough to eat and that they thought the food in the program was good. Both youth also indicated they could make
private calls to persons on their approved contact list, as they could use the program's land-line phone in one of the program's main
living areas, without other youth or staff present, and staff would watch them on silent video to ensure they did not make other calls.
Both youth also reported they would not change anything about the program and both stated they liked this program over others they
have been enrolled as this program allowed them the opportunity to go on community outings.
During an individual telephonic interview with 1 program staff, it was reported the program was a good place to work and that they felt
well trained, valued, and appreciated. It was also reported they received sufficient training to effectively do their work and that if an
issue arose, their program's supervisor was very available to assist and answer questions. This staff also reported that the program's
management supported continued learning and that if he wanted to learn more about an issue, the program's management would do all
they could to see that they received training in the area. This staff also stated that since the program had only been in operation for
less than 6 months, the program continued to implement new routine and process, as unique circumstances arose. This staff also
seemed well versed on the program's behavior management and suicide prevention protocols. This staff also reported that the
program did a great job of meeting each youth's education and treatment needs and that the program provided good care to each of the
youth.
During walkthrough of the program, it was observed that the house was in a well-maintained middle-class neighborhood and that the
house was a well-constructed and designed, with main living and outdoor areas which were well maintained, welcoming, and in good
P age 2 | 24

repair. The bathrooms and kitchen also had very nice appliances and fixtures and most of the showers were nicely tiled. The areas
where youth congregated were also nicely painted and included comfortable and nice furniture.

program_strengths:
The program's supervisor reports they are maintaining best practices in several areas, including having a 30-
minute overlap of staffing at shift change, which allows incoming and outgoing staff opportunity to discuss how each youth is doing. In
addition, the program's supervisor reports she has frequent discussions with program staff on protocols, what is working well, and areas
in need of improvement. The program's supervisor and the 1-line staff interviewed also report that program staff provide a high level of
care to the youth, that they want to make a difference in the lives of the youth, and that staff truly care about each of the youth and that
they want the youth to be successful and make needed changes. The program's manager also reports they are creating a consistent
routine in the program, that the leadership in the program has been "phenomenal," that the program's supervisor is readily "available" to
staff, and that the staff in the program feel supported and are well trained.

program_challenges:
Although the program is currently fully staffed, in the first 6 months of operation, the program's management
reports staffing has been an issue, as interview pools have not been strong and 2 staff quit shortly after hire after they realized the job
was not a good fit. In addition, the program's management states they have had a couple youth in the program who have been
prematurely discharged due to the youth's verbal and physical aggression toward staff and other youth.
Changes that have occurred since the program opened: NA

lawsuits:
NA
Grievances and complaints: NA

exceptions:
NA
P age 3 | 24

observations:
, identified need for
services, and how agency will provide
services
(e) (A)&(B) Service plan within 60
days (parent, guardian and child
X
actively involved). Describes how
child's issues will be addressed,
P age 21 | 24

anticipated outcomes, and reviewed
by child and guardian/parent.
(e)(C)&(D) Service plan is reviewed
quarterly and revised when
X
information indicates other services
should be provided
Case Management
Yes No N/A Corrective Actions/Comments
419-470-0170(3)
(a) Services are documented,
progress toward achieving goals is X
tracked
(c) Discharge summary must include:
(A)Current medications
(B)Name of the physician or qualified
medical professional who prescribed
- The program's discharge summaries do not include all
each medication
required information. The program's discharge summaries do
(C)Any outstanding medical or other
not include (A) Current medications of child; (B) Name of the
appointments
X physician or qualified medical professional who prescribed
(D)Summary of the child's
each medication; (C) Any outstanding medical or other
participation in the program and
appointments; and (E) Results of evaluations. The program's
progress achieved
discharge summaries must include all required information.
(E)Results of evaluations
(F)Recommendations regarding
services
(G)Discharge destination
(e) Follow up services X
(f) Incident Reports X
Records Relating to Restraint &
Yes No N/A Corrective Actions/Comments
Involuntary Seclusion
419-400-0180 (12) Records X
419-400-0180(13)(e) Each child
- The program is not providing notice regarding how to access
caring agency shall provide notice
the quarterly restraint reports to the parents or guardians of
regarding how to access the quarterly
children in the program. The program must ensure they are
reports to the parents or guardians of X
providing notice regarding how to access the quarterly
children in care in the program. The
restraint report to the parents or guardians of children in the
child caring agency shall provide the
program. The program shall provide the notice upon the child
notice upon the child in care's
P age 22 | 24

admission and at least two times in care's admission and at least two times each year
each year thereafter. thereafter.
419-400-0190(1) Information o All the children in the program are committed to OYA. As a
provided to children in care relating to X result, the OYA caseworker provides the children with
Restraint & Involuntary Seclusion information regarding 419-400-0190(1).
Financial Records
Yes No N/A Corrective Actions/Comments
419-470-0170(4)
- The program is not maintaining an updated financial record for
each youth in the program. The program's financial record
form also does not include all required fields, or the financial
Records contain date, amount, record form is not being fully completed. The program must
X
source, purpose, signatures ensure that each youth in the program has an updated
financial record and that the program's financial record form
contains all required fields and that all required fields are
being fully completed by program staff.
Personal Possessions Records
Yes No N/A Corrective Actions/Comments
419-470-0170 (5)
- The program is not maintaining an updated written inventory
Individual written inventory of all
of each child's personal possessions. The program must
personal possessions is maintained X
ensure they are maintaining an updated personal possessions
and updated as needed
inventory for each child in the program.
Records and Documentation
Yes No N/A Corrective Actions/Comments
419-400-0140
(1) Stored safely X
(2) Permanent, legible, dated, and
X
signed
(3)&(4) Uniform in organization,
readily identifiable and accessible,
current, and complete, containing all X
required info. No eraser tape or white
out.
(7) Permanent registry for each child
includes:
Name
Gender X
Birth date
Names, addresses of parents or
guardians
P age 23 | 24

Dates of admission
Placement upon discharge
Comments

excerpt:
&(c) Buildings
are smoke free, clean and in good
repair • Although the program was found to be in good repair, well-kept
and clean, there was some mold in one of the youth’s showers
where the youth’s shampoo was kept. The program must
ensure there is not any mold in the youth’s showers.

excerpt:
(5)(a) Evacuation drill occurs monthly
under varying conditions, is retained
2 years and contains:
(A) identify of person conducting drill
(B) date & time
(C) notification method
(D) staff participating
(E) # of children & staff evacuated
(F) special conditions simulated
(G) problems encountered
(H) time to complete • Since the program opened, the program has not been having
monthly evacuation drills as, to date, the program has
documented only 2 drills, in September and October 2023. In
addition, the program’s fire drill log does not contain all
required fields AND staff are sometimes not completing the
required fields on the form. These fields include: (A) Identity of
person conducting drill; (D) Staff participating; and (C)
Problems encountered. The program must ensure that
monthly evacuation drills are occurring, that their evacuation
drill log contains all required fields, and that the evacuation
drill log is being fully completed by staff.

excerpt:
(7)(c) Medications are inaccessible to
children and stored behind at least
two locking mechanisms. This does
not apply to Naloxone. • The children’s medications are currently kept in a locked metal
storage cabinet and the metal storage cabinet is in one of the
main living areas of the house. The program must ensure that
medications are stored behind at least two locking
mechanisms.

excerpt:
(10) Written record of the
administration of medication includes:
(a) name
(b) description
(c) dates and times
(d) missed doses
(e) medication disposed
(f) method of administration
(g) ID of person administering
(h) possible adverse reactions
(i) medication taken outside facility • The program’s MAR contains all required fields. However, all
required fields are not being completed. These fields include:
(b) description of the medication; and (h) possible adverse
reactions. The program must ensure that staff are fully
completing each child’s MAR.

excerpt:
(e) Allow access as defined in 419-
400-0230 & 0240 • The program does not have a consent stating that the program
will allow access as defined in 419-400-0230 and 0240. The
program must have a consent stating that the program will
allow access as defined in 419-400-0230 and 0240.

excerpt:
(g) Apply the reasonable and prudent
parent standard • The program does not have a consent that it will apply the
reasonable and prudent parent standard. The program must
have a consent that it will apply the reasonable and prudent
parent standard.

excerpt:
(a) Information regarding personal or
room searches and protocols for
confiscation of contraband • The program does not have a disclosure regarding personal or
room searches and protocols for confiscation of contraband.
The program must have a disclosure regarding personal or
room searches and protocols for confiscation of contraband.

excerpt:
(c) Visitation resources are pre-
approved • Although the program is documenting approved visitation
resources for each youth in the program, the program does
not have an authorization that all visitation resources must be
pre-approved. The program must ensure that they have an
authorization that all visitation resources must be pre-
approved.

excerpt:
(d) Activity specific authorizations are
pre-approved to allow children to
participate in potentially hazardous
activities, including but not limited to
using motorized yard equipment,
swimming, and horseback riding. • The program does not have a pre-approved authorization to
allow children to participate in potentially hazardous activities,
including but not limited to hiking or using motorized yard
equipment such as lawnmowers. The program must have a
pre-approved authorization to allow children to participate in
potentially hazardous activities including but not limited to
hiking or using a motorized lawn mower.

excerpt:
(a)The name, gender, date of birth,
religious preference, and previous
address • The program’s summary sheet does not include an area to list
the previous address for the child. Also, although the
program’s summary sheet includes an area to document a
child’s religious preference, the program’s staff are not providing documentation in the allowed area. The program’s
summary sheet must include an area to indicate the child’s
previous address and the program’s staff must complete all
required fields on the program’s summary sheet, including the
child’s religious preference, if applicable.

excerpt:
(e) The name, address, and
telephone number of:
(A) The child in care's parents.
(B) The child in care's legal
guardian, if different than the
parents, and a copy of the
document that provides for his or
her authority over the child in care.
(C) Other persons significant to
child
(D) Other professionals to be involved
in service planning (if applicable) • The program’s summary sheet does not include an area to list
(c) Other professionals to be involved in service planning (if
applicable). The program’s summary sheet must include an
area to list other professionals to be involved in service
planning (if applicable).

excerpt:
(c) Discharge summary must include:
(A)Current medications
(B)Name of the physician or qualified
medical professional who prescribed
each medication
(C)Any outstanding medical or other
appointments
(D)Summary of the child’s
participation in the program and
progress achieved
(E)Results of evaluations
(F)Recommendations regarding
services
(G)Discharge destination • The program’s discharge summaries do not include all
required information. The program’s discharge summaries do
not include (A) Current medications of child; (B) Name of the
physician or qualified medical professional who prescribed
each medication; (C) Any outstanding medical or other
appointments; and (E) Results of evaluations. The program’s
discharge summaries must include all required information.

excerpt:
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 • The program is not providing notice regarding how to access
the quarterly restraint reports to the parents or guardians of
children in the program. The program must ensure they are
providing notice regarding how to access the quarterly
restraint report to the parents or guardians of children in the
program. The program shall provide the notice upon the child

excerpt:
Records contain date, amount,
source, purpose, signatures • The program is not maintaining an updated financial record for
each youth in the program. The program’s financial record
form also does not include all required fields, or the financial
record form is not being fully completed. The program must
ensure that each youth in the program has an updated
financial record and that the program’s financial record form
contains all required fields and that all required fields are
being fully completed by program staff.

excerpt:
Individual written inventory of all
personal possessions is maintained
and updated as needed • The program is not maintaining an updated written inventory
of each child’s personal possessions. The program must
ensure they are maintaining an updated personal possessions
inventory for each child in the program.