summary: Unannounced - 5 findings

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Residential Care
Licensee: Klamath County Juvenile Dept – Crimson Rose
Executive Director: Dan Golden
Program Director(s): Steve Quick
Date of Unannounced: July 10th, 2024
Licensing Coordinator: Ed Wyller
Other Regulatory or Accrediting Agencies: Oregon Youth Authority (OYA)
Purpose: Per OAR 419-400-0240 (1)(b) Children’s Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Comments
License Renewal Site Visit 02-07-2024 Findings
Further Action
Needed
Governance of the Agency Yes☐ No✓ • On 3/29/24 CCLP had verified that this was completed during the corrective action
419-400-0040 process. (In Compliance).
(2)(f) Formally evaluate the exec. Director’s
performance annually
• Finding: Missing Dan Golden’s 2023
performance evaluation
Executive Director or Program Director Yes☐ No✓ • On 3/29/24 CCLP had verified that this was completed during the corrective action
419-400-0040 process. (In Compliance).
(3)(g) Approval from BCU
• Finding: Missing Dan Golden’s and Steve
Quick’s completed background checks
Installation and Use of Video Equipment Yes☐ No✓ • On 3/29/24 CCLP had verified that this was completed during the corrective action
Used to Monitor or Record Children in process. (In Compliance).
Care 419-400-0145
Form Rev. 11/14/2023 P age 1 | 4
(1)If a child-caring agency installs video
equipment to monitor or record a child in care,
all employees, volunteers, parents or
guardians, and children in care must be
informed about the intended use and locations
of the equipment.
• Finding: Crimson Rose does have
video equipment and was missing this
new requirement
Supplemental Information Provided by Yes☐ No✓ • On 3/29/24 CCLP had verified that this was completed during the corrective action
CCA process. (In Compliance).
All required policies and procedures as
identified in the “Umbrella Rules”
• Finding: Crimson Rose is missing
policy on Interstate Compact on the
Placement of Children (ICPC) see
(ORS 417.200 to 417.260). Missing
policy for Indian Child Welfare Act
(ICWA) and OAR chapter 419,
Division 400
Personnel Files 419-400-0120 Yes☐ No✓ • On 7/10/24 I verified missing annual performance appraisals were completed. (In
(3)(d) Annual performance evaluations Compliance)
• Finding: Employees were missing
2023 performance evaluations
Case Management 419-470-0170(3) Yes✓ No☐ • Repeated Finding: I reviewed recent program discharge summaries. Discharge
(c) Discharge summary must include: summary form is missing the following: (F) Recommendations regarding services
(A)Current medications and (G) Discharge destination. The program must update the form to include
(B)Name of the physician or qualified medical fields for this information and must ensure these fields are completed.
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
• Finding: Current discharge
summaries were missing a, b, c, and
e.
Form Rev. 11/14/2023 P age 2 | 4
New Findings from Site Visit Comments
N/A No new findings
Interview Summary
I met with two youth individually in the front foyer to ensure privacy for youth interviews. This front foyer is where youth receive phone calls to ensure their
privacy. The foyer has a door that can be closed that separates it from the living unit. On a scale from 0-10 (0=worst program and 10=best program) youth
reported Crimson Rose to be a 5, and 9 on that scale. The youth reporting 5 reported feeling safe in program and is currently working with management to
resolve a current grievance. When asked what each has learned at Crimson Rose, youth reported: how to listen, how to have conversations, maturity,
patience, and the ability to focus on what motivates them. Both youths reported attending groups daily and meeting weekly with a counselor. One youth
indicated really trusting her counselor and that counselor really cares and understands. Regarding food, one youth reported it to be “good” while the other
youth reported “don’t like it”. Both reported getting enough to eat and that they receive snacks. One reported enjoying the chips and cup of noodles from the
Crimson Rose store that youth can access based on their performance in the program. Reported community outings: going for ice cream, walks, hiking, local
parks, high school graduation, movies (Inside Out 2) and library. Both youths indicated school to be “good” and “really good”. Both youths are pleased with
the ability to take advantage of the credit recovery program, and one youth is soon to graduate. Both reported having visits and phone calls. If given a magic
wand and could improve the program, the youth reported: “hard to be in a closed space when others are upset”, and “wish I could go swimming”.
I spoke with one staff member who described working at Crimson Rose, “Love it, and Amazing.” This staff reported feeling supported by management and
enjoys working with the young women.
Form Rev. 11/14/2023 P age 3 | 4
Observations
I observed Crimson Rose to be clean and organized. I observed youth engaged in school activities in the dayroom. Bedrooms and bathrooms are clean. I
observed prosocial interactions between youth and staff. While I was present, a youth requested a phone call with JPPO and I observed a youth being set up
for a private phone call with their Juvenile Parole Probation Officer (JPPO).
Juvenile Department Director Dan Golden gave me a tour of the adjacent construction of the new Crimson Rose program facility. . I also toured the future
build site of an adjacent transition house that will be named Shasta House with a view of Mt. Shasta. Site is cleared, utilities are in place, and program is
hoping to receive funding for the project with plans developed and ready to go.
Corrective Actions and Timeframes:
Please submit the following to verify compliance.
Within 45 days of receipt of this report Klamath County Juvenile Department must submit a letter of verification indicating the agency is in
compliance with the specific rules cited above and describing how compliance will be maintained going forward. Along with the letter of verification,
the agency must submit any and all specific documentation requested in the body of this report. The letter of verification and any additional
requested documents can be emailed directly to Ed Wyller Edward.Wyller@odhsoha.oregon.gov.
Licensing Coordinator’s Signature: ________________________ Date: _7_.2_2_._2_4_____________
7-17-2024
Manager Review: ______________________________________ Date: __________________
Form Rev. 11/14/2023 P age 4 | 4

licensee: Klamath County Juvenile Dept - Crimson Rose

purpose:
Per OAR 419-400-0240 (1)(b) Children's Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Comments
License Renewal Site Visit 02-07-2024 Findings
Further Action
Needed
Governance of the Agency Yes[ ] No✓ - On 3/29/24 CCLP had verified that this was completed during the corrective action
419-400-0040 process. (In Compliance).
(2)(f) Formally evaluate the exec. Director's
performance annually
- Finding: Missing Dan Golden's 2023
performance evaluation

interview_summary:
I met with two youth individually in the front foyer to ensure privacy for youth interviews. This front foyer is where youth receive phone calls to ensure their
privacy. The foyer has a door that can be closed that separates it from the living unit. On a scale from 0-10 (0=worst program and 10=best program) youth
reported Crimson Rose to be a 5, and 9 on that scale. The youth reporting 5 reported feeling safe in program and is currently working with management to
resolve a current grievance. When asked what each has learned at Crimson Rose, youth reported: how to listen, how to have conversations, maturity,
patience, and the ability to focus on what motivates them. Both youths reported attending groups daily and meeting weekly with a counselor. One youth
indicated really trusting her counselor and that counselor really cares and understands. Regarding food, one youth reported it to be "good" while the other
youth reported "don't like it". Both reported getting enough to eat and that they receive snacks. One reported enjoying the chips and cup of noodles from the
Crimson Rose store that youth can access based on their performance in the program. Reported community outings: going for ice cream, walks, hiking, local
parks, high school graduation, movies (Inside Out 2) and library. Both youths indicated school to be "good" and "really good". Both youths are pleased with
the ability to take advantage of the credit recovery program, and one youth is soon to graduate. Both reported having visits and phone calls. If given a magic
wand and could improve the program, the youth reported: "hard to be in a closed space when others are upset", and "wish I could go swimming".
I spoke with one staff member who described working at Crimson Rose, "Love it, and Amazing." This staff reported feeling supported by management and
enjoys working with the young women.

previous_findings:
Repeat Comments
License Renewal Site Visit 02-07-2024 Findings
Further Action
Needed
Governance of the Agency Yes[ ] No✓ - On 3/29/24 CCLP had verified that this was completed during the corrective action
419-400-0040 process. (In Compliance).
(2)(f) Formally evaluate the exec. Director's
performance annually
- Finding: Missing Dan Golden's 2023
performance evaluation
Executive Director or Program Director Yes[ ] No✓ - On 3/29/24 CCLP had verified that this was completed during the corrective action
419-400-0040 process. (In Compliance).
(3)(g) Approval from BCU
- Finding: Missing Dan Golden's and Steve
Quick's completed background checks
Installation and Use of Video Equipment Yes[ ] No✓ - On 3/29/24 CCLP had verified that this was completed during the corrective action
Used to Monitor or Record Children in process. (In Compliance).
Care 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 children in care must be
informed about the intended use and locations
of the equipment.
- Finding: Crimson Rose does have
video equipment and was missing this
new requirement
Supplemental Information Provided by Yes[ ] No✓ - On 3/29/24 CCLP had verified that this was completed during the corrective action
CCA process. (In Compliance).
All required policies and procedures as
identified in the "Umbrella Rules"
- Finding: Crimson Rose is missing
policy on Interstate Compact on the
Placement of Children (ICPC) see
(ORS 417.200 to 417.260). Missing
policy for Indian Child Welfare Act
(ICWA) and OAR chapter 419,
Division 400
Personnel Files 419-400-0120 Yes[ ] No✓ - On 7/10/24 I verified missing annual performance appraisals were completed. (In
(3)(d) Annual performance evaluations Compliance)
- Finding: Employees were missing
2023 performance evaluations
Case Management 419-470-0170(3) Yes✓ No[ ] - Repeated Finding: I reviewed recent program discharge summaries. Discharge
(c) Discharge summary must include: summary form is missing the following: (F) Recommendations regarding services
(A)Current medications and (G) Discharge destination. The program must update the form to include
(B)Name of the physician or qualified medical fields for this information and must ensure these fields are completed.
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
- Finding: Current discharge
summaries were missing a, b, c, and
e.

New Findings from Site Visit Comments
N/A No new findings

new_findings: N/A No new findings

excerpt:
419-470-0170(3) Yes✓ No[ ] - Repeated Finding: I reviewed recent program discharge summaries. Discharge
(c) Discharge summary must include: summary form is missing the following: (F) Recommendations regarding services
(A)Current medications and (G) Discharge destination. The program must update the form to include
(B)Name of the physician or qualified medical fields for this information and must ensure these fields are completed.
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
- Finding: Current discharge
summaries were missing a, b, c, and
e.
New Findings from Site Visit Comments
N/A No new findings
N/A No new findings


state: OR

facility_name: Crimson Rose

summary: Unannounced - 1 finding

raw_content:
Licensed Child Caring Agency Site Visit Report
Residential Care - Unannounced
Licensee: Klamath County Juvenile Dept – Crimson Rose Date of site visit: April 9th, 2025
Executive Director: Dan Golden Licensing Coordinator: Ed Wyller
Program Director: Steve Quick – Retired March 31st, 2025
Other regulatory or accrediting agencies: Oregon Youth Authority (OYA)
Purpose: Per OAR 419-400-0240 (1)(b) Children’s Care Licensing is required to perform at least one unannounced site visit a year
where children in care reside.
Previous findings Repeat findings Comments
Unannounced Site Visit – 7/10/2024 further action
needed
Case Management 419-470-0170(3)
(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 • Discharge summary form has been updated and
(D)Summary of the child’s participation in the now includes recommendations regarding services
program and progress achieved No and discharge destination. Discharge summaries
(E)Results of evaluations also included these sections completed. (In-
(F)Recommendations regarding services compliance).
(G)Discharge destination
• Repeated Finding: I reviewed recent
program discharge summaries.
Discharge summary form is missing
the following:
Form Rev. 3/12/2025 P a g e 1 | 5
Previous findings Repeat findings Comments
Unannounced Site Visit – 7/10/2024 further action
needed
(F) Recommendations regarding
services and
(G) Discharge destination. The
program must update the form to
include fields for this information and
must ensure these fields are
completed.
New findings from site visit Comments
N/A No new findings
Form Rev. 3/12/2025 P a g e 2 | 5
Interview summary
I interviewed two of the seven youth that are currently in the Crimson Rose program. I interviewed the youth separately in the
adjacent gym to maintain a space of privacy. On a scale from 0-10 (0=worst program and 10=best program) the youth rated
Crimson rose as a 7.5 and 8 on that scale. Youth reported feeling safe in the program. Food was described as “pretty good”
and “amazing”. Both reported having enough food to eat. One youth reported they loved the homemade style mac and
cheese meal.
Both youths reported attending various treatment groups: Dialectical Behavioral Therapy (DBT), Anger management,
boundaries, Relapse prevention, drug and alcohol, breaking free of addiction, and teen relationships. Both youths reported
receiving weekly counseling and monthly therapy. Both were able to list their treatment goals and what is required to
successfully discharge from the program. One youth shared they are learning how to be “honest with myself and others”. The
other youth reported they have learned in program “how to control my anger, drug and alcohol skills regarding relapse
prevention.”
For fun, youth reported playing cards, reading, drawing, watching tv, and listening to music. Youth reported going on outings
in the community such as the park, library, and local sores. One youth reported they wished recreation time was longer but
does appreciate it. The other youth wished there were more books on unit. When debriefing with program staff they indicated
they are looking forward to having the new classroom and dedicated education space with a library in that location. Youth
report they can check out books at the library.
Staff reported they enjoy working at Crimson Rose. Two of the staff are taking on more duties and are excited about the ability
to take on more responsibility and challenges. I was told one of the staff working today during my visit had her daughter go
through the program and that was an impetus to work at Crimson Rose due to her daughter’s success.
Form Rev. 3/12/2025 P a g e 3 | 5
Observations
Klamath County Juvenile Department Director Dan Golden gave me a tour of the new construction of the new Juvenile
Department administrative offices and Crimson Rose program. Sheet rock is up, siding is currently being installed and work is
expected to be completed by July of 2025. The big news is that Steve Quick, Crimson Rose program director, recently retired
on March 31st, 2025. There has been some shuffling of job duties, and interviews start tomorrow for an open case manager
position.
When I arrived at the current Crimson Rose program I observed a multidisciplinary team meeting occurring with a crimson rose
youth, crimson rose case worker, and an Oregon Youth Authority Juvenile Parole and Probation Officer. When I entered the
day room youth were participating in their afternoon DBT group. I found youth bedrooms to be clean and organized. I noticed
more pictures on the walls and the outside and inside of their bedroom doors. Youth are posting their treatment goals,
inspirational quotes, and family photos. Crimson Rose is housed in an older detention style pod; however, they continue to
make this environment less institutional.
I observed the youth and staff interacting positively, and youth were eager to share their experiences with the program when I
requested their input, and there plenty of volunteers to speak with me.
Corrective actions and timeframes: N/A (Previous finding has been addressed and no new findings.
Please submit the following to verify compliance.
Within 45 days of receipt of this report Klamath County Juvenile Dept – Crimson Rose must submit a letter of verification indicating
the agency is in compliance with the specific rules cited above and describing how compliance will be maintained going forward. Along
with the letter of verification, the agency must submit any and all specific documentation requested in the body of this report. The letter
of verification and any additional requested documents can be emailed directly to Ed Wyller at
Edward.Wyller@odhsoha.oregon.gov.
Licensing Coordinator’s signature: ________________________ Date: _4_.2_8_.2_5______________
Form Rev. 3/12/2025 P a g e 4 | 5
4-25-2025
Manager review: ______________________________________ Date: __________________
Form Rev. 3/12/2025 P a g e 5 | 5

agency_name: Klamath County Juvenile Department (KCJD)

program_name: Crimson Rose

program_type: (RC) Residential Care Programs

report_type: Unannounced

view_code: RC

facility_type: Residential Care - Unannounced

licensee: Klamath County Juvenile Dept - Crimson Rose Date of site visit: April 9th, 2025

program_director: Steve Quick - Retired March 31st, 2025

visit_date: April 9th, 2025

licensing_coordinator: Ed Wyller

other_regulatory_agencies: Oregon Youth Authority (OYA)

purpose:
Per OAR 419-400-0240 (1)(b) Children's Care Licensing is required to perform at least one unannounced site visit a year
where children in care reside.
Previous findings Repeat findings Comments
Unannounced Site Visit - 7/10/2024 further action
needed
Case Management 419-470-0170(3)
(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 - Discharge summary form has been updated and
(D)Summary of the child's participation in the now includes recommendations regarding services
program and progress achieved No and discharge destination. Discharge summaries
(E)Results of evaluations also included these sections completed. (In-
(F)Recommendations regarding services compliance).
(G)Discharge destination
- Repeated Finding: I reviewed recent
program discharge summaries.
Discharge summary form is missing
the following:

Previous findings Repeat findings Comments
Unannounced Site Visit - 7/10/2024 further action
needed
(F) Recommendations regarding
services and
(G) Discharge destination. The
program must update the form to
include fields for this information and
must ensure these fields are
completed.
New findings from site visit Comments
N/A No new findings

Interview summary
I interviewed two of the seven youth that are currently in the Crimson Rose program. I interviewed the youth separately in the
adjacent gym to maintain a space of privacy. On a scale from 0-10 (0=worst program and 10=best program) the youth rated
Crimson rose as a 7.5 and 8 on that scale. Youth reported feeling safe in the program. Food was described as "pretty good"
and "amazing". Both reported having enough food to eat. One youth reported they loved the homemade style mac and
cheese meal.
Both youths reported attending various treatment groups: Dialectical Behavioral Therapy (DBT), Anger management,
boundaries, Relapse prevention, drug and alcohol, breaking free of addiction, and teen relationships. Both youths reported
receiving weekly counseling and monthly therapy. Both were able to list their treatment goals and what is required to
successfully discharge from the program. One youth shared they are learning how to be "honest with myself and others". The
other youth reported they have learned in program "how to control my anger, drug and alcohol skills regarding relapse
prevention."
For fun, youth reported playing cards, reading, drawing, watching tv, and listening to music. Youth reported going on outings
in the community such as the park, library, and local sores. One youth reported they wished recreation time was longer but
does appreciate it. The other youth wished there were more books on unit. When debriefing with program staff they indicated
they are looking forward to having the new classroom and dedicated education space with a library in that location. Youth
report they can check out books at the library.
Staff reported they enjoy working at Crimson Rose. Two of the staff are taking on more duties and are excited about the ability
to take on more responsibility and challenges. I was told one of the staff working today during my visit had her daughter go
through the program and that was an impetus to work at Crimson Rose due to her daughter's success.

Observations
Klamath County Juvenile Department Director Dan Golden gave me a tour of the new construction of the new Juvenile
Department administrative offices and Crimson Rose program. Sheet rock is up, siding is currently being installed and work is
expected to be completed by July of 2025. The big news is that Steve Quick, Crimson Rose program director, recently retired
on March 31st, 2025. There has been some shuffling of job duties, and interviews start tomorrow for an open case manager
position.
When I arrived at the current Crimson Rose program I observed a multidisciplinary team meeting occurring with a crimson rose
youth, crimson rose case worker, and an Oregon Youth Authority Juvenile Parole and Probation Officer. When I entered the
day room youth were participating in their afternoon DBT group. I found youth bedrooms to be clean and organized. I noticed
more pictures on the walls and the outside and inside of their bedroom doors. Youth are posting their treatment goals,
inspirational quotes, and family photos. Crimson Rose is housed in an older detention style pod; however, they continue to
make this environment less institutional.
I observed the youth and staff interacting positively, and youth were eager to share their experiences with the program when I
requested their input, and there plenty of volunteers to speak with me.

excerpt:
419-470-0170(3)
(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 - Discharge summary form has been updated and
(D)Summary of the child's participation in the now includes recommendations regarding services
program and progress achieved No and discharge destination. Discharge summaries
(E)Results of evaluations also included these sections completed. (In-
(F)Recommendations regarding services compliance).
(G)Discharge destination
- Repeated Finding: I reviewed recent
program discharge summaries.
Discharge summary form is missing
the following:
Previous findings Repeat findings Comments
Unannounced Site Visit - 7/10/2024 further action
needed
(F) Recommendations regarding
services and
(G) Discharge destination. The
program must update the form to
include fields for this information and
must ensure these fields are
completed.
New findings from site visit Comments
N/A No new findings
N/A No new findings


facility_name: Lane County Youth Services, Phoenix Program

summary: Unannounced - 9 findings

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Executive Director: Star Felty
Program Director(s): Melissa Westerman
Date of Unannounced: June 3, 2021
Licensing Coordinator: Holly Ivey
Other Regulatory or Accrediting Agencies: The Oregon Health Authority
Purpose: Per OAR 413-215-0101 (1) (b) Children’s Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Comments
Findings
Further Action
Needed
Medication 413-215-0551 (10) Written Yes☐ No On June 3,2021, at the Unannounced Site Inspection, Holly Ivey, Licensing Coordinator,
record of the administration of observed medication records. The medication records form being utilized had the following
medication includes:(e) medication information: medication disposed, and medication taken out of the facility. The program
was found to be in compliance regarding the rule requirement.
disposed (i) medication taken outside
facility.
 The above stated domains were
missing on the medication
records.
Personnel Files 413-215-0061(3)(a) Yes No☐ Personnel Files 413-215-0061(3)(a) record of education, training and
record of education, training and previous employment. (3)(d) Annual performance evaluations.
previous employment. (3)(d) Annual (REPEAT FINDING 2020)
performance evaluations.  The staff were conducting self-evaluations. There was no documentation of
The above requirements were missing in management conducting evaluations of staff annually. Annual evaluations
the personnel files. for staff must be completed by management.
1
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 200115)
Ongoing Training Yes☐ No Holly Ivey, Licensing Coordinator, observed some training records of staff. The training
413-215-0556(2)(b) Universal records verified the following annual trainings had occurred: Universal Precautions, and
Precautions. (REPEAT FINDING 2018 Mandatory Reporting. The program was found to be in compliance regarding the rule
requirement.
REPORT)
413-215-0061(5) Mandatory reporting
(annually) that includes:
(a) legal definition of child abuse ORS
419B.005, Oregon Laws 2016, chapter
106, section 36
(b) legal responsibility to immediately
report
(c) legal responsibility to report is
personal to the employee
Documentation of the above required
trainings occurring annually were not
found in the personnel files reviewed.
Consents 413-215-0576(1) (e) Allow Yes☐ No Holly Ivey, Licensing Coordinator, observed youth records. The following consents were
access as defined in 413-215-0091 & found: Apply the Reasonable and Prudent Parent Standard. The program was found to be
0101 (REPEAT FINDING FROM 2018 in compliance regarding the rule requirement.
REPORT) (g) Apply the reasonable and
prudent parent standard.
 The above required consents
were not found in the files
reviewed.
Disclosures 413-215-0576(2) Yes☐ No Holly Ivey, Licensing Coordinator, observed youth records. The following Disclosure was
Parent/guardian has acknowledged in found: Any policies and procedures upon request. The program was found to be in
writing: (c) Any policies and compliance regarding the rule requirement.
procedures upon request. (REPEAT
FINDING FROM 2018 REPORT)
 The above disclosure was not
found in the files reviewed.
Information about Children in Care Yes☐ No Holly Ivey, Licensing Coordinator, observed youth records. The following was found on the
413-215-0581(1) Summary sheet youth summary sheets: Religious preference, previous address name and location of
contains the following: (a)……. previous and current school, the name address, and telephone number of other significant
persons to the child. The program was found to be in compliance regarding the rule
religious preference, (REPEAT
requirements.
FINDING FROM 2018 REPORT) and
previous address. (b) Name and
location of previous and current
2
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 200115)
school. (e) The name, address, and
telephone number of: (C) Other
persons significant to child
The above requirements were not found
on the youth summary sheet’s observed.
New Findings from Site Visit Comments
N/A
Interview Summary
At the unannounced inspection Melissa Westerman, Program Manager, accompanied Holly Ivey, the Licensing Coordinator, with the walk
through of the site. Three youth were interviewed at the time of the inspection. All the youth reported that things were going well at the
program. They stated they always received enough food to eat, to include two daily snacks. It was reported that the food was the same as
detention, (the food is prepared in the main detention kitchen and brought down for the program). One youth stated he thought the food could
be better. He stated the cook puts a lot of celery into the food, instead of meat. The youth stated, the program did serve meat, his favorite meal
was hamburgers. They stated their favorite things about the program were: being away from family, wearing their own clothing, the bedroom
doors were not locked, they had ability to play video games and basketball. They stated there were are no restrictions to their approved contact
list for making phone calls. The youth reported hygiene products were provided to them and replenished if needed. When asked what changes
the youth would make to the program the following was stated: ability to have their cell phones, being able to be on social media, more
electronics, a pool, and more down time. The youth reported the following activities: ping pong, movies, playing X Box, drawing, coloring, board
games, reading, going on walks, basketball, and playing volleyball in the courtyard. They reported always feeling safe at the program.
3
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 200115)
Observations
Several staff and youth were observed at the program during the unannounced inspection. The youth that were at the program that day
appeared to be at ease and comfortable in the environment. The facility was observed to be clean and in good repair.
Corrective Actions and Timeframes:
Please submit the following to verify compliance.
Within 45 days of receipt of this report Lane County, Phoenix Program must submit a letter of verification indicating the agency is in compliance
with the specific rules cited above and describing how compliance will be maintained going forward. Along with the letter of verification, the agency
must submit any and all specific documentation requested in the body of this report. The letter of verification and any additional requested
documents can be emailed directly to Holly.r.ivey@state.or.us or sent by regular mail to the following address:
Department of Human Services
Children’s Care Licensing Program
Attn: Holly Ivey, Licensing Coordinator
201 High St. SE Suite 500
Salem, OR 97301
6-29-2021
Licensing Coordinator’s Signature: ________________________ Date: ___________________
6-28-2021
Manager Review: ______________________________________ Date: __________________
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I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 200115)

agency_name: Lane County Youth Service CCA (LCYS)

program_name: Phoenix

executive_director: Star Felty

program_director: Melissa Westerman

licensing_coordinator: Holly Ivey

other_regulatory_agencies: The Oregon Health Authority

purpose:
Per OAR 413-215-0101 (1) (b) Children's Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Comments
Findings
Further Action
Needed
Medication 413-215-0551 (10) Written Yes[ ] No On June 3,2021, at the Unannounced Site Inspection, Holly Ivey, Licensing Coordinator,
record of the administration of observed medication records. The medication records form being utilized had the following
medication includes:(e) medication information: medication disposed, and medication taken out of the facility. The program
was found to be in compliance regarding the rule requirement.
disposed (i) medication taken outside
facility.
- The above stated domains were
missing on the medication
records.
Personnel Files 413-215-0061(3)(a) Yes No[ ] Personnel Files 413-215-0061(3)(a) record of education, training and
record of education, training and previous employment. (3)(d) Annual performance evaluations.
previous employment. (3)(d) Annual (REPEAT FINDING 2020)
performance evaluations. - The staff were conducting self-evaluations. There was no documentation of
The above requirements were missing in management conducting evaluations of staff annually. Annual evaluations
the personnel files. for staff must be completed by management.
1

Ongoing Training Yes[ ] No Holly Ivey, Licensing Coordinator, observed some training records of staff. The training
413-215-0556(2)(b) Universal records verified the following annual trainings had occurred: Universal Precautions, and
Precautions. (REPEAT FINDING 2018 Mandatory Reporting. The program was found to be in compliance regarding the rule
requirement.
REPORT)
413-215-0061(5) Mandatory reporting
(annually) that includes:
(a) legal definition of child abuse ORS
419B.005, Oregon Laws 2016, chapter
106, section 36
(b) legal responsibility to immediately
report
(c) legal responsibility to report is
personal to the employee
Documentation of the above required
trainings occurring annually were not
found in the personnel files reviewed.
Consents 413-215-0576(1) (e) Allow Yes[ ] No Holly Ivey, Licensing Coordinator, observed youth records. The following consents were
access as defined in 413-215-0091 & found: Apply the Reasonable and Prudent Parent Standard. The program was found to be
0101 (REPEAT FINDING FROM 2018 in compliance regarding the rule requirement.
REPORT) (g) Apply the reasonable and
prudent parent standard.
- The above required consents
were not found in the files
reviewed.
Disclosures 413-215-0576(2) Yes[ ] No Holly Ivey, Licensing Coordinator, observed youth records. The following Disclosure was
Parent/guardian has acknowledged in found: Any policies and procedures upon request. The program was found to be in
writing: (c) Any policies and compliance regarding the rule requirement.
procedures upon request. (REPEAT
FINDING FROM 2018 REPORT)
- The above disclosure was not
found in the files reviewed.
Information about Children in Care Yes[ ] No Holly Ivey, Licensing Coordinator, observed youth records. The following was found on the
413-215-0581(1) Summary sheet youth summary sheets: Religious preference, previous address name and location of
contains the following: (a)……. previous and current school, the name address, and telephone number of other significant
persons to the child. The program was found to be in compliance regarding the rule
religious preference, (REPEAT
requirements.
FINDING FROM 2018 REPORT) and
previous address. (b) Name and
location of previous and current
2

school. (e) The name, address, and
telephone number of: (C) Other
persons significant to child
The above requirements were not found
on the youth summary sheet's observed.
New Findings from Site Visit Comments
N/A
Interview Summary
At the unannounced inspection Melissa Westerman, Program Manager, accompanied Holly Ivey, the Licensing Coordinator, with the walk
through of the site. Three youth were interviewed at the time of the inspection. All the youth reported that things were going well at the
program. They stated they always received enough food to eat, to include two daily snacks. It was reported that the food was the same as
detention, (the food is prepared in the main detention kitchen and brought down for the program). One youth stated he thought the food could
be better. He stated the cook puts a lot of celery into the food, instead of meat. The youth stated, the program did serve meat, his favorite meal
was hamburgers. They stated their favorite things about the program were: being away from family, wearing their own clothing, the bedroom
doors were not locked, they had ability to play video games and basketball. They stated there were are no restrictions to their approved contact
list for making phone calls. The youth reported hygiene products were provided to them and replenished if needed. When asked what changes
the youth would make to the program the following was stated: ability to have their cell phones, being able to be on social media, more
electronics, a pool, and more down time. The youth reported the following activities: ping pong, movies, playing X Box, drawing, coloring, board
games, reading, going on walks, basketball, and playing volleyball in the courtyard. They reported always feeling safe at the program.
3

Observations
Several staff and youth were observed at the program during the unannounced inspection. The youth that were at the program that day
appeared to be at ease and comfortable in the environment. The facility was observed to be clean and in good repair.

excerpt:
413-215-0581(1) Summary sheet youth summary sheets: Religious preference, previous address name and location of
contains the following: (a)……. previous and current school, the name address, and telephone number of other significant
persons to the child. The program was found to be in compliance regarding the rule
religious preference, (REPEAT
requirements.
FINDING FROM 2018 REPORT) and
previous address. (b) Name and
location of previous and current
2
school. (e) The name, address, and
telephone number of: (C) Other
persons significant to child
The above requirements were not found
on the youth summary sheet's observed.
New Findings from Site Visit Comments
N/A
N/A


summary: License Renewals - 9 findings

raw_content:
Licensed Child Caring Agency Site Visit Report
Residential Care
Licensee: Lane County Youth Services (Phoenix Program) Date of site visit: June 6, 2022
Executive Director: Greg Rikhoff Licensing Coordinator: Holly Ivey
Board Chairperson: Joe Berney
Other Regulatory or Accrediting Agencies: The Oregon Health Authority
Program Compliance: The program was found to be compliant or will be compliant with OAR 413-215-0001 to 413-215-0131, Licensing Umbrella
Rules, and OAR 413-215-0501 to 413-215-0586, Licensing Residential Care Agencies Rules. Personnel records were reviewed and compliance
with required background checks was documented for employees in all programs.
Program Description(s): The Phoenix Program serves youth involved in the Juvenile Justice System who are at risk of being committed to a more
secure setting. The program serves male and female and utilizes a cognitive/behavioral approach. The county subcontracts with Center for Family
Development for therapeutic services. The program has a capacity for 16 and the average length of stay is 4-6 months based upon the youth and
family’s needs. School is provided on site by the 4J School District.
Program type and services: Residential Services
Capacity and Age Range: The capacity is 16, ages 12-17.
Funding sources: Behavior Rehabilitation Services (BRS) Funding, county local options funding.
Contracts and sources for referrals: Referrals come from the Lane County Juvenile Counselors.
Average length of stay: 55 days
Average daily population served: 6
Number of children served annually: 28 youth
(rev. 03/25/2021)
Use of seclusion or restraint: The staff receive restraint training in CPI, and utilize the de-escalation techniques, they do not utilize restraints in
the program unless there is an extreme safety risk.
Interviews, Observations:
Interviews: During the review, Timothy Davis, Program Director, was informally interviewed, as he assisted with the walk-through of the facility.
Three youth were privately interviewed by Holly Ivey, Licensing Coordinator. When asked what they appreciated most about the Phoenix Program
the youth reported: ”The staff are super welcoming, it’s nice not to be homeless, staff teach you new skills, staff take time out of their day to hang
out and find out about the interests the kids have.” All youth reported getting enough food at the program and daily snacks. All youth reported
having daily private phone contact with their approved contacts. Visits at the program with approved contacts were reported to happen every
Thursday and Sunday. The youth reported the following recreational activities: “Playing: basketball, ping pong, and board games, going on outings,
mini-golfing, going to parks as a group, and watching movies.” All youth reported hygiene products were provided by the program. When the youth
were asked what they would change about the program, they reported: “The food would be home cooked, I would prefer the food to have more
seasoning and to taste better, and there would be community visits with family.” All youth reported feeling safe at the program and respected by
the staff. One youth stated, “I am treated respectfully here, even if I’m not being respectful, staff talk respectfully to me.”
Observations: A walk-through of the program was conducted in all areas where youth were allowed access. The program was well kept and
observed to be clean and in good repair. It was reported that youth are assigned a daily chore, to assist with the cleaning of the program. A
contracted agency in the Lane County Detention Facility is responsible for all meals, which are prepared in the detention facilities kitchen. Meals
are brought from detention to the Phoenix Program’s kitchen at mealtime. The DHS Licensing Coordinator did not observe the Lane County
Detention Kitchen. The kitchen at the Phoenix Program was clean and in good repair. The DHS Licensing Coordinator observed food in the
refrigerator, and snacks available for the youth. The DHS Licensing Coordinator observed the van that staff utilizes to transport youth in the
program. There were no deficiencies observed with the vehicle.
Program Strengths: The following strengths were identified by the Program Leadership at the time of the review:
 “The Phoenix program is a program that is dedicated to helping youth and their families/guardians learn and use new skills so that when
they transition to the community, they will have created a healthier environment with improved communication. We do this by providing
family and individual therapy, competency groups, diversity groups, and prosocial recreational opportunities.
 Another strength we have is our program staff. The staff in our program have a passion to guide and mentor our youth and are able to see
and build on the strengths of the youth. They do an excellent job of creating rapport while maintaining professional boundaries. Staff are
continuously innovating and coming up with strategic and creative ways to help youth achieve their goals.
 The Phoenix Program is currently reviewing evidence-based assessment tools and curriculum to effectively measure youth success, meet
the individual needs of each youth and their families/guardians, and reduce criminogenic risk factors specific to each youth.
 The program is currently participating in Performance Based Standards (PBS) evaluation services in an effort to ensure we are following
best practices and our program structure meets industry standards. This year the program plans to implement a residential care-giving
database that will streamline our workflows, data entry, and allow us to maintain paperless youth files.
 This year the program plans to implement a training database platform which will allow us to efficiently monitor and implement onboarding
training for new staff, and ongoing training or career path training for existing staff.”
2
Program Challenges: The following strengths were identified by the Program Leadership at the time of the review:
 “A reduction of police referrals and probation adjudications resulting from Covid19 restrictions has reduced the number of youth referred to
the program.
 We have also been looking at ways to effectively engage youth upon intake and reduce crisis or behavior escalation to prevent youth from
running away.
 The program has struggled to retain staff and recruit new staff as a result of Covid19 requirements.”
Changes that have occurred in the last 2 years: The following changes were identified by the Program Leadership at the time of the review:
 “The program has received a new program supervisor, a program manager, a division manager, and multiple new line staff during the past
two years.
 The program has also moved from the Lane County Health and Human Services Department to a new department called Community Justice
and Rehabilitation Services (CJRS). A new director has been hired for this new department as well.”
Lawsuits: N/A
Grievances and complaints filed in the last two years: N/A
Corrective Actions and Timeframes: Please submit the following to verify compliance.
Within 45 days of receipt of this report Lane County Phoenix Program must submit a letter of verification indicating the agency is in compliance with
the specific rules cited above and describing how compliance will be maintained going forward. Along with the letter of verification, the agency must
submit any and all specific documentation requested in the body of this report. The letter of verification and any additional requested documents can
be emailed directly to Holly Ivey, at Holly.r.ivey@state.or.us
Exceptions: N/A
Changes in License: N/A
Summary of Review
Program and Services Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0011(2) Completed
Program and services are in scope of license X
Governance of the Agency Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0021 Completed
(1)(a) Minimum of 5 board members X
(2)(f) Formally evaluate the exec. Director’s X
performance annually
3
(2)(g) Approves annual budget X
(2)(h) Obtain and review an annual X
independent financial review or audit of
financial records.
(2)(k) Written quality improvement program X
(2)(l) Meeting minutes X
Executive Director or Program Director Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0021 Completed
(3)(a) knowledge of requirements for X
providing care and treatment appropriate to
programs
(3)(g) Approval from BCU X
Discipline, Behavior Management, and Corrective Action
Yes No N/A Corrective Actions/Comments
Suicide Prevention 413-215-0076 Completed
(3) Agency uses appropriate and positive
methods of behavior management and
X
nationally recognized non-violent crisis
intervention
(3)(b)(C) Agency does not use chemical and
mechanical restraint (excluding medically X
necessary devices/prescriptions)
(3)(c) Agency uses appropriate time-out
rooms (adequate space, heat, light and
ventilation and is not capable of locking) and X
documents use in child’s record when
applicable
(3)(e) Agency uses seclusion
X
appropriately/consistent with policy
(4) Agency has adequate plan in place to
X
respond to suicidal behavior/warning signs
Contractors (if applicable) Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0061(6) Completed
(a) Agency ensures the contractor meets the
requirements of this rule and Chapter 413 X
division 215
(b)(B) Contract includes the following:
(i) Services provided
(ii) Contractor fees
(iii) Disclosure of information from contractor
X
to agency
(iv) Lines of authority
(v) Adherence to rules, including background
check
4
(vi) Any liability of the agency for acts of the
contractor, rights of indemnity and limitations
on liability
Supplemental Information Provided by Corrective Action
Yes No N/A Corrective Actions/Comments
CCA Completed
Documents as indicated on the form titled The following Renewal Required Documents must be
“Renewal Licensing Required Documents” submitted to the Licensing Coordinator:
X  Fire Marshal Inspection (scheduled to occur 8.16.22)
 Resume of the Executive Director.
Documents as indicated on form titled
“Required Financial Documents and X
Information”
All required policies and procedures as Supplemental Information Provided by CCA All required
identified in the “Umbrella Rules” policies and procedures as identified in the “Umbrella Rules”
X  *Required policy revisions are stated in detail at the
end of the report.
All required policies and procedures as Supplemental Information Provided by CCA All required
identified in “Agency Type Specific Rules” policies and procedures as identified in the “Umbrella Rules”
X  *Required policy revisions are stated in detail at the
end of the report.
Physical Plant Corrective Action
Yes No N/A Corrective Actions/Comments
Completed
413-215-0046(3)(a) Foster Rights Posted (if X
children in DHS custody)
413-215-0051(1) Sufficient safe space, X
equipment, and office equipment
413-215-0091(12) License is posted in X
common area at each facility
413-215-0001(5)(d), 0516(4(a)(I) & 0521(1) X
Adequate furnishings and personal items Physical Plant 413-215-0511(2)(a) &(c) Buildings are smoke
413-215-0511(2)(a) &(c) Buildings are X free, clean and in good repair
smoke free, clean and in good repair  The blinds were broken and in need of repair in
413-215-0511(2)(d) Rooms are free of X bedroom 163.
harmful drafts, odors, and excessive noise
413-215-0511(2)(e) Rooms are adequate in X
size and arrangement
413-215-0511(2)(f) System provides a X
continuous supply of hot and cold water to
taps located throughout the facility
5
413-215-0511(2)(h) Building is well X
ventilated and room temperature is within a
normal comfort range
413-215-0516(1) All parts of the facility X
ensure the safety of children
Room and Space Requirements Corrective Action
Yes No N/A Corrective Actions/Comments
Bedrooms 413-215-0516(3) Completed
(a) Adequate furnishings and personal items X
(b) Separate from rooms used for dining, X
living, laundry, kitchen, and storage
(c) Outside room with window allowing X
egress from building
(d) Ceiling at least 90 inches X
(e) Minimum 60 SF per bed X
(f) No more than 25 if dorm style X
(g) Permanently wired fixtures X
(h) Window covering X
(i) Beds are 3 feet apart and maintained to X
ensure safety
Room and Space Requirements Corrective Action
Yes No N/A Corrective Actions/Comments
Bathrooms 413-215-0516(4) Completed
(a)(A )& (B) 1:8 ratio for toilets and sinks X
(a)(D) Hot and cold running water, soap, and X
approved hand drying options
(a)(E) 1:10 ratio for shower or bathtub X
(a)(E) Individual privacy X
(a)(F) Window covering X
(a)(G) Permanently wired fixtures X
(a)(H) Adequate ventilation X
(b)&(c) Wooden racks on floors are X
prohibited and impervious shower mats are
disinfected & dried daily
Room and Space Requirements Corrective Action
Yes No N/A Comments
Kitchen 413-215-0516(6) Completed
(a) Used exclusively for storage, food X Comment: (The Licensing Coordinator, viewed the Phoenix
preparation, dish washing, and activities Program’s Kitchen, which is not where meals are prepared
related to eating for the youth. Meals are prepared in the detention building’s
(b) Walls, floors are easily cleanable X kitchen and brought to the Phoenix Program.)
(c) Equipment and utensils are easily X
cleanable, durable, nontoxic, and kept clean
(e) Equipment is easy to clean beneath, X
between and behind
Room and Space Requirements Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0516 Completed
6
(2) There is a separate living room or lounge X
area – 15 SF minimum per child
(5) There is a separate dining room with X
capacity for ½ of children in care and 15 SF
per child in care
(7) Laundry is separate from living areas, X
kitchen and dining
(8) Separate storage areas are provided for X
food, kitchen supplies, utensils, clean linens,
soiled linens and clothing, cleaning supplies
and equip, poisons, chemicals, outdoor
recreational and maintenance equipment
(9) Outdoor activity area is protected from X
vehicles and other hazards and of a size and
availability appropriate to the age and needs
of children in care
(11) & 413-215-0076(3)(c)(C) Time out X
rooms have adequate space, heat, light and
ventilation and is not capable of locking
Furnishings and Personal Items Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0521 Completed
(1) There is a bed with frame, clean mattress X
and pillow and personal storage (dresser,
closet)
(2) Linens are in good repair. There is a X
waterproof mattress cover or mattress.
Linens are appropriate and towels and
washcloths are provided
(3) Bedding is changed weekly or when X
soiled
(4) & (5) Personal hygiene supplies and X
appropriate clothing are provided
Food Services Corrective Action
Yes No N/A Comments
413-215-0536(1)&(2) Completed
(1)(a) Meals are arranged daily, consistent X Food is cooked and brought over to the program from Lane
with normal mealtimes that occur during the County’s Detention Facility. The DHS Licensing Coordinator
hours of operation did not inspect the kitchen of the Lane Detention Facility.
(1)(b) Menus are prepared in advance in X
accordance with USDA guidelines, provide a
variety of foods and are adjusted for
seasonal changes.
(1)(b) Menus are kept for at least 6 months X
(1)(c) Drinking water is freely available X
(2)(a) Food is stored, prepared & served in a X
sanitary manner
7
(2)(c) & (d) Food products are obtained from X
commercial suppliers (exception of fruits &
vegetables), unpasteurized juice is
prohibited, and only Grade A pasteurized
and fortified milk in appropriate container.
Safety Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0541 Completed
(2)(a) Written emergency plan X Safety413-215-05413) (a) Evacuation drill occurs monthly
(2)(b) Telephone numbers for local police X under varying conditions, is retained 2 yrs.
and fire are posted near all telephones  Over the two-year span reviewed, some of the fire
(2)(c) Operative flashlights sufficient in X drill logs were not found.
number are readily available to staff
(3)(a) Evacuation drill occurs monthly under X
varying conditions, is retained 2 yrs. and
contains;
(A) identify of person conducting drill
(B) date & time
(C) notification method
(D) staff participating
(E) # of children & staff evacuated
(F) special conditions simulated
(G) problems encountered
(H) time to complete
Safety – Transportation Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0541 Completed
(5)(b) Vehicle has insurance policy, is smoke X
free, safe operating condition, and has first
aid kit and fire extinguisher 2-A:10-BC
Medication Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0551 Completed
(3) & (7)(e) Medications have a prescription X
and are stored in the original container with
prescription label
(4) & (5) Herbal supplements and remedies, X
medical treatments, special diets, physical
therapy, physical aides or limitations have a
written order signed by a physician or
qualified medical professional.
(7)(c) Medications are inaccessible to X
children
(8) Medications are disposed in accordance X
with state and federal law
(9) Written record of the disposal of X
medications is maintained and includes:
(a) description and amount
8
(b) name
(c) reason
(d) method
(e) staff & witness signature
(10) Written record of the administration of X
medication includes:
(a) name
(b) description
(c) dates and times
(d) missed doses
(e) medication disposed
(f) method of administration
(g) ID of person administering
(h) possible adverse reactions
(i) medication taken outside facility
Extracurricular, Enrichment, Cultural &
Corrective Action
Social Activities Yes No N/A Corrective Actions/Comments
Completed
413-215-0554
(2) Children have ongoing opportunities to X
participate in at least one age-appropriate or
developmentally appropriate activity
Minimum Staffing Requirements Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0561 Completed
(1)&(2) Supervision is adequate for the type X
of program, location, age and type of
children, ability of supervisor to respond,
electronic back-up systems.
Minimum ratios are maintained:
Under 30 months of age: 1:4
30 months to ˃ 6 yrs. or non-ambulatory: 1:6
Ages 6 and older: 1:7
Overnight (staff awake)
1:10
(4)(a) When one staff on duty, there is X
additional staff immediately available with
max response time of 30 minutes
(5) There is at least one on-site employee X
authorized to apply the reasonable and
prudent parent standard
Separation of Residents Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0566 Completed
9
(1) Children are in separate bedrooms than X
adults, unless parent and child, or there is
written approval from guardian/parent and
licensing coordinator
(2) There is adequate supervision of children X
if both males and females are served by the
program
Personnel Files Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0061 Completed
Staff Name/Position X
(3)(g) Date of Hire X
(3)(a) record of education, training and X
previous employment
(1)(b) & (3)(b) reference checks completed X
and documented
(1)(a) & (3)(c) Background check completed X
and documented
(3)(d) Annual performance evaluations X
(3)(f) Record of personnel actions X
(3)(g) Termination date, reason for X
termination
(3)(h) Current job description (1)(c) X
Employee meets minimum qualifications
stated in current job description
New Employee Orientation – Umbrella
Corrective Action
Requirements (30 days) Yes No N/A Corrective Actions/Comments
Completed
413-215-0061(4)
(a) Agency policies and procedures X
(b) Ethical and professional guidelines X
(c) Organizational lines of authority X
(d) Attributes of population served X
New Employee Orientation – Umbrella Requirements (30
(e) & (5)(a) to (c) Mandatory reporting that X days) 413-215-0061(4) (a) Agency policies and
includes: procedures(d) Attributes of population served.
(a) legal definition of child abuse ORS
419B.005, Oregon Laws 2016, chapter 106,
section 36
(b) legal responsibility to immediately report
10
(c) legal responsibility to report is personal to
the employee
(f) Privacy laws X
(g) Emergency procedures X
New Employee Orientation – Residential
Corrective Action
(30 days) Yes No N/A Corrective Actions/Comments
Completed
413-215-0556
(1)(a) Discipline and behavior management X
including de-escalation, crisis prevention,
positive behavior management, and
disciplinary techniques that are non-punitive
in nature
(1)(b) Restraint and seclusion (if applicable) X
Ongoing Training Corrective Action
Yes No N/A Corrective Actions/Comments
Completed
413-215-0536(2)(b) Employees who handle X
food served to children have a valid food
handler’s card
413-215-0541(5)(a) Employees transporting X
children have: current driver’s license,
insurance, trained in emergency procedures
and behavior management, and training for
15+ passenger vans if applicable)
413-215-0556(2)(a) Environmental X
emergencies
413-215-0556(2)(b) Universal Precautions X
413-215-0556(2)(c) Discipline and Behavior X
Management
413-215-0556(3) Staff providing direct care X
must maintain current CPR/First Aid
certification
413-215-0556(4) Designated staff authorized X
to apply reasonable and prudent parent
standard are trained in application of the
standard
413-215-0061(5) Mandatory reporting
(annually) that includes:
(a) legal definition of child abuse ORS
X
419B.005, Oregon Laws 2016, chapter 106,
section 36
(b) legal responsibility to immediately report
11
(c) legal responsibility to report is personal to
the employee
Comments:
Children’s Records Corrective Action
Yes No N/A Corrective Actions/Comments
Completed
Health Services
413-215-0546
(2) Medical history obtained within 30 days X
(significant findings, current immunizations,
history of surgical procedures-health issues-
injuries, allergies, dental, vision, hearing,
behavioral health, and physician orders)
(2)(e) Documentation of age-appropriate X
instruction – pregnancy prevention, nutrition,
prevention of HIV & AIDS, and prevention
and treatment of sexually transmitted
disease
(4)(a) to (f) Medical exams (3 in first year of
life, 2,4,6,9,14) X
Consents Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0576(1) Completed
(a) Provide routine and emergency medical X
care
(b) Use the discipline and behavior X
management system
(c) Use restraint or seclusion (if applicable).
Consents 413-215-0576(1) (c) Use restraint or seclusion (if
Must specify the reasons for the intervention X
applicable). Must specify the reasons for the intervention
and how staff are trained and supervised
and how staff are trained and supervised
(d) Restrict contact with persons outside of X  The consents signed by guardians did not specify
the agency the reasons for the intervention and how staff are
(e) Allow access as defined in 413-215-0091 X trained and supervised.
& 0101
(f) Impose a dress code X
(g) Apply the reasonable and prudent parent X
standard
12
Disclosures
Corrective Action
413-215-0576(2) Parent/guardian has Yes No N/A Corrective Actions/Comments
Completed
acknowledged in writing:
(a) Information regarding personal or room X
searches and protocols for confiscation of
contraband
(b) Statement of Rights of Children and X
Parents/Guardians
(c) Any policies and procedures upon X
request
Authorizations Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0576(3) Completed
(a) Disclose or exchange information with X
others
(b) Child specific visitors X
(c) Visitation resources are pre-approved X
(d) Activity specific authorizations are pre- X
approved to allow children to participate in
potentially hazardous activities, including but
not limited to using motorized yard
equipment, swimming, and horseback riding.
Information about Children in Care
Corrective Action
413-215-0581(1) Summary sheet contains Yes No N/A Corrective Actions/Comments
Completed
the following:
(a)The name, gender, date of birth, religious
X
preference, and previous address
(b) Name and location of previous and X
current school
(c) Date of admission X
(d) Legal custody X
Information about Children in Care
(e) The name, address, and telephone X
413-215-0581(1) Summary sheet contains the following: (a)
number of:
gender.
(A) The child in care's parents.
 Identification of youths’ gender was not found on the
(B) The child in care's legal guardian, if
summary sheets reviewed.
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 Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0581(2) Completed
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(b) Intake document is completed the date X
child accepted into care (emergency
placement 48 hours)
(d) Assessment is completed within 30 days X
and contains relevant historical info., current
behavioral observations, identified need for
services, and how agency will provide
services
(e) (A)&(B) Service plan within 60 days X
(parent, guardian and child actively
involved). Describes how child’s issues will
be addressed, anticipated outcomes and
reviewed by child and guardian/parent.
(e)(C) & (D) Service plan is reviewed X
quarterly and revised when information
indicates other services should be provided
Case Management Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0581(3) Completed
(a) Services are documented, progress X
toward achieving goals is tracked
(b)-(d) discharge planning and instructions X
(f) Incident Reports X
Financial Records Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0581(4) Completed
Records contain date, amount, source,
X
purpose, signatures
Personal Possessions Records Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0581(5) Completed
Individual written inventory of all personal
possessions is maintained and updated as X
needed
Records and Documentation Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0071 Completed
(1) Stored safely X
(2) Permanent, legible, dated, and signed X
(3) & (4) Uniform in organization, readily X
identifiable and accessible, current, and
complete, containing all required info. No
eraser tape or white out.
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(7) Permanent registry for each child X
includes:
Name
Gender
Birth date
Names, addresses of parents or guardians
Dates of admission
Placement upon discharge
Comments:
*Supplemental Information provided by the CCA as stated above (page 5). Required policy and procedure revisions:
(Please highlight all revisions made to policies prior to resubmitting to the Licensing Coordinator.)
413-215-0046 Licensing Umbrella Rules: Children and Families Rights Policy and Grievance Procedures (Amended 1/1/19)
(1) Rights of children in care and families served by the child-caring agency….. afford the following rights: (a) Except as provided in paragraph
(B) of this subsection, the child in care's right to uncensored communication with legal guardians, caseworkers, legal representatives, and other
persons approved for communication by the legal guardian or as provided in a court order. (A) This right cannot be waived, including voluntarily.
Restriction on communication between a child in care and his or her legal guardian may not be a condition of participation in the program. (B) A
child-caring agency may place reasonable limits on communication, but only as provided in the child-caring agency's policy. Reasonable limits
include, but are not limited to, having set time periods during the day for visitation and phone calls and imposing moderate limits on the duration of
calls or visits. However, a limitation is not considered reasonable if it prevents the ability to meaningfully communicate, such as not allowing contact
with a child in care's attorney during regular business hours. (2) Grievance Procedures. (a)….The procedures must include all of the following: (C)
A procedure to follow, in the event the grievance is filed against the executive director, that ensures that the executive director does not make the
final decision on the grievance. (D) The name, address, and phone number of: (i) A Department licensing coordinator; and (ii) Any other
governmental entities with oversight responsibilities. (b) Grievances and complaints filed with the child-caring agency and all information obtained
in their resolution must be maintained for a minimum of two years and provided to the Department upon request.
 The above required information was not found in the policy submitted.
413-215-0056 Licensing Umbrella Rules: Policies and Procedures (Amended 1/1/19) (1) (a) A written policy on mandatory child abuse reporting,
consistent with ORS 418.257, 418.258, 419B.005, 419B.010, and 419B.015 that includes requirements that child-caring agency employees, staff,
contractors, agents, and proctor foster parents do all of the following: (A) Immediately report suspected child abuse directly to the Department via
the child abuse reporting hotline. (B) Receive child-caring agency-provided training on mandatory abuse reporting requirements as part of employee
orientation and at least annually thereafter as described in OAR 413-215-0061. (C) Receive child-caring agency-provided training on the definitions
of child abuse in ORS 418.257 and 419B.005 that apply in child-caring agencies.
 The above stated information was not found in the policy submitted.
15
 In the policy it states, “Action 1 HHS Staff member immediately and without delay reports this information to their supervisor or manager.”
Staff must immediately report child abuse to the child abuse hotline prior to notifying their supervisor. It is recommended to add the state
child abuse hotline phone number as this is no longer called into local offices. The phone number is 1-855-503-7233. The Statewide Child
Abuse Hotline is open 365 days a year and is open 24 hours a day.
413-215-0061 Licensing Umbrella Rules: Personnel (Amended 1/1/19) (1) Staff requirements and hiring. To ensure that the child-caring agency
uses only staff and volunteers who do not jeopardize the health, safety, or welfare of children, a child-caring agency and its contractors must meet all
of the following requirements: (a) Comply with the Department's background check rules at OAR 407-007-0200 to 407-007-0370. (b) Obtain
reference checks. (c) Employ individuals who meet the staff minimum qualifications as stated in the current job description. (2) Personnel policies of
the child-caring agency and its contractors must include all of the following: (a) For each staff position, a job title and a written job description that
defines the qualifications, duties, and lines of authority for the position. (b) A staff development plan providing for opportunities for professional
growth through supervision, training, and experience. (c) Procedures for a written annual evaluation of the work and performance of each staff
member that include provision for employee participation in the evaluation process. (d) A description of the termination procedures established for
resignation, retirement, and dismissal. (e) A written grievance procedure for staff.
 The Volunteer Policy states, “Volunteers who have past criminal charges and/or convictions must be approved in advance by the Division
Manager taking into account consideration of the length of time that has passed since the criminal conduct, the seriousness of the conduct,
the rehabilitation and restorative steps taken by the individual, and the individual’s history of integrity, contribution, and good woks since the
incident.” Volunteers’ criminal history check must be run by the ODHS Background Check Unit (BCU) the same as a potential staff, and only
the BCU is allowed to make the final fitness determination. The Phoenix program may screen further, and potentially deny prospective
volunteers, after prospective volunteers have been approved by the BCU, but the program cannot approve volunteers who have been
denied by the BCU.
 The agency must submit a personnel policy with all of the above required information.
413-215-0066 Privacy (Amended 06/29/18) (4) A person making a report of abuse as required in ORS 418.258 and 419B.010 may include
references to otherwise confidential information for the sole purpose of making the report.
 The above required information was not found in the policy submitted.
413-215-0073 Licensing Umbrella Rules: Discipline, Behavior Management & Training, and Suicide Prevention (Excluding Adoption Agencies)
(Adopted 07/01/2022) (1) A child-caring agency, except a child-caring agency licensed only to provide adoption services under OAR 413-215-0401
to 413-215-0481, must adopt and adhere to written policies and procedures on discipline, behavior management, and suicide prevention that meet
all of the requirements of this rule. (b) The discipline and behavior management policies and procedures must prohibit the following: (H) Using any
other kind of harsh punishment. (I) Denying a parent, guardian, or sibling the right to visit or communicate with a child in care solely as a
disciplinary measure against the child in care. (J) Aversive conditions, which includes, but is not limited to, any technique designed to or likely to
cause a child physical pain, the application of startling stimuli, and the release of noxious stimuli or toxic sprays, mists, or substances in proximity to
the child in care. (K) Removing or limiting the use of a mobility aid or other assistive device for the purpose of controlling a child in care's behavior.
(3) Behavior Management. (c) Time out. (B) "Time out" must include frequent contact with staff. (C) Rooms used for "time out" must have adequate
space, temperature, light, and ventilation, and must not be capable of locking. (D) "Time out" episodes must be documented in the child in care's
record
 The Behavior Management Policy was missing the above required information.
16
 The Time Out Policy was missing the above required information.
(4) Suicide Prevention. The policy must include the following: (d) Training requirements for staff, including….suicide risk assessment tool training;
(f) Suicide risk assessment procedures on the day of intake; (g) Documentation requirements for suicide ideation, self-harm, and special observation
precautions to ensure immediate communication to all staff; (i) A "post-intervention" plan with identified resources.
 The Policy states, “For youth coming from detention, a suicide risk assessment will have been recently completed.” The DHS Licensing
Rule requires suicide risk assessment procedures are completed on the day of intake. The policy must change to reflect the rule
requirement.
 The policy must state how the agency will ensure “immediately communication to all staff” as stated (g) above.
413-215-0576 Consents, Disclosures, and Authorizations (Amended 02/01/2022) (1) Consents. For each child in care in placement with a
residential care agency, the residential care agency must ensure that a parent or legal guardian signs a consent that authorizes the residential care
agency to undertake each of the following: (a) To provide routine and emergency medical care. However, if the parent or legal guardian relies on
prayer or spiritual means for healing in accordance with the creed or tenets of a well-recognized religion or denomination, the residential care
agency is not required to use medical, psychological or rehabilitative procedures, unless the child in care is old enough to consent to these
procedures and does so. The residential care agency must have policies and procedures for this practice, which are reviewed and approved by the
child in care's parent or legal guardian.
 The above required information was not found in the policy submitted.
413-215-0077 Licensing Umbrella Rules: Restraints and Involuntary Seclusion (Amended 07/01/2022) (13) Reporting Requirements (e) Each
child caring agency shall provide notice regarding how to access the quarterly reports to the parents or guardians of children in care in the
program. The child caring agency shall provide the notice upon the child in care’s admission and at least two times each year thereafter.
 The above requirement was not found in the youth files, documentation must be kept regarding this requirement.
(10) Restraint. (C) Using a physical intervention if: (e) Limitations. The child-caring agency must have a policy that prohibits the application of a
nonviolent restraint to a child in care who has a documented physical condition that would contraindicate the use of that particular restraint, unless
a qualified medical professional has previously and specifically authorized its use in writing for the child in care. Documentation of the authorization
must be maintained in the child of care’s record.
 The above information must be added to the agency’s restraint policy.
Licensing Coordinator’s Signature: ________________________ Date: _8_-_4_-2_0_2__2_ __________
Manager Review: ______________________________________ Date: _ _8_-_3_-2__0_2_2_ ________
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report_type: License Renewals

facility_type: Residential Care

board_chairperson: Joe Berney

program_description:
The Phoenix Program serves youth involved in the Juvenile Justice System who are at risk of being committed to a more
secure setting. The program serves male and female and utilizes a cognitive/behavioral approach. The county subcontracts with Center for Family
Development for therapeutic services. The program has a capacity for 16 and the average length of stay is 4-6 months based upon the youth and
family's needs. School is provided on site by the 4J School District.

program_services: Residential Services

capacity_age_range: The capacity is 16, ages 12-17.

average_length_of_stay: 55 days

number_of_children_served_annually: 28 youth

interviews_observations:
Interviews: During the review, Timothy Davis, Program Director, was informally interviewed, as he assisted with the walk-through of the facility.
Three youth were privately interviewed by Holly Ivey, Licensing Coordinator. When asked what they appreciated most about the Phoenix Program
the youth reported: "The staff are super welcoming, it's nice not to be homeless, staff teach you new skills, staff take time out of their day to hang
out and find out about the interests the kids have." All youth reported getting enough food at the program and daily snacks. All youth reported
having daily private phone contact with their approved contacts. Visits at the program with approved contacts were reported to happen every
Thursday and Sunday. The youth reported the following recreational activities: "Playing: basketball, ping pong, and board games, going on outings,
mini-golfing, going to parks as a group, and watching movies." All youth reported hygiene products were provided by the program. When the youth
were asked what they would change about the program, they reported: "The food would be home cooked, I would prefer the food to have more
seasoning and to taste better, and there would be community visits with family." All youth reported feeling safe at the program and respected by
the staff. One youth stated, "I am treated respectfully here, even if I'm not being respectful, staff talk respectfully to me."
Observations: A walk-through of the program was conducted in all areas where youth were allowed access. The program was well kept and
observed to be clean and in good repair. It was reported that youth are assigned a daily chore, to assist with the cleaning of the program. A
contracted agency in the Lane County Detention Facility is responsible for all meals, which are prepared in the detention facilities kitchen. Meals
are brought from detention to the Phoenix Program's kitchen at mealtime. The DHS Licensing Coordinator did not observe the Lane County
Detention Kitchen. The kitchen at the Phoenix Program was clean and in good repair. The DHS Licensing Coordinator observed food in the
refrigerator, and snacks available for the youth. The DHS Licensing Coordinator observed the van that staff utilizes to transport youth in the
program. There were no deficiencies observed with the vehicle.

program_strengths:
The following strengths were identified by the Program Leadership at the time of the review:
- "The Phoenix program is a program that is dedicated to helping youth and their families/guardians learn and use new skills so that when
they transition to the community, they will have created a healthier environment with improved communication. We do this by providing
family and individual therapy, competency groups, diversity groups, and prosocial recreational opportunities.
- Another strength we have is our program staff. The staff in our program have a passion to guide and mentor our youth and are able to see
and build on the strengths of the youth. They do an excellent job of creating rapport while maintaining professional boundaries. Staff are
continuously innovating and coming up with strategic and creative ways to help youth achieve their goals.
- The Phoenix Program is currently reviewing evidence-based assessment tools and curriculum to effectively measure youth success, meet
the individual needs of each youth and their families/guardians, and reduce criminogenic risk factors specific to each youth.
- The program is currently participating in Performance Based Standards (PBS) evaluation services in an effort to ensure we are following
best practices and our program structure meets industry standards. This year the program plans to implement a residential care-giving
database that will streamline our workflows, data entry, and allow us to maintain paperless youth files.
- This year the program plans to implement a training database platform which will allow us to efficiently monitor and implement onboarding
training for new staff, and ongoing training or career path training for existing staff."
2

program_challenges:
The following strengths were identified by the Program Leadership at the time of the review:
- "A reduction of police referrals and probation adjudications resulting from Covid19 restrictions has reduced the number of youth referred to
the program.
- We have also been looking at ways to effectively engage youth upon intake and reduce crisis or behavior escalation to prevent youth from
running away.
- The program has struggled to retain staff and recruit new staff as a result of Covid19 requirements."

changes_in_last_two_years:
The following changes were identified by the Program Leadership at the time of the review:
- "The program has received a new program supervisor, a program manager, a division manager, and multiple new line staff during the past
two years.
- The program has also moved from the Lane County Health and Human Services Department to a new department called Community Justice
and Rehabilitation Services (CJRS). A new director has been hired for this new department as well."

excerpt:
Documents as indicated on the form titled
“Renewal Licensing Required Documents” The following Renewal Required Documents must be
submitted to the Licensing Coordinator:
 Fire Marshal Inspection (scheduled to occur 8.16.22)
 Resume of the Executive Director.

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

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

excerpt:
&(c) Buildings are
smoke free, clean and in good repair

excerpt:
(3)(a) Evacuation drill occurs monthly under
varying conditions, is retained 2 yrs. and
contains;
(A) identify of person conducting drill
(B) date & time
(C) notification method
(D) staff participating
(E) # of children & staff evacuated
(F) special conditions simulated
(G) problems encountered
(H) time to complete

excerpt:
(a) Agency policies and procedures New Employee Orientation – Umbrella Requirements (30
days) 413-215-0061(4) (a) Agency policies and
procedures(d) Attributes of population served.

excerpt:
(d) Attributes of population served Consents 413-215-0576(1) (c) Use restraint or seclusion (if
applicable). Must specify the reasons for the intervention
and how staff are trained and supervised
 The consents signed by guardians did not specify
the reasons for the intervention and how staff are
trained and supervised.

excerpt:
(a)The name, gender, date of birth, religious
preference, and previous address Information about Children in Care
413-215-0581(1) Summary sheet contains the following: (a)
gender.
 Identification of youths’ gender was not found on the
summary sheets reviewed.