summary: Unannounced - 1 finding

raw_content:
Licensed Child Caring Agency Site Visit Report
Residential Care - Unannounced
Licensee: Calo Programs Missouri, Inc., d.b.a. Embark Date of site visit: 04/15/2025
Behavioral Health – Bend
Executive Director: Diana Teem Licensing Coordinator: Jeff Minden
Program Director: Amber Simmons
Other regulatory or accrediting agencies: Joint Commission Accreditation
Purpose: Per OAR 419-400-0240 (1)(b) Children’s Care Licensing is required to perform at least one unannounced site visit a year
where children in care reside.
Previous findings Repeat findings Comments
Unannounced Site Visit – 5/13/2024 further action
needed
Medication 419-470-0100(10) Written record No Medication Administration Records were reviewed and
of the administration of medication includes: complete. No blanks were noted, and any refused or not
(a) name administered medications had explanations for the reason.
(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
▪ Bend - Blanks were observed on the
Medication Administration Records
(MAR) with no corresponding notation.
Form Rev. 3/12/2025 P a g e 1 | 4
Previous findings Repeat findings Comments
Unannounced Site Visit – 5/13/2024 further action
needed
During the review, this was discussed
with the program RN and they will
increase their weekly audit to 3-4 times
weekly.
Corrective action: The agency shall ensure
medication errors, or anomalies in
documentation, are documented by adding a
notation to the MAR.
This is a repeat violation.
New findings from site visit Comments
None
Form Rev. 3/12/2025 P a g e 2 | 4
Interview summary
2 clients and 2 staff were interviewed as a part of the site visit. One client reported having been at the program for almost 2
months, and the other was close to three months at the program and nearing discharge. Both clients reported liking being at
Embark, feeling safe at the program and liking staff. Both clients reported favorite staff being Violet and Anna, and one client
also noted Lexi as a favorite as well. Both clients reported liking the food, and both spoke highly of dessert nights on
Tuesday’s and Thursday’s. Neither client reported feeling unsafe and both talked about being able to call home when they
wanted and that the calls were private without staff listening in. One client wished that the program had therapy dogs and that
dessert night was every night. The other client wished for more safe space when having groups with other clients, as
sometimes other clients are not respectful of sharing.
Both staff interviewed reporting liking working at Embark Bend. One staff reported being with the program since December,
and the other since December 2023. Both staff reported their favorite part of the job was working with the kids, and one staff
specifically noted how much they liked being able to help clients through hard and sad times. When asked about the most
challenging part of the job one noted that there are a lot of “hoops” to jump through to get new things approved (which they
described as multiple levels of approvals) and the other noted keeping staff focused on their own work and not what other
teams were doing as being difficult. Both staff spoke highly of management, noting specifically that things have improved in
the last few months with the new and recently promoted leadership team. When asked about training, both reported that it was
good and noted that onboard training has improved recently with shift supervisors taking on more responsibility. One staff
wished the program had a bigger budget for outings, as clients really look forward to the weekends and getting to go do things.
The other staff wished the program would replace the bunnies with different therapy animals.
Observations
The program was well maintained, clean and in good shape. The site tour included all areas that clients have access to and
rooms were consistently clean, organized, and in good condition. Furnishings throughout appeared to be well cared for.
Corrective actions and timeframes:
Please submit the following to verify compliance.
Form Rev. 3/12/2025 P a g e 3 | 4
Within 45 days of receipt of this report Embark Behavioral Health – Calo Programs Missouri, Inc. 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 Jeff Minden at
Jeffrey.E.Minden@odhsoha.oregon.gov.
Licensing Coordinator’s signature: ________________________ Date: _4_-2_5_-_2_02_5____________
4-25-2025
Manager review: ______________________________________ Date: __________________
Form Rev. 3/12/2025 P a g e 4 | 4

facility_type: Residential Care - Unannounced

executive_director: Diana Teem

program_director: Amber Simmons

visit_date: 04/15/2025 Behavioral Health - Bend

licensing_coordinator: Jeff Minden

purpose:
Per OAR 419-400-0240 (1)(b) Children's Care Licensing is required to perform at least one unannounced site visit a year
where children in care reside.
Previous findings Repeat findings Comments
Unannounced Site Visit - 5/13/2024 further action
needed
Medication 419-470-0100(10) Written record No Medication Administration Records were reviewed and
of the administration of medication includes: complete. No blanks were noted, and any refused or not
(a) name administered medications had explanations for the reason.
(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
▪ Bend - Blanks were observed on the
Medication Administration Records
(MAR) with no corresponding notation.

Previous findings Repeat findings Comments
Unannounced Site Visit - 5/13/2024 further action
needed
During the review, this was discussed
with the program RN and they will
increase their weekly audit to 3-4 times
weekly.
Corrective action: The agency shall ensure
medication errors, or anomalies in
documentation, are documented by adding a
notation to the MAR.
This is a repeat violation.
New findings from site visit Comments
None

Interview summary
2 clients and 2 staff were interviewed as a part of the site visit. One client reported having been at the program for almost 2
months, and the other was close to three months at the program and nearing discharge. Both clients reported liking being at
Embark, feeling safe at the program and liking staff. Both clients reported favorite staff being Violet and Anna, and one client
also noted Lexi as a favorite as well. Both clients reported liking the food, and both spoke highly of dessert nights on
Tuesday's and Thursday's. Neither client reported feeling unsafe and both talked about being able to call home when they
wanted and that the calls were private without staff listening in. One client wished that the program had therapy dogs and that
dessert night was every night. The other client wished for more safe space when having groups with other clients, as
sometimes other clients are not respectful of sharing.
Both staff interviewed reporting liking working at Embark Bend. One staff reported being with the program since December,
and the other since December 2023. Both staff reported their favorite part of the job was working with the kids, and one staff
specifically noted how much they liked being able to help clients through hard and sad times. When asked about the most
challenging part of the job one noted that there are a lot of "hoops" to jump through to get new things approved (which they
described as multiple levels of approvals) and the other noted keeping staff focused on their own work and not what other
teams were doing as being difficult. Both staff spoke highly of management, noting specifically that things have improved in
the last few months with the new and recently promoted leadership team. When asked about training, both reported that it was
good and noted that onboard training has improved recently with shift supervisors taking on more responsibility. One staff
wished the program had a bigger budget for outings, as clients really look forward to the weekends and getting to go do things.
The other staff wished the program would replace the bunnies with different therapy animals.
Observations
The program was well maintained, clean and in good shape. The site tour included all areas that clients have access to and
rooms were consistently clean, organized, and in good condition. Furnishings throughout appeared to be well cared for.

excerpt:
419-470-0100(10) Written record No Medication Administration Records were reviewed and
of the administration of medication includes: complete. No blanks were noted, and any refused or not
(a) name administered medications had explanations for the reason.
(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
▪ Bend - Blanks were observed on the
Medication Administration Records
(MAR) with no corresponding notation.
Previous findings Repeat findings Comments
Unannounced Site Visit - 5/13/2024 further action
needed
During the review, this was discussed
with the program RN and they will
increase their weekly audit to 3-4 times
weekly.
Corrective action: The agency shall ensure
medication errors, or anomalies in
documentation, are documented by adding a
notation to the MAR.
This is a repeat violation.
New findings from site visit Comments
None
None


state: OR

summary: License Renewals - 25 findings

raw_content:
Licensed Child Caring Agency Site Visit Report
Residential Care & Foster Care
Licensee: Connections365 Board Chairperson: Priscilla Sattergren
Executive Director: Debby Lute Date of site visit: 6.13.2023
Program Director: Brandi Haws Licensing Coordinator: Jorge Pelinski & Mary Torres
Other Regulatory or Accrediting Agencies:
Program Compliance: The program was found to be compliant or will be compliant with OAR 419-400-0005 to 419-400-0310, Licensing Umbrella
Rules, and OAR 419-470-0010 to 419-470-0180, Licensing Residential Care Agencies Rules. Personnel records were reviewed and compliance
with required background checks was documented for employees in all programs.
Program Description(s): As summarized by the program’s website, Connections365 offers therapeutic foster care for youth referred through
various programs affiliated with the Oregon Youth Authority, the Oregon Department of Human Services, and the Clackamas County Juvenile
Department. Therapeutic foster homes (also known as “Proctor Homes”) provide a stable environment for youth to live and receive services, with
the goal of transitioning back into the community. These homes provide a higher level of care and supervision than “typical” foster homes, due to
the specialized needs of the youth.
Connections365 operates two residential programs, Project 180 and the Continuum. Young men are referred to these programs through Oregon’s
juvenile justice system and are provided with all basic living needs, as well as individualized services to address personal areas of growth. These
programs provide at-risk youth with the stability they need to return to a residential or community placement rather than being committed to a
correctional facility.
Placements in Project 180 vary from seven to 90 days, depending on the youth’s ongoing needs. This program provides a staffed, secure, and
structured living environment for youth in crisis. Program hallmarks are immediate response to referrals, quick placement, and thorough evaluation
of the youth offender in preparation for his next placement.
The Continuum provides a 24/7 secure structured living environment with an intensive transition process both into the program and from the
program.
P a g e 1 | 35
Form Rev. 04/18/2023
Program type and services: Continued information from the program’s website: Treatment Foster Care Connections365 provides all youth in
therapeutic foster care with counseling (individual, family, and group, as necessary), educational support, vocational support, and skill building
curriculum. Each youth is provided with an individualized service plan, and the therapeutic foster homes work directly alongside Connections365
case managers, counselors, mentors, and other staff to implement each client’s plan. Youth residing in either the program’s Intensive Residential –
Non-Qualified Residential Treatment Program (QRTP) or Intensive Behavioral Services (IBS) – Non-Qualified Residential Treatment Program
(QRTP) receive care and direction from the program’s round-the-clock staff. Educational services are provided through online schooling, and case
management and counseling are provided by Connections365. Services include individual, family, and group counseling, educational and
vocational support, and evidence-based skill building curriculum. Services for medical/dental/vision, medication management and drug and alcohol
treatment are accessed through community providers.
Capacity and Age Range:
Foster Care – (Age Range 7-20)
Project 180 (residential) – Capacity – 5 (Age Range 12-20)
The Continuum (residential)- Capacity - 4 (Age Range – 12-20)
Funding sources: Oregon Department of Human Services (ODHS) – Child Welfare Treatment Services, Oregon Youth Authority (OYA), grants,
fundraisers
Contracts and sources for referrals: Oregon Department of Human Services (ODHS) – Child Welfare Treatment Services, Oregon Youth
Authority (OYA), Clackamas County Juvenile Department
Average length of stay: Therapeutic Foster Care – 1.5 year Continuum - 1 year Project 180 – 60 to 90 days
Average daily population served: 4
Number of children served annually: Project 180 – 18 Continuum – 6 Therapeutic Foster Care – 8
Use of seclusion or restraint: Connections365 does not use seclusion or restraints. De-escalation training for staff and foster parents is
completed through Crisis Prevention Institute (CPI) training and Collaborative Problem Solving (CPS).
Interviews: Opening interview was held with the program’s Executive Director, Debby Lute, and Program Director, Brandi Haws. An update
regarding the program staffing and status on the three programs were discussed. They shared that due to staffing shortages they are only able to
staff 5 youth currently. As staff numbers increase the census of the youth will be increased.
P a g e 2 | 35
Form Rev. 04/18/2023
A resident of the Continuum site was interviewed during the visit. The resident reports being in program for over a year and has no immediate plans
for discharge while his probation officer locates an appropriate placement. While in the program, the resident was able to graduate high
school. The youth reports feeling safe during his stay in the program, except when peers “freak out.” The youth reports that staff handle these
types of situations well, having all other youth go to their rooms until the situation has deescalated. Staff will reach out to the on-call worker for extra
assistance if needed and will check in on youth who were sent to their rooms. Strengths of the program included staff keeping youth “in check” and
not talking to youth “like a child.” A change that this resident would like to see made is allowing more flexibility in supervision. Examples given were
accessing bedrooms and bathrooms without asking staff to unlock the doors.
Two proctor parents participated in the interview process. Both have been foster parents for more than ten years. Both foster parents shared that
things have been going well overall. They receive annual trainings and are visited regularly by the program personnel who conduct walk-throughs
and safety checks. Both proctor parents feel like they receive enough information about children prior to them coming into the home. They also feel
supported by the program when children exhibit struggling behavior in their homes. Both foster parents shared that they appreciate the overall
support that the program provides. One thing one foster parent would change about the program is being able to have more homes as they
expressed there are a lot of kids out there that need homes. The other foster parent shared that they would like more clarity on some of the general
resources available for children, such as clothing. They also mentioned that sometimes the therapists change and foster parents are not sure who
to always go through to find the right personnel. Both proctor parents feel like they can express their needs and concerns with the program. They
both feel like the program does a great job of meeting the needs to the best of their abilities.
Observations:
Staff and youth were observed at the programs during the inspection. The youth that were at the programs, appeared to be at ease and comfortable
in the environments. All areas of the programs (inside and outside) where youth had access were observed to be well kept, clean and in good
repair. One of the agency vehicles that the youth ride in was observed and met the requirements per Licensing Rules. The kitchens at both
residential sites were observed to have adequate food. Medication was observed to be in locked medication carts in locked rooms which were
inaccessible to the youth.
Program Strengths: Program Director, Brandi Haws talked about how committed staff are to their jobs and they desire for more training. Brandi
shared that the staff work well together and value the work that they do with the kids. The Executive Director shared that they feel like they have
good support from the Board of Directors, and they look forward to expanding the number of Board Members. Recently two youth have graduated
from the program.
Program Challenges: Executive Director Debby Lute shared that hiring new staff continues to be a challenge.
Changes that have occurred in the last 2 years: Executive Director Debby Lute talked about the challenges with hiring staff and low wages for
staff.
Lawsuits: 1 – There is a pending litigation involving a former youth from twenty years ago.
Grievances and complaints filed in the last two years: None as reported by the program.
P a g e 3 | 35
Form Rev. 04/18/2023
Corrective Actions and Timeframes: Please submit the following to verify compliance.
Within 45 days of receipt of this report (insert name of agency) 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 Jorge Pelinski @ jorge.l.pelinski@odhsoha.oregon.gov
Recommendations: None
Exceptions: Over the last licensing period the program requested and was granted two exceptions. Both exceptions were related to foster care. For
this next licensing period the program has renewed one of the exceptions until July 2025.
Changes in License: N/A
Residential
Summary of Review
Program and Services
Yes No N/A Corrective Actions/Comments
419-400-0020 (2)
Program and services are in scope of license x
Governance of the Agency
Yes No N/A Corrective Actions/Comments
419-400-0040
(1)(a) Minimum of 5 board members x
(2)(f) Formally evaluate the exec. Director’s
x
performance annually
(2)(g) Approves annual budget x
(2)(h) Obtain and review an annual
independent financial review or audit of x
financial records.
(2)(k) Written quality improvement program x
(2)(l) Meeting minutes x
Executive Director or Program Director
Yes No N/A Corrective Actions/Comments
419-400-0040
P a g e 4 | 35
Form Rev. 04/18/2023
(3)(a) knowledge of requirements for
providing care and treatment appropriate to x
programs
(3)(g) Approval from BCU x
Discipline, Behavior Management, and
Suicide Prevention Yes No N/A Corrective Actions/Comments
419-400-0150
(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)
Yes No N/A Corrective Actions/Comments
419-400-0120(6)
(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
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
(11)(d) Each child caring agency that
submits a report under this section shall
x
make its quarterly report available to the
public upon request at the Child Caring
P a g e 5 | 35
Form Rev. 04/18/2023
Agency’s main office and on the child caring
agency’s website if applicable.
Supplemental Information Provided by
Yes No N/A Corrective Actions/Comments
CCA
Documents as indicated on the form titled
x *See comments section below
“Renewal Licensing Required Documents”
Documents as indicated on form titled
“Required Financial Documents and x
Information”
All required policies and procedures as
x *See comments section below
identified in the “Umbrella Rules”
All required policies and procedures as
x *See comments section below
identified in “Agency Type Specific Rules”
Physical Plant
Yes No N/A Corrective Actions/Comments
419-400-0090(3)(a) Foster Rights Posted (if
x
children in DHS custody)
419-400-0100(1) Sufficient safe space,
x
equipment, and office equipment
419-400-0230(12) License is posted in
x
common area at each facility
419-470-0020(2)(a) &(c) Buildings are
x
smoke free, clean and in good repair
419-470-0020 (2)(d) Rooms are free of
x
harmful drafts, odors, and excessive noise
419-470-0020 (2)(e) Rooms are adequate in
x
size and arrangement
419-470-0020 (2)(f) System provides a
continuous supply of hot and cold water to x
taps located throughout the facility
419-470-0020 (2)(h) Building is well
ventilated and room temperature is within a x
normal comfort range
419-470-0030 (1) All parts of the facility
x
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 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, kitchen, x
and dining areas
P a g e 6 | 35
Form Rev. 04/18/2023
(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.
(Hazardous materials are properly labeled, in
original container and locked)
(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) Time-out rooms: Rooms used for time x
out or quiet time must have adequate space,
heat, light and ventilation and must not be
capable of locking.
Room and Space Requirements
Bedrooms Yes No N/A Corrective Actions/Comments
419-470-0030(3)
(a) Adequate furnishings and personal items x
(b) Separate from rooms used for dining,
x
living, laundry, kitchen, and storage
(c) Meet Oregon Fire Code Requirements x
(d) Be an outside room, with a window that
operates as designed. If the window is
modified from its original design, the fire
x
marshal must 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 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
P a g e 7 | 35
Form Rev. 04/18/2023
(b)&(c) Wooden racks on floors are
prohibited and impervious shower mats are
x
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 activities
x
related to eating and food preparation
activities
(b) Walls, floors are easily cleanable x
(c) Equipment and utensils are easily
x
cleanable, durable, nontoxic, and kept clean
(e) Equipment is easy to clean beneath,
x
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 mattress.
x
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
Yes No N/A Corrective Actions/Comments
419-470-0070
(1)(a) Meals are arranged daily, consistent
with normal mealtimes that occur during the
x
hours of operation and provide snacks
between mealtimes
(1)(b) Menus are prepared in advance in
accordance with USDA guidelines, provide a
x
variety of foods and are adjusted for
seasonal changes including snacks
(1)(b) Menus are kept for at least 6 months x
P a g e 8 | 35
Form Rev. 04/18/2023
(1)(c) Drinking water is freely available x
(2)(a) Food is stored, prepared & served in a
x
sanitary manner
(2)(c) & (d) Food products are obtained from
commercial suppliers (exception of fruits &
vegetables), unpasteurized juice is x
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 includes x
(a) Identifying the types of emergencies most
likely to happen where the residential care x
agency is located
(b) Identifying a place to meet for each type
x
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 recover
x
after a disaster
(3) Telephone numbers for local police, fire
department, poison control, after hours
medical advice and other appropriate x
emergency numbers must be posted near all
telephones.
(4) Operative flashlights sufficient in number
x
are 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 & time
(C) notification method x
(D) staff participating
(E) # of children & staff evacuated
(F) special conditions simulated
(G) problems encountered
(H) time to complete
Umbrella Safety
Yes No N/A Corrective Actions/Comments
419-400-0200
(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
P a g e 9 | 35
Form Rev. 04/18/2023
(1)(b)(A) Each vehicle used to transport a x
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 swimming x
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 obtaining consents,
assessing swimming ability of children in
care, and ensuring the safety of pool access.
(4)(a) The program protects children from x
potentially harmful items and materials.
(4)(b) Direct supervision of children who do x
not have the ability to adjust and control
water temperature
(4)(c) Light fixtures have protective covers x
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 original container with x
prescription 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
qualified medical professional. A written x
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
x
locking mechanisms. This does not apply to
Naloxone.
(8) Medications are disposed in accordance
x
with state and federal law
(9) Written record of the disposal of
medications is maintained and includes:
x
(a) description and amount
(b) name
P a g e 10 | 35
Form Rev. 04/18/2023
(c) reason
(d) method
(e) staff & witness signature
(10) Written record of the administration of
medication includes:
(a) name
(b) description
(c) dates and times
(d) missed doses x
(e) medication disposed
(f) method of administration
(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 opportunities to x
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 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 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 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
Sleeping Arrangements
Yes No N/A Corrective Actions/Comments
419-470-0140
(1) Children are in separate bedrooms than x
adults, unless parent and child, or there is
P a g e 11 | 35
Form Rev. 04/18/2023
written approval from guardian/parent and
licensing coordinator
(2) There is adequate supervision of children x
when sleeping
(3) When assigning bedrooms a residential x
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
(3)(g) Date of Hire x
(3)(a) record of education, training, and
x
previous employment
One Reference checks was not found.
(1)(b) & (3)(b) reference checks completed Corrective Action:
x
and documented • Ensure a process where all reference checks are completed and
documented moving forward.
(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)
Employee meets minimum qualifications x
stated in current job description
New Employee Orientation – Umbrella
Requirements (30 days) Yes No N/A Corrective Actions/Comments
419-400-0120(4)
(a) Agency policies and procedures x
(b) Ethical and professional guidelines x
(c) Suicide prevention and intervention x
Documentation of this training was not found in the files reviewed. In speaking to
(d) Attributes of population served x
the Executive Director, the topic is covered during employee orientation.
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Corrective Action:
• Agency will consistently document Attributes of population served in staff
training records.
(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
One file did not have documentation of training on privacy laws.
(f) Privacy laws x Corrective Action:
• Agency will document attributes of population serving in staff training
records moving forward.
(g) Emergency procedures x
New Employee Orientation
Residential (Prior to working alone and
Yes No N/A Corrective Actions/Comments
within 30 days)
419-470-0120(1)
(a) Discipline and behavior management
including de-escalation, crisis prevention,
positive behavior management, and x
disciplinary techniques that are non-punitive
in nature
(b) CPR and First Aid sufficient to retain a
x
current certification
(c) Universal precautions and hygiene x
Documentation of training on the application of the reasonable and prudent parent
standard was not found in one record that was reviewed.
(d) Application of the reasonable and Corrective Action:
x
prudent parent standard • Agency will document training on the application of the reasonable and
prudent parent standard in staff training records consistently moving
forward.
(e) Training on the agency’s policy on
suicide prevention and suicide risk x
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
x
training in person from a certified instructor,
P a g e 13 | 35
Form Rev. 04/18/2023
including but not limited to a minimum of six
hours of training focused on positive
behavior support, nonviolent crisis
intervention and other methods of
nonphysical intervention to support children
in care during a crisis
(d) Receive a certificate that states:
(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 x
(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 One employee’s food handler’s card was expired.
food served to children have a valid food
x
handler’s card Corrective Action:
• Agency will ensure that employees retain a current food handler’s card.
419-400-0200 (1) Employees transporting
children have: current driver’s license,
insurance, trained in emergency procedures x
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 Precautions x
419-470-0120 (2)(c) Discipline and Behavior
x
Management
419-470-0120 (2)(d) Agency’s policy on
x
suicide prevention and risk assessment tool
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Form Rev. 04/18/2023
419-470-0120 (3) Staff providing direct care
must maintain current CPR/First Aid x
certification
419-470-0120 (4) Designated staff
authorized to apply reasonable and prudent
x
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
x
intervention training) from a certified
instructor on an annual basis
Comments:
Children’s Records Yes No N/A Corrective Actions/Comments
Health Services
419-470-0090
(2) Medical history obtained within 30 days Program depends on information provided by OYA and Child Welfare captured in
(significant findings, current immunizations, the referral paperwork.
history of surgical procedures-health issues- x
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) 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.
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Consents
Yes No N/A Corrective Actions/Comments
419-470-0160(1)
(a) Provide routine and emergency medical
x
care
(b) Use the discipline and behavior
x
management system
(c) Use restraint or seclusion (if applicable).
Must specify the reasons for the intervention x
and how staff are trained and supervised
(d) Restrict contact with persons outside of
x
the agency
(e) Allow access as defined in 419-400-0230
x
& 0240
(f) Impose a dress code x
(g) Apply the reasonable and prudent parent
x
standard
Disclosures
419-470-0160(2) Yes No N/A Corrective Actions/Comments
Parent/guardian has acknowledged in writing:
(a) Information regarding personal or room
searches and protocols for confiscation of x
contraband
(b) Statement of Rights of Children and
x
Parents/Guardians
4 files were found to not reflect this required disclosure.
(c) Any policies and procedures upon request x Repeat Finding:
• Agency will ensure that this disclosure is in their current intake packet and
utilized moving forward.
Authorizations
Yes No N/A Corrective Actions/Comments
419-470-0160(3)
(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-
approved to allow children to participate in
potentially hazardous activities, including but x
not limited to using motorized yard
equipment, swimming, and horseback riding.
Information about Children in Care
419-400-0190(1) Yes No N/A Corrective Actions/Comments
Summary sheet contains the following:
(a)The name, gender, date of birth, religious
x
preference, and previous address
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Form Rev. 04/18/2023
(b) Name and location of previous and
x
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 guardian, if
different than the parents, and a copy of
x
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 N/A Corrective Actions/Comments
419-470-0170(2)
(b) Intake document is completed the date
child accepted into care (emergency x
placement 48 hours)
(d) Assessment is completed within 30 days
and contains relevant historical info., current
behavioral observations, identified need for x
services, and how agency will provide
services
(e) (A)&(B) Service plan within 60 days
(parent, guardian and child actively involved).
Describes how child’s issues will be x
addressed, anticipated outcomes, and
reviewed by child and guardian/parent.
(e)(C)&(D) Service plan is reviewed quarterly
and revised when information indicates other x
services should be provided
Case Management
Yes No N/A Corrective Actions/Comments
419-470-0170(3)
(a) Services are documented, progress
x
toward achieving goals is tracked
(c) Discharge summary must include:
(A)Current medications
(B)Name of the physician or qualified medical One file’s discharge summary did not have current medications.
professional who prescribed each medication
(C)Any outstanding medical or other x Corrective Action:
appointments • Agency will ensure that current medications are listed in discharge
(D)Summary of the child’s participation in the summaries moving forward.
program and progress achieved
(E)Results of evaluations
P a g e 17 | 35
Form Rev. 04/18/2023
(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
The agency does not have a process for providing access to quarterly reports for
419-400-0180(13)(e) Each child caring
parents or guardians of children.
agency shall provide notice regarding how to
access the quarterly reports to the parents or
Corrective Action:
guardians of children in care in the program. x
• Agency will create a process for providing access to quarterly reports for
The child caring agency shall provide the
parents and guardians of children. Licensing provided an example for the
notice upon the child in care’s admission and
agency.
at least two times each year thereafter.
The agency does not have a process for providing information to children in care
relating to suspected inappropriate use of restraint & seclusion.
419-400-0190(1) Information provided to
Corrective Action:
children in care relating to Restraint & x
• The agency will create a process for providing information to children in
Involuntary Seclusion
care relating to suspected inappropriate use of restraint & seclusion.
Licensing provided an example for the agency.
Financial Records
Yes No N/A Corrective Actions/Comments
419-470-0170(4)
Records contain date, amount, source,
x
purpose, signatures
Personal Possessions Records
Yes No N/A Corrective Actions/Comments
419-470-0170 (5)
Individual written inventory of all personal
possessions is maintained and updated as x
needed
Records and Documentation
Yes No N/A Corrective Actions/Comments
419-400-0140
(1) Stored safely x
(2) Permanent, legible, dated, and signed x
(3)&(4) Uniform in organization, readily
identifiable and accessible, current, and
x
complete, containing all required info. No
eraser tape or white out.
(7) Permanent registry for each child
includes:
x
Name
Gender
P a g e 18 | 35
Form Rev. 04/18/2023
Birth date
Names, addresses of parents or guardians
Dates of admission
Placement upon discharge
419-400-0090
Licensing Umbrella Rules: Children and Families Rights Policy and Grievance Procedures
(2) Grievance Procedures.
(a) A child-caring agency must create and adhere to written procedures for the children in care and families the child-caring agency serves to submit a grievance.
The procedures must include all of the following:
(D) The name, address, and phone number of:
Department of Human Services
Salem, Oregon 97301
201 High Street SE, Suite 500
(i) A Department licensing coordinator; and
Jorge Pelinski – (503)480-9530
The program’s grievance policy didn’t meet the above requirements, and the missing info must be added.
419-470-0100
Medication
A residential care agency must meet all of the following requirements:
(1) Policy and procedures. The residential care agency must have policies and procedures that cover all prescription and non-prescription medications and
that address all of the following:
(c) How the staff of the residential care agency who administer medication will be trained.
The program was missing the above required info in its Medication Policy, and it must be added.
419-400-0120
Licensing Umbrella Rules: Personnel
P a g e 19 | 35
Form Rev. 04/18/2023
(2) Personnel policies of the child-caring agency and its contractors must include 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.
The program was missing the above required information in its Personnel Policy, and it must be added.
419-400-0150
Licensing Umbrella Rules: Discipline, Behavior Management & Training, and Suicide Prevention (Excluding Adoption Agencies)
(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.
The program was missing the above required info in its Discipline, Behavior Management & Training, and Suicide Prevention Policy, and
it must be added.
419-400-0150
Licensing Umbrella Rules: Discipline, Behavior Management & Training, and Suicide Prevention (Excluding Adoption Agencies)
(4) Suicide Prevention. The policy must include the following:
(g) Documentation requirements for suicide ideation, self-harm, and special observation precautions to ensure immediate communication to all staff;
The program was missing the above requirement for Discipline, Behavior Management & Training, and Suicide Prevention, and must be
added.
419-400-0180
Licensing Umbrella Rules: Restraints and Involuntary Seclusion
(13) Reporting Requirements
(e) Each child caring agency shall provide notice regarding how to access the quarterly reports to the parents or guardians of children in care in the program. The
child caring agency shall provide the notice upon the child in care’s admission and at least two times each year thereafter.
The program was missing the above requirement for Restraints and Involuntary Seclusion, and it must provide notice regarding how to
access the quarterly reports to the parents or guardians of children in care in the program.
P a g e 20 | 35
Form Rev. 04/18/2023
Foster Care
Summary of Review
Program and Services
Yes No N/A Corrective Actions/Comments
419-400-0020 (2)
Program and services are in scope of license x
Governance of the Agency
Yes No N/A Corrective Actions/Comments
419-400-0040
(1)(a) Minimum of 5 board members x
(2)(f) Formally evaluate the exec. Director’s performance annually x
(2)(h) Obtain and review an annual independent financial review or
x
audit of financial records.
(2)(k) Written quality improvement program x
(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 x
Discipline, Behavior Management, and Suicide Prevention
Yes No N/A Corrective Actions/Comments
419-400-0150
(3) Agency uses appropriate and positive methods of behavior
x
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 capable of locking) and documents use x
in child’s record when applicable
(3)(e) Agency uses seclusion appropriately/consistent with policy x
(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
and Chapter 413 division 215
(b)(B) Contract includes the following:
x
(i) Services provided
P a g e 21 | 35
Form Rev. 04/18/2023
(ii) Contractor fees
(iii) Disclosure of information from contractor to agency
(iv) Lines of authority
(v) Adherence to rules, including background check
(vi) Any liability of the agency for acts of the contractor, rights of
indemnity and limitations on liability
Restraints and Involuntary Seclusion
Yes No N/A Corrective Actions/Comments
419-400-0180
(11)(d) Each child caring agency that submits a report under this x
section 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 Provided by CCA Yes No N/A Corrective Actions/Comments
Documents as indicated on the form titled “Renewal Licensing
x
Required Documents”
Documents as indicated on form titled “Required Financial Documents
x
and Information”
All required policies and procedures as identified in the “Umbrella
x
Rules”
All required policies and procedures as identified in “Agency Type
x
Specific Rules”
Physical Plant Yes No N/A Corrective Actions/Comments
419-400-0090(3)(a) Foster Rights Posted (if children in DHS custody) x
419-400-0100(1) Sufficient safe space, equipment, and office
x
equipment
419-400-0230(12 License is posted in common area at each facility x
Medication
Yes No N/A Corrective Actions/Comments
419-440-0180
(2)&(5)(e) Medications have a prescription and are stored in the
x
original container with prescription label
(3) Medical treatments, special diets, physical therapy, physical aids or
limitations have a written order signed by a physician or qualified x
medical professional.
(4) Self-administering medications by a child is approved in writing by
x
physician, recommended by agency, and closely monitored
(6) Medications are disposed in accordance with state and federal law x
(7) Written record of the disposal of medications includes:
(a) description
(b) name
x
(c) reason
(d) method
(e) staff & witness signature
(10) Written record of the administration of medication includes:
(a) name x
(b) description
P a g e 22 | 35
Form Rev. 04/18/2023
(c) dates, 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
Placement of a Child by Agency
Yes No N/A Corrective Actions/Comments
419-440-0130
(2) Placement is consistent with recommendations in the current home
x
assessment
(3) Home does not exceed:
(a) 4:1 ratio approved proctor foster parent
x
(b) 6:2 ratio approved proctor foster parents
(c) 2 children under the age of 3
(6) At time of placement the agency provides proctor foster home
parents with:
(a) Child’s name, date of birth and reason for placement x
(b) Name and phone# of assigned worker
(c) Information on health, behavioral characteristics and needs of child
(d) Authorization and written instructions for obtaining medical, dental,
x
and other and emergency care
Respite Care
Yes No N/A Corrective Actions/Comments
419-440-0150
(1) Agency has and adheres to a respite care policy x
(2)(a) Alternate caregivers are
(A) at least 21 years of age and x
(B) have completed background checks
(2)(b) Agency approval is received prior to using respite care x
(2)(c) Proctor foster home notifies agency in advance when providing
x
respite care that will exceed max number of children authorized
(2)(d)&(e) Respite care plan for each child and includes emergencies x
Records of Proctor Foster Homes
Yes No N/A Corrective Actions/Comments
419-440-0120
Last Name of Proctor Foster Parent(s) x
(2)(a) Certificate that includes: age range of children, x
restrictions or limitations, and statement that the home meets
standards established in these rules
(2)(b) & 419-440-0040(4) Notification of acceptance or denial of x
application. If denial is due to substantiated abuse, the reason
for denial is disclosed to applicant.
(2)(d) All documents pertaining to formal complaints. See also x
413-215-0336
P a g e 23 | 35
Form Rev. 04/18/2023
(2)(e) and 419-440-0130(5) Signed contract x
(2)(f) List of all children placed that includes identifying and x
placement information
419-440-0130(4) Documentation of the basis for placement
(2)(g) Documentation of home visit (every 90 days) x Two files did not have the required documentation of home
visits (every 90 days).
Repeat Finding:
• The agency will ensure that visits occur every 90 days
and are documented.
(3) Documentation of changes in address, name and household x
composition, and exceptions or suspensions
(4) Documentation of inactive status (if applicable) x
419-440-0030(1)(a) at least 21 years of age x
419-440-0100 Written notice to proctor foster home if x
decertified
Assessment and Approval of Proctor Foster Homes
Written Assessment Yes No N/A Corrective Actions/Comments
419-440-0040
(1)&(2) Assessment is based on an on-site review of the home, x Agency has not had new foster homes during this review period.
observations and interviews of each household member,
background check, any information gathered during
assessment.
(2)(a) Application signed by all applicants x Agency has not had new foster homes during this review period.
(2)(b) Home is primary residence and where each child will x Agency has not had new foster homes during this review period.
reside
(2)(c) Statement of physical and mental health x Agency has not had new foster homes during this review period.
(2)(d) Report from licensed health care or mental health x Agency has not had new foster homes during this review period.
professional if determined appropriate by agency
(2)(e) Minimum of 4 references (only one can be relative) x Agency has not had new foster homes during this review period.
(2)(f) Contact information for 2 individuals if applicant displaced x Agency has not had new foster homes during this review period.
by natural disaster
Assessment and Approval of Proctor Foster Homes
Written Home Study includes the following: Yes No N/A Corrective Actions/Comments
419-440-0040(3)
(b) Names and ages of children in the home and children no x Agency has not had new foster homes during this review period.
longer in the home
(c) Background check for all household members over 18 and x Agency has not had new foster homes during this review period.
those under 18 as determined appropriate
(d) Background check from every state (or country) of x Agency has not had new foster homes during this review period.
residence in last 5 years for household members over 18 and
those under 18 as determined appropriate
(e) Placement preferences x Agency has not had new foster homes during this review period.
(f) Motivation for providing foster care x Agency has not had new foster homes during this review period.
(g) Life experiences and challenges x Agency has not had new foster homes during this review period.
P a g e 24 | 35
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(h) Relevant health history x Agency has not had new foster homes during this review period.
(i) Education and training x Agency has not had new foster homes during this review period.
(j) Employment and finances x Agency has not had new foster homes during this review period.
(k) Current support systems and need for additional support x Agency has not had new foster homes during this review period.
services
(l) Marital history, including previous marriages, divorces, and x Agency has not had new foster homes during this review period.
long-term relationships
(m) Parenting skills and values x Agency has not had new foster homes during this review period.
(n) Lifestyle x Agency has not had new foster homes during this review period.
(o) Religion or spiritual beliefs x Agency has not had new foster homes during this review period.
(p) Cultural background and experiences with diverse cultural x Agency has not had new foster homes during this review period.
groups
(q) Ability to respect spiritual beliefs, sexual orientation, gender x Agency has not had new foster homes during this review period.
identity, and gender expression, disabilities, national origin, and
cultural identities of each child and provide opportunities to
enhance the positive self-concept and understanding of child’s
heritage
(r) Assessment of current and previous licenses, certifications, x Agency has not had new foster homes during this review period.
and other applications for providing care including adults.
Information must include any denials, suspensions revocations,
or terminations
(s) Assessment of the areas in which training is needed and the x Agency has not had new foster homes during this review period.
plan of the agency for providing needed training and
timeframes
(t) Applicant’s home and community x Agency has not had new foster homes during this review period.
(u) Assessment and recommendations including the x Agency has not had new foster homes during this review period.
characteristics and maximum number of children who may be
placed in care
Standards for the Proctor Foster Home Environment
Yes No N/A Corrective Actions/Comments
419-440-0050
(1)(a) the primary residence of the applicant and where the x Agency has not had new foster homes during this review period.
child in care will reside
(1)(b) adequate space including space for safe and appropriate x Agency has not had new foster homes during this review period.
sleeping arrangements for each child in care
(1)(c) child in care and parent/guardian must be notified of any x Agency has not had new foster homes during this review period.
electronic monitoring that occurs in the home
(1)(d) posted Foster Children’s Bill of Rights x Agency has not had new foster homes during this review period.
(1)(g) Authorization must be received from the agency and x Agency has not had new foster homes during this review period.
parent/guardian prior to the beginning of hunting or target
practice by the child
(2)(a) If there are potential hazards in or around the home, a x Agency has not had new foster homes during this review period.
plan to prevent exposure of the child to the hazard must be
developed and approved by the agency
(2)(d) Home and furnishings must be clean and in good repair x Agency has not had new foster homes during this review period.
and grounds must be maintained
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(2)(e) No accumulation of garbage or debris x Agency has not had new foster homes during this review period.
(2)(f) Home has an adequate source of safe water to be used x Agency has not had new foster homes during this review period.
for personal hygiene
(2)(g) There is a provision for safe storage and administration x Agency has not had new foster homes during this review period.
of all medications in the household
(2)(i)(A) Children may not be exposed to any second-hand x Agency has not had new foster homes during this review period.
smoke in home or vehicle.
(2)(i)(B) Household members may not provide any form of x Agency has not had new foster homes during this review period.
tobacco, nicotine, or other product illegal for a minor to possess
(2)(i)(C) All products referenced in (B) must be stored safe and x Agency has not had new foster homes during this review period.
in a manner inaccessible to children
(3)(a) The home must have the following: x Agency has not had new foster homes during this review period.
(A) working smoke alarm in each bedroom where a child in
care sleeps within 24 hours of the time the applicant is certified
(B) A working carbon monoxide detector within 15 feet of each X Agency has not had new foster homes during this review period.
bedroom where a child in care sleeps and at least one on each
floor within 24 hours of the time the applicant is certified
(C) At least one operable fire extinguisher rated 2-A:10-B-C or x Agency has not had new foster homes during this review period.
higher within 24 hours of the time the applicant is certified
(F) a written comprehensive home evacuation planed shared x Agency has not had new foster homes during this review period.
with each child in care at time of placement and practiced at
least every six months. The written plan must include a
provision for the safe exit of a child in care who is not capable
of understanding or participating in the evacuation plan.
(G) Interior doors that lock must be operable from both sides of x Agency has not had new foster homes during this review period.
the door.
(3)(b) Each bedroom used by a child in care must have: x Agency has not had new foster homes during this review period.
(A) At least one unrestricted exit
(B) At least one secondary means of exit or rescue x Agency has not had new foster homes during this review period.
(D) Unrestricted, direct access at all times to hallways, x Agency has not had new foster homes during this review period.
corridors, living rooms, or other such common areas
(E) Quick release mechanisms on all barred windows x Agency has not had new foster homes during this review period.
(4)(a) Maintain and share emergency preparedness plan with x Agency has not had new foster homes during this review period.
foster care agency. At minimum the plan will include:
(A) types of emergencies most likely to happen where the
proctor foster home is located
(B) Identifying a place to meet for each type of emergency
identified
(C) Identifying an alternate shelter if necessary
(D) Ensuring access to all necessary medication or medical
equipment
(E) How to help each child in care recover after a disaster
(4)(b) Maintain a comprehensive list of emergency telephone x Agency has not had new foster homes during this review period.
numbers including 911 and poison control and post in
prominent place in the home
P a g e 26 | 35
Form Rev. 04/18/2023
(5)(d) Written authorization must be received by proctor foster x Agency has not had new foster homes during this review period.
home prior to transporting a child out of state or country
(5)(e) Proctor foster home must request approval from x Agency has not had new foster homes during this review period.
Department no less than 90 days prior to international travel
Annual Review and Approval
Yes No N/A Corrective Actions/Comments
419-440-0080(2)
(a) Updated home study x
(b) Background check(s) x
(d) Out of state background check (if applicable) x
(e) Documentation that home remains in compliance with safety x One file did not have a completed safety standard form. Page 2
standards 419-440-0050 was missing. The agency shared that they could not find the
second page.
Corrective Action:
• The agency will ensure a process that all required
documentation is obtained and filed from this point
forward. Initials for the foster parent is J.I.
(f) Recommendation to approve or deny re-issuance of x
certificate
Orientation for Proctor Foster Homes Applicants 419-440-
Yes No N/A Corrective Actions/Comments
0060(2)
(a) & 419-400-0120(4)(a) Policies and procedures of the x Agency has not had new foster homes during this review period.
agency
(b) & 419-400-0120(4)(d) Attributes of population. Needs and x Agency has not had new foster homes during this review period.
characteristics of children needing placement
(c) Attachment, separation, and loss issues for children and x Agency has not had new foster homes during this review period.
families
(d) Importance of cultural identity and ways to foster this x Agency has not had new foster homes during this review period.
identity
(e) Impact of foster care on child and family x Agency has not had new foster homes during this review period.
(f) Rights and responsibilities of proctor foster parent and x Agency has not had new foster homes during this review period.
agency
(g) Resources available x Agency has not had new foster homes during this review period.
(h) Confidentiality x Agency has not had new foster homes during this review period.
(i) Rights of families and children x Agency has not had new foster homes during this review period.
(j) Provided copies of x Agency has not had new foster homes during this review period.
(A) Program statement
(B) Requirements for Proctor Homes
(C) Policies of agency governing proctor foster homes
(D) Training requirements
(E) Licensing rules
(F) Expectations for working with the agency
Orientation – Umbrella
Yes No N/A Corrective Actions/Comments
Requirements (30 days)
P a g e 27 | 35
Form Rev. 04/18/2023
419-400-0120(4)
(b) Ethical and professional guidelines x Agency has not had new foster homes during this review period.
(c) Suicide prevention and intervention x Agency has not had new foster homes during this review period.
(e) & (5)(a) to (c) Mandatory reporting that includes:
(a) legal definition of child abuse in ORS 418.257 and
419B.005 x Agency has not had new foster homes during this review period.
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to the employee
(f) Privacy laws x Agency has not had new foster homes during this review period.
(g) Emergency procedures x Agency has not had new foster homes during this review period.
Training for Parents in Proctor Foster Care Written
Training Plan includes: Yes No N/A Corrective Actions/Comments
419-440-0070
(a) Minimum of 15 hours of training before placement x
(b) Minimum of 15 hours training annually prior to approval x
(c)(A) Characteristics and needs of children who are placed x One file did not reflect training in this area.
Corrective Action:
• Ensure that all foster parents are receiving this training
from this point forward.
(c)(B) Ways to effectively parent children, including application x One file did not reflect training in this area.
of the reasonable and prudent parent standard
Corrective Action:
• Ensure that all foster parents are receiving this training
from this point forward.
(c)(C) Positive behavior management x
(c)(D) Importance of family of the child and working with the x Agency reports that this is covered under cultural
family competency.
Corrective Action:
• Agency will create a separate training title for
Importance of family of the child and working with the
family.
(c)(E) Importance of age-appropriate or developmentally x
appropriate extracurricular, enrichment, cultural, and social
activities
(c)(F) Preparation of child for independence based on age, x Two files did not reflect training in this area.
stage of development, and child’s needs
Corrective Action:
• Ensure that all foster parents are receiving this training
from this point forward.
(c)(G) Legal responsibility to report suspected child abuse x One file did not reflect training in this area.
Corrective Action:
P a g e 28 | 35
Form Rev. 04/18/2023
• Ensure that all foster parents are receiving this training
from this point forward.
(2) Training is documented x
Personnel Files
Yes No N/A Corrective Actions/Comments
419-400-0120
Staff Name x
Position x
(3)(g) Date of Hire x
(3)(a) record of education, training, and previous employment x
Two files were found to not have this required information.
(1)(b) & (3)(b) reference checks completed and documented x Corrective Action:
• Agency will ensure that all reference checks are
completed and documented moving forward.
(1)(a) & (3)(c) Background check completed and documented x
Two Files were found to not have this required information.
(3)(d) Annual performance evaluations x Repeat Finding:
• Agency will ensure that all annual performance
evaluations are completed and filed.
(3)(f) Record of personnel actions x
(3)(g) Termination date, reason for termination x
(3)(h) Current job description x
New Employee Orientation – Umbrella Requirements (30
days) Yes No N/A Corrective Actions/Comments
419-400-0120(4)
(a) Agency policies and procedures x
(b) Ethical and professional guidelines x
(c) Suicide prevention and intervention x
One staff file did not reflect attributes of population served.
(d) Attributes of population served x Corrective Action:
• Agency will ensure that attributes of population
served are completed and filed.
(e) & (5)(a) to (c) Mandatory reporting (annually) that includes: x
P a g e 29 | 35
Form Rev. 04/18/2023
(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
(f) Privacy laws x
(g) Emergency procedures x
New Employee Orientation – Foster Care (30 days)
Yes No N/A Corrective Actions/Comments
419-440-0160
(1)(a) Discipline and behavior management including de-
escalation, crisis prevention, positive behavior management, and x
disciplinary techniques that are non-punitive in nature
(1)(b) Restraint and seclusion
x
(If applicable)
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 support, x
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 x
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
x
provider
(B) May be valid for no more than two years with recertification
Ongoing Training Yes No N/A Corrective Actions/Comments
419-440-0160(2)(a) Environmental emergencies x
419-440-0160(2)(b) Universal Precautions x
419-440-0160(2)(c) Discipline and Behavior Management x
419-440-0160(3) Maintain current CPR/First Aid certification x
P a g e 30 | 35
Form Rev. 04/18/2023
419-440-0160(4) Training related to the reasonable and prudent
x
parent standard and developmentally appropriate activities
419-400-0120(5) 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
419-400-0160(4)(b) Receive continuing education (as applicable
on crisis intervention training) from a certified instructor on an x
annual basis
Comments:
Children’s Records Yes No N/A Corrective Actions/Comments
Name x
Initial Evaluation
Yes No N/A Corrective Actions/Comments
419-440-0190(2)
(a) Agency request and review all available reports of child’s
past and present behavior, educational status, and physical and x
mental health.
(b) Preliminary determination whether prospective child has
disorders, disabilities, or deficits for which care, supervision, x
training, rehab, or treatment is needed
Information about Children in Care
419-440-0210(1) Yes No N/A Corrective Actions/Comments
Summary sheet contains the following:
(a)The name, gender, date of birth, religious preference, and
x
previous address
(b) Name and location of previous and current school x
(c) Date of admission x
(d) Legal custody x
(e) The name, address, and telephone number of:
(A) The child's parents.
(B) The child's legal guardian, if different than parents, and
legal relationship x
(C) Other persons significant to child
(D) Other professionals to be involved in service planning (if
applicable)
(f) Required consents and authorizations x
P a g e 31 | 35
Form Rev. 04/18/2023
Records Relating to Restraint & Involuntary Seclusion Yes No N/A Corrective Actions/Comments
419-400-0180 (12) Records x
419-400-0180(13)(e) Each child caring agency shall provide The agency does not have a process for providing access to
notice regarding how to access the quarterly reports to the quarterly reports for parents or guardians of children.
parents or guardians of children in care in the program. The
child caring agency shall provide the notice upon the child in Corrective Action:
care’s admission and at least two times each year thereafter. x • Agency will create a process for proving access to
quarterly reports for parents and guardians of
children. Licensing provided an example for the
agency.
419-400-0190(1) Information provided to children in care The agency does not have a process for providing
relating to Restraint & Involuntary Seclusion information to children in care relating to suspected
inappropriate use of restraint & seclusion.
Corrective Action:
x
• The agency will create a process for providing
information to children in care relating to suspected
inappropriate use of restraint & seclusion. Licensing
provided an example for the agency.
Health Services
Yes No N/A Corrective Actions/Comments
419-440-0170
(2) Medical history obtained within 30 days The agency depends on information provided by Child
(a) significant findings Welfare.
(b) current immunizations, history of surgical procedures-health
issues-injuries x
(c) allergies
(d) dental, vision, hearing, behavioral health, and
(f) physician orders
The agency did not have documentation of age-appropriate
instruction.
(2)(e) Documentation of age-appropriate instruction –
pregnancy prevention, nutrition, prevention of HIV & AIDS, and x
Corrective Action:
prevention and treatment of sexually transmitted disease
• Agency will create a process for documentation of
age-appropriate instruction.
(3) Agency provides or arranges for A review of files did not reflect that reproductive health and
(a) information on maintaining reproductive health and birth birth control information had been provided.
control
(b) prenatal care Corrective Action:
(c) well baby care x • Agency will create a process for providing
(d) fetal alcohol syndrome information on maintaining reproductive health and
(e) accessing health insurance birth control.
(f) cancer screenings
(g) feminine hygiene products
P a g e 32 | 35
Form Rev. 04/18/2023
(h) access to birth control and vaccinations
(4)(a) to (f) Medical exams (3 in first year of life, 2,4,6,9,14) x
Consents
Yes No N/A Corrective Actions/Comments
419-440-0200(1)
(a) Provide routine and emergency medical care x
(b) Use the discipline and behavior management system x
(c) Use restraint or seclusion (if applicable). Must specify the
reasons for the intervention and how staff and proctor foster x
home parents are trained and supervised
(d) Restrict contact with persons outside of the agency x
(e) Allow access as defined in
x
419-400-0230 & 0240
(f) Impose a dress code x
(g) Apply the reasonable and prudent parent standard x
Disclosures
419-440-0200(2) Yes No N/A Corrective Actions/Comments
Parent/guardian has acknowledged in writing:
(a) Mandatory child abuse reporting requirements x
(b) Information regarding personal or room searches and
x
protocols for confiscation of contraband
(c) Statement of Rights of Children and Parents/Guardians x
(d) Grievance policies and procedures x
Two files reviewed did not reflect this required disclosure.
(e) Any policies and procedures upon request x Repeat Finding:
• Agency will ensure this disclosure is included in
their intake packet and utilized.
Authorizations
Yes No N/A Corrective Actions/Comments
419-440-0200(3)
(a) Disclose information x
(b) Child specific visitors x
(c) Visitation resources are pre-approved x
Two files reviewed were not found to have activity specific
(d) Activity specific authorizations are pre-approved to allow authorizations.
children to participate in potentially hazardous activities,
x
including but not limited to using motorized yard equipment, Repeat Finding:
swimming, and horseback riding. • Agency will ensure specific authorization is in intake
packet and utilized.
Service Planning
Yes No N/A Corrective Actions/Comments
419-440-0210(2)
(a) All documentation written in terms that are easily understood x
P a g e 33 | 35
Form Rev. 04/18/2023
(b) Intake document is completed the date child accepted into
x
care (emergency placement 48 hours)
(c) Child is served according to an individual service plan that
x
outlines goals for services and care coordination
(d) Assessment is completed within 30 days and contains
relevant historical info., current behavioral observations,
x
identified need for services, and how agency will provide or
coordinate services
(e) (A)&(B) Service plan within 60 days (parent, guardian and
child actively involved). Describes how child’s issues will be
x
addressed, 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
419-440-0210(3)
(a) Services are documented, progress toward achieving goals
x
is tracked
(b)-(d) discharge planning and instructions x
(e) Follow-up services identified (if applicable) x
(f) Incident Reports x
Financial Records
Yes No N/A Corrective Actions/Comments
419-440-0210(4)
Records contain (if applicable) One file was found to not have youth signatures.
(a) date, amount,
(b) source x Corrective Actions:
(c) purpose • Agency will ensure that all records have youth
(d)&(e) signatures signatures.
Personal Possessions Records
Yes No N/A Corrective Actions/Comments
419-440-0210(5)
One file was found to not have individual written inventory
of all personal possessions.
Individual written inventory of all personal possessions is
x
maintained and updated as needed Corrective Action:
• Agency will ensure that all records have individual
written inventory of all youth personal possessions.
Records and Documentation
Yes No N/A Corrective Actions/Comments
419-400-0140
(1) Stored safely x
(2) Permanent, legible, dated, and signed x
P a g e 34 | 35
Form Rev. 04/18/2023
(7) Permanent registry for each child in care includes (name,
gender, birth date, names, addresses of parents or guardians, x
dates of admission, and placement upon discharge)
Comments/Corrective Actions:
419-440-0180
Foster Care Agencies: Medication
(1) Policy and procedures. The foster care agency must have policies and procedures that cover prescriptions, herbal remedies, and all non-
prescription medications that address all of the following:
(c) How the staff of the foster care agency and the proctor foster home parents who administer medication will be trained.
The program was missing the above requirements for Medication, and it must be added to the policy.
Licensing Coordinator’s Signature: ________________________ Date: ___________________
Manager Review: ______________________________________ Date: _7_-2_0_-_2_0_2_3_ _________
P a g e 35 | 35
Form Rev. 04/18/2023

agency_name: Connections365 (C365)

program_type: (RC) Residential Care Programs | (FC) Foster Care Programs

report_type: License Renewals

view_code: RC

facility_type: Residential Care & Foster Care

board_chairperson: Priscilla Sattergren

licensing_coordinator: Jorge Pelinski & Mary Torres

program_description:
As summarized by the program's website, Connections365 offers therapeutic foster care for youth referred through
various programs affiliated with the Oregon Youth Authority, the Oregon Department of Human Services, and the Clackamas County Juvenile
Department. Therapeutic foster homes (also known as "Proctor Homes") provide a stable environment for youth to live and receive services, with
the goal of transitioning back into the community. These homes provide a higher level of care and supervision than "typical" foster homes, due to
the specialized needs of the youth.
Connections365 operates two residential programs, Project 180 and the Continuum. Young men are referred to these programs through Oregon's
juvenile justice system and are provided with all basic living needs, as well as individualized services to address personal areas of growth. These
programs provide at-risk youth with the stability they need to return to a residential or community placement rather than being committed to a
correctional facility.
Placements in Project 180 vary from seven to 90 days, depending on the youth's ongoing needs. This program provides a staffed, secure, and
structured living environment for youth in crisis. Program hallmarks are immediate response to referrals, quick placement, and thorough evaluation
of the youth offender in preparation for his next placement.
The Continuum provides a 24/7 secure structured living environment with an intensive transition process both into the program and from the
program.
P a g e 1 | 35

program_services:
Continued information from the program's website: Treatment Foster Care Connections365 provides all youth in
therapeutic foster care with counseling (individual, family, and group, as necessary), educational support, vocational support, and skill building
curriculum. Each youth is provided with an individualized service plan, and the therapeutic foster homes work directly alongside Connections365
case managers, counselors, mentors, and other staff to implement each client's plan. Youth residing in either the program's Intensive Residential -
Non-Qualified Residential Treatment Program (QRTP) or Intensive Behavioral Services (IBS) - Non-Qualified Residential Treatment Program
(QRTP) receive care and direction from the program's round-the-clock staff. Educational services are provided through online schooling, and case
management and counseling are provided by Connections365. Services include individual, family, and group counseling, educational and
vocational support, and evidence-based skill building curriculum. Services for medical/dental/vision, medication management and drug and alcohol
treatment are accessed through community providers.

capacity_age_range: Foster Care - (Age Range 7-20) Project 180 (residential) - Capacity - 5 (Age Range 12-20) The Continuum (residential)- Capacity - 4 (Age Range - 12-20)

funding_sources: Oregon Department of Human Services (ODHS) - Child Welfare Treatment Services, Oregon Youth Authority (OYA), grants, fundraisers

contracts_and_referrals:
Oregon Department of Human Services (ODHS) - Child Welfare Treatment Services, Oregon Youth
Authority (OYA), Clackamas County Juvenile Department

average_length_of_stay: Therapeutic Foster Care - 1.5 year Continuum - 1 year Project 180 - 60 to 90 days

number_of_children_served_annually: Project 180 - 18 Continuum - 6 Therapeutic Foster Care - 8

use_of_seclusion_or_restraint: Connections365 does not use seclusion or restraints. De-escalation training for staff and foster parents is completed through Crisis Prevention Institute (CPI) training and Collaborative Problem Solving (CPS). Interviews: Opening interview was held with the program's Executive Director, Debby Lute, and Program Director, Brandi Haws. An update regarding the program staffing and status on the three programs were discussed. They shared that due to staffing shortages they are only able to staff 5 youth currently. As staff numbers increase the census of the youth will be increased. P a g e 2 | 35 A resident of the Continuum site was interviewed during the visit. The resident reports being in program for over a year and has no immediate plans for discharge while his probation officer locates an appropriate placement. While in the program, the resident was able to graduate high school. The youth reports feeling safe during his stay in the program, except when peers "freak out." The youth reports that staff handle these types of situations well, having all other youth go to their rooms until the situation has deescalated. Staff will reach out to the on-call worker for extra assistance if needed and will check in on youth who were sent to their rooms. Strengths of the program included staff keeping youth "in check" and not talking to youth "like a child." A change that this resident would like to see made is allowing more flexibility in supervision. Examples given were accessing bedrooms and bathrooms without asking staff to unlock the doors. Two proctor parents participated in the interview process. Both have been foster parents for more than ten years. Both foster parents shared that things have been going well overall. They receive annual trainings and are visited regularly by the program personnel who conduct walk-throughs and safety checks. Both proctor parents feel like they receive enough information about children prior to them coming into the home. They also feel supported by the program when children exhibit struggling behavior in their homes. Both foster parents shared that they appreciate the overall support that the program provides. One thing one foster parent would change about the program is being able to have more homes as they expressed there are a lot of kids out there that need homes. The other foster parent shared that they would like more clarity on some of the general resources available for children, such as clothing. They also mentioned that sometimes the therapists change and foster parents are not sure who to always go through to find the right personnel. Both proctor parents feel like they can express their needs and concerns with the program. They both feel like the program does a great job of meeting the needs to the best of their abilities. Observations: Staff and youth were observed at the programs during the inspection. The youth that were at the programs, appeared to be at ease and comfortable in the environments. All areas of the programs (inside and outside) where youth had access were observed to be well kept, clean and in good repair. One of the agency vehicles that the youth ride in was observed and met the requirements per Licensing Rules. The kitchens at both residential sites were observed to have adequate food. Medication was observed to be in locked medication carts in locked rooms which were inaccessible to the youth.

lawsuits: 1 - There is a pending litigation involving a former youth from twenty years ago.

changes_in_license:
N/A
Residential

excerpt:
Documents as indicated on the form titled
“Renewal Licensing Required Documents” *See comments section below

excerpt:
All required policies and procedures as
identified in the “Umbrella Rules” *See comments section below

excerpt:
All required policies and procedures as
identified in “Agency Type Specific Rules” *See comments section below

excerpt:
(1)(b) & (3)(b) reference checks completed
and documented One Reference checks was not found.
Corrective Action:
• Ensure a process where all reference checks are completed and
documented moving forward.

excerpt:
(d) Attributes of population served Documentation of this training was not found in the files reviewed. In speaking to
the Executive Director, the topic is covered during employee orientation. Corrective Action:
• Agency will consistently document Attributes of population served in staff
training records.

excerpt:
(f) Privacy laws One file did not have documentation of training on privacy laws.
Corrective Action:
• Agency will document attributes of population serving in staff training
records moving forward.

excerpt:
(d) Application of the reasonable and
prudent parent standard Documentation of training on the application of the reasonable and prudent parent
standard was not found in one record that was reviewed.
Corrective Action:
• Agency will document training on the application of the reasonable and
prudent parent standard in staff training records consistently moving
forward.

excerpt:
(c) Any policies and procedures upon request 4 files were found to not reflect this required disclosure.
Repeat Finding:
• Agency will ensure that this disclosure is in their current intake packet and
utilized moving forward.

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 One file’s discharge summary did not have current medications.
Corrective Action:
• Agency will ensure that current medications are listed in discharge
summaries moving forward.

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 admission and
at least two times each year thereafter. The agency does not have a process for providing access to quarterly reports for
parents or guardians of children.
Corrective Action:
• Agency will create a process for providing access to quarterly reports for
parents and guardians of children. Licensing provided an example for the
agency.

excerpt:
Information provided to
children in care relating to Restraint &
Involuntary Seclusion The agency does not have a process for providing information to children in care
relating to suspected inappropriate use of restraint & seclusion.
Corrective Action:
• The agency will create a process for providing information to children in
care relating to suspected inappropriate use of restraint & seclusion.
Licensing provided an example for the agency.

excerpt:
(2)(g) Documentation of home visit (every 90 days) Two files did not have the required documentation of home
visits (every 90 days).
Repeat Finding:
• The agency will ensure that visits occur every 90 days
and are documented.

excerpt:
(e) Documentation that home remains in compliance with safety
standards 419-440-0050 One file did not have a completed safety standard form. Page 2
was missing. The agency shared that they could not find the
second page.
Corrective Action:
• The agency will ensure a process that all required
documentation is obtained and filed from this point
forward. Initials for the foster parent is J.I.

excerpt:
(c)(A) Characteristics and needs of children who are placed One file did not reflect training in this area.
Corrective Action:
• Ensure that all foster parents are receiving this training
from this point forward.

excerpt:
(c)(B) Ways to effectively parent children, including application
of the reasonable and prudent parent standard One file did not reflect training in this area.
Corrective Action:
• Ensure that all foster parents are receiving this training
from this point forward.

excerpt:
(c)(D) Importance of family of the child and working with the
family Agency reports that this is covered under cultural
competency.
Corrective Action:
• Agency will create a separate training title for
Importance of family of the child and working with the
family.

excerpt:
(c)(F) Preparation of child for independence based on age,
stage of development, and child’s needs Two files did not reflect training in this area.
Corrective Action:
• Ensure that all foster parents are receiving this training
from this point forward.

excerpt:
(c)(G) Legal responsibility to report suspected child abuse One file did not reflect training in this area.
Corrective Action:

excerpt:
(1)(b) & (3)(b) reference checks completed and documented Two files were found to not have this required information.
Corrective Action:
• Agency will ensure that all reference checks are
completed and documented moving forward.

excerpt:
(3)(d) Annual performance evaluations Two Files were found to not have this required information.
Repeat Finding:
• Agency will ensure that all annual performance
evaluations are completed and filed.

excerpt:
(d) Attributes of population served One staff file did not reflect attributes of population served.
Corrective Action:
• Agency will ensure that attributes of population
served are completed and filed. instruction. • Agency will create a process for documentation of age-appropriate instruction. A review of files did not reflect that reproductive health and birth control information had been provided. • Agency will create a process for providing information on maintaining reproductive health and birth control.

excerpt:
(e) Any policies and procedures upon request Two files reviewed did not reflect this required disclosure.
Repeat Finding:
• Agency will ensure this disclosure is included in
their intake packet and utilized.

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. Two files reviewed were not found to have activity specific
authorizations.
Repeat Finding:
• Agency will ensure specific authorization is in intake
packet and utilized.

excerpt:
Records contain (if applicable)
(a) date, amount,
(b) source
(c) purpose
(d)&(e) signatures One file was found to not have youth signatures.
Corrective Actions:
• Agency will ensure that all records have youth
signatures.

excerpt:
Individual written inventory of all personal possessions is
maintained and updated as needed One file was found to not have individual written inventory
of all personal possessions.
Corrective Action:
• Agency will ensure that all records have individual
written inventory of all youth personal possessions.