summary: Unannounced - 16 findings

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Residential Care
Licensee: Team Bailey
Executive Director: Kathy Bailey
Program Director(s): Jaylynn Bailey
Date of Unannounced: 12/05/2023
Licensing Coordinator: Jeff Minden
Other Regulatory or Accrediting Agencies: Oregon Youth Authority
Purpose: Per OAR 419-400-0240 (1)(b) Children’s Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Comments
License Renewal Site Visit 07/10/2023 Findings
Further Action
Needed
Residential Care Safety Yes✓No☐ Program completed fire drills for August and September. However, documentation for the
419-470-0080 October and November fire drills could not be located.
(5)(a) Evacuation drill occurs monthly under
varying conditions, is retained 2 years and
contains:
(A) identify of person conducting drill
(B) date & time
(C) notification method
(D) staff participating
(E) # of children & staff evacuated
(F) special conditions simulated
(G) problems encountered
(H) time to complete
• Evacuation form is very thorough.
Agency had only conducted 1 drill as
they believed the requirement to be
quarterly. This has been clarified and
Agency confirms they will be
conducted monthly moving forward.
Medication Yes☐ No✓ Medications are stored in a locked safe that is kept in a locked closet.
419-470-0100 (7)(c) Medications are
inaccessible to children and stored behind at
Form Rev. 11/14/2023 P age 1| 6
least two locking mechanisms. This does not
apply to Naloxone.
• Medications were being stored in a
cabinet behind only 1 lock, and
cabinet was unlocked during the visit.
Prior to completion of the visit Agency
adjusted medication storage to
ensure 2 locks were in place to
secure medications.
Personnel Files Yes☐ No✓ Reviewed Personnel Files included applications which covered previous employment
419-400-0120
(3)(a) record of education, training, and
previous employment
• Personnel Files contained information
on education and training, but not
previous employment
Personnel Files Yes✓No☐ Reviewed documentation included names and contact information for reference checks.
419-400-0120 However, there was no documentation confirming references were checked.
(1)(b) & (3)(b) reference checks completed
and documented
• Reference checks were reported as
completed however documentation of
reference checks was not being
maintained in files
Personnel Files Yes☐ No✓ The program has added job descriptions to personnel files and is having employees sign
419-400-0120 them.
(3)(h) Current job description (1)(c) Employee
meets minimum qualifications stated in
current job description
• Job descriptions were not recorded in
personnel files
New Employee Orientation Yes☐ No✓ The program has included behavior management on the documentation for New Employee
Residential (Prior to working alone and Training
within 30 days)
419-470-0120(1)
(a) Discipline and behavior management
including de-escalation, crisis prevention,
positive behavior management, and
disciplinary techniques that are non-punitive in
nature
• Behavior Management training was
not included in Personnel files
Form Rev. 11/14/2023 P age 2| 6
Children’s Records Yes☐ No✓ Reviewed Client files indicated that medical history is being documented in client files.
Health Services
419-470-0090
(2) Medical history obtained within 30 days
(significant findings, current immunizations,
history of surgical procedures-health issues-
injuries, allergies, dental, vision, hearing,
behavioral health, and physician orders)
• Medical history is not being
documented in youth files
Children’s Records Yes✓No☐ 1 reviewed client file did not have a record of physical examinations being completed.
Health Services
419-470-0090
(g) Have a physical examination within the
first 60 days after admission of a child in care.
Documentation of a physical examination
having occurred within the calendar year will
meet this requirement.
• Physical examinations, or
documentation of physical
examinations within the calendar year
are not documented in the youth files.
Information about Children in Care Yes✓No☐ Summary sheets could not be located in client files
419-400-0190(1)
Summary sheet contains the following:
(a)The name, gender, date of birth, religious
preference, and previous address
• Some information contained in youth
files, but not all required data is
clearly available
Information about Children in Care Yes✓No☐ Summary sheets could not be located in client files
419-400-0190(1)
Summary sheet contains the following:
(b) Name and location of previous and current
school
• School information was not located in
youth files.
Information about Children in Care Yes✓No☐ Summary sheets could not be located in client files
419-400-0190(1)
Summary sheet contains the following:
(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
Form Rev. 11/14/2023 P age 3| 6
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)
• This documentation was not clearly
available in youth files.
Case Management Yes☐ No✓ Client files have a section for incident reports.
419-470-0170(3)
(f) Incident Reports
• Program has incident reports, but
they were not maintained in the youth
files.
Records Relating to Restraint & Yes✓No☐ Intake documentation did not have information about how to access quarterly restraint
Involuntary Seclusion reports.
419-400-0180(13)(e) Each child caring
agency shall provide notice regarding how to
access the quarterly reports to the parents or
guardians of children in care in the program.
The child caring agency shall provide the
notice upon the child in care’s admission and
at least two times each year thereafter.
• Notices regarding quarterly restraint
reporting were not included in youth
files.
Records Relating to Restraint & Yes☐ No✓ Program is now documenting that information has been provided to children in care about
Involuntary Seclusion restraint and seclusion.
419-400-0190(1) Information provided to
children in care relating to Restraint &
Involuntary Seclusion
• Files did not indicate information was
provided to children in care relating to
Restraint and Seclusion
Personal Possessions Records Yes☐ No✓ Property records were updated to include information about currency. Reviewed client files
419-470-0170 (5) had property logs.
Individual written inventory of all personal
possessions is maintained and updated as
needed
• 1 reviewed file did not include a
property log. Logs were not clear
about property added after intake,
including currency in youth
possession. Program needs a
procedure for tracking currency in
youth possession.
Form Rev. 11/14/2023 P age 4| 6
New Findings from Site Visit Comments
419-400-0140(3) Records must be uniform in Program records were not organized or consistently filed, including several stacks of loose documents in the
organization, readily identifiable and Director’s office, incomplete folders, and documents that could not be located when requested due to the
accessible, current and complete, and disorganization. The program currently keeps some records physically and reportedly has other records kept
contain all of the information required of the electronically, though it was not clear which laptop computer had which records. The program must establish
child-careing agency by rule in OAR Chapter a consistent method of storing records and having them easily and readily accessible in one place.
419, division 400
Interview Summary
One youth was interviewed as a part of the unannounced site visit. Youth is 17 years old and reports having been at the program for approximately 6 months.
He reported that he had been previously at a program in Polk County and at J Bar J. In the youth’s opinion Team Bailey is the best program in the State of
Oregon. The youth reported that the best part of the program is that they operate on a trust system and that you can earn privileges for following the rules, but
that there is not a rigid level system like at other programs. The youth explained that part of his program allowed for community time and that when it started,
he was able to stay out until 8pm. Eventually he was able to stay out until 9pm, but that was difficult as he would then stay out too late and be late getting
back. Youth reported that program staff worked with him and, although he did have to start returning at 8pm, he didn’t lose the ability to have community time.
Youth reported that he just got a job at Subway and is excited to start this week. The youth reported that he feels safe in the program and that Jaylynn is his
favorite staff and someone he would feel comfortable reaching out to if he needed something. Youth reported that the food is really good, and he mostly helps
with preparing desserts. Ribs were noted as one of his favorite foods. The youth reported the only thing he wished he could change would be being allowed
to stay out later.
One staff was also interviewed. Staff reported that they have worked for Team Bailey for approximately 6-7 months, after an extensive career at McClaren
Youth Correctional. Staff reported liking it at Team Bailey. They reported that everyone does a good job of being consistent and on the same page, and that
there isn’t any infighting. Staff reported that they felt like the onboarding training was good, although they felt they already had many of the needed skills from
their prior work experience. The staff reported that clients are decent and there isn’t any acting out or talking back and that everyone is respectful. The staff
reported that management is very open and 100% supportive. Staff reported that there wasn’t anything they would want to change, and that they didn’t have
a favorite part of the job, they just really enjoyed the job overall or they wouldn’t keep working there.
Form Rev. 11/14/2023 P age 5| 6
Observations
A tour of the program was conducted as a part of the unannounced site visit. All communal spaces were observed, as well as 2 client bedrooms and 2 client
bathrooms. The bedrooms are large and well furnished, and both bedrooms appeared well maintained and clean. Both bathrooms looked like they were
cleaned regularly and were well organized. A youth had just finished a shower in one bathroom just before it was observed, and there were no noted puddles
or water on the bathroom floor. The kitchen was organized, clean and well stocked.
Corrective Actions and Timeframes:
Please submit the following to verify compliance.
Within 45 days of receipt of this report Team Bailey 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 Jeffrey.e.minden@odhsoha.oregon.gov.
Licensing Coordinator’s Signature: ________________________ Date: _1_2_-_1_2_-_2_0_2_3_ ________
Manager Review: ______________________________________ Date: _1_2_-1_2_-_2_0_2_3_ ________
Form Rev. 11/14/2023 P age 6| 6

licensee: Team Bailey

executive_director: Kathy Bailey

program_director: Jaylynn Bailey

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 Comments
License Renewal Site Visit 07/10/2023 Findings
Further Action
Needed
Residential Care Safety Yes✓No[ ] Program completed fire drills for August and September. However, documentation for the
419-470-0080 October and November fire drills could not be located.
(5)(a) Evacuation drill occurs monthly under
varying conditions, is retained 2 years and
contains:
(A) identify of person conducting drill
(B) date & time
(C) notification method
(D) staff participating
(E) # of children & staff evacuated
(F) special conditions simulated
(G) problems encountered
(H) time to complete
- Evacuation form is very thorough.
Agency had only conducted 1 drill as
they believed the requirement to be
quarterly. This has been clarified and
Agency confirms they will be
conducted monthly moving forward.
Medication Yes[ ] No✓ Medications are stored in a locked safe that is kept in a locked closet.
419-470-0100 (7)(c) Medications are
inaccessible to children and stored behind at

least two locking mechanisms. This does not
apply to Naloxone.
- Medications were being stored in a
cabinet behind only 1 lock, and
cabinet was unlocked during the visit.
Prior to completion of the visit Agency
adjusted medication storage to
ensure 2 locks were in place to
secure medications.
Personnel Files Yes[ ] No✓ Reviewed Personnel Files included applications which covered previous employment
419-400-0120
(3)(a) record of education, training, and
previous employment
- Personnel Files contained information
on education and training, but not
previous employment
Personnel Files Yes✓No[ ] Reviewed documentation included names and contact information for reference checks.
419-400-0120 However, there was no documentation confirming references were checked.
(1)(b) & (3)(b) reference checks completed
and documented
- Reference checks were reported as
completed however documentation of
reference checks was not being
maintained in files
Personnel Files Yes[ ] No✓ The program has added job descriptions to personnel files and is having employees sign
419-400-0120 them.
(3)(h) Current job description (1)(c) Employee
meets minimum qualifications stated in
current job description
- Job descriptions were not recorded in
personnel files
New Employee Orientation Yes[ ] No✓ The program has included behavior management on the documentation for New Employee
Residential (Prior to working alone and Training
within 30 days)
419-470-0120(1)
(a) Discipline and behavior management
including de-escalation, crisis prevention,
positive behavior management, and
disciplinary techniques that are non-punitive in
nature
- Behavior Management training was
not included in Personnel files

Children's Records Yes[ ] No✓ Reviewed Client files indicated that medical history is being documented in client files.
Health Services
419-470-0090
(2) Medical history obtained within 30 days
(significant findings, current immunizations,
history of surgical procedures-health issues-
injuries, allergies, dental, vision, hearing,
behavioral health, and physician orders)
- Medical history is not being
documented in youth files
Children's Records Yes✓No[ ] 1 reviewed client file did not have a record of physical examinations being completed.
Health Services
419-470-0090
(g) Have a physical examination within the
first 60 days after admission of a child in care.
Documentation of a physical examination
having occurred within the calendar year will
meet this requirement.
- Physical examinations, or
documentation of physical
examinations within the calendar year
are not documented in the youth files.
Information about Children in Care Yes✓No[ ] Summary sheets could not be located in client files
419-400-0190(1)
Summary sheet contains the following:
(a)The name, gender, date of birth, religious
preference, and previous address
- Some information contained in youth
files, but not all required data is
clearly available
Information about Children in Care Yes✓No[ ] Summary sheets could not be located in client files
419-400-0190(1)
Summary sheet contains the following:
(b) Name and location of previous and current
school
- School information was not located in
youth files.
Information about Children in Care Yes✓No[ ] Summary sheets could not be located in client files
419-400-0190(1)
Summary sheet contains the following:
(e) The name, address, and telephone
number of:
(A) The child in care's parents.
(B) The child in care's legal guardian, if
different than the parents, and a copy of

the document that provides for his or her
authority over the child in care.
(C) Other persons significant to child
(D) Other professionals to be involved in
service planning (if applicable)
- This documentation was not clearly
available in youth files.
Case Management Yes[ ] No✓ Client files have a section for incident reports.
419-470-0170(3)
(f) Incident Reports
- Program has incident reports, but
they were not maintained in the youth
files.
Records Relating to Restraint & Yes✓No[ ] Intake documentation did not have information about how to access quarterly restraint
Involuntary Seclusion reports.
419-400-0180(13)(e) Each child caring
agency shall provide notice regarding how to
access the quarterly reports to the parents or
guardians of children in care in the program.
The child caring agency shall provide the
notice upon the child in care's admission and
at least two times each year thereafter.
- Notices regarding quarterly restraint
reporting were not included in youth
files.
Records Relating to Restraint & Yes[ ] No✓ Program is now documenting that information has been provided to children in care about
Involuntary Seclusion restraint and seclusion.
419-400-0190(1) Information provided to
children in care relating to Restraint &
Involuntary Seclusion
- Files did not indicate information was
provided to children in care relating to
Restraint and Seclusion
Personal Possessions Records Yes[ ] No✓ Property records were updated to include information about currency. Reviewed client files
419-470-0170 (5) had property logs.
Individual written inventory of all personal
possessions is maintained and updated as
needed
- 1 reviewed file did not include a
property log. Logs were not clear
about property added after intake,
including currency in youth
possession. Program needs a
procedure for tracking currency in
youth possession.

New Findings from Site Visit Comments
419-400-0140(3) Records must be uniform in Program records were not organized or consistently filed, including several stacks of loose documents in the
organization, readily identifiable and Director's office, incomplete folders, and documents that could not be located when requested due to the
accessible, current and complete, and disorganization. The program currently keeps some records physically and reportedly has other records kept
contain all of the information required of the electronically, though it was not clear which laptop computer had which records. The program must establish
child-careing agency by rule in OAR Chapter a consistent method of storing records and having them easily and readily accessible in one place.
419, division 400
Interview Summary
One youth was interviewed as a part of the unannounced site visit. Youth is 17 years old and reports having been at the program for approximately 6 months.
He reported that he had been previously at a program in Polk County and at J Bar J. In the youth's opinion Team Bailey is the best program in the State of
Oregon. The youth reported that the best part of the program is that they operate on a trust system and that you can earn privileges for following the rules, but
that there is not a rigid level system like at other programs. The youth explained that part of his program allowed for community time and that when it started,
he was able to stay out until 8pm. Eventually he was able to stay out until 9pm, but that was difficult as he would then stay out too late and be late getting
back. Youth reported that program staff worked with him and, although he did have to start returning at 8pm, he didn't lose the ability to have community time.
Youth reported that he just got a job at Subway and is excited to start this week. The youth reported that he feels safe in the program and that Jaylynn is his
favorite staff and someone he would feel comfortable reaching out to if he needed something. Youth reported that the food is really good, and he mostly helps
with preparing desserts. Ribs were noted as one of his favorite foods. The youth reported the only thing he wished he could change would be being allowed
to stay out later.
One staff was also interviewed. Staff reported that they have worked for Team Bailey for approximately 6-7 months, after an extensive career at McClaren
Youth Correctional. Staff reported liking it at Team Bailey. They reported that everyone does a good job of being consistent and on the same page, and that
there isn't any infighting. Staff reported that they felt like the onboarding training was good, although they felt they already had many of the needed skills from
their prior work experience. The staff reported that clients are decent and there isn't any acting out or talking back and that everyone is respectful. The staff
reported that management is very open and 100% supportive. Staff reported that there wasn't anything they would want to change, and that they didn't have
a favorite part of the job, they just really enjoyed the job overall or they wouldn't keep working there.

Observations
A tour of the program was conducted as a part of the unannounced site visit. All communal spaces were observed, as well as 2 client bedrooms and 2 client
bathrooms. The bedrooms are large and well furnished, and both bedrooms appeared well maintained and clean. Both bathrooms looked like they were
cleaned regularly and were well organized. A youth had just finished a shower in one bathroom just before it was observed, and there were no noted puddles
or water on the bathroom floor. The kitchen was organized, clean and well stocked.


state: OR

facility_name: Team Bailey - Patricia

summary: Unannounced - 9 findings

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Residential Care
Licensee: Team Bailey
Executive Director: Kathy Bailey
Program Director(s): Jaylynn Bailey
Date of Unannounced: 05/15/2024
Licensing Coordinator: Jeff Minden, Aubrey Kelly
Other Regulatory or Accrediting Agencies: Oregon Youth Authority
Purpose: Per OAR 419-400-0240 (1)(b) Children’s Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Comments
Unannounced Site Visit 12/05/2023 Findings
Further Action
Needed
Residential Care Safety Yes✓ No☐ Program documentation around fire drills was more consistent then the previous review,
419-470-0080 however the April fire drill documentation could not be located during the site visit.
(5)(a) Evacuation drill occurs monthly under
varying conditions, is retained 2 years and
contains:
(A) identify of person conducting drill
(B) date & time
(C) notification method
(D) staff participating
(E) # of children & staff evacuated
(F) special conditions simulated
(G) problems encountered
(H) time to complete
• Evacuation form is very thorough. Agency
had only conducted 1 drill as they believed the
requirement to be quarterly. This has been
clarified and Agency confirms they will be
conducted monthly moving forward.
• Program completed fire drills for
August and September. However,
Form Rev. 11/14/2023 P age 1 | 6
documentation for the October and
November fire drills could not be
located.
Personnel Files Yes☐ No✓ Documentation reviewed indicated reference checks are being completed.
419-400-0120
(1)(b) & (3)(b) reference checks completed
and documented
• Reference checks were reported as
completed however documentation of
reference checks was not being maintained in
files
• Reviewed documentation included
names and contact information for
reference checks. However, there
was no documentation confirming
references were checked.
Children’s Records Yes☐ No✓ Documentation reviewed indicated that physical examinations are being completed.
Health Services
419-470-0090
(g) Have a physical examination within the
first 60 days after admission of a child in care.
Documentation of a physical examination
having occurred within the calendar year will
meet this requirement.
• Physical examinations, or documentation of
physical examinations within the calendar
year are not documented in the youth files.
• 1 reviewed client file did not have a
record of physical examinations being
completed.
Information about Children in Care Yes✓ No☐ Program has greatly improved their documentation process and summary sheets are
419-400-0190(1) detailed and easily located. However, there was not a field on the form for Religious
Summary sheet contains the following: Preferences.
(a)The name, gender, date of birth, religious
preference, and previous address
• Some information contained in youth files,
but not all required data is clearly available
• Summary sheets could not be located
in client files
Form Rev. 11/14/2023 P age 2 | 6
Information about Children in Care Yes☐ No✓ Program has greatly improved their documentation process and summary sheets are
419-400-0190(1) detailed and easily located.
Summary sheet contains the following:
(b) Name and location of previous and current
school
• School information was not located in youth
files.
• Summary sheets could not be located
in client files
Information about Children in Care Yes☐ No✓ Program has greatly improved their documentation process and summary sheets are
419-400-0190(1) detailed and easily located.
Summary sheet contains the following:
(e) The name, address, and telephone
number of:
(A) The child in care's parents.
(B) The child in care's legal guardian, if
different than the parents, and a copy of
the document that provides for his or her
authority over the child in care.
(C) Other persons significant to child
(D) Other professionals to be involved in
service planning (if applicable)
• This documentation was not clearly available
in youth files.
• Summary sheets could not be located
in client files
Records Relating to Restraint & Yes✓ No☐ Program documentation did not clearly identify how notifications about quarterly restraints
Involuntary Seclusion are being made to parents and guardians
419-400-0180(13)(e) Each child caring
agency shall provide notice regarding how to
access the quarterly reports to the parents or
guardians of children in care in the program.
The child caring agency shall provide the
notice upon the child in care’s admission and
at least two times each year thereafter.
• Notices regarding quarterly restraint
reporting were not included in youth files.
• Intake documentation did not have
information about how to access
quarterly restraint reports.
Form Rev. 11/14/2023 P age 3 | 6
Records and Documentation Yes☐ No✓ Program has made considerable improvement in their record keeping practices since the
419-400-0140 last review.
(3) Records must be uniform in organization,
readily identifiable and accessible, current and
complete, and contain all of the information
required of the child-careing agency by rule in
OAR Chapter 419, division 400
• Program records were not organized
or consistently filed, including several
stacks of loose documents in the
Director’s office, incomplete folders,
and documents that could not be
located when requested due to the
disorganization. The program
currently keeps some records
physically and reportedly has other
records kept electronically, though it
was not clear which laptop computer
had which records. The program must
establish a consistent method of
storing records and having them
easily and readily accessible in one
place.
New Findings from Site Visit Comments
419-470-0020(c) – All areas of buildings The living areas downstairs, the kitchen, and client bedrooms were all well maintained. However, the upstairs
where children in care are present must be bathroom, hallway, and staircase were in need of cleaning. Specifically, the upstairs bathroom toilet and
kept clean and in good repair. Major shower fans needed extra cleaning, and a towel bar that needed repairing.
appliances and heating, ventilation,
plumbing, and electrical systems must be
functional and in good repair.
Form Rev. 11/14/2023 P age 4 | 6
Interview Summary
2 youth and one staff were interviewed as a part of the unannounced site visit. One youth has been at the program for 1.5 months.
He was previously Kairos and Turning Point and liked them. This program is the best he’s been to, he likes the freedom here, staff
aren’t on his back all the time. Staff are available when he needs them. He graduated high school and is currently job searching. He
feels safe here and gets along with the other clients. He has no favorite staff. Residents cook when they want to, staff takes the
residents one time a week. He has contact with his family and talks to them every other day. He thinks he’ll be here until October
and then hopes to get his own apartment. If he could change anything, he would like walks to be 25 minutes instead of 15 minutes.
The second youth has been at the program for 5 days. It’s good so far, he’s slowly gaining privileges. He feels safe here and gets
along with the other residents. He had a job interview at Walmart. The food is good, he’s a vegetarian and they accommodate his
needs. No one has put their hands on him since being at the program and there is nothing he thinks needs to change.
Interviewed staff has worked at the program for 1 year. He previously worked at McLaren. Orientation trainings included
expectations of staff, transportation, he met PO’s. He had CPR training in 2022. His supervisors are Kathy and Jaylynn, he
feels supported by them. Nothing needs to change at this program, it operates like a family. Residents fit into the program;
the program does not change to fit them. Ongoing trainings have been about meds, food prep, supervision. Training goes on
24/7 here.
Observations
Form Rev. 11/14/2023 P age 5 | 6
A facility walkthrough was conducted as a part of the unannounced site visit. The living areas where clients spend most of their time (the downstairs) was
immaculately clean and well organized. The client bedrooms that were observed were also clean and well organized. The upstairs hallway, upstairs
bathroom, and the stairs were in need of cleaning and sweeping, and minor repair. A hole was noted in the ceiling downstairs below the upstairs bathroom,
but the program explained it was the result of a water leak, and a plumber had just fixed the leak, and drywall repair was already scheduled.
The program has also made significant improvement in its record keeping of staff and client files. Files were much more organized, and it was easier to locate
required documentation during the review.
The program is in the process of getting ready to apply for a second program site as they continue to grow and expand.
Corrective Actions and Timeframes:
Please submit the following to verify compliance.
Within 45 days of receipt of this report Team Bailey 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: _6_/_4_/2_4______________
Manager Review: ______________________________________ Date: _6_/4_/_2_4_____________
Form Rev. 11/14/2023 P age 6 | 6

agency_name: Team Bailey (TB)

program_type: (RC) Residential Care Programs

report_type: Unannounced

view_code: RC

facility_type: Residential Care

licensing_coordinator: Jeff Minden, Aubrey Kelly

other_regulatory_agencies: Oregon Youth Authority

purpose:
Per OAR 419-400-0240 (1)(b) Children's Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Comments
Unannounced Site Visit 12/05/2023 Findings
Further Action
Needed
Residential Care Safety Yes✓ No[ ] Program documentation around fire drills was more consistent then the previous review,
419-470-0080 however the April fire drill documentation could not be located during the site visit.
(5)(a) Evacuation drill occurs monthly under
varying conditions, is retained 2 years and
contains:
(A) identify of person conducting drill
(B) date & time
(C) notification method
(D) staff participating
(E) # of children & staff evacuated
(F) special conditions simulated
(G) problems encountered
(H) time to complete
- Evacuation form is very thorough. Agency
had only conducted 1 drill as they believed the
requirement to be quarterly. This has been
clarified and Agency confirms they will be
conducted monthly moving forward.
- Program completed fire drills for
August and September. However,

documentation for the October and
November fire drills could not be
located.
Personnel Files Yes[ ] No✓ Documentation reviewed indicated reference checks are being completed.
419-400-0120
(1)(b) & (3)(b) reference checks completed
and documented
- Reference checks were reported as
completed however documentation of
reference checks was not being maintained in
files
- Reviewed documentation included
names and contact information for
reference checks. However, there
was no documentation confirming
references were checked.
Children's Records Yes[ ] No✓ Documentation reviewed indicated that physical examinations are being completed.
Health Services
419-470-0090
(g) Have a physical examination within the
first 60 days after admission of a child in care.
Documentation of a physical examination
having occurred within the calendar year will
meet this requirement.
- Physical examinations, or documentation of
physical examinations within the calendar
year are not documented in the youth files.
- 1 reviewed client file did not have a
record of physical examinations being
completed.
Information about Children in Care Yes✓ No[ ] Program has greatly improved their documentation process and summary sheets are
419-400-0190(1) detailed and easily located. However, there was not a field on the form for Religious
Summary sheet contains the following: Preferences.
(a)The name, gender, date of birth, religious
preference, and previous address
- Some information contained in youth files,
but not all required data is clearly available
- Summary sheets could not be located
in client files

Information about Children in Care Yes[ ] No✓ Program has greatly improved their documentation process and summary sheets are
419-400-0190(1) detailed and easily located.
Summary sheet contains the following:
(b) Name and location of previous and current
school
- School information was not located in youth
files.
- Summary sheets could not be located
in client files
Information about Children in Care Yes[ ] No✓ Program has greatly improved their documentation process and summary sheets are
419-400-0190(1) detailed and easily located.
Summary sheet contains the following:
(e) The name, address, and telephone
number of:
(A) The child in care's parents.
(B) The child in care's legal guardian, if
different than the parents, and a copy of
the document that provides for his or her
authority over the child in care.
(C) Other persons significant to child
(D) Other professionals to be involved in
service planning (if applicable)
- This documentation was not clearly available
in youth files.
- Summary sheets could not be located
in client files
Records Relating to Restraint & Yes✓ No[ ] Program documentation did not clearly identify how notifications about quarterly restraints
Involuntary Seclusion are being made to parents and guardians
419-400-0180(13)(e) Each child caring
agency shall provide notice regarding how to
access the quarterly reports to the parents or
guardians of children in care in the program.
The child caring agency shall provide the
notice upon the child in care's admission and
at least two times each year thereafter.
- Notices regarding quarterly restraint
reporting were not included in youth files.
- Intake documentation did not have
information about how to access
quarterly restraint reports.

Records and Documentation Yes[ ] No✓ Program has made considerable improvement in their record keeping practices since the
419-400-0140 last review.
(3) Records must be uniform in organization,
readily identifiable and accessible, current and
complete, and contain all of the information
required of the child-careing agency by rule in
OAR Chapter 419, division 400
- Program records were not organized
or consistently filed, including several
stacks of loose documents in the
Director's office, incomplete folders,
and documents that could not be
located when requested due to the
disorganization. The program
currently keeps some records
physically and reportedly has other
records kept electronically, though it
was not clear which laptop computer
had which records. The program must
establish a consistent method of
storing records and having them
easily and readily accessible in one
place.
New Findings from Site Visit Comments
419-470-0020(c) - All areas of buildings The living areas downstairs, the kitchen, and client bedrooms were all well maintained. However, the upstairs
where children in care are present must be bathroom, hallway, and staircase were in need of cleaning. Specifically, the upstairs bathroom toilet and
kept clean and in good repair. Major shower fans needed extra cleaning, and a towel bar that needed repairing.
appliances and heating, ventilation,
plumbing, and electrical systems must be
functional and in good repair.

Interview Summary
2 youth and one staff were interviewed as a part of the unannounced site visit. One youth has been at the program for 1.5 months.
He was previously Kairos and Turning Point and liked them. This program is the best he's been to, he likes the freedom here, staff
aren't on his back all the time. Staff are available when he needs them. He graduated high school and is currently job searching. He
feels safe here and gets along with the other clients. He has no favorite staff. Residents cook when they want to, staff takes the
residents one time a week. He has contact with his family and talks to them every other day. He thinks he'll be here until October
and then hopes to get his own apartment. If he could change anything, he would like walks to be 25 minutes instead of 15 minutes.
The second youth has been at the program for 5 days. It's good so far, he's slowly gaining privileges. He feels safe here and gets
along with the other residents. He had a job interview at Walmart. The food is good, he's a vegetarian and they accommodate his
needs. No one has put their hands on him since being at the program and there is nothing he thinks needs to change.
Interviewed staff has worked at the program for 1 year. He previously worked at McLaren. Orientation trainings included
expectations of staff, transportation, he met PO's. He had CPR training in 2022. His supervisors are Kathy and Jaylynn, he
feels supported by them. Nothing needs to change at this program, it operates like a family. Residents fit into the program;
the program does not change to fit them. Ongoing trainings have been about meds, food prep, supervision. Training goes on
24/7 here.
Observations

A facility walkthrough was conducted as a part of the unannounced site visit. The living areas where clients spend most of their time (the downstairs) was
immaculately clean and well organized. The client bedrooms that were observed were also clean and well organized. The upstairs hallway, upstairs
bathroom, and the stairs were in need of cleaning and sweeping, and minor repair. A hole was noted in the ceiling downstairs below the upstairs bathroom,
but the program explained it was the result of a water leak, and a plumber had just fixed the leak, and drywall repair was already scheduled.
The program has also made significant improvement in its record keeping of staff and client files. Files were much more organized, and it was easier to locate
required documentation during the review.
The program is in the process of getting ready to apply for a second program site as they continue to grow and expand.


summary: Unannounced - 6 findings

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Residential Care
Licensee: Team Bailey - Patricia
Executive Director: Kathy Bailey
Program Director(s): Jaylynn Bailey
Date of Unannounced: 03/03/2025
Licensing Coordinator: Jeff Minden, Aubrey Kelley
Other Regulatory or Accrediting Agencies: Oregon Youth Authority
Purpose: Per OAR 419-400-0240 (1)(b) Children’s Care Licensing is required to perform at least one unannounced site visit a year
where children in care reside.
Previous Findings Repeat Comments
Unannounced Site Visit – 05/15/2024 Findings
Further Action
Needed
Residential Care Safety Yes☐ No✓ Documentation Review showed that Team Bailey had completed
419-470-0080 all required fire drills.
(5)(a) Evacuation drill occurs monthly under
varying conditions, is retained 2 years and
contains:
(A) identify of person conducting drill
(B) date & time
(C) notification method
(D) staff participating
(E) # of children & staff evacuated
(F) special conditions simulated
(G) problems encountered
(H) time to complete
Form Rev. 11/14/2023 P age 1 | 5
• REPEAT FINDING:
Program documentation around fire drills
was more consistent then the previous
review, however the April fire drill
documentation could not be located
during the site visit.
Information about Children in Care Yes☐ No✓ Religious Preference was added to the client summary sheets
419-400-0190(1)
Summary sheet contains the following:
(a)The name, gender, date of birth, religious
preference, and previous address
• REPEAT FINDING:
Program has greatly improved their
documentation process and summary
sheets are detailed and easily located.
However, there was not a field on the
form for Religious Preferences.
Records Relating to Restraint & Yes☐ No☐ Finding deferred until the next review. The staff office was locked
Involuntary Seclusion during the site visit and one of the managers had left for the other
419-400-0180(13)(e) Each child caring program site with the keys and was unable to return.
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.
• REPEAT FINDING:
Program documentation did not clearly
identify how notifications about quarterly
restraints are being made to parents and
guardians
Form Rev. 11/14/2023 P age 2 | 5
419-470-0020(c) All areas of buildings Yes☐ No✓ The building was clean and in good repair.
where children in care are present must be
kept clean and in good repair. Major
appliances and heating, ventilation,
plumbing, and electrical systems must be
functional and in good repair.
• The living areas downstairs, the
kitchen, and client bedrooms were all
well maintained. However, the
upstairs bathroom, hallway, and
staircase were in need of cleaning.
Specifically, the upstairs bathroom
toilet and shower fans needed extra
cleaning, and a towel bar that needed
repairing.
New Findings from Site Visit Comments
419-400-0200(1)(b)(B)Each vehicle The program does have a fire extinguisher in their vehicle; however, it was not secured
owned by a child-caring agency and inside the vehicle. The program secured the fire extinguisher after the visit prior to the
used to transport a child in care must completion of this report.
have aboard a first aid kit and a fully
charged, properly secured, and
working fire extinguisher with a rating
of at least 2-A:10-BC
419-400-0200(1)(b)(A)(i) – Vehicles The van used by the program to transport clients had an expired registration. The program
used by the program shall be confirmed that after visit, and prior to the completion of this report, that a new registration
properly registered had been secured from the Oregon DMV.
Form Rev. 11/14/2023 P age 3 | 5
Interview Summary
2 clients and 1 staff were interviewed as a part of the unannounced site visit. One client was non-responsive and did not provide
answers to the questions. The other client reported liking the program a lot and having been at Team Bailey for approximately 3
months. Client reported previously spending time at NorCor and P180 through the Oregon Youth Authority. The best part of the
program was reportedly how flexible the program was with work and school, and that clients could cook for themselves and make a
food list that staff filled. The hardest part of the program was not being home with family, but it was reported that clients could make
phone calls whenever they liked, and there was an option to get their own cell phones. Staff were reported to be “really cool”, and
the client reported feeling comfortable reaching out to Kathy or Jaylynn if they needed anything. Client reported feeling safe, and
they have 3-4 more months left at the program.
Staff interviewed reported having been at the program for 3 years and loving what they do. They reported that they love coming to
work every day, and they feel 100% supported by staff and management. 80% of their job is teaching life skills to the residents.
Staff reported getting along with all the clients, and that they treat the clients fair and show them respect. Clients prepare their own
meals, and staff help when needed. All the clients have jobs or attend school. Staff also noted having CPR/First Aid training that
morning.
Observations
A tour was conducted of the Team Bailey Patricia Court site as a part of the unannounced visit. The facility was clean and in good
repair; although, a ceiling vent in the bathroom did need cleaning and was vacuumed prior to the completion of the tour. Toilets,
sinks and showers were all kept very clean, and the client rooms were spacious, clean and uncluttered. The program van was also
viewed and was found to be clean and well-kept as well.
Corrective Actions and Timeframes:
Please submit the following to verify compliance.
Within 45 days of receipt of this report Team Bailey - Patricia 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,
Form Rev. 11/14/2023 P age 4 | 5
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: _3_-_1_3_-_2_0_2_5__________
Manager Review: ______________________________________ Date: _____3__-1_3_-_2_0_2_5_____
Form Rev. 11/14/2023 P age 5 | 5

licensee: Team Bailey - Patricia

licensing_coordinator: Jeff Minden, Aubrey Kelley

purpose:
Per OAR 419-400-0240 (1)(b) Children's Care Licensing is required to perform at least one unannounced site visit a year
where children in care reside.
Previous Findings Repeat Comments
Unannounced Site Visit - 05/15/2024 Findings
Further Action
Needed
Residential Care Safety Yes[ ] No✓ Documentation Review showed that Team Bailey had completed
419-470-0080 all required fire drills.
(5)(a) Evacuation drill occurs monthly under
varying conditions, is retained 2 years and
contains:
(A) identify of person conducting drill
(B) date & time
(C) notification method
(D) staff participating
(E) # of children & staff evacuated
(F) special conditions simulated
(G) problems encountered
(H) time to complete

- REPEAT FINDING:
Program documentation around fire drills
was more consistent then the previous
review, however the April fire drill
documentation could not be located
during the site visit.
Information about Children in Care Yes[ ] No✓ Religious Preference was added to the client summary sheets
419-400-0190(1)
Summary sheet contains the following:
(a)The name, gender, date of birth, religious
preference, and previous address
- REPEAT FINDING:
Program has greatly improved their
documentation process and summary
sheets are detailed and easily located.
However, there was not a field on the
form for Religious Preferences.
Records Relating to Restraint & Yes[ ] No[ ] Finding deferred until the next review. The staff office was locked
Involuntary Seclusion during the site visit and one of the managers had left for the other
419-400-0180(13)(e) Each child caring program site with the keys and was unable to return.
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.
- REPEAT FINDING:
Program documentation did not clearly
identify how notifications about quarterly
restraints are being made to parents and
guardians

419-470-0020(c) All areas of buildings Yes[ ] No✓ The building was clean and in good repair.
where children in care are present must be
kept clean and in good repair. Major
appliances and heating, ventilation,
plumbing, and electrical systems must be
functional and in good repair.
- The living areas downstairs, the
kitchen, and client bedrooms were all
well maintained. However, the
upstairs bathroom, hallway, and
staircase were in need of cleaning.
Specifically, the upstairs bathroom
toilet and shower fans needed extra
cleaning, and a towel bar that needed
repairing.
New Findings from Site Visit Comments
419-400-0200(1)(b)(B)Each vehicle The program does have a fire extinguisher in their vehicle; however, it was not secured
owned by a child-caring agency and inside the vehicle. The program secured the fire extinguisher after the visit prior to the
used to transport a child in care must completion of this report.
have aboard a first aid kit and a fully
charged, properly secured, and
working fire extinguisher with a rating
of at least 2-A:10-BC
419-400-0200(1)(b)(A)(i) - Vehicles The van used by the program to transport clients had an expired registration. The program
used by the program shall be confirmed that after visit, and prior to the completion of this report, that a new registration
properly registered had been secured from the Oregon DMV.

Interview Summary
2 clients and 1 staff were interviewed as a part of the unannounced site visit. One client was non-responsive and did not provide
answers to the questions. The other client reported liking the program a lot and having been at Team Bailey for approximately 3
months. Client reported previously spending time at NorCor and P180 through the Oregon Youth Authority. The best part of the
program was reportedly how flexible the program was with work and school, and that clients could cook for themselves and make a
food list that staff filled. The hardest part of the program was not being home with family, but it was reported that clients could make
phone calls whenever they liked, and there was an option to get their own cell phones. Staff were reported to be "really cool", and
the client reported feeling comfortable reaching out to Kathy or Jaylynn if they needed anything. Client reported feeling safe, and
they have 3-4 more months left at the program.
Staff interviewed reported having been at the program for 3 years and loving what they do. They reported that they love coming to
work every day, and they feel 100% supported by staff and management. 80% of their job is teaching life skills to the residents.
Staff reported getting along with all the clients, and that they treat the clients fair and show them respect. Clients prepare their own
meals, and staff help when needed. All the clients have jobs or attend school. Staff also noted having CPR/First Aid training that
morning.
Observations
A tour was conducted of the Team Bailey Patricia Court site as a part of the unannounced visit. The facility was clean and in good
repair; although, a ceiling vent in the bathroom did need cleaning and was vacuumed prior to the completion of the tour. Toilets,
sinks and showers were all kept very clean, and the client rooms were spacious, clean and uncluttered. The program van was also
viewed and was found to be clean and well-kept as well.