summary: Visit conducted on 6/27/2024. Visit covered 3 main areas/topics. Found 1 compliance issues. Implemented 1 corrective actions.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

  NAME OF FACILITY / PROGRAM: Boys and Girls Village / Safe Haven Residential

 TIME OF VISIT (FROM - TO):     9am to 12pm               DATE: 6/27/2024

 AGENCY PERSONNEL WHO PARTICIPATED:

	Job Title
	VP of Administrative Operations
	Milieu Supervisor

List of Areas / Topics covered during visit:
•	LBC 12.  Census is 13.
•	At the time of the visit youth were engaged in an activity in the big dining room.  School has been out since 6/19/24 and starts again 7/1/24.  Staff report numerous structured recreation time such as table games, gym and assorted outdoor activities.
•	Physical plant inspection completed.  Room 615 had an exposed wire in the metal frame (hooked up to the door). It was repaired during the visit.

Corrective Actions implemented as a result of previous visit:
No RCP

Areas of regulatory non-compliance identified during this visit:
No RCP

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Thomas S. Cuchara                           7/15/24
Regulatory Consultant                         Date

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

description: No RCP


state: CT

facility_name: Boys & Girls Village / Safe Haven / CCF-RT#153

summary: Visit conducted on 2-15-2024. Visit covered 4 main areas/topics. Found 1 compliance issues. Implemented 1 corrective actions.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

  NAME OF FACILITY / PROGRAM: Boys and Girls Village / Safe Haven Residential

 TIME OF VISIT (FROM - TO):     9am to 12pm               DATE: 2-15-2024

 AGENCY PERSONNEL WHO PARTICIPATED:

	Job Title
	VP of Administrative Operations

List of Areas / Topics covered during visit:
•	LBC 12.  Census is 13.
•	At the time of the visit youth were in school.
•	Program admitted one youth exceeding the LBC by one via a waiver. Youth is 10 years old.
•	Physical plant inspection completed.

Corrective Actions implemented as a result of previous visit:
No SDP

Areas of regulatory non-compliance identified during this visit:
No SDP

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Thomas S. Cuchara                           2/16/24
Regulatory Consultant                         Date

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

type: general

description: No SDP


summary: Visit conducted on 12/18/23. Visit covered 4 main areas/topics. No compliance issues identified. Implemented 1 corrective actions.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

  NAME OF FACILITY / PROGRAM: Boys and Girls Village / Safe Haven Residential

 TIME OF VISIT (FROM - TO):     1:30pm to 4pm               DATE: 12/18/23

 AGENCY PERSONNEL WHO PARTICIPATED:

	Job Title
	VP of Administrative Operations
	Milieu Coordinator

List of Areas / Topics covered during visit:
•	LBC 12.  Census is 12.
•	Youth were in the building with staff getting ready for an activity in the gym.  They seemed excited and were in good spirits.
•	No concern with physical plant. Residents had been spending time making the big room more festive by making Christmas decorations and wreaths.
•	Reviewed one case record. Discussed the limitations and differences between a room check and room search.

Corrective Actions implemented as a result of previous visit:
No SDP

Areas of regulatory non-compliance identified during this visit: NONE.
   No SDP required.

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Thomas S. Cuchara                           12/26/23
Regulatory Consultant                         Date

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|


summary: Visit conducted on 8/29/23. Visit covered 5 main areas/topics. No compliance issues identified. Implemented 1 corrective actions.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

  NAME OF FACILITY / PROGRAM: Boys and Girls Village / Safe Haven Residential

 TIME OF VISIT (FROM - TO):     1:30pm to 2pm               DATE: 8/29/23

 AGENCY PERSONNEL WHO PARTICIPATED:

	Job Title
	VP of Administrative Operations

List of Areas / Topics covered during visit:
•	LBC 12.  Census is 10.
•	At the time youth were in school except for one.
•	Spoke with one resident. He likes it at the program, but prefers to live elsewhere.
•	Discussed the programing and resident behaviors.
•	Physical plant inspection completed. No concern.

Corrective Actions implemented as a result of previous visit:
No SDP

Areas of regulatory non-compliance identified during this visit: NONE.
   No SDP required.

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Thomas S. Cuchara                           9/21/23
Regulatory Consultant                         Date

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|


summary: Visit conducted on 4/13/23. Visit covered 5 main areas/topics. No compliance issues identified. Implemented 2 corrective actions.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

  NAME OF FACILITY / PROGRAM: Boys and Girls Village / Safe Haven Residential

 TIME OF VISIT (FROM - TO):     10:30am-12pm               DATE: 4/13/23

 AGENCY PERSONNEL WHO PARTICIPATED:

	Job Title
	VP of Administrative Operations

List of Areas / Topics covered during visit:
•	LBC 12.  Census is 11.
•	At the time of the visit the youth were eating lunch.
•	Discussed the programing and resident behaviors.
•	Physical plant inspection completed. No concern.
•	Reviewed two client charts. No concern.

Corrective Actions implemented as a result of previous visit:
Sec. 17a-16. Client Rights- Room Searches.  Completed.
At the time of the inspection staff were observed searching a client's bedroom. Staff state the program completes daily room searches while clients are attending school during the week.  Residents are not present or asked to be present while the room search is conducted.  This is a citation.  There is no evidence a resident was present when a room search is completed by staff.  Residents should be present during the room search, unless there is an emergency situation that requires immediate search of the resident's bedroom.

Medication Administration: Completed.
Security of Medication Keys.  The identified medication certified staff member gave the medication keys (noncontrolled and controlled keys) to another medication certified staff who subsequently left the building and later returned handing the keys back.  This key exchange was observed by Licensing.  No controlled medication count was completed.  This writer did complete a controlled medication count and all pills are accounted for.  Staff also report the medication keys are stored in the staff office.
The program will be cited for the following reasons:
•	Security of controlled medication keys is lack.  A key exchange was completed, but no documentation occurred.  Staff left the building and returned.
•	Staff did not complete a controlled medication count at the time of the initial key exchange or document a key exchange was done and document the count was completed when the key was returned.
•	Non-controlled and controlled medication keys are stored in the staff office.  The keys should be stored in the nurse's station, which has a lock box for both sets of keys.
•	The sheet used to document key exchanges calendar dates are predated.  The document has room for only signatures of staff handing the key off to the oncoming shift.  The document does not have sufficient space to accommodate multiple key exchanges for each shift.

Areas of regulatory non-compliance identified during this visit: NONE.
   N/A

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Thomas S. Cuchara                           4/14/23
Regulatory Consultant                         Date

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|


summary: Visit conducted on 2/9/23. Visit covered 5 main areas/topics. No compliance issues identified. Implemented 1 corrective actions.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

  NAME OF FACILITY / PROGRAM: Boys and Girls Village / Safe Haven Residential

 TIME OF VISIT (FROM - TO):       __12:30pm _______               DATE: 2/9/23

 AGENCY PERSONNEL WHO PARTICIPATED:

Name	Job Title
TK	Clinical Coordinator
DL	Milieu Supervisor
KH	Mental Health Worker

List of Areas / Topics covered during visit:
•	Census is 12. One resident is in the hospital due to psychiatric concerns.
•	At the time of the visit the youth were in school.
•	Discussed the programing and resident behaviors. See below.
•	Physical plant inspection completed. No concerns.
•	Completed review of medication room. See below.

Corrective Actions implemented as a result of previous visit:
No corrective action required from last visit.

Areas of regulatory non-compliance identified during this visit: NONE.
Sec. 17a-16. Client Rights- Room Searches.
At the time of the inspection staff were observed searching a client's bedroom. Staff state the program completes daily room searches while clients are attending school during the week.  Residents are not present or asked to be present while the room search is conducted.  This is a citation.  There is no evidence a resident was present when a room search is completed by staff.  Residents should be present during the room search, unless there is an emergency situation that requires immediate search of the resident's bedroom.

Medication Administration:
Security of Medication Keys.  The identified medication certified staff member gave the medication keys (noncontrolled and controlled keys) to another medication certified staff who subsequently left the building and later returned handing the keys back.  This key exchange was observed by Licensing.  No controlled medication count was completed.  This writer did complete a controlled medication count and all pills are accounted for.  Staff also report the medication keys are stored in the staff office.
The program will be cited for the following reasons:
•	Security of controlled medication keys is lack.  A key exchange was completed, but no documentation occurred.  Staff left the building and returned.
•	Staff did not complete a controlled medication count at the time of the initial key exchange or document a key exchange was done and document the count was completed when the key was returned.
•	Non-controlled and controlled medication keys are stored in the staff office.  The keys should be stored in the nurse's station, which has a lock box for both sets of keys.
•	The sheet used to document key exchanges calendar dates are predated.  The document has room for only signatures of staff handing the key off to the oncoming shift.  The document does not have sufficient space to accommodate multiple key exchanges for each shift.

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Thomas S. Cuchara                           2/14/23
Regulatory Consultant                         Date

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|


summary: Visit conducted on 12/27/2022____. Visit covered 5 main areas/topics. No compliance issues identified. Implemented 1 corrective actions.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

  NAME OF FACILITY / PROGRAM: Boys and Girls Village / Safe Haven Residential

 TIME OF VISIT (FROM - TO):       __9:30am _______________________               DATE: 12/27/2022____

 AGENCY PERSONNEL WHO PARTICIPATED:

Name	Job Title
DB	Vice President of Residential Services

List of Areas / Topics covered during visit:
•	Census is 12.
•	At the time of the visit the youth were in school.
•	Discussed the programing and resident behaviors.
•	Physical plant inspection completed. No concerns.
•	Discussed staffing and staff vacancies.

Corrective Actions implemented as a result of previous visit:
No corrective action required from last visit.

Areas of regulatory non-compliance identified during this visit: NONE.
No SDP required

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Thomas S. Cuchara                           ___12/27/2022_______
Regulatory Consultant                                   Date

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|


facility_name: Justice Resource Institute / Susan Wayne / RT#117

summary: Visit conducted on December 8, 2025. Visit covered 12 main areas/topics. No compliance issues identified.

raw_content:
DCF-3034
1/2013 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

 NAME OF FACILITY / PROGRAM: JRI/ Susan Wayne Residential Center

 TIME OF VISIT (FROM - TO): 11:35am to 12:45pm           DATE: December 8, 2025

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Title
Senior Vice President of Residential Services

Areas / Topics covered during visit:

•	Census: The residential program census was thirty (17 males and 13 females) at the time of the scheduled quarterly visit.
•	Admissions: In the last quarter the program confirmed that there were four new admissions.
•	Discharges: It was reported by the program that in the last quarter there were two planned discharges.
•	Staff: The residential staffing included ninety-three full-timers and twenty-six per-diem employees.
•	Staff vacancies: The program currently has one director vacancy, one supervisor vacancy and three direct care full-time vacancies.
•	Physical plant: A walkthrough of the facility was conducted to confirm residential units were in compliance with regulatory requirements.
•	Personnel files: An audit of personnel records was not conducted in this quarter.

During the past quarter, licensing responded to one incident and completed one incident response note.  The incident which occurred in October of 2025, involved allegations of inappropriate force by staff during a restraint.

Corrections implemented as a result of previous visit:
N/A

Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning)
N/A

Areas of regulatory non-compliance identified during this visit:
N/A

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Penny Woodward, LCSW                                     December 15, 2025
Regulatory Consultant                                                        Date

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

facility_name: JRI/ Susan Wayne Residential Center

visit_date: December 8, 2025


summary: Visit conducted on August 21, 2025. Visit covered 12 main areas/topics. No compliance issues identified.

raw_content:
DCF-3034
1/2013 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

 NAME OF FACILITY / PROGRAM: JRI/ Susan Wayne Residential Center

 TIME OF VISIT (FROM - TO): 10:52am to 12:39pm                     DATE: August 21, 2025

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Title
 Director
 Division Director

Areas / Topics covered during visit:

•	Census: The residential program census was thirty-three (18 males and 15 females) at the time of the scheduled quarterly visit.
•	Admissions: In the last quarter the program confirmed that there were three new admissions.
•	Discharges: The program confirmed that in the last quarter there were three planned discharges.
•	Staff: The residential staffing consisted of one hundred full-timers and thirty part-timers.
•	Staff vacancies: In the last quarter, the program had three residential vacancies.
•	Physical plant: A walkthrough of the facility was conducted with the director to confirm residential units were in compliance with regulatory requirements.
•	Personnel: On 8/12/25, twenty-two employee records were reviewed, and all files contained the required background check information.
•	SIU Reports: There were no reports in this quarter.

Corrections implemented as a result of previous visit:
N/A

Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning)
N/A

Areas of regulatory non-compliance identified during this visit:
N/A

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Penny Woodward, LCSW                                     August 26, 2025
Regulatory Consultant                                                    Date

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

personnel:
Director
Division Director


summary: Visit conducted on June 18, 2025. Visit covered 12 main areas/topics. No compliance issues identified.

raw_content:
DCF-3034
1/2013 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

 NAME OF FACILITY / PROGRAM: JRI/ Susan Wayne Residential Center

 TIME OF VISIT (FROM - TO): 11:00am to 12:15pm                     DATE: June 18, 2025

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Title
                                                                          Director
                                                                    Division Director
Areas / Topics covered during visit:

•	Census: The residential program census was thirty-three (18 males and 15 females) at the time of the scheduled quarterly visit.
•	Admissions: In the last quarter the program confirmed that there were three new admissions.
•	Discharges: The program confirmed that in the last quarter there were three planned discharges.
•	Staff: The residential staffing remains at ninety-seven full-timers and twenty-four part-timers.
•	Staff vacancies: In the last quarter, the program had four residential vacancies.
•	Physical plant: A walkthrough of the facility was conducted with the director and division director to confirm buildings were in compliance with regulatory requirements.
•	SIU Reports: There were no reports in this quarter.

Corrections implemented as a result of previous visit:
N/A

Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning)
N/A

Areas of regulatory non-compliance identified during this visit:
N/A

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Penny Woodward, LCSW                                     July 1,2025
Regulatory Consultant                                                Date

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|


summary: Visit conducted on January 28, 2025. Visit covered 13 main areas/topics. No compliance issues identified.

raw_content:
DCF-3034
1/2013 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

 NAME OF FACILITY / PROGRAM: JRI/ Susan Wayne Residential Center

 TIME OF VISIT (FROM - TO): 11:35am to 1:00pm                     DATE: January 28, 2025

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Title
Director

Areas / Topics covered during visit:

•	Census: The residential program census was thirty-three (17 males and 16 females) at the time of the scheduled quarterly visit.
•	Admissions: In the last quarter the program confirmed that there were nine new admissions.
•	Discharges: The program confirmed that in the last quarter there were six discharges.
•	Staff: The residential staffing remains at ninety-seven full-timers and twenty-four part-timers.
•	Staff vacancies: The facility has four residential vacancies and one nursing vacancy.
•	Physical plant: A walkthrough of the facility was conducted with the director, and the buildings were being maintained in compliance with regulatory requirements.
•	Personnel: Employee records were not reviewed.
•	SIU Reports: There were no reports in this quarter.

Corrections implemented as a result of previous visit:
N/A

Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning)
N/A

Areas of regulatory non-compliance identified during this visit:
N/A

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Penny Woodward, LCSW                               February 10, 2025
Regulatory Consultant                                            Date

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

visit_date: January 28, 2025


summary: Visit conducted on November 21, 2024. Visit covered 12 main areas/topics. No compliance issues identified.

raw_content:
NAME OF FACILITY / PROGRAM: JRI/ Susan Wayne Residential Center

 TIME OF VISIT (FROM - TO): 11:00am to 12:00pm                     DATE: November 21, 2024

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Title
 Director

Areas / Topics covered during visit:

•	Census: The residential program census was thirty-two (17 males and 15 females) at the time of the scheduled quarterly visit.
•	Admissions: In the last quarter the program confirmed that there were three new admissions.
•	Discharges: The program confirmed that in the last quarter there were four discharges.
•	Staff: The residential staffing consists of ninety-seven full-timers and twenty-four part-timers.
•	Staff vacancies: The facility has four residential vacancies and one nursing vacancy.
•	Physical plant: A walkthrough of the residential units was conducted with the director, and the buildings were being maintained in compliance with regulatory requirements.
•	Personnel: Employee records and files were not reviewed during the quarterly visit.

During the past quarter, licensing responded to one incident and completed one incident response note. The incident occurred on 8/28/24, and it involved staff supervision.

Corrections implemented as a result of previous visit:
N/A

Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning)
N/A

Areas of regulatory non-compliance identified during this visit:
N/A

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Penny Woodward, LCSW                               December 5, 2024|

visit_date: November 21, 2024


raw_content:
September 5, 2024

Justice Resource Institute, Inc.
160 Gould Street. Suite 300
Needham, MA. 02494

Re: Bi-annual licensing inspection of JRI Susan Wayne Center in Thompson, CT. Regulatory Consultants: Penny Woodward, Tom Cuchara and James Funaro.

On August 12th through August 15th a bi-annual re-licensing inspection was conducted at the Susan Wayne Center to determine compliance with Regulations for Operation of Child Caring Agencies and Facilities Sections 17a-145-48 through 17a-145-98, as well as the DCF Guidelines for the Administration of Medication by certified staff.

DCF has determined that the program is in compliance with all applicable regulatory provisions except those itemized below: Please review areas identified and submit a plan of correction to address each area.

The service development plan must be submitted within 30 days of receipt of this letter and should identify: 1. The steps to be taken to correct the non-compliance.  2. The date the correction(s) will be completed. The areas of non-compliance identified are as follows:

Section 17a-145-52: Interstate placement of children.
Evidence: Upon review of case records, one file did not contain interstate placement information as required by regulation.

Section 17a-145-61: Written policies and procedures.
Evidence: Upon review of the agency manual, there were no policies on the process for removal of personal items from a client's bedroom when there is a safety concern. The policy for clients on a high-risk status needs to be amended and the requirement for residents to only wear loose fitting shoes must be removed. Policy on room searches was not included in the manual and information needs to be added.

Section 17a-145-71: Living room lounge.
Evidence: Upon inspection of the Cedar Unit, the lounge flooring was heavily scratched and worn from daily use. The citation needs to be addressed.

Section 17a-145-73: Sleeping accommodations.
Evidence: Upon inspection of the Cedar Unit, flooring in all bedrooms were either scratched, marked up or stained.  The citation needs to be addressed.

Evidence: Upon inspection of the Elm Unit, flooring in most of the bedrooms were worn and marked up from daily use. The citation needs to be addressed.

Section 17a-16-8: Use of telephone.
Evidence: Upon review of telephone policies and procedures, the program practice was not always in compliance with statute requirements. This is a statute violation.

Section 46a-153: Physical restraint and seclusion.
Evidence: Upon review of seclusion practices, on one occasion, the safe space area was used to seclude a resident that was not at imminent risk. This practice is a statute violation.

Once licensing has reviewed and accepted the service development plan and has determined that your agency is in compliance with the regulations a decision on the issuance of a regular twenty-four-month license for the program will be made. Until DCF makes this decision the current license will remain in effect.

Please be advised that failure to submit an acceptable service development plan within the specified time frame may lead to a licensing action up to and including revocation. Should you have any questions or comments regarding the contents of this report please do not hesitate to call me at (959) 255-0615.

Sincerely,

Penny Woodward

Penny Woodward, LCSW
DCF Regulatory Consultant
Copy: File|

report_type: unstructured


summary: Visit conducted on April 25, 2024. Visit covered 12 main areas/topics. Found 1 compliance issues.

raw_content:
DCF-3034
1/2013 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

 NAME OF FACILITY / PROGRAM: JRI/ Susan Wayne Residential Center

 TIME OF VISIT (FROM - TO): 11:40am to 1:40pm                     DATE: April 25, 2024

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Title
Director

Areas / Topics covered during visit:

•	Census: The residential program census was thirty-four (18 males and 16 females) at the time of the scheduled quarterly visit.
•	Admissions: In the last quarter the program confirmed that there were five new admissions.
•	Discharges: The program confirmed that in the last quarter there were two planned discharges.
•	Staff: The residential staffing consists of ninety-seven full-timers and twenty-four part-timers.
•	Staff vacancies: The facility has one educational vacancy and one nursing vacancy.
•	Physical plant: A walkthrough of the residential units were conducted with the director and buildings were being maintained according to regulatory requirements.
•	Personnel: Employee records and files were not reviewed during the quarterly visit.

During the past quarter, licensing responded to three incidents and completed three incident response notes.  The first incident occurred on 1/22/24 and involved an inappropriate restraint hold.  The second incident occurred on 2/29/24 and involved allegations of neglect.  The third incident occurred on 3/8/24 and involved inappropriate behavior of a former employee.

Corrections implemented as a result of previous visit:
N/A

Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning)
N/A

Areas of regulatory non-compliance identified during this visit:
17a-145-74. Lavatory Facilities: Upon inspection of the physical plant, one of the bathrooms on the Elm Unit contained cracked flooring and it needs to be fixed.

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Penny Woodward, LCSW                               May 9, 2024
Regulatory Consultant                                         Date

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|


summary: Visit conducted on February 6, 2024. Visit covered 13 main areas/topics. No compliance issues identified.

raw_content:
DCF-3034
1/2013 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

 NAME OF FACILITY / PROGRAM: JRI/ Susan Wayne Residential Center

 TIME OF VISIT (FROM - TO): 11:00am to 1:30pm                     DATE: February 6, 2024

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Title   Director

Areas / Topics covered during visit:

•	Census: The residential program census was thirty-three (18 males and 15 females) at the time of the scheduled quarterly visit.
•	Admissions: In the last quarter the program confirmed that there were two admissions.
•	Discharges: The program confirmed that in the last quarter there were three discharges.
•	The residential staffing consists of ninety-eight full-timers and twenty-four part-timers.
•	Staff vacancies: The facility has four residential vacancies and one nursing vacancy.
•	Physical plant: A walkthrough of the residential units were conducted with the director and buildings were being maintained according to regulatory requirements.
•	Personnel: On January 9th the Department conducted a six-months personnel audit and a total of nineteen files were reviewed.

During the past quarter, licensing responded to three incidents and completed three incident response notes.  The first incident occurred on 8/12/23 and involved questions about intervention of staff during an incident.  The second incident occurred on 10/26/23 and involved supervision of staff.  The third incident occurred on 11/3/23 and involved a resident with contraband.

Corrections implemented as a result of previous visit:
N/A

Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning)
N/A

Areas of regulatory non-compliance identified during this visit:
N/A

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Penny Woodward, LCSW                              __February 21, 2024___
Regulatory Consultant                                            Date

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

visit_date: February 6, 2024


summary: Visit conducted on October 11, 2023. Visit covered 1 main areas/topics. No compliance issues identified. Implemented 2 corrective actions.

raw_content:
DCF-3034
1/2013 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

 NAME OF FACILITY / PROGRAM: JRI/ Susan Wayne Residential Center

 TIME OF VISIT (FROM - TO): 11:00am to 12:30pm                     DATE: October 11, 2023

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Title
Director

Areas / Topics covered during visit:
The residential program census was thirty-two (17 males and 15 females) at the time of the scheduled quarterly visit. The program reported that there were six residential workers' vacancies and the positions are expected to be filled soon.  A walkthrough of the physical plant was conducted with the residential director and there was a noticeable decline in the appearance of bedrooms in the Elm and Cedar Units.  The licensing unit will issue a citation if issues are not addressed and there is a continued decline in the maintenance of residents' bedrooms.

Corrections implemented as a result of previous visit:
In the last quarter a service development plan was submitted to the Department to confirm that Regulations 17a-145-73 and 17a-145-77 have been addressed.

Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning)
N/A

Areas of regulatory non-compliance identified during this visit:
N/A

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Penny Woodward, LCSW                              November 9, 2023
Regulatory Consultant                                            Date

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

corrective_actions:
73 and 17a
77 have been addressed.

visit_date: October 11, 2023


summary: Visit conducted on July 25, 2023. Visit covered 2 main areas/topics. Found 2 compliance issues.

raw_content:
DCF-3034
1/2013 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

 NAME OF FACILITY / PROGRAM: JRI/ Susan Wayne Residential Center

 TIME OF VISIT (FROM - TO): 11:00am to 1:00pm                     DATE: July 25, 2023

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Title     Program Director

Areas / Topics covered during visit:
The residential program census was thirty-three (19 males,13 females and 1 overcapacity approval) at the time of the quarterly visit and the licensed bed capacity has been temporarily extended to thirty-four. The program reported that there is a nurse and six residential workers' vacancies.  A walkthrough of the physical plant was conducted with the residential director and several deficiencies were identified.

Corrections implemented as a result of previous visit:
N/A

Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning)
N/A

Areas of regulatory non-compliance identified during this visit:
Section 17a-145-73: Sleeping accommodations. Upon inspection of the Pine Unit, bedroom 18 contained a wall with repair patches and it needs to be addressed.  Bedroom 19 contained a wall with a small repair patch (near the electrical outlet) and it needs to be addressed.

Section 17a-145-77: Dining areas and supervision. Upon inspection of the cafeteria, several of the dining room tables were in disrepair and they need to be addressed.

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Penny Woodward, LCSW                              August 14, 2023
Regulatory Consultant                                            Date

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

regulation: Sleeping accommodations.

description: Upon inspection of the

regulation: Dining areas and supervision.


summary: Visit conducted on May 16, 2023. Visit covered 2 main areas/topics. No compliance issues identified.

raw_content:
DCF-3034
1/2013 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

 NAME OF FACILITY / PROGRAM: JRI/ Susan Wayne Residential Center

 TIME OF VISIT (FROM - TO): 11:30am to 1:00pm                     DATE: May 16, 2023

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Title
Program Director

Areas / Topics covered during visit:
The residential program census was thirty-three (17 males and 16 females) at the time of the quarterly visit and the licensed bed capacity remains at thirty-three. The program reported that there is a nurse and four residential workers' vacancies.  A walkthrough of the physical plant was conducted with the residential director and no deficiencies were identified.

Corrections implemented as a result of previous visit:
N/A

Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning)
N/A

Areas of regulatory non-compliance identified during this visit:
N/A

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Penny Woodward, LCSW                              __June 16, 2023___
Regulatory Consultant                                            Date

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|


summary: Visit conducted on March 14, 2023. Visit covered 2 main areas/topics. No compliance issues identified.

raw_content:
DCF-3034
1/2013 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

 NAME OF FACILITY / PROGRAM: JRI/ Susan Wayne Residential Center

 TIME OF VISIT (FROM - TO): 11:00am to 1:30pm                     DATE: March 14, 2023

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Title
Program Director

Areas / Topics covered during visit:
The census was thirty-three at the time of the quarterly visit and the residential program licensed bed capacity is thirty-three. The program reported that there is a nurse and three residential workers' vacancies.  A walkthrough of the physical plant was conducted with the program director and minor deficiencies were identified that will need to be addressed before the next quarterly visit.

Corrections implemented as a result of previous visit:
N/A

Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning)
N/A

Areas of regulatory non-compliance identified during this visit:
N/A

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Penny Woodward, LCSW                              April 10, 2023
Regulatory Consultant                                            Date

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|


raw_content:
October 31, 2022

Re: Bi-annual licensing inspection of JRI Susan Wayne Center in Thompson, CT. Regulatory Consultants: Penny Woodward, Tom Cuchara and Keith Bryan.

On October 3rd through October 7tha biennial re-licensing inspection was conducted at the Susan Wayne Center to determine compliance with Regulations for Operation of Child Caring Agencies and Facilities Sections 17a-145-48 through 17a-145-98, as well as the DCF Guidelines for the Administration of Medication by certified staff.

DCF has determined that the program is in compliance with all applicable regulatory provisions except those itemized below: Please review areas identified and submit a plan of correction to address each area.

The service development plan must be submitted within 30 days of receipt of this letter and should identify: 1. The steps to be taken to correct the non-compliance.  2. The date the correction(s) will be completed. The areas of non-compliance identified are as follows:

Section 17a-145-61: Written policies and procedures.
Evidence: Upon review of the telephone policy, the restricted list and suspension of telephone privilege sections contained confusing language that could be misinterpreted by staff and the information needs to be amended or removed.  The repair policy contained vague language and the information needs to be amended or removed. The seclusion policy contained incorrect information and the statement needs to be amended.  The supervision policy contained information that was a regulatory violation and it should be removed.  The safety assessment plan contained vague information that could be misinterpreted by staff and it needs to be amended or removed. The resident handbook contained vague information under the student belongings section and it needs to be amended or removed.

Section 17a-145-63: Chief administrative officer.
Evidence: Upon review of seclusion practices, it was found that the use of the procedure was not always consistent with program policies and on multiple occasions the use of seclusions did not always ensure the safety or emotional well-being of residents.

Section 17a-145-64: Personnel policies.
Evidence: Upon review of the program manual, the personnel section did not contain information that required new employees to have TB and physical health exams prior to hire.

Section 17a-145-71: Dining areas.
Evidence: Upon inspection of the dining hall, several of the walls contained chipping paint and scuffmarks and they need to be addressed.

Section 17a-145-73: Sleeping accommodations.
Evidence: Upon inspection of the residential facility, the Cedar Unit contained a bedroom that had a dresser with scuffmarks and it needs to be addressed. The Pine Unit contained a bedroom that had a window with chipping glazed material and it needs to be addressed.

Section 17a-145-74: Lavatory facilities.
Evidence: Upon inspection of the residential facility, one of the bathrooms in the Cedar Unit contained a tub that was in disrepair and it needs to be addressed. The Pine Unit contained a bathroom that had a window with chipping glazed material and it needs to be addressed.

Section 17a-145-98: Case records.
Evidence: Upon review of case files, one record did not contain a signed placement agreement form as required by regulations.

Section 46a-153: Physical restraint.
Evidence: Upon review of seclusion documentation, it was confirmed that the program was allowing staff to use seclusion as a form of discipline to control and address residents' behavioral issues. This practice is a statute violation.

Once licensing has reviewed and accepted the service development plan and has determined that your agency is in compliance with the regulations a decision on the issuance of a regular twenty-four-month license for the program will be made. Until DCF makes this decision the current license will remain in effect.

Please be advised that failure to submit an acceptable service development plan within the specified time frame may lead to a licensing action up to and including revocation. Should you have any questions or comments regarding the contents of this report please do not hesitate to call me at (959) 255-0615.

Sincerely,

Penny Woodward, LCSW
DCF Regulatory Consultant
Copy: File|


summary: No compliance issues identified.

raw_content:
DCF-3034
1/2013 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM:  JRI / Susan Wayne Residential Center

TIME OF VISIT: (FROM–TO): 11:30 a.m. to 1:00 p.m.     DATE: 8/11/22

AGENCY PERSONNEL WHO PARTICIPATED:
Name	Job Title
                                  N/A	                Program Director

Areas / Topics covered during visit:
The Department of Children and Families conducted a scheduled quarterly inspection visit at the Susan Wayne Center on August 11, 2022. Topics covered during the quarterly visit included program staffing, physical plant inspection, milieu services and the fall biannual inspection visit.

Physical plant: A walkthrough of the physical plant with the residential director was conducted to confirm that the facility was in compliance with regulatory standards.

Corrections implemented as a result of previous visit:
N/A

Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning)
N/A

Areas of regulatory non-compliance identified during this visit:
N/A

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Penny Woodward, LCSW                          September 12, 2022
Regulatory Consultant                                   Date

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

facility_name: JRI / Susan Wayne Residential Center


summary: No compliance issues identified.

raw_content:
DCF-3034
1/2013 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM:  JRI / Susan Wayne Residential Center

TIME OF VISIT: (FROM–TO):  Morning to Afternoon     DATE: 4/29/22

AGENCY PERSONNEL WHO PARTICIPATED:
Name	Job Title
                                  N/A Program Director

Areas / Topics covered during visit:
The Department of Children and Families conducted a scheduled quarterly inspection visit at the  Susan Wayne Center on April 29, 2022. Topics covered during the quarterly visit included program staffing, physical plant inspection, milieu services and medication administration system.

Physical plant: A walkthrough of the physical plant with the program director was conducted; deficiencies were identified and discussed with the director.

Corrections implemented as a result of previous visit:
N/A

Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning)
N/A

Areas of regulatory non-compliance identified during this visit:
N/A

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Penny Woodward, LCSW                          April 29, 2022
Regulatory Consultant                                   Date

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|


facility_name: Monroe Operations LLC/ Newport Riverview

summary: Visit covered 5 main areas/topics. No compliance issues identified.

raw_content:
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM:  Newport Academy Riverview

TIME OF VISIT:  10:00 AM                   Date June 20, 2025

AGENCY PERSONNEL WHO PARTICIPATED:
Newport Academy Compliance Specialists.
Newport Academy Riverview Program Director

Areas / Topics covered during visit:

•	Discussion of the current census, which is 5, and the LBC is 7.

•	Discussion of Newport Academy Riverview's current staffing levels, vacant positions, and hiring activities.

•	Discussion with Newport Academy Riverview's staff regarding the status of Riverview's milieu, the clinical programming, incidents, and activities for the residents.

•	Inspection of the Newport Academy Riverview's physical plant to assess the cleanliness of the home, as well as to ensure there are no health or safety concerns.

•	Observation and brief interviews with the residents at the program during the time of this regulatory consultant's visit.

Corrections implemented as a result of previous visit:
Not applicable.

Areas of regulatory non-compliance identified during this visit:
Not applicable.

Patrick Hughes                                                   8/5/2025
Regulatory Consultant                                            Date|

facility_name: Newport Academy Riverview


raw_content:
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM:  Newport Academy Riverview

TIME OF VISIT:  10:00 AM                   DATE: February 11, 2025

AGENCY PERSONNEL WHO PARTICIPATED:
Two (2) Newport Academy Compliance Specialists.
Newport Academy Riverview Executive Director
Newport Academy Riverview Program Director

Areas / Topics covered during visit:

•	Discussion of the current census, which is 6, and the LBC is 7.

•	Discussion of Newport Academy Riverview's current staffing levels, vacant positions, and hiring activities.

•	Discussion with Newport Academy Riverview's staff regarding the status of Riverview's milieu, the clinical programming, incidents, and activities for the residents.

•	Inspection of the Newport Academy Riverview's physical plant to assess the cleanliness of the home, as well as to ensure there are no health or safety concerns.

•	Observation and brief interviews with the residents at the program during the time of this regulatory consultant's visit.

Corrections implemented as a result of previous visit:
Not applicable.

Areas of regulatory non-compliance identified during this visit:
Not applicable.

Patrick Hughes                                                 3/17/2025
Regulatory Consultant                                            Date|


raw_content:
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM:  Newport Academy Riverview

TIME OF VISIT:  10:00 AM                   DATE: November 26, 2024

AGENCY PERSONNEL WHO PARTICIPATED:
Two (2) Newport Academy Compliance Specialists.
Newport Academy Medical Director.
Newport Academy Riverview Executive Director
Newport Academy Riverview Maintenance Director

Areas / Topics covered during visit:

•	Discussion of the current census, which is 7, and the LBC is 7.

•	Discussion of Newport Academy Riverview's current staffing levels, vacant positions, and hiring activities.

•	Discussion with Newport Academy Riverview's staff regarding the status of Riverview's milieu, the clinical programming, incidents, and activities for the residents.

•	Inspection of the Newport Academy Riverview's physical plant to assess the cleanliness of the home, as well as to ensure there are no health or safety concerns.

•	Observation and brief interview with the one resident at the program during the time of this regulatory consultant's visit.

Corrections implemented as a result of previous visit:
Not applicable.

Areas of regulatory non-compliance identified during this visit:
Not applicable.

Patrick Hughes                                                      11/29/2024
Regulatory Consultant                                            Date|


facility_name: Monroe Operations LLC/Newport Academy-DoubleHill

summary: Visit covered 7 main areas/topics. No compliance issues identified.

raw_content:
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM:  Newport Academy / Double Hill campus

TIME OF VISIT:  11:30 AM                DATE: 6/2/2025

AGENCY PERSONNEL WHO PARTICIPATED:
Newport Academy   Compliance Specialist.
Director of Operations.

Areas / Topics covered during visit:

•	Discussion of the current census, which is 52, and the LBC is 54.

•	Discussion of Newport Academy Double Hill's current staffing levels, vacant positions, and hiring activities.

•	Discussion with Newport Academy Double Hill's staff regarding recent Unusual Circumstance Reports.

•	Discussion with Newport Academy Double Hill's staff regarding the status of Double Hill's milieu, the clinical programming, incidents, and activities for the residents.

•	Inspection of the Double Hill's physical plant to assess the cleanliness of the homes, as well as to ensure there are no health or safety concerns.

•	Observations and brief discussions with some of the residents at Double Hill.

•	Two (2) IRN's were completed during this quarter.

Corrections implemented as a result of previous visit:
Not applicable.

Areas of regulatory non-compliance identified during this visit:
Not applicable.

Patrick Hughes                                                       6/2/2025
Regulatory Consultant                                            Date|

facility_name: Newport Academy / Double Hill campus


summary: Visit covered 6 main areas/topics. No compliance issues identified.

raw_content:
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM:  Newport Academy / Double Hill campus

TIME OF VISIT:  10:00 AM                DATE: 2/18/2025

AGENCY PERSONNEL WHO PARTICIPATED:
Two (2) Newport Academy   Compliance Specialists.

Areas / Topics covered during visit:

•	Discussion of the current census, which is 5, and the LBC is 54.

•	Discussion of Newport Academy Double Hill's current staffing levels, vacant positions, and hiring activities.

•	Discussion with Newport Academy Double Hill's staff regarding recent Unusual Circumstance Reports.

•	Discussion with Newport Academy Double Hill's staff regarding the status of Double Hill's milieu, the clinical programming, incidents, and activities for the residents.

•	Inspection of the Double Hill's physical plant to assess the cleanliness of the homes, as well as to ensure there are no health or safety concerns.

•	Observations and brief discussions with some of the residents at Double Hill.

Corrections implemented as a result of previous visit:
Not applicable.

Areas of regulatory non-compliance identified during this visit:
Not applicable.

Patrick Hughes                                                   3/17/2025
Regulatory Consultant                                            Date|


raw_content:
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM:  Newport Academy / Double Hill campus

TIME OF VISIT:  1:30 PM                DATE: 11/26/2024

AGENCY PERSONNEL WHO PARTICIPATED:
Two (2) Newport Academy   Compliance Specialists.
Newport Director of Operations

Areas / Topics covered during visit:

•	Discussion of the current census, which is 51, and the LBC is 54.

•	Discussion of Newport Academy Double Hill's current staffing levels, vacant positions, and hiring activities.

•	Discussion with Newport Academy Double Hill's staff regarding recent Exceptional Circumstance Reports.

•	Discussion with Newport Academy Double Hill's staff regarding the status of Double Hill's milieu, the clinical programming, incidents, and activities for the residents.

•	Inspection of the Double Hill's physical plant to assess the cleanliness of the home, as well as to ensure there are no health or safety concerns.

•	Observations of resident participating in the Double Hill programing.

Corrections implemented as a result of previous visit:
Not applicable.

Areas of regulatory non-compliance identified during this visit:
Not applicable.

Patrick Hughes                                                        11/29/2024
Regulatory Consultant                                            Date|


raw_content:
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM:  Newport Academy / Double Hill campus

TIME OF VISIT:  9:00 AM                DATE: August 29, 2024

AGENCY PERSONNEL WHO PARTICIPATED:
 Two (2) Newport Academy   Compliance Specialists.

Areas / Topics covered during visit:

•	Discussion of the current census, which is 50, and the LBC is 54.

•	Discussion of Newport Academy Double Hill's current staffing levels, vacant positions, and hiring activities.

•	Discussion with Newport Academy Double Hill's staff regarding recent Exceptionall Circumstance Reports.

•	Discussion with Newport Academy Double Hill's staff regarding the status of Double Hill's milieu, the clinical programming, incidents, and activities for the residents.

•	Inspection of the Double Hill's physical plant to assess the cleanliness of the home, as well as to ensure there are no health or safety concerns.

•	Observations of resident participating in the Double Hill programing.

Corrections implemented as a result of previous visit:
Not applicable.

Areas of regulatory non-compliance identified during this visit:
Not applicable.

Patrick Hughes                                                      8/29/2024
Regulatory Consultant                                            Date|


raw_content:
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM:  Newport Academy / Double Hill campus

TIME OF VISIT:  10:00 AM                DATE: June 18, 2024

AGENCY PERSONNEL WHO PARTICIPATED:
 Two (2) Newport Academy   Compliance Specialists.

Areas / Topics covered during visit:

•	Discussion of the current census, which is 50, and the LBC is 54.

•	Discussion of Newport Academy Double Hill's current staffing levels, vacant positions, and hiring activities.

•	Discussion with Newport Academy Double Hill's staff regarding the status of Double Hill's milieu, the clinical programming, incidents, and activities for the residents.

•	Inspection of the Double Hill's physical plant to assess the cleanliness of the home, as well as to ensure there are no health or safety concerns.

•	Observations of resident participating in the Double Hill programing.

Corrections implemented as a result of previous visit:
Not applicable.

Areas of regulatory non-compliance identified during this visit:
Not applicable.

Patrick Hughes                                                      7/1/2024
Regulatory Consultant                                            Date|


raw_content:
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM:  Newport Academy / Double Hill campus

TIME OF VISIT:  9:00 AM                DATE: March 20, 2024

AGENCY PERSONNEL WHO PARTICIPATED:
Newport Academy   Compliance Specialist.
Newport Director of Operations

Areas / Topics covered during visit:

•	Discussion of the current census, which is 52, and the LBC is 54.

•	Discussion of Newport Academy Double Hill's current staffing levels, vacant positions, and hiring activities.

•	Discussion with Newport Academy Double Hill's staff regarding the status of Double Hill's milieu, the clinical programming, incidents, and activities for the residents.

•	Inspection of the Double Hill's physical plant to assess the cleanliness of the home, as well as to ensure there are no health or safety concerns.

•	Observations of resident participating in the Double Hill programing.

Corrections implemented as a result of previous visit:
Not applicable.

Areas of regulatory non-compliance identified during this visit:
Not applicable.

Patrick Hughes                                                        3/25/2024
Regulatory Consultant                                            Date|


raw_content:
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM:  Newport Academy / Double Hill campus

TIME OF VISIT:  1:00PM                   DATE: December 20,2023 & January 10,2024

AGENCY PERSONNEL WHO PARTICIPATED:
Newport Academy   Compliance Specialist.

Areas / Topics covered during visit:

•	Due to this Regulatory Consultant being positive for covid 19, the December 20th visit was held virtually, an in-person visit was made 1/10/24.

•	Discussion of the current census, which is 50, and the LBC is 54.

•	Discussion of Newport Academy Double Hill's current staffing levels, vacant positions, and hiring activities.

•	Discussion with Newport Academy Double Hill's staff regarding the status of Double Hill's milieu, the clinical programming, incidents, and activities for the residents.

•	Inspection of the Double Hill's physical plant to assess the cleanliness of the home, as well as to ensure there are no health or safety concerns.

•	Observations of resident participating in the Double Hill programing.

Corrections implemented as a result of previous visit:
Not applicable.

Areas of regulatory non-compliance identified during this visit:
Not applicable.

Patrick Hughes                                                     1/23/2023
Regulatory Consultant                                            Date|


raw_content:
November 3, 2023

Christopher Burke Ph.D.
Newport Academy Double Hill
3990 Double Hill Road
Bethlehem, CT 06751

Dear Mr. Burke,

We visited your agency program on September 25th, 26th, and 27th, 2023 for a biennial relicensing inspection. This inspection was conducted to determine the compliance of this program with the Regulations for the Operation of Child Caring Agencies and Facilities; Sections 17a-145-48 through 17a-145-98, as well as DCF Guidelines for the Administration of Medication by Certified Staff. The areas of regulatory non-compliance which were identified during the re-licensing inspection were corrected at the time of the visit.  Therefore, the Department has determined that your agency has met the requirements for a regular license.

This license is effective as of November 1, 2023, and is valid for twenty-four months. We thank you and your staff for your cooperative participation in the review process.

17a-145-61:  Written Policies and Procedures
Evidence: The telephone policy needs to be changed to comply with CT General Statute 17a-16-8.  This was corrected at the time of the inspection; no service development plan response is needed.

Evidence: The room search policy needs to be updated to conform to the CT General Statute 17a-16. This was corrected at the time of the inspection; no service development plan response is needed.

17a-145-80: Internal and External Security
Evidence: An outside door of Cardinal House was missing a door handle.
This was corrected at the time of the inspection; no service development plan response is needed.

Sincerely,
Patrick Hughes
Patrick Hughes
DCF Regulatory Consultant
505 Hudson Street
Hartford, CT  06106|


summary: Visit covered 4 main areas/topics. No compliance issues identified.

raw_content:
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM:  Newport Academy / Double Hill campus

TIME OF VISIT:  10:30 am                   DATE: May 24, 2023

AGENCY PERSONNEL WHO PARTICIPATED:
Newport Academy   Compliance Specialist.

Areas / Topics covered during visit:

•	Discussion of the current census, which is 51, and the LBC is 54.

•	Discussion of Newport Academy Double Hill's current staffing levels, vacant positions, and hiring activities.

•	Discussion with Newport Academy Double Hill's staff regarding the status of Double Hill's milieu, the clinical programming, incidents and activities for the residents.

•	Inspection of the Double Hill's physical plant to assess the cleanliness of the home, as well as to ensure there are no health or safety concerns.

Corrections implemented as a result of previous visit:

Not applicable.

Areas of regulatory non-compliance identified during this visit:
Not applicable.

Patrick Hughes                                           5/30/2023
Regulatory Consultant                                      Date

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|


summary: Visit covered 1 main areas/topics. No compliance issues identified.

raw_content:
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM:  Newport Academy / Double Hill campus

TIME OF VISIT:  11:00 am                   DATE: March 8, 2023

AGENCY PERSONNEL WHO PARTICIPATED:
Newport Academy   Compliance Specialist.

Areas / Topics covered during visit:

Census
The current census is 49 and the bed capacity for Newport Double Hill is 53.
Currently one resident is hospitalized and is expected to return soon.
Newport Double Hill will be applying to increase their Licensed Bed Capacity (LBC) to 54.

Staffing / Hiring
Newport Double Hill's staffing is reported to be stable, with a recent hiring of 12 direct care staff.
Newport Double Hill has all their clinical positions filled.

Program / Milieu
Overall, the girls are doing well at Newport Academy.
There have been very few significant event reports this quarter at Newport Double Hill.
Newport Double Hill has restarted family visitation on campus and increased off-grounds activities.
This regulatory consultant toured the campus during this quarterly visit. The atmosphere on the campus was calm and quiet.  The girls were moving around the campus from classrooms to the cafeteria. This regulatory consultant passed several groups of students who were quick to say hello to this writer. All residents observed appeared to be in good spirits and comfortable in their surroundings. All interactions observed between staff and residents were friendly and professional.

Physical Plant
During this quarterly visit this regulatory consultant completed a physical plant inspection.
All areas observed were clean and nicely decorated with no health or safety concerns noted.

Corrections implemented as a result of previous visit:
Not applicable.

Areas of regulatory non-compliance identified during this visit:
Not applicable.

Patrick Hughes                                           3/14/2023
Regulatory Consultant                                      Date

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|


raw_content:
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM:  Newport Academy / Double Hill campus

TIME OF VISIT:  1:00 pm                   DATE: December 21, 2022

AGENCY PERSONNEL WHO PARTICIPATED:
HB     Newport Academy   Compliance Specialist.

Areas / Topics covered during visit:

Census
The current census is 50 and the bed capacity for Newport Double Hill is 53.
Newport Academy's licensed age range has recently changed to include 13-year-olds.

Staffing / Hiring
Newport Double Hill has sufficient staff to maintain staffing ratios across all 3 shifts.
Newport Double Hill has direct care vacancies (Care Coordinators) on all 3 shifts, but are fully staffed at the Residential Program Director, Clinician, and Residential Supervisor positions.
Newport Double Hill continues to hire for their open positions.

Program / Milieu
Overall, the girls are doing well at Newport Academy. There haven't been any significant incidents this quarter at Newport Double Hill. Newport Academy has seen an uptick in covid 19 cases, but the residents have been quarantined and there hasn't been any further spread.  During this quarterly visit this regulatory consultant toured the Newport Double Hill campus. The atmosphere on the campus was calm and quiet.  The girls appeared engaged with their school programming but did greet this regulatory consultant. All interactions observed between staff and residents were friendly and professional.

Physical Plant
During this quarterly visit this regulatory consultant completed a physical plant inspection.
All areas observed were clean and nicely decorated with no health or safety concerns noted.

Corrections implemented as a result of previous visit:
None at this time.

Areas of regulatory non-compliance identified during this visit:
None at this time

Patrick Hughes                                           2/10/23
Regulatory Consultant                                      Date

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|


summary: No compliance issues identified.

raw_content:
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM:  Newport Academy / Double Hill campus

TIME OF VISIT:  10:30                     DATE: September 22, 2022

AGENCY PERSONNEL WHO PARTICIPATED:
HB     Newport Academy   Compliance Specialist.

Areas / Topics covered during visit:
Census
The current census is 47 and the bed capacity for Newport Double Hill is 53.
One of the residents is currently hospitalized. Recently the age of clients being referred to Newport Double has been trending younger than previously.
Staffing / Hiring
Newport Double Hill has 18 vacancies campus wide. There is some hiring currently in process for some of these positions. Newport Academy has sufficient staff to maintain staffing ratios across all shifts.
Program / Milieu
Newport Double Hill has opened their own horse barn to provide Equine Therapy to all residents. Prior to acquiring the horse barn, Newport Double Hill was using a community provider for Equine Therapy. Overall, the girls are doing well at Newport Academy. There haven't been any significant incidents this quarter at Newport Double Hill. During this quarterly visit this regulatory consultant toured the Newport Double Hill campus. The atmosphere on the campus was calm and quiet.  The girls appeared engaged with their school programming but did greet this regulatory consultant. All interactions observed between staff and residents were friendly and professional.
Physical Plant
During this quarterly visit this regulatory consultant completed a physical plant inspection.
All areas observed were clean and nicely decorated with no health or safety concerns noted.

Corrections implemented as a result of previous visit:
None at this time.

Areas of regulatory non-compliance identified during this visit:
None at this time

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Patrick Hughes                                           9/22/2022
Regulatory Consultant                                      Date

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|


summary: Visit conducted on May 9, 2022. Visit covered 9 main areas/topics. No compliance issues identified.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM:  Newport Academy Double Hill campus

TIME OF VISIT (FROM - TO):  1:00 pm                       DATE: May 9, 2022

 AGENCY PERSONNEL WHO PARTICIPATED:

Name	Job Title
HB 	Compliance Specialist

List of Areas / Topics covered during visit:

•	Current census is 53 and the licensed bed capacity is 53.
•	Discussion of the residents in the program and the program's milieu.
•	Discussion of Newport's staffing and hiring, and changes to the supervisory structure.
•	New Executive Director CB has started at Double Hill.
•	Physical plant inspection of the facility; no health or safety concerns observed.
•	Observation of the residents participating in their daily programming.
•	Interviews with residents; (no concerns for their safety or well-being reported).
•	Review of personnel files for newly hired staff.

Corrective Actions implemented as a result of previous visit:

•	Not applicable

Areas of regulatory non-compliance identified during this visit:

•	None at the time of this quarterly visit.

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Patrick Hughes                                                                  5/18/2022
Regulatory Consultant|

facility_name: Newport Academy Double Hill campus


facility_name: Monroe Operations, LLC / RT #166 / Bethlehem (TH)

raw_content:
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM:  Newport Academy / Todd Hill campus

TIME OF VISIT:   9:50 AM                   DATE: June 2, 2025

AGENCY PERSONNEL WHO PARTICIPATED:
Newport Academy   Compliance Specialist.
Newport Academy Operations Director

Areas / Topics covered during visit:

•	Discussion of the current census, which is 52, and the LBC is 54.

•	Discussion of Newport Academy Todd Hill's current staffing levels, vacant positions, and hiring activities.

•	Discussion with Newport Academy Todd Hill's staff regarding the status of Todd Hill's milieu, the clinical programming, incidents, and activities for the residents.

•	Inspection of the Todd Hill's physical plant to assess the cleanliness of the home, as well as to ensure there are no health or safety concerns.

•	Observations and brief interviews with a few residents participating in the Todd Hill programing.

•	One (1) IRN completed for this quarter.

Corrections implemented as a result of previous visit:
Not applicable.

Areas of regulatory non-compliance identified during this visit:
Not applicable.

Patrick Hughes                                                      6/2/2025
Regulatory Consultant                                             Date|

facility_name: Newport Academy / Todd Hill campus


raw_content:
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM:  Newport Academy / Todd Hill campus

TIME OF VISIT:  11:30 AM                   DATE: February 18, 2025

AGENCY PERSONNEL WHO PARTICIPATED:
Two (2) Newport Academy   Compliance Specialists.
Newport Todd Hill Residential Director

Areas / Topics covered during visit:

•	Discussion of the current census, which is 50, and the LBC is 54.

•	Discussion of Newport Academy Todd Hill's current staffing levels, vacant positions, and hiring activities.

•	Discussion with Newport Academy Todd Hill's staff regarding the status of Todd Hill's milieu, the clinical programming, incidents, and activities for the residents.

•	Inspection of the Todd Hill's physical plant to assess the cleanliness of the home, as well as to ensure there are no health or safety concerns.

•	Observations and brief interviews with a few residents participating in the Todd Hill programing.

Corrections implemented as a result of previous visit:
Not applicable.

Areas of regulatory non-compliance identified during this visit:
Not applicable.

Patrick Hughes                                                      3/17/2025
Regulatory Consultant                                             Date|


raw_content:
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM:  Newport Academy / Todd Hill campus

TIME OF VISIT:  12:00 PM                   DATE: November 26, 2024

AGENCY PERSONNEL WHO PARTICIPATED:
Two (2) Newport Academy   Compliance Specialists.
Newport Academy Director of Operations
Newport Academy Residential Supervisor

Areas / Topics covered during visit:

•	Discussion of the current census, which is 52, and the LBC is 54.

•	Discussion of Newport Academy Todd Hill's current staffing levels, vacant positions, and hiring activities.

•	Discussion with Newport Academy Todd Hill's staff regarding the status of Todd Hill's milieu, the clinical programming, incidents, and activities for the residents.

•	Inspection of the Todd Hill's physical plant to assess the cleanliness of the home, as well as to ensure there are no health or safety concerns.

•	Observations and brief interviews with a few residents participating in the Todd Hill programing.

Corrections implemented as a result of previous visit:
Not applicable.

Areas of regulatory non-compliance identified during this visit:
Not applicable.

Patrick Hughes                                                     11/29/2024
Regulatory Consultant                                            Date|


raw_content:
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM:  Newport Academy / Todd Hill campus

TIME OF VISIT:  10:30 AM                   DATE: August 29, 2024

AGENCY PERSONNEL WHO PARTICIPATED:
Two (2) Newport Academy   Compliance Specialist.

Areas / Topics covered during visit:

•	Discussion of the current census, which is 42, and the LBC is 54.

•	Discussion of Newport Academy Todd Hill's current staffing levels, vacant positions, and hiring activities.

•	Discussion with Newport Academy Todd Hill's staff regarding the status of Todd Hill's milieu, the clinical programming, incidents, and activities for the residents.

•	Discussion with Newport Academy Todd Hill's staff regarding recent Exceptional Circumstances Reports, and recent SIU investigations.

•	Inspection of the Todd Hill's physical plant to assess the cleanliness of the home, as well as to ensure there are no health or safety concerns.

•	Observations of resident participating in the Todd Hill programing.

Corrections implemented as a result of previous visit:
Not applicable.

Areas of regulatory non-compliance identified during this visit:
Not applicable.

Patrick Hughes                                           8/29/2024
Regulatory Consultant                                            Date|


raw_content:
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM:  Newport Academy / Double Hill campus

TIME OF VISIT:  10:00 AM                DATE: June 18, 2024

AGENCY PERSONNEL WHO PARTICIPATED:
 Two (2) Newport Academy   Compliance Specialists.

Areas / Topics covered during visit:

•	Discussion of the current census, which is 50, and the LBC is 54.

•	Discussion of Newport Academy Double Hill's current staffing levels, vacant positions, and hiring activities.

•	Discussion with Newport Academy Double Hill's staff regarding the status of Double Hill's milieu, the clinical programming, incidents, and activities for the residents.

•	Inspection of the Double Hill's physical plant to assess the cleanliness of the home, as well as to ensure there are no health or safety concerns.

•	Observations of resident participating in the Double Hill programing.

Corrections implemented as a result of previous visit:
Not applicable.

Areas of regulatory non-compliance identified during this visit:
Not applicable.

Patrick Hughes                                                        7/1/2024
Regulatory Consultant                                            Date|


raw_content:
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM:  Newport Academy / Todd Hill campus

TIME OF VISIT:  10:30 AM                   DATE: March 20,2024

AGENCY PERSONNEL WHO PARTICIPATED:
Newport Academy   Compliance Specialist.
Newport Academy Director of Operations

Areas / Topics covered during visit:

•	Discussion of the current census, which is 49, and the LBC is 54.

•	Discussion of Newport Academy Todd Hill's current staffing levels, vacant positions, and hiring activities.

•	Discussion with Newport Academy Todd Hill's staff regarding the status of Todd Hill's milieu, the clinical programming, incidents, and activities for the residents.

•	Inspection of the Todd Hill's physical plant to assess the cleanliness of the home, as well as to ensure there are no health or safety concerns.

•	Observations of resident participating in the Todd Hill programing.

Corrections implemented as a result of previous visit:
Not applicable.

Areas of regulatory non-compliance identified during this visit:
Not applicable.

Patrick Hughes                                                         3/25/2024
Regulatory Consultant                                            Date|


raw_content:
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM:  Newport Academy / Todd Hill campus

TIME OF VISIT:  1:00PM                   DATE: December 20,2023 & January 10,2024

AGENCY PERSONNEL WHO PARTICIPATED:
Newport Academy   Compliance Specialist.

Areas / Topics covered during visit:

•	Due to this Regulatory Consultant being positive for covid 19, the December 20th visit was held virtually, an in-person visit was made 1/10/24.

•	Discussion of the current census, which is 38, and the LBC is 54.

•	Discussion of Newport Academy Todd Hill's current staffing levels, vacant positions, and hiring activities.

•	Discussion with Newport Academy Todd Hill's staff regarding the status of Todd Hill's milieu, the clinical programming, incidents, and activities for the residents.

•	Inspection of the Todd Hill's physical plant to assess the cleanliness of the home, as well as to ensure there are no health or safety concerns.

•	Observations of resident participating in the Todd Hill programing.

Corrections implemented as a result of previous visit:
Not applicable.

Areas of regulatory non-compliance identified during this visit:
Not applicable.

Patrick Hughes                                                    1/23/2023
Regulatory Consultant                                            Date|


facility_name: Silver Hill Therapeutic Services, LLC.

summary: No compliance issues identified. Implemented 1 corrective actions.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM:           Silver Hill Therapeutic Services-Klingenstein House Residential

TIME OF VISIT (FROM - TO) 11:00am to 11:45am 	 DATE: 3/20/26

AGENCY PERSONNEL WHO PARTICIPATED:
Job Titles:
Unit Supervisor

List of Areas / Topics covered during visit: This was an announced quarterly Licensing visit to obtain a program update and tour the physical plant.

A meeting was held with the Unit Supervisor. Topics discussed included:

•	Current LBC is 10.  Current census is 10. (5 females and 5 males)
•	No Exceptional Circumstances filed during the quarter.
•	Discussed current residents and milieu.
•	Discussed staffing and shift coverage.
•	Discussed educational programming.  8 residents were in school and 2 in the day room.
•	Met with 2 residents in the dayroom.
•	Discussed clinical programming and cooperation.

Milieu Observation:
•	Two residents in the dayroom with 8 in school.

Physical Plant:
•	Toured the home with the unit supervisor.  No safety concerns observed.  The home is very clean and maintained very well.

Corrective Actions implemented as a result of previous visit:
NA

Areas of regulatory non-compliance identified during this visit:
NA

Please submit a regulation compliance plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The Regulation Compliance Plan must be submitted to the attention of the undersigned at the address listed above. No Regulation Compliance Plan is required for this Licensing visit.

James Funaro  				Date:    3/20/26
Regulatory Consultant

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM
Cc: File, Program Director|