raw_content:
October 20, 2023

Mr. Jeffrey S. Bravin
Executive Director
The American School for the Deaf, Inc.
139 North Main Street
West Hartford, CT  06107

Re: Relicensing inspection – CORE License #CCF-144
Regulatory Consultants: Kathleen Forsythe, Patrick Hughes, Amita Patel

Dear Mr. Bravin,

On October 18-19, 2023, a biennial re-licensing inspection was conducted in the CORE residential education program at The American School for the Deaf, located at 139 North Main Street, West Hartford, CT. This inspection was conducted to determine the compliance of this program with the DCF Regulations for Operation of Child-Caring Agencies and Facilities 17a-145-48 through 17a-145-124. Additionally, a review was conducted on 10-18-23 by DCF Nurse Consultant Errolee Miller, RN to determine the program’s compliance with the DCF Medication Administration Guidelines and the DCF Nursing Standards. A full standard of compliance was issued. A copy of the nursing site visit summary report is included with this report.

Listed below are the areas of regulatory non-compliance which were identified during the re-licensing inspection. Please review the areas identified and submit a service development plan (SDP) to address each area of noncompliance utilizing the SDP template included with this report. The service development plan must be submitted to the assigned Regulatory Consultant within 30 days of receipt of this emailed report.

Also included in this report are recommendations.  Recommendations are meant to highlight areas that are not currently areas of non-compliance, but may become non-compliant if actions are not taken, or, highlight areas for improvement. Recommendations do not require the submission of a service development plan.

The areas of regulatory noncompliance are as follows:

17a-145-61     	Written Policies and Procedures.
Written policies with procedures applicable to the Core residential program were not found to address the following:
•	Discharge
•	Feeding
•	Cardiopulmonary resuscitation (CPR)

17a-145-64     		Personnel Policies and Procedures.
Fifteen (15) personnel files were reviewed. The following deficiencies were noted:
•	Two personnel files (BA, NV) contained the results of police background checks completed more than eight months prior to hire date. These employees reportedly started as interns in December 2022, however no documentation of a physical exam or TB testing results from December 2022 were found in the files.
•	One file (CD) contained the results of a criminal history and a child protective services background check completed 11 months after the hire date.
•	One file (JT) did not contain evidence of CPR certification.
•	Three files (KG, JT, JoW) did not contain evidence of physical restraint training.
•	One file (JoW) did not contain evidence of mandatory reporter of abuse/neglect training.

17a-145-86     		Instructions in Safety Procedures. Supervision.
A review of Core program fire drill evacuation reports for 2023 was conducted. The following deficiencies were noted:

•	Butterworth & Cogswell dormitories
     o	Fire drill evacuation reports are missing for the third shift in the 3rd quarter of 2023.
     o	Fire drills were conducted without residents present on the second shift in the 2nd and 3rd  quarter of 2023.

17a-145-96     		Discharge of a Child.
Discharge paperwork (withdrawal notice) for four former Core program residents was reviewed.

Recommendation: It is again recommended that the facility write a comprehensive discharge summary for inclusion in the case record when a CORE residential student is discharged. Discharge summary content should include, but not be limited to: progress made in both the academic and residential programs, a description of the services the student received while residing at ASD such as, education, medical, recreation, clinical, vocational experiences, life skill training, etc. Discharge summary documents should also include the manner in which the student left the facility, legal guardian address/contact information, and the new address of where the discharged student will be residing.

17a-145-94     		Written Treatment Plan.
Ten (10) case records were reviewed.
•	Treatment or service plans with goals and objectives to be achieved in the residential program for Core residents were not found.

17a-145-98     	Case Records.
•	Information on family history was not found in one record (JD).
•	The plan for discharge was not found in two open records (DD, WM).

Recommendation: It is recommended that the facility development and implement a comprehensive biopsychosocial assessment that includes a family, social and health history, to be completed on all Core program residents as a component of the intake process.

Once the Licensing Unit 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. Should you have any questions or comments regarding the contents of this report please do not hesitate to contact me at (860) 937-7551.

Sincerely,

Kathleen Forsythe, LCSW
DCF Regulatory Consultant

Copy: file
           Assoc. Director of Residential Services
           Asst. Executive Director
           CFO|


state: CT

facility_name: American School for the Deaf  / CORE / RE#144

summary: Visit conducted on 8-31-23. 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: The American School for the Deaf, Inc. - CORE Residential Education Program

TIME OF VISIT (FROM - TO):       10:00am-12:15pm                    		DATE: 8-31-23

AGENCY PERSONNEL WHO PARTICIPATED:
     Job Titles:
Independent Interpreter
			Senior Administrative Assistant
Overnight Dean of Students
		Associate Director of Student Life
Head of Security

List of Areas / Topics covered during visit:  This was a scheduled quarterly Licensing visit to obtain an update on the Core residential education program and tour the physical plant of the CORE program dorms.

Brief meeting held with Senior Administrative Assistant
•	Discussed the elements of the relicensing inspection for Core program scheduled for October 2023.

A meeting was held with an Associate Director of Student Life (KF) with an interpreter present. Topics discussed included:
•	Core residents returned to campus this week from summer break. School year started 8-28-23.
•	Census = 15 (6 females, 9 males). Census will increase by 3-4 residents when admission paperwork is completed.
•	Core  staffing vacancies = 0
•	Division of duties among three Associate Directors of Student Life
•	Selected Core residents (6-8) to participate in the International Study Club with out-of-country trips. Trip to Costa Rica planned for April 2024.
•	Fall athletics: Male soccer team and female volleyball team. Games scheduled against other schools for the deaf in RI, NY and MA.
•	Camp Isla Bella: New Camp Director. Summer camp completed.
•	Homecoming scheduled for weekend of 9-30-23; dozens of alumni expected to attend; homecoming dance, social events.
•	New Director of Student health Center expected to start early September. Current Director is retiring - will remain as a consultant for remainder of 2023.
•	ASD completed initial survey for accreditation by the Council on Accreditation earlier this summer.
•	Trauma Informed Care model ('Risking Connections') to be implemented at ASD. Train-the trainer scheduled for this fall with 8 instructors selected. All ASD staff to be trained in the model this fall.
•	Applying for Quality Residential Treatment Program (QRTP) status with DCF.

Physical plant inspection facilitated by the Overnight Dean of Students. Butterworth and Cogswell Core dorms were toured. All areas appeared very clean and organized.

Corrective Actions implemented as a result of previous visit: Not applicable

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

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

Kathleen Forsythe, LCSW                               		 Date: 8-31-23
Regulatory Consultant

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM
Cc: 	File
Asst. Executive Director,
Assoc. Director of Student Life (KF)
Director of Operations|


summary: Visit conducted on 5-24-23. 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: The American School for the Deaf, Inc. - CORE Residential Education   Program

TIME OF VISIT (FROM - TO):       10:00am-12:15pm               		DATE: 5-24-23

AGENCY PERSONNEL WHO PARTICIPATED:
Job Titles:
Independent Interpreter
			Human Resources Director
Associate Director of Student Life
	Human Resources Manager
Human Resources Associate

List of Areas / Topics covered during visit:  This was a scheduled quarterly Licensing visit to obtain an update on the Core residential education program and tour the physical plant of the CORE program dorms.

A meeting was held with an Associate Director of Student Life with an interpreter present. Topics discussed included:
•	Census = 19 (12 males, 7 females)
•	Core program staffing vacancies = 0
•	Incident data from the past quarter
•	Graduation scheduled for June 12th
•	End of year activities for Core residents (Prom, BBQ, Senior trip, etc.
•	Supervision protocol & med administration during upcoming senior class trip to New Jersey
•	Core students move home for summer vacation in June
•	Opening Cottage E in the fall for older female students
•	Search policy & contraband
•	New HR Director
•	Revised three week Orientation program for new hires: required trainings, ASL immersion, shadowing
•	New hires train for three weeks prior to assuming job duties
•	ASD to host a one week summer basketball camp in collaboration with Gallaudet University
•	Male Core resident representing ASD while wrestling on a team in Avon; recently featured on ESPN

Physical plant inspection conducted for Butterworth and Cogswell Core dorms. All areas appeared very clean and organized.
•	New laundry hampers in use
•	New hygiene totes in girls' dorm
•	New water cooler in Cogswell
•	Posted laundry and shower schedules
•	Radiator covers in Cogswell dorm

Introductory meeting held with new HR Director who assumed the position last month. Topics discussed:
•	New pilot 3-week Orientation program to launch in June
•	Twenty-eight (28) applicants offered positions
•	Staff incentives to involve current employees in training opportunities
•	DCF semi-annual personnel file review schedule
•	Deaf/HOH employee joined HR Dept. last summer

Corrective Actions implemented as a result of previous visit: Not applicable

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

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

Kathleen Forsythe, LCSW                                				Date: 5-24-23
Regulatory Consultant

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM.
Cc: File,     Asst. Executive Director,   Assoc. Director of Student Life|


summary: Visit conducted on 2-23-23. 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: The American School for the Deaf, Inc. - CORE Residential   Education  Program

TIME OF VISIT (FROM - TO):       11:00am-1:15pm                       DATE: 2-23-23

AGENCY PERSONNEL WHO PARTICIPATED:
Job Titles:
•	Independent Interpreters (2)
•	Interpreter Student Intern
•	Associate Director of Student Life
•	Assistant Director of Operations
•	Security Manager
•	Maintenance Staff Member

List of Areas / Topics covered during visit:  This was a scheduled quarterly Licensing visit to obtain an update on the Core residential education program and tour the physical plant of the CORE program dorms.

Associate Director of Student Life facilitated tours of the Cogswell and Butterworth dormitories with interpreters and Assistant Director of Operations present. Topics discussed included:
•	Census = 20 (14 males, 6 females)
•	Male students in Core program relocated from Butterworth to Cogswell dorm this week to provide more space.
•	Female students in Core program reside in Butterworth dorm.
•	Core program students go home on weekends; One male student remains on campus on the weekends and  resides in Holt dorm.
•	Fall sports
•	Bedroom and lounge furniture
•	Flooring
•	Water temperatures
•	New delayed crash bars on exit doors with alarms in Cogswell
•	Accommodations for a deaf/blind student in Cogswell
•	Internet access safety measures
•	Bedroom temperatures; individual thermostats
•	Bathroom supervision protocol
•	Proposed new dorms for Paces program
•	AED signage and location map at Butterworth dorm entrance

Corrective Actions implemented as a result of previous visit: Not applicable

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

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

Kathleen Forsythe, LCSW                                   				Date: 2-24-23
Regulatory Consultant

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM
Cc: File
      Director of Finance & Operations
      Asst. Executive Director
      Assoc. Director of Student Life|


summary: Visit conducted on 12-22-22. No compliance issues identified.

raw_content:
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: The American School for the Deaf, Inc. - CORE Residential
                                                                                Education  Program
TIME OF VISIT (FROM - TO):       morning                          DATE: 12-22-22

AGENCY PERSONNEL WHO PARTICIPATED:
                        Job Titles:
•	Independent Interpreters (2)
•	Associate Director of Student Life (KF)
•	Employment Specialist
•	HR Manager

List of Areas / Topics covered during visit:  This was a scheduled quarterly Licensing visit to obtain an update on the Core program, observe the dorm physical plant, and to conduct a semiannual personnel file review.

A meeting was held with an Associate Director of Student Life with interpreters present. Topics discussed included:
•	Core program residents are on home visit for Christmas break
•	Census = 18 (10 males, 8 females)
•	Two female residents are transitioning into the Core program from the Paces program
•	Homecoming celebration held on campus for the first time since pandemic started; alumni in attendance, vendor booths, etc.
•	On campus rec activities: soccer and volleyball team practices, cooking projects, Halloween, Winter party
•	Off campus rec activities, weekly trips into the community, safety/supervision procedures for crossing streets in West Hartford
•	UCONN Dental School students to provide a workshop on campus in January re: good oral health
•	Core residents' participation in Fall and Winter sports teams; Volleyball team traveled to OHIO to compete in a tournament; ASD hosted a multi-school 'Tip-Off Tournament' for basketball and both ASD male and female teams won the Sportsmanship award
•	Core program staff vacancies: 2 full time direct care positions
•	New Associate Director position filled, completing the team of three; discussed division of responsibilities
•	Core progress reports with individualized goals/objectives
•	Over age waiver for a Core program resident
•	Tour of the Butterworth dorm: All areas appeared extremely clean, organized, and decorated for the holiday season. Minor adjustments made to dorm at start of school year to accommodate a new deaf blind resident, based on recommendations from the Bureau of Education and Services for the Blind (BESB) consult in September 2022. Workshop held with Core male residents on how to interact with deaf blind student. Observed new 'suggestion' box. Discussed 'resident grievance' process.

A semiannual personnel file review was conducted in HR. Five files were reviewed. Personnel files are well organized. No regulatory deficiencies were noted.

Corrective Actions implemented as a result of previous visit: Not applicable

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

Kathleen Forsythe, LCSW                                     				Date: 12-27-22
______________________________
Regulatory Consultant

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM
Cc: File
      Director of Finance & Operations
      Asst. Executive Director
      Assoc. Director of Student Life|

visit_time: morning


summary: Visit conducted on 9-28-22. Visit covered 12 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: The American School for the Deaf, Inc. - CORE Program

 TIME OF VISIT (FROM - TO):       1:00pm-2:00pm                           DATE: 9-28-22

 AGENCY PERSONNEL WHO PARTICIPATED:
Job Titles:
•	Independent Interpreters (2)
•	Associate Director of Student Life

List of Areas / Topics covered during visit:  This was a scheduled quarterly Licensing visit to obtain an update on the Core program and to tour the dorm. This visit was conducted virtually due to COVID concerns.
•	Core program residents returned to campus earlier this month from summer break for new school year.
•	Census = 16 (10 males, 6 females)
•	Fall sports teams (soccer and volleyball)
•	Core program staff vacancies: 1 full time direct care
•	Interviews in process for the Director of Student Life position
•	ASD online Academy
•	Off-campus recreation activities for Core residents
•	Camp Isla Bella: ASD's summer camp had a successful season after being closed for two years due to the pandemic. Nine (9) Core residents attended a two-week session this year.
•	Dorm bathroom supervision protocol
•	One Core resident employed on campus
•	Tour of the Butterworth dorm: All areas appeared very clean and organized. Seasonally decorated. New bean bag chairs in living rooms at students' request

Corrective Actions implemented as a result of previous visit: Not applicable

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

Kathleen Forsythe, LCSW                                                                     				Date: 9-29-22
______________________________
Regulatory Consultant

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM
Cc: File
      Director of Finance & Operations
      Asst. Executive Director
      Assoc. Director of Student Life|


summary: Visit conducted on 6-20-22. Visit covered 13 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: The American School for the Deaf, Inc. - CORE Program

 TIME OF VISIT (FROM - TO):       11:00am-1:45pm               DATE: 6-20-22

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:
Director of Student Life
Interim Assistant Director of Student Life
HR Manager

List of Areas / Topics covered during visit:  This was a scheduled visit to obtain an update on the program.
•	Core program residents home for the summer; three residents graduated
•	One Core resident interning in ASD IT Dept. for the summer
•	Core dorm (Butterworth) closed for the summer
•	Butterworth dorm security
•	End-of-year student activities (Prom, Graduation, etc.)
•	Director of Student Life resignation effective 7/2022 & interim Residential Dept. management plan
•	ASD hosting Gallaudet basketball camp
•	Semiannual personnel file review scheduled - no new hires in CORE residential program
•	Three graduates living on campus in independent living housing
•	Core resident personal cell phone protocol
•	Agency vehicles
•	Planned vocational training opportunities

Corrective Actions implemented as a result of previous visit: Not applicable

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

Kathleen Forsythe, LCSW                                                                  				Date: 6-20-22
______________________________
Regulatory Consultant

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


facility_name: Devereux Glenholme / RE #6

summary: Visit conducted on _3-25-26_______. Visit covered 11 main areas/topics. Found 4 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: ____Devereux Glenholme RE__________________________________

 TIME OF VISIT (FROM - TO):       __________________________         DATE:_3-25-26_______

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:
DB - Excutive Dir.
JM -  Dir. Of Operations
K O-D  _ Dir. Of Residential Services
YM
MG - Director of Clinical Services
SS  - Nurse Manager
IS  - People Ops Director
EM - DCF Consulting Nurse

List of Areas / Topics covered during visit:
•	Census -33/13 day students
•	Current  staff ratios - 1:4 (Whiteholme & Birch); 1:12 (all other buildings). Supervisors provide additional coverage. There are currently 4 Program Supervisor  and 5 Direct Support Professional positions that are open.
•	The agency has entered into an agreement with CT DDS to develop several programs. One of the programs in development is a short-term program that will accept residents aged 8-20 (male & female). The program is to be located in the upstairs of Hollyhouse. Community based adult program locations including the Glen Ridge building are also in development.
•	New furniture and flooring for some of the buildings will be purchased in the next few months.
•	Tour of Carriage House (6), Whiteholme (6) and Pueblo House (7). In Carriage House the living room furniture was worn (outer layer peeling off). In one bedroom the molding along the baseboard was broken off and in another room the rug was stained. In Whiteholm there was a small rip in the couch. It was recommended that more snacks/non-perishable items be kept in the home.  It was noted that supervisors do have access to the kitchen after hours (kitchen closes at 6pm). Common areas and bathrooms were clean.  Bedrooms had a varying degree of items but they were properly stored.
•	DCF Nurse Consultant, EM, met with Nurse Manager, SS , to discuss  DCF expectations around medication administration and future trainings and meetings.

Corrective Actions implemented as a result of previous visit: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Areas of regulatory non-compliance identified during this visit:
Section 17a-145-71 Living room, lounge.
•	Some of the furniture pieces (Carriage & Whiteholm) in the living room were worn or torn.

Section 17a-145-73 Sleeping accommodations.
•	The carpet in one bedroom was stained.
•	The baseboard molding was broken off in one bedroom.

Please submit a service development plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The service development plan must be submitted to the attention of the undersigned at the address listed above.
     Terri Bohara                                                3-27-26
______________________________            _________________
Regulatory Consultant                                   Date

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

type: general

description: 71 Living room, lounge.

description: The carpet in one bedroom was stained.


summary: Visit conducted on __12-4-25______. Visit covered 9 main areas/topics. 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: ____Devereux Glenholme__________________________________

 TIME OF VISIT (FROM - TO):       ___Morning_______________________         DATE:__12-4-25______

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:
DB - ED
JM - Dir. Of Operations
PD
K O-D - Residential Services Director

List of Areas / Topics covered during visit:
•	Census -24 plus 13 Day Students
•	The nurse manage has submitted her resignation and the agency is looking to fill the position. This remains a difficult position to maintain despite efforts to increase pay and be flexible with scheduling.
•	Eleven personnel files were reviewed.  There were no issues.
•	Physical plant inspection of the 4 buildings that are currently being used. Bedrooms were in varying states but were clean and fairly well organized. The rugs in Carriage House were stained in places and showing signs of wear. A plan for eventual replacement should be considered. Common areas and bathrooms were clean in all of the buildings.
•	A tour of The Barn, the transitional program, was also conducted. This program is not licensed by DCF and consists of youth over the age 18. Youth live semi-independently in these units. Some of the furniture was worn but still functional.
•	The school recently secured a DDS contract (Dept. of Developmental Services) and will providing adult services across two 4 bed sites in the community. One site will be at the former Glen Ridge unit.
•	The buildings toured included:
Pueblo - 7 students; Ages 15-18; male/female
Carriage House - 6 students; Ages 14-17; Female
Whiteholme - 6 students; Ages 15-18; Males (lower functioning)
Birchwood - 5 students: Ages 10-14 ; Females (lower functioning)
Laurelholme, Vanholme and Holly House are currently closed.
Corrective Actions implemented as a result of previous visit: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Areas of regulatory non-compliance identified during this visit:

Please submit a regulatory compliance plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The regulatory compliance plan must be submitted to the attention of the undersigned at the address listed above.
      Terri Bohara                                             12-11-25
______________________________            _________________
Regulatory Consultant                                   Date

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


raw_content:
May 29, 2025

Devereux Glenholme, Inc.
81 Sabbaday Ln.
Washington, CT  06793-1318
Attn: Dan Bailey, Executive Director

Re: Licensing Inspection for Devereux Glenholme RE
Inspectors: Terri Bohara and Pat Hughes.

Dear Mr. Bailey,
 In May 2025 a biennial re-licensing inspection was conducted at Devereux Glenholme residential educational facility.  This inspection was conducted to determine the compliance of this facility with the Regulations for Operation of Child-Caring Agencies and Facilities 17a-145-48 through 17a-145-98, as well as the DCF Guidelines for the Administration of Medication by Certified Staff.  Below are listed the areas of regulatory non-compliance which were identified during the re-licensing inspection. Please review the areas identified and submit a regulation compliance plan to address each area.  The 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; and 2. the date the correction(s) will be completed.  The areas of non-compliance are listed below.   Also included in the report are recommendations.  Recommendations are meant to highlight areas that are not currently areas of non-compliance, but may become non-compliant if actions are not taken.  Recommendations do not require the submission of a plan of correction.

Section 17a-145-61 Written policies and procedures.
•	The Board minutes provided for 2023 did not meet the frequency identified in the by-laws (An annual meeting plus 3 additional meetings.)

Section 17a-145-64 Personnel policies and procedures.
•	Twenty-one (21) were reviewed.
•	Four files did not have documentation of CPR certification.  One file had indications took the class however there was no card.  One staff had an expired certification.
•	Four files were missing documentation of restraint training.  Two only completed Parts 1 & 2 (out of 3).
•	The LPN license on file for one employee was expired.
•	In some files the physicals presented were dated outside the " within 90 days prior to hire" timeline established by the department.

Section 17a-145-86. Instructions in safety procedures. Supervision.
•	There were no fire drills documented for the second shift/second quarter of 2023.
Once licensing has reviewed and accepted the Regulation Compliance 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.

Should you have any questions or comments regarding the contents of this report please do not hesitate to call me at (959) 255-0614.
Sincerely,

Terri Bohara
Regulatory Consultant
Department of Children and Families
505 Hudson St.
Hartford, CT 06106
Phone: 959-255-0614
Fax: 860-860-550-6665
Theresa. Bohara@ct.gov

Copy: file|

report_type: unstructured


summary: Visit conducted on ___3-12-25_____. Visit covered 11 main areas/topics. Found 5 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: ___Devereux RE___________________________________

 TIME OF VISIT (FROM - TO):       ___Morning_______________________         DATE:___3-12-25_____

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:
DB - Executive Dir.
JM
PD - QI
MG - Dir. Of Clinical Services

List of Areas / Topics covered during visit:
•	Census - 49. The number of day students continues to grow.
•	Staffing -  There are currently four direct care openings. Two newly hired staff will be overseeing QI issues. The program is also in the  process of filling key nursing positions.
•	The agency is looking at restructuring their program offerings. They are looking to expand programming to include youth with lower IQ's  (FSIQ 50-80). They currently have one house with 5 youth and a 1:4 staffing ratio. The transition program has 17 youth.  Some youth reside in Van Holme but occasionally participate in some of the programming held by the transition program.
•	Tour of Whiteholm. It was recommended that either cork boards or blackboard paint be utilized so residents have an area to display items.  The lower level of Whiteholm is being transitioned to a staff office and sensory room for residents. The school is installing new anti-ligature doorknobs and taking additional measures ( new shower curtain rod) in an effort to enhance safety in the Whiteholm unit. These efforts will eventually move to other units on the campus. The sidewalk outside of Whiteholm is scheduled to be replaced. It currently has patches of crumbling cement.
•	Thirty-five (35) personnel records were reviewed in January 2025. Several files did not have documentation of CPR certification One file has an expired CPR certificate.  Multiple files did not have  documentation of restraint training. Two files did not have documentation of mandated reporter certification. Three files had physical exams outside of the 90 day window.
•	A relicensing visit is scheduled for May 2025. Discussion regarding the case file reviews, physical plant tour and Personnel file reviews.

Corrective Actions implemented as a result of previous visit: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Areas of regulatory non-compliance identified during this visit:

Section 17a-145-64. Personnel policies and procedures.
•	Several files did not have evidence of CPR certification. One file had an expired CPR certification.
•	Several files did not have documentation of restraint training (SPA) and certification.
•	Two files did not have evidence of mandated reporter training.
•	Four files had physical exams done outside the 90 day window.

Please submit a service development plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The service development plan must be submitted to the attention of the undersigned at the address listed above.
    Terri Bohara                                              3-14-25
______________________________            _________________
Regulatory Consultant                                   Date

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

description: 64. Personnel policies and procedures.


summary: Visit conducted on ___12-3-24_____. Visit covered 11 main areas/topics. Found 2 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: _______Devereux - Residential Education _____________

 TIME OF VISIT (FROM - TO):       ___Morning_______________________         DATE:___12-3-24_____

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:
DB - Executive Director
JM - Operations Manager
LK - Clinical Director

List of Areas / Topics covered during visit:
•	Census - 38/ 15 in transition program (ages 18-22)
•	Staffing - A new Director of Nursing has been hired and is starting 12/16/24. The Director of Education position remains vacant. The Director of Clinical Services will be resigning effective January 2025. There are 4 direct care positions that are currently open. JS, who has remotely assisted with recruitment and admissions, recently resigned. Two LPN's recently resigned. One remains on a per diem status. The positions have been posted.
•	The Laurel building is currently closed. Glen Ridge has been put on the market for sale.
•	The apartments at Garden and Whiteholm have been turned into staff offices.
•	The ORR program is fully staffed. There has been no information provided regarding any changes forthcoming with the new administration. The federal government has implemented  very "intensive" background checks for all staff who work at the program.  The ORR has now approved the use of selective restraints within the ORR program. The Devereux SPA model has been approved along with 5-6 physical hold.
•	Discussion with administrative team regarding recent changes in the Nursing department.
•	Tour of the ORR classroom and meeting with program director.
•	Tour of Whiteholme building. One bedroom window did not have a curtain.

Corrective Actions implemented as a result of previous visit: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Areas of regulatory non-compliance identified during this visit:

Section 17a-145-73 Sleeping accommodations.
•	One bedroom did not have a curtain in one of the windows.

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

__Terri Bohara    ____________________________            _____12-6-24____________
Regulatory Consultant                                   Date

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

description: 73 Sleeping accommodations.


summary: Visit conducted on ___8-20-24_______________. Visit covered 11 main areas/topics. Found 3 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:Devereux_____________________________________________________

 TIME OF VISIT (FROM - TO):       __Morning/afternoon________________DATE: ___8-20-24_______________

 AGENCY PERSONNEL WHO PARTICIPATED:

Name	Job Title
Errolee Miller	DCF Nurse Consultant
DB	Executive Director
JM	Operations Manager
LK	Clinical Director
AV	Nurse Manager
JL	Nurse

List of Areas / Topics covered during visit:
•	Census - ORR -5; 62 including transition & day
•	Staff openings - 4 direct care; 1 supervisor.  There are administrative positions vacancies (Financial and Education departments).  The school is looking to create a Director of Education position.
•	Van Holme and the "Barn" are identified as the transitional programs. They anticipate 20 youth by October and are hoping to expand the program.
•	The program is looking at ways to accommodate requests for gender neutral housing.
•	Tour of G-2 (East) 6 total capacity with 3 on East. Includes a living room and kitchen area.
•	Tour of Holley House. Census of 8. Chairs ripped in the hallway/TV area. The bathroom door was cracked. The shower curtain was stained and additional hooks were needed. The couch cushion was ripped in the living room area.  The Carpet in the stairwell leading to the outside door was stained. The furniture and carpet will need to be replaced in the near future.
•	DCF Consulting nurse met with the Nurse Manager to review the med room and go over the DCF expectations around med management.
•	Follow up on two incidents this quarter. (July and August)
Corrective Actions implemented as a result of previous visit: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Areas of regulatory non-compliance identified during this visit:
Section 17a-145-74. Lavatory facilities. Toilet articles and linens.
•	A shower curtain was heavily stained and not properly secure (additional hooks needed).
•	A bathroom door had a crack in the wood panel.

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.
Terri Bohara                                                       9-9-24
______________________________            _________________
Regulatory Consultant                                   Date

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DI|


summary: Visit conducted on __5-13-24______. Visit covered 8 main areas/topics. Found 5 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: ____Devereux - Glenholme__________________________________

 TIME OF VISIT (FROM - TO):       ____Morning______________________         DATE:__5-13-24______

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:
DB- Executive Director
JM - Ops Manager
JM - Dir. Of Oops and Finance
LK - Clinical Director
AV - Nursing Supervisor
Y M-D - ORR PD
AS - Dean of Student Services
SH - Dir. Of Milieu Treatment

List of Areas / Topics covered during visit:
•	Census - 58 total (3-ORR)
•	 Six month review of 23 personnel files completed. Several staff are in need of CPR and /or SPA trainings.
•	Discussion regarding transitional programming options, "on-site" staffing requirements, targeted population for the programs, DCF requirements regarding supervision.
•	Restraint training requirements for ORR staff were clarified. All components of SPA must be completed by staff. Federal guidelines prohibit restraints however Connecticut requires it.
•	Tour of the campus including Whiteholme, Laurelholme, Glenholme 2 (G2) and the ORR program. Several of the windows did not have screens or had ripped screens however no windows were open. A toilet in Laurelholme had some scratches.  There was an older water stain in the ceiling in one of the bedrooms in Laurelholme. The grouting along the tub in the ORR program is starting to disintegrate.
•	The DCF training academy determined that the Devereux mandated reporter training provided by Devereux was not sufficient and that only the mandated reporter training provided by DCF was acceptable.

Corrective Actions implemented as a result of previous visit:
•	Physical plant upgrades have been made in in several units. These upgrades include new furniture and carpet/flooring.

Areas of regulatory non-compliance identified during this visit:
 Section 17a-145-64. Personnel policies and procedures.
•	Twenty-three personnel files were reviewed.
•	Eleven files did not have evidence of CPR certification.
•	Fourteen staff did not have evidence of restraint training (SPA) while two staff only have completed Parts 1 & 2.

Please submit a Regulation Compliance plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The service development plan must be submitted to the attention of the undersigned at the address listed above.
   Terri Bohara                                                5-16-24
______________________________            _________________
Regulatory Consultant                                   Date

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

description: 64. Personnel policies and procedures.

description: Twenty

description: three personnel files were reviewed.


summary: Visit conducted on ____1-31-24 ________. Visit covered 15 main areas/topics. 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: ___Devereux Glenholme RE___________________________________

 TIME OF VISIT (FROM - TO):       ___Morning_______________________         DATE: ____1-31-24 ________

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:
DB
JM
JM
VL
MF
CS
MB

List of Areas / Topics covered during visit:
•	Census - 55 + 8 (ORR)
•	Staffing - Currently looking to fill 1 Program Supervisor position and 3-4 direct care worker positions. They are also looking to fill the Nurse Manager position (The current manager recently gave her notice that she will be leaving.) Trainings in CPR & SPA are ongoing. CPR is now largely  completed in the first 30 days of employment. The clinical and education departments are both fully staffed.
•	There is currently 1 Registered Nurse, 2 LPN's and 1 CNA overseeing medical services. A Medical Coordinator assists with scheduling and overseeing appointments.
•	The occupants of Glen Ridge building were recently moved to the newly created Barn Apartments. The current census is 13 (total of 6 apartments). This program will target 17-21+ year olds for transitional services. A tour of the apartments was conducted. One window did not have a window covering. Fuse boxes are locked to prevent unauthorized use of stoves/ovens. There is supervision around cooking which varies according to skill level.  Staff are located in a building a short distance from the apartments. Monitoring is done in-person and by camera but there are no staff located on-site.  Nursing staff are providing oversight of medication administration. The sidewalk leading to the back of the building is slated for repair due to several cracks.
•	There are currently 7 open buildings (as of 2-5-24). There is a plan to convert "G-2" into apartments.
•	The need for on-site staffing on all three shifts for units licensed by DCF and that house youth under 18 was clarified.

Corrective Actions implemented as a result of previous visit: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Areas of regulatory non-compliance identified during this visit:

Please submit a service development plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The service development plan must be submitted to the attention of the undersigned at the address listed above.
Terri Bohara                                                      2-8-24
______________________________            _________________
Regulatory Consultant                                   Date

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

personnel: DB JM JM VL MF CS MB


summary: Visit conducted on __12-13-23__ ________. Visit covered 13 main areas/topics. Found 6 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: _____Devereux_________________________________

 TIME OF VISIT (FROM - TO):       __Morning (unannounced)________DATE: __12-13-23__ ________

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:
DB
JM
JM
LK
MF
Y M-D

List of Areas / Topics covered during visit:
•	Census -55. Program experienced some unexpected discharges. Focusing efforts on enrollment of students. Looking at expanding international efforts (Dubai, China, Switzerland). They anticipate 10 admissions in the next month.
•	There is currently one social worker position open. The school is also looking to hire a part-time nurse.
•	Review of 18 personnel files. Five files did not have evidence of completed restraint training. Four files did not have evidence of CPR certification.
•	The school is holding a Christmas play as well as a community dinner (fund raiser).
•	Currently Laurelholme and Glenholme 2 are closed.  The school is operating with 4 open cottages.
•	Campus upgrades include the installation of gates at entryways and the paving and expansion of select parking areas. They have also increased the number of cameras on campus.  The cameras have a 30 day recording capability but videos can be saved. The school is also testing a new overnight system (Guard one) where 3rd shift staff will be required to "wand" in during nightly room checks.  This system is currently limited to certain buildings.
•	The ORR program has a census of 10. Only one cottage is currently open. They are holding at a 12 LBC due to staffing issues. All staff must be bi-lingual which limits the pool of candidates.  The continued to try and reassess incentives in effort to recruit staff.
•	The introduction of the new electronic record to Devereux Glenholme is slated for April 2024. Devereux has begun to roll out "My Avatar" at various campuses throughout their network.
•	Tour of the ORR school building. Meeting with new PD. The building has a brightly painted mural and messages are placed throughout the building in Spanish.
•	Tour of Hollyhouse.  Living room and common areas were clean. The arm of one of the couches had a hole that was deep enough to expose the wooden frame. It was suggested that the hole be covered with tape. There was discoloration (mold?) in one of the bathroom showers. A plate of food was found in one bedroom.  Food in the refrigerator was not properly covered.

Corrective Actions implemented as a result of previous visit: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Areas of regulatory non-compliance identified during this visit:

Section 17a-145-64. Personnel policies and procedures.
•	Eighteen personnel files were reviewed.
•	Five personnel files did not have documentation of restraint training and certification.
•	Four files did not have documentation of CPR certification.

Section 17a-145-76 Kitchens, equipment, food-handling.
•	Food in the refrigerator was not properly stored with tight fitting lids.
•	A plate of food was found in the bedroom of one youth. ( Removed during the visit.)

Please submit a service development plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The service development plan must be submitted to the attention of the undersigned at the address listed above.
Terri Bohara                                                  12-27-23
______________________________            _________________
Regulatory Consultant                                   Date

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

description: 64. Personnel policies and procedures.

description: Eighteen personnel files were reviewed.

personnel:
DB
JM
JM
LK
MF
Y M-D


summary: Visit conducted on ____9-6-23 ________. Visit covered 14 main areas/topics. Found 2 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: ______Devereux Glenholme________________________________

 TIME OF VISIT (FROM - TO):       ____Morning______________________         DATE: ____9-6-23 ________

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:
JM - Operations Manager
JM - Director of Ops and Finance
CS - People Operation Manager
MF -Dean of Student Services
SH - Director of Milieu Treatment
DT - Program Supervisor

List of Areas / Topics covered during visit:
•	Joint visit with DCF Regulatory Consultant, AP.
•	Census - 40 with new admissions occurring throughout the week. ORR - 18. This is one of the largest groups they've had since opening.
•	First day of school. Students just returned to the campus.
•	The agency has established contacts with educational consultants in India and China. International admissions were halted during COVID.
•	The PD of the ORR program has resigned.  They are looking to fill several vacancies (PD; PSA; 2    teachers;2 - 2nd shift; 1-2 overnight positions; CNA). The H1B visa program is currently on hold. There is one more employee who is coming in via the process. No more are expected after that.
•	The program has almost completed the updated swipe card reader installation. Perimeter fencing is being installed along the far side of the campus. A fire escape was recently repaired. Paving will be done in conjunction with the expansion of one of the parking lots.  Laurelholme and Glenholme (G-2) are closed.
•	The program continues to get staff in compliance with CPR and SPA trainings. They now have 4 staff qualified to train in CPR.
•	Tour of the Whiteholm and Gardens apartments.  Both apartments have decreased supervision with a supervisor checking in throughout the night. Parents must sign off on this arrangement. Both apartment units were a bit cluttered as students had just returned to the campus. Cleaning schedules and expectations were posted in one unit. In the Garden apartment the faucet in the bathroom shower appeared to have a minor leak. The couch was in need of replacement as it was torn/worn in places.
•	Tour of ORR program. Planned interviews could not occur due to permissions not being obtained from assigned attorneys (federal requirements). There was water in the basement (where items/clothing are stored) that reportedly occurs during rain storms. Residents are not allowed there however it was suggested that corrective measures take place since items are kept there. The unit was clean and residents were observed in the kitchen interacting with staff.

Corrective Actions implemented as a result of previous visit:
•	Training of staff in CPR and SPA is ongoing.

Areas of regulatory non-compliance identified during this visit:
Section 17a-145-71 Living room, lounge.
•	The couch in the Garden apt. was worn/torn and in need of replacement.

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.
Terri Bohara                                                  9-14-23
______________________________            _________________
Regulatory Consultant                                   Date

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

description: 71 Living room, lounge.


raw_content:
June 1, 2023

Devereux Glenholme, Inc.
81 Sabbaday Ln.
Washington, CT  06793-1318
Attn: Dan Bailey, Executive Director

Re: Licensing Inspection for Devereux Glenholme RE
Inspectors: Terri Bohara , Kathy Forsyth, Keith Bryan and Pat Hughes.

Dear Mr. Bailey,

In May 2023 a biennial re-licensing inspection was conducted at Devereux Glenholme residential educational facility.  This inspection was conducted to determine the compliance of this facility with the Regulations for Operation of Child-Caring Agencies and Facilities 17a-145-48 through 17a-145-98, as well as the DCF Guidelines for the Administration of Medication by Certified Staff.  Below are listed the areas of regulatory non-compliance which were identified during the re-licensing inspection. Please review the areas identified and submit a service development plan to address each area.  The 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; and 2. the date the correction(s) will be completed.  The areas of non-compliance are listed below.   Also included in the report are recommendations.  Recommendations are meant to highlight areas that are not currently areas of non-compliance, but may become non-compliant if actions are not taken.  Recommendations do not require the submission of a plan of correction.

Section 17a-145-61 Written policies and procedures.
•	A policy attestation indicating a review and approval of policies for the year 2022 was not provided.

Section 17a-145-64 Personnel policies and procedures.
•	On 5-17-23 34 personnel files were reviewed.
•	One file had no documentation of a physical.
•	The date of the exam was not noted in one file.
•	One file had noted a physical 5 months prior to hire.
•	Two files did not contain the results of the TB test.
•	Two files had expired CPR certification.
•	Twenty files did not contain evidence of CPR certification.
•	Four files contained documentation of incomplete restraint training.
•	Nine files had no evidence of restraint training.

Section 17a-145-75. Health and medical treatment. Administration of first aid. Prescription medication. Administration of medicine or treatment. Written records. Storage of drugs, medicines, and instruments. Sick room, telephone.

Section 17a-145-86. Instructions in safety procedures. Supervision.
•	There were multiple fire drills not documented for all 3 shifts and for all four quarters for the year 2022.
•	There was no documentation of a first quarter/second shift drill for 2023.
•	Building opening and closing dates were not clearly documented making it difficult to determine if a drill was missed or a building was closed.

*Based on nursing review conducted on 5-17-23.

ORR program

Responsibilities in Administration of the Medication Training Program: DCF Regulation 17a-6(g)-15 (a - g)
Annual Observation of Medication Administration Skills Once a year the facility nurse must observe medication certified staff performing the DCF medication administration procedure. This must be documented using the DCF-2275 DCF Medication Administration Program Procedure Checklist and placed in the employees file.
Violation 1
Based on the review of the records the facility failed to do Annual Observation of Medication Administration Skills Once a year for two staff members.
Staff Members: M. G & L.M.

Storage of Internal and External (Topical) Medications Internal medications must be kept separate from External medications: • Internal medications are kept on a different shelf or in a different cabinet or drawer than the external medications. OR • External medication are placed in plastic bins or baskets that are used for external medications only. • Storage  areas for external medications must be labeled, "For External Medications Only".

Violation 2
Based on the inspection of the medication cabinet the facility failed separate external & Internal medications.

…………………………………………………………………………………………………………………

RE Program

DCF Responsibilities in Administration of the Medication Training Program:
DCF Regulation 17a-6(g)-15 (a - g)

Submit a DCF-2272 Monthly Medication Administration Program Supervision and Review to DCF Risk Management.
Violation 1
Based on the review of the DCF Data system the facility failed to submit  Monthly Medication Administration Program to the DCF Risk Management from 06/01/2021 to 03/01/2023.

DCF Reg: 17a-6(g) -16 (c): "Day programs and residential facilities shall provide continuing education on administration of medication to trained person staff members." Facility nurses and/or appropriate personnel must offer continuing education opportunities for DCF medication certified staff. The facility nurse must document on a quarterly basis all continued education opportunities offered in the past 3 months.
Violation 2
Based on the review of the training records the facility failed in providing quarterly training in April & July 2022

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 DCF
-four month license for the program will be made.  Until DCF makes this decision the current license will remain in effect.

Should you have any questions or comments regarding the contents of this report please do not hesitate to call me at (860) 550-6395.

Sincerely,

Terri Bohara
_______________________________________
Terri Bohara
Regulatory Consultant
Department of Children and Families
505 Hudson St.
Hartford, CT 06106
Phone: 860-550-6395
Fax: 860-860-550-6665|


summary: Visit conducted on _____2-15-23_____________. Visit covered 15 main areas/topics. Found 2 compliance issues. Implemented 1 corrective actions.

raw_content:
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: _____Devereux Glenholme_________________

 TIME OF VISIT (FROM - TO):       __________________________               DATE: _____2-15-23_____________

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:
DB
JM
JM
LK
RE

List of Areas / Topics covered during visit:
•	Census - 55/9 - ORR
•	The program is pursuing an accreditation (Praesidium Accreditation) which requires additional background checks.
•	Staff vacancies - ORR program - 1 clinician and 3 direct care (1 each shift); RE - 2 overnight vacancies; 2 - 3pm-11pm direct care
•	Four potential staff are ready to come to the program from Jamaica on an H1Visa
•	Physical plant upgrades include a new sidewalk in front of the main administrative building. A new brick walkway has been installed as well. The installation of new cameras continues. The cameras will be integrated with a new key card system. The cameras will retain video for 30 days with an option to "bookmark" segments that can be saved.
•	New bedroom furniture, carpeting and laminate flooring has been installed in several of the homes.
•	In October 2022 a tree fell on local power lines causing a power outage to the school and local homes. When the power was turned back on a power surge destroyed several hard wire items on campus as well posed a potential for fire. Surge protectors saved some equipment.
•	Tour of Whiteholm. New bedroom furniture. Unit was clean and well maintained.
•	Tour of the Garden apartments. Semi-independent living for youth ages 16-18. Average length of stay is one year. The apartment houses 4 males (2 in each bedroom). Bathrooms were extremely dirty and in need of cleaning. The floors, sinks and shower stalls did not appear to have been regularly and thoroughly cleaned.

Corrective Actions implemented as a result of previous visit:
•	Photos were submitted with the previous SDP showing that light fixtures had been cleaned and curtains have been hung up in the bedroom.

Areas of regulatory non-compliance identified during this visit:
Section 17a145-74 Lavatory facilities. Toilet articles and linens.
•	Bathrooms in the Garden apartment were extremely dirty and in need of cleaning.

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.
Terri Bohara                                                  3-9-23
______________________________            _________________
Regulatory Consultant                                   Date

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

personnel: DB JM JM LK RE


summary: Visit conducted on ____11-30-22______________. Visit covered 11 main areas/topics. Found 3 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: ____Devereux Glenholme _________________________________

 TIME OF VISIT (FROM - TO):       __________________________               DATE: ____11-30-22______________

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:
NN - Executive Director
JM - Operations Manager
JM - Dir. Of Finance & Operations
LK - Clinical Director
DB - Dean of Students

List of Areas / Topics covered during visit:
•	Census - 54.  The ORR program has 9.
•	Staffing - There are currently 2 overnight staff positions and 1 clinician position open. There is currently a vacant (bi-lingual) clinician and lead case manager position.
•	The installation of campus wide security cameras ( in and outside throughout the campus) continues.
•	Housing units are being upgraded with new bedroom furniture, new carpeting/flooring and painting being done.
•	The agency continues to pursue the installation of a new EHR - "My Avatar".  It has not yet been installed at the Connecticut site. In addition, each Devereux site (in various states) will be registered as its own corporation.
•	Tour of Holleyhouse. Upgrades including new furniture and painting have been done on the unit.  One bedroom did not have a window covering in the bedroom. There were bugs in several of the light covers.  Mold was found in one shower unit.
•	Had lunch with 2 students.  They both indicated that they have found staff helpful and had no complaints about the school. One resident said he had no window covering (verified/staff said they would correct) and he recommended additional lighting on one of the campus paths. Students have access to phones for calls in the dorm as well as video calls with clinicians.

Corrective Actions implemented as a result of previous visit: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Areas of regulatory non-compliance identified during this visit:
Section 17a-145-68 Heating, Ventilation, lighting.
•	Light fixture coverings in the Holleyhouse unit were in need of cleaning (dead bugs).

Section 17a-145-73. Sleeping accommodations.
•	One bedroom had no window covering.

Please submit a service development plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The service development plan must be submitted to the attention of the undersigned at the address listed above.
Terri Bohara                                                         12-19-22
______________________________            _________________
Regulatory Consultant                                   Date

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

description: 68 Heating, Ventilation, lighting.

description: One bedroom had no window covering.


summary: Visit conducted on ____8-10-22______________. Visit covered 11 main areas/topics. Found 1 compliance issues. 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: _______Devereux Glenholme RE ___________________

 TIME OF VISIT (FROM - TO):       __________________________               DATE: ____8-10-22______________

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:
JM
TT
EL

List of Areas / Topics covered during visit:
•	Census - 68  (total) 51 - Glenholme RE; 7 - ORR
•	There are currently 132 staff employed at Glenholme. (full & pt staff)
•	Two buildings (Van Holme & Glenholme) are closed at the moment.
•	The current summer schedule is academics until noon followed by recreational activities for the afternoon. There are 2 recreational "blocks" offered. Students are allowed to select the activities they want to participate in and are encouraged to make selections.
•	The ORR program is currently utilizing two cottages. Pueblo for girls and Birchwood for boys. There is a certified teacher along with classroom educational assistants.
•	Tour of both ORR cottages. Common areas and rooms were clean. Carpeted areas throughout the campus are slowly being replaced with a plank flooring. Both houses were stocked with food. In addition to food from the kitchen staff reported that they will often cook foods that the children may be more familiar with and likely to enjoy.
•	The Office of Refugee Resettlement visits approx. monthly to inspect the program compliance.  They also review for compliance with PREA standards.  The average length of stay remains between 10-12 days.
•	Review of Biopsychosocial and treatment plan from case file.

Corrective Actions implemented as a result of previous visit:
•	The decking on Laurelholme has been replaced.
•	Two entry doors in Laurelholme have been replaced.

Areas of regulatory non-compliance identified during this 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.
Terri Bohara                                                    8-16-22
______________________________            _________________
Regulatory Consultant                                   Date

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

personnel: JM TT EL


summary: Visit conducted on ___5-25-22. Visit covered 18 main areas/topics. Found 4 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: ____Devereux RE _______________________________________

 TIME OF VISIT (FROM - TO):       _____Mid Morning ( Approx. 11am)______DATE: ___5-25-22

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:
NN
JM
DB
LK
JM
TT

List of Areas / Topics covered during visit:
•	Current census - 69. The ORR has a census of 4 but with approx. 10 pending admissions.  Some staff positions have been filled since the last visit. The medical dept. currently has 5 staff (2- RN's; 2 LPN's & a CNA). There are 6 staff openings in the RE program and 3 openings in the ORR program.
•	A new Program Administrator has been hired to work 1pm-9pm. He will provide additional support to supervisors and staff.
•	SPA (restraint training) is currently on hold due to Covid.
•	There has been a slight increase in Covid cases on campus.  At the time of the visit 8 students and some staff had tested positive for Covid but were out of quarantine. The majority of the students were home for the holiday and only 14 were on campus.
•	The school prom has been moved to on-grounds and other activities are being re-structured to limit in-person contact.
•	It is anticipated that approx. 23 students will leave in June due to graduation or leaving the program.
•	Review of MAR's. The effect of a prn is documented in a general communication log. It was suggested that this documentation be captured in the individual students record.
•	There were no counter signatures for staff initials on the cardex.
•	A tour of Laurelholme (boys 14-17). New flooring has been installed.  Expectations of the residents were posted throughout the house. Two knobs were missing from the kitchen cabinets.
•	There were holes in the wall in one bedroom.
•	There is gap between the kitchen floor (threshold) and the entry door.

Corrective Actions implemented as a result of previous visit: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Areas of regulatory non-compliance identified during this visit:

Section 17a-145-73. Sleeping accommodations.
•	One bedroom had several holes in the wall.

Section 17a-145-75. Health and medical treatment. Administration of first aid. Prescription medication. Administration of medicine or treatment. Written records. Storage of drugs, medicines and instruments. Sick room, telephone.
•	There were no staff counter signatures on the cardex's or in the MARs.

Section 17a-145-76 Kitchens, equipment, food-handling.
•	There is a gap between the kitchen floor (threshold) and the door.

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.
Terri Bohara                                                      6-10-22
______________________________            _________________
Regulatory Consultant                                   Date

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

description: 73. Sleeping accommodations.

personnel: NN JM DB LK JM TT


facility_name: Grove School, Inc. / RE #4

summary: Visit conducted on 12/17/25. Found 4 compliance issues. Implemented 3 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: Grove School

TIME OF VISIT (FROM - TO):       ____First shift__________________              DATE: 12/17/25

AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:
Principal

List of Areas / Topics covered during visit:
Status of the campus, cafeteria, gymnasium and the transition house. I met with the principal to discuss the status of the campus. There were no staff positions currently available at the school.

Five youth were residing in transition house, comprised of 3 female and 2 male students, with one staff on duty. All students had moved to the campus for easier supervision as most students were leaving or had left for vacation. There were 41 male and 43 female students on campus the day of this visit.

Corrective Actions implemented as a result of previous visit:
Section 17a-145-73. Sleeping accommodations and Section 17a-145-76. Kitchens, equipment, food-handling
 were both responded to satisfactorily.

Areas of regulatory non-compliance identified during this visit:
Section 17a-145-76. Kitchens, equipment, food-handling
All kitchens shall be clean, well lighted, properly ventilated and screened, and provided with essential and proper equipment for the preparation and serving of food. Storage, refrigeration and freezer facilities shall be adequate for the number of persons to be served. All perishable foods shall be refrigerated at a temperature at or below 45° Fahrenheit. Freezers and frozen food compartments shall be maintained at minus 10° to 0° Fahrenheit. Cooking utensils, dishes and tableware shall be in good condition and proper cleaning facilities for this equipment shall be provided. dishes shall be stored in a clean, dry place protected from flies, dust or other contamination. Food preparation and serving areas shall comply with Section 19-13-B42 of the public health code. Proper food handling techniques and sanitation to minimize the possibility of the spread of food-borne diseases shall be maintained.
•	Plywood used to patch the wall over the kitchen sink needed painting.

Section 17a-145-78. Recreational facilities
Indoor and outdoor recreational facilities, supplies and equipment shall be provided and used by the children. Appropriate safety measures, instructions and supervision should be provided to protect the children from bodily harm.
•	The door sweep for an outer gymnasium door needed replacing to prevent outside air and insects from entering the building.

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.

_Keith Bryan___________                       12/17/25
Regulatory Consultant                                   Date

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

description: 76. Kitchens, equipment, food

facility_name: Grove School


summary: Visit conducted on _09/26/25____. Visit covered 1 main areas/topics. Found 3 compliance issues. 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: Grove School

TIME OF VISIT (FROM - TO):       ____First shift__________________              DATE: _09/26/25____

AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:
Program Director

List of Areas / Topics covered during visit:
Status of the campus and home in which the male residents reside. I met with the executive director to discuss the status of the campus. There was one staff position currently available at the school.

Three youth were 5 males residing in White house with 2 staff on duty. There were 7 male youth residing in Lodge house with 2 staff. There were 5 male youth residing in Redlich house with 2 staff. There were 4 male youth residing in Perlman house with 2 staff. There were 8 female youth residing in Patch house with 2 staff. There were 10 female youth residing in Olshin house with 2 staff. There were 9 female youth residing in Middle house with 2 staff. There were 10 female youth residing in Tessler house with 2 staff. There were 3 female youth residing in Emmerich house with 2 staff. The Charles and Blue house had no youth residing in them. There were 8 youth residing in Transition house.

Ten-day students were enrolled at the school. There were 16 clinicians and a psychiatrist were on duty the day of this visit.

Corrective Actions implemented as a result of previous visit:
Section 17a-145-68. Heating, ventilation, lighting & Section 17a-145-73. Sleeping accommodations were both responded to satisfactorily.

Areas of regulatory non-compliance identified during this visit:
Section 17a-145-73. Sleeping accommodations
(a) Sleeping accommodations for each child shall have adequate area, spacing and equipment in accordance with the child's age and needs. Bedrooms shall contain a window unless there is a 24-hour ventilation system approved by the state or local health department. Heating facilities shall be sufficient to maintain a room temperature consistent with existing department of health services' guidelines. Separate sleeping quarters shall be provided for children of the opposite sex six years of age or over. The facility shall provide each such child with a single bed with adequate linens and covers suitable for the temperature, and a locker, dresser or other storage space for the child's private use conveniently located in or near the child's sleeping room.
•	Bedroom #2 in Pearlman house contained a strong offensive foot odor,

Section 17a-145-76. Kitchens, equipment, food-handling
All kitchens shall be clean, well lighted, properly ventilated and screened, and provided with essential and proper equipment for the preparation and serving of food. Storage, refrigeration and freezer facilities shall be adequate for the number of persons to be served. All perishable foods shall be refrigerated at a temperature at or below 45° Fahrenheit. Freezers and frozen food compartments shall be maintained at minus 10° to 0° Fahrenheit. Cooking utensils, dishes and tableware shall be in good condition and proper cleaning facilities for this equipment shall be provided. dishes shall be stored in a clean, dry place protected from flies, dust or other contamination. Food preparation and serving areas shall comply with Section 19-13-B42 of the public health code. Proper food handling techniques and sanitation to minimize the possibility of the spread of food-borne diseases shall be maintained.
•	The refrigerator handle was missing in the kitchenette area of Pearlman House.

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.

_Keith Bryan___________                       09/26/25
Regulatory Consultant                                   Date

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


summary: Visit conducted on _06/18/25____. Visit covered 1 main areas/topics. Found 3 compliance issues.

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: Grove School

TIME OF VISIT (FROM - TO):       ____First shift__________________              DATE: _06/18/25____

AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:
Executive Director
President
Principle

List of Areas / Topics covered during visit:
Status of the campus and home in which the female residents reside. I met with the executive director to discuss the status of the campus. Two weeks summer vacation starts on 6/27/25. There are currently no available staff positions at the school.

Three youth were residing in White house with 2 staff on duty. There were 7 youth residing in Blue house with 2 staff. There were 9 youth residing in Lodge house with 2 staff. There were 8 youth residing in Redlich house with 2 staff. There were 7 youth residing in Perlman house with 2 staff. There were 8 youth residing in Patch house with 2 staff. There were 9 youth residing in Olshin house with 2 staff. There were 5 youth residing in Middle house with 2 staff. There were 9 youth residing in Tessler house with 2 staff. The Charles had no youth residing in it. There were 8 youth residing in Transition house.

Twelve-day students were enrolled at the school. There were 16 clinicians and a psychiatrist were on duty the day of this visit.

Corrective Actions implemented as a result of previous visit:
•	None

Areas of regulatory non-compliance identified during this visit:
Section 17a-145-68. Heating, ventilation, lighting
Comfortable heating, sufficient ventilation, and both natural and artificial lighting shall be provided.
•	In Olshin House, the tester on the emergency light in the stairwell did not work when pressed.

Section 17a-145-73. Sleeping accommodations
(a) Sleeping accommodations for each child shall have adequate area, spacing and equipment in accordance with the child's age and needs. Bedrooms shall contain a window unless there is a 24-hour ventilation system approved by the state or local health department. Heating facilities shall be sufficient to maintain a room temperature consistent with existing department of health services' guidelines. Separate sleeping quarters shall be provided for children of the opposite sex six years of age or over. The facility shall provide each such child with a single bed with adequate linens and covers suitable for the temperature, and a locker, dresser or other storage space for the child's private use conveniently located in or near the child's sleeping room.
•	In the first bedroom in Patch House, the laminate flooring was becoming scratched beyond repair by a chair. The flooring shall be monitored for eventual replacement.

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.

_Keith Bryan___________                       06/18/25
Regulatory Consultant                                   Date

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

personnel:
Executive Director
President
Principle


summary: Visit conducted on _03/19/25____. 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: Grove School

TIME OF VISIT (FROM - TO):       ____First shift__________________              DATE: _03/19/25____

AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:
Executive Director
President
Principle

List of Areas / Topics covered during visit:
Status of the campus, the kitchen, gymnasium and transition house. I met with the president and executive director to discuss the status of the campus. All the youth that reside in transition home had left for spring vacation. There are currently no available staff positions at the school.

Four youth were residing in White house with 2 staff on duty. There were 7 youth residing in Blue house with 2 staff. There were 8 youth residing in Lodge house with 2 staff. There were 8 youth residing in Redlich house with 2 staff. There were 7 youth residing in Perlman house with 2 staff. There were 10 youth residing in Patch house with 2 staff. There were 10 youth residing in Olshin house with 2 staff. There were 8 youth residing in Middle house with 2 staff. There were 9 youth residing in Tessler house with 2 staff. There were 3 youth residing in Charles house with 2. There were 9 youth residing in Transition house but they were all home on spring vacation. Seventeen day students were enrolled at the school. There were 14 clinicians on duty the day of this visit.

Corrective Actions implemented as a result of previous visit:
•	None

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

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.

_Keith Bryan___________                       03/19/25
Regulatory Consultant                                   Date

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


summary: Visit conducted on _10/15/24____. 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: Grove School

TIME OF VISIT (FROM - TO):       ____First shift__________________              DATE: _10/15/24____

AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:
Executive Director
Director of Human Resources

List of Areas / Topics covered during visit:
Status of the campus and all housing on campus. Five personnel files reviewed for state police background checks as they were not presented during the biannual inspection as required. All files reviewed presented with state police background and FBI background checks.

Three youth were residing in White house with 2 staff on duty. There were 7 youth residing in Blue house with 2 staff. There were 9 youth residing in Lodge house with 2 staff. There were 8 youth residing in Redlich house with 2 staff. There were 8 youth residing in Perlman house with 2 staff. There were 5 youth residing in Patch house with 2 staff. There were 10 youth residing in Olshin house with 2 staff. There were 4 youth residing in Middle house with 2 staff. There were 8 youth residing in Tessler house with 2 staff. There were 3 youth residing in Charles house with 2 and there were 14 youth residing in Transition house with 3 staff. All youth were at school or work. Eleven day students were enrolled at the school. There were 16 clinicians on duty the day of this visit.

Corrective Actions implemented as a result of previous visit:
•	None

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

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.

_Keith Bryan___________                       10/15/24
Regulatory Consultant                                   Date

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


summary: Visit conducted on _09/30/24____. No compliance issues identified. Implemented 4 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: Grove School

 TIME OF VISIT (FROM - TO):       ____First shift__________________              DATE: _09/30/24____

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:
Executive Director

List of Areas / Topics covered during visit:
Status of the campus and all housing on campus. Three youth were residing in White house with 2 staff on duty. There were 7 youth residing in Blue house with 2 staff. There were 9 youth residing in Lodge house with 2 staff. There were 8 youth residing in Redlich house with 2 staff. There were 8 youth residing in Perlman house with 2 staff. There were 5 youth residing in Patch house with 2 staff. There were 10 youth residing in Olshin house with 2 staff. There were 4 youth residing in Middle house with 2 staff. There were 2 youth residing in Tessler house with 2 staff. There were 3 youth residing in Charles house with 2 and there were 14 youth residing in Transition house with 3 staff. All youth were at school or work. Eleven day students were enrolled at the school.

Corrective Actions implemented as a result of previous visit:
The following areas were identified in the biannual report.
Section 17a-145-63. Chief administrative officer; Section 17a-145-64. Personnel policies and procedures; Section 17a-131 of the CGS Cardiopulmonary Resuscitation Training required for persons who directly supervise children; & Section 17a-131 of the CGS Cardiopulmonary Resuscitation Training required for persons who directly supervise children, were all responded to satisfactorily.

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

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.

_Keith Bryan___________                     __09/30/24____
Regulatory Consultant                                   Date

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