summary: Unannounced - 1 finding

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

facility_type: Residential Care - Unannounced

licensee: Calo Programs Missouri, Inc., d.b.a. Embark Date of site visit: 04/15/2025 Behavioral Health - Bend

program_director: Amber Simmons

visit_date: 04/15/2025 Behavioral Health - Bend

licensing_coordinator: Jeff Minden

purpose:
Per OAR 419-400-0240 (1)(b) Children's Care Licensing is required to perform at least one unannounced site visit a year
where children in care reside.
Previous findings Repeat findings Comments
Unannounced Site Visit - 5/13/2024 further action
needed
Medication 419-470-0100(10) Written record No Medication Administration Records were reviewed and
of the administration of medication includes: complete. No blanks were noted, and any refused or not
(a) name administered medications had explanations for the reason.
(b) description
(c) dates and times
(d) missed doses
(e) medication disposed
(f) method of administration
(g) ID of person administering
(h) possible adverse reactions
(i) medication taken outside facility
▪ Bend - Blanks were observed on the
Medication Administration Records
(MAR) with no corresponding notation.

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

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

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


state: OR

facility_name: Embark

summary: License Renewals - 11/06/2023

raw_content:
Licensed Child Caring Agency Site Visit Report
Residential Care
Licensee: Calo Programs Missouri, Inc., d.b.a. Embark Behavioral Health Date of site visit: November 6-7, 2023
Executive Director: Deveney Marshall Licensing Coordinator: Robin DuVal
Board Chairperson: Russell Petrella
Other Regulatory or Accrediting Agencies: Joint Commission Accreditation.
Program Compliance: The program was found to be compliant or will be compliant with OAR 419-400-0005 to 419-400-0310, Licensing Umbrella
Rules, and OAR 419-470-0010 to 419-470-0180, Licensing Residential Care Agencies Rules. Personnel records were reviewed and compliance with
required background checks was documented for employees in all programs.
Program Description, type, and services: 24-hour residential program for adolescents who struggle with mental health challenges and who require
increased levels of support to maximize their individual potential. Through the milieu model that a residential stay can afford, youth are able to receive
assistance through individual evidence-based psychotherapy (e.g., Dialectical Behavioral Therapy (DBT), Trauma-Focused Cognitive Behavioral
Therapy (TF-CBT), Sensory Motor Arousal Regulation Treatment (SMART), Eye Movement Desensitization and Reprocessing (EMDR)) and
specialized psychosocial groups (e.g., health and human sexuality, family relationships, social skills, group therapy). Concurrently, psychiatric and
medication monitoring help ensure that all aspects of the participant’s health are being supported. The program is designed to treat youth with a
variety of mental health struggles and diagnoses, in a safe, structured, and therapeutic environment. The goal is to leverage our therapeutic services
to minimize the risk of hospitalization by giving the participant the stability needed to achieve independence in the general community. Our core
purpose is to create Joy and Heal Generations. This purpose is lived out through our core values of empathy, service, trusting relationships, growth,
and results – the lens by which they approach their therapeutic program.
Capacity and Age Range: 50, ages 10-17
Funding sources: Commercial insurance.
Contracts and sources for referrals: No contracts. Sources for referrals: internet, hospitals, OP therapists, medical providers.
Average length of stay: 65 days
Average daily population served: 5
P a g e 1 | 14
Form Rev. 11/14/2023
Number of children served annually: 12 since new programming took effect February 2023.
Use of seclusion or restraint: No.
Interviews: Two youth were individually interviewed, ages 14 and 13, with stays of 7 weeks and 3 weeks, respectively. Both report feeling safe in
the program and that they feel the program is helping them. They have regular contact with people on their approved contact list, have privacy and
time isn’t restricted. Youth described regular activities on and off-site. The food is good and plentiful. Neither youth report any issues getting
medications as prescribed. School is going well, and they get help when needed. Youth report giving input on their treatment plan and feeling listened
to. They report the program does well at the educational component and their therapists. If there was something they could change about the
program, it would be changing the age-range to group the younger residents and older residents together and allow more freedoms.
Two staff were individually interviewed and have worked in the program for almost 3 years and 6 months, respectively. Both described the types and
frequency of training at time of hire and ongoing. They have regular staff meetings, have regular contact with their immediate supervisor, and
management is responsive to concerns or suggestions made by staff. Staffing is sufficient for the current census. Forms of recreation for the youth,
both on-site and off-site, were described. They described the ways to obtain information when a child enters the program. They report the program
does well at building relationships with the youth, are attuned to their needs, and affirming to youth’s gender fluidity. The program could improve on
having more staff, staff consistency with boundaries within shifts, and improved communication. When asked if there was anything they could change
about the program, they reported having more time in the morning for youth to be outside, more outdoor experiences, and more structure and staff
consistency around areas of laundry and clean-up.
Observations: The walk-through consisted of the youth bedrooms, dorm rooms, bathrooms, living rooms, kitchen, medication room. Areas observed
were clean, odor-free, and in good condition.
Program Strengths: Joint Commission Accredited, outcome driven, 1 to 3 staff to youth ratio, weekly treatment meetings with parental involvement,
therapist caseload of 6 or less, family services programming including weekly parent coaching, monthly family workshops, daily family phone calls,
two therapeutic groups per day, 7 day a week nursing, weekly psychiatric oversight, insurance funded.
Program Challenges: Current leadership challenge is visibility and marketing. There’s a need to do more outreach to let Oregon families know this
program is an option for youth.
Changes that have occurred in the last 2 years: In January of 2023, New Leaf Academy changed ownership to Calo Programs Missouri, Inc. The
program kept the private pay long term program open until June of 2023 and started to take student funding through commercial insurance in February
2023, and have since served 12 youth via insurance funding. The agency received their Joint Commission Accreditation following a site visit in April
2023.
Lawsuits: none
P a g e 2 | 14
Form Rev. 11/14/2023
Grievances and complaints filed in the last two years: none
Corrective Actions and Timeframes: Please submit the following to verify compliance.
Within 45 days of receipt of this report Calo Programs Missouri, Inc. must submit a letter of verification indicating the agency is in
compliance with the specific rules cited above and describing how compliance will be maintained going forward. Along with the letter
of verification, the agency must submit any and all specific documentation requested in the body of this report. The letter of verification
and any additional requested documents are to be emailed directly to Robin DuVal at robin.m.duval@odhsoha.oregon.gov.
Summary of Review
Program and Services 419-400-0020 (2) Yes No N/A
Program and services are in scope of license X
Governance of the Agency 419-400-0040 Yes No N/A
(1)(a) Minimum of 5 board members X
(2)(f) Formally evaluate the exec. Director’s performance annually X
(2)(g) Approves annual budget X
(2)(h) Obtain and review an annual independent financial review or audit of financial
X
records.
(2)(k) Written quality improvement program X
(2)(l) Meeting minutes X
Executive Director or Program Director 419-400-0040 Yes No N/A
(3)(a) knowledge of requirements for providing care and treatment appropriate to
X
programs
(3)(g) Approval from BCU X
Discipline, Behavior Management, and Suicide Prevention 419-400-0150 Yes No N/A Corrective Actions/Comments
(3) Agency uses appropriate and positive methods of behavior management and
X
nationally recognized non-violent crisis intervention
(3)(b)(C) Agency does not use chemical and mechanical restraint (excluding
X
medically necessary devices/prescriptions)
(3)(c) Agency uses appropriate time-out rooms (adequate space, heat, light and
ventilation and is not capable of locking) and documents use in child’s record when X
applicable
(3)(e) Agency uses seclusion appropriately/consistent with policy X
(4) Agency has adequate plan in place to respond to suicidal behavior/warning
X
signs
P a g e 3 | 14
Form Rev. 11/14/2023
Contractors (if applicable) 419-400-0120(6) Yes No N/A
(a) Agency ensures the contractor meets the requirements of this rule and Chapter
X
413 division 215
(b)(B) Contract includes the following:
(i) Services provided
(ii) Contractor fees
(iii) Disclosure of information from contractor to agency
X
(iv) Lines of authority
(v) Adherence to rules, including background check
(vi) Any liability of the agency for acts of the contractor, rights of indemnity and
limitations on liability
Restraints and Involuntary Seclusion 419-400-0180 Yes No N/A Corrective Actions/Comments
(13)(d) Each child caring agency that submits a report under this section shall make
its quarterly report available to the public upon request at the Child Caring Agency’s X
main office and on the child caring agency’s website if applicable.
Supplemental Information Provided by CCA Yes No N/A Corrective Actions
Documents as indicated on the form titled “Renewal Licensing Required
X
Documents”
Documents as indicated on form titled “Required Financial Documents and
X
Information”
All required policies and procedures as identified in the “Umbrella Rules” Upon review of the following policies and procedures,
there are minor to moderate edits needed.
Corrective Action: The agency shall update the
following policies and procedures pursuant to each
OAR and submit for review.
• Conflict of interest in OAR 419-400-0070
• Children Rights in OAR 419-400-0090(1)
• Grievance Procedures in OAR 419-400-
0090(2)
X • Mandatory Abuse Reporting in OAR 400-
0110(2)(a)
• Incident reporting in OAR 419-400-0110(2)(b)
• Personnel in OAR 419-400-0120
• Privacy in OAR 419-400-0130
• Suicide Prevention in OAR 419-400-0150(4)
• Discipline and behavior management in OAR
419-400-0150
• Transportation in OAR 419-400-0200(1)
• Searches in OAR 419-400-0200(2)
• Hazards in OAR 419-400-0200(4)
P a g e 4 | 14
Form Rev. 11/14/2023
All required policies and procedures as identified in “Agency Type Specific Rules”
The agency shall update the following policy and
procedure pursuant to the OAR and submit for review.
X
• Medications in OAR 419-470-0110
Physical Plant Yes No N/A Comments
419-400-0090(3)(a) Foster Rights Posted (if children in DHS custody) X
419-400-0100(1) Sufficient safe space, equipment, and office equipment X
419-400-0230(12) License is posted in common area at each facility Comment: This licensor recommended the license
X also be posted in the foyer as it’s a common area at
the program.
419-470-0020(2)(a) &(c) Buildings are smoke free, clean and in good repair X
419-470-0020 (2)(d) Rooms are free of harmful drafts, odors, and excessive noise X
419-470-0020 (2)(e) Rooms are adequate in size and arrangement X
419-470-0020 (2)(f) System provides a continuous supply of hot and cold water to
X
taps located throughout the facility
419-470-0020 (2)(h) Building is well ventilated and room temperature is within a
X
normal comfort range
419-470-0030 (1) All parts of the facility ensure the safety of children X
Room and Space Requirements 419-470-0030 Yes No N/A
(2) There is a separate living room or lounge area – 15 SF minimum per child X
(5) There is a separate dining room with capacity for ½ of children in care and 15 X
SF per child in care
(7) Laundry is separate from living, kitchen, and dining areas X
(8) Separate storage areas are provided for food, kitchen supplies, utensils, clean X
linens, soiled linens and clothing, cleaning supplies and equip, poisons, chemicals,
outdoor recreational and maintenance equipment. (Hazardous materials are
properly labeled, in original container and locked)
(9) Outdoor activity area is protected from vehicles and other hazards and of a size X
and availability appropriate to the age and needs of children in care
(11) Time-out rooms: Rooms used for time out or quiet time must have adequate X
space, heat, light and ventilation and must not be capable of locking.
Room and Space Requirements Bedrooms 419-470-0030(3) Yes No N/A
(a) Adequate furnishings and personal items X
(b) Separate from rooms used for dining, living, laundry, kitchen, and storage X
(c) Meet Oregon Fire Code Requirements X
(d) Be an outside room, with a window that operates as designed. If the window is
modified from its original design, the fire marshal must approve the modification X
and indicate this room still meets applicable Oregon Fire Code.
(d) Ceiling at least 90 inches X
(e) Minimum 60 SF per occupant X
(f) No more than 25 if dorm style X
(g) Permanently wired fixtures X
(h) Window covering X
P a g e 5 | 14
Form Rev. 11/14/2023
Room and Space Requirements Bathrooms 419-470-0030(4) Yes No N/A
(a)(A)&(B) 1:8 ratio for toilets and sinks X
(a)(D) Hot and cold running water, soap, and approved hand drying options X
(a)(E) 1:10 ratio for shower or bathtub X
(a)(E) Individual privacy X
(a)(F) Window covering X
(a)(G) Permanently wired fixtures X
(a)(H) Adequate ventilation X
(b)&(c) Wooden racks on floors are prohibited and impervious shower mats are
X
disinfected & dried daily be in good condition and free of mold
Room and Space Requirements - Kitchen 419-470-0030(6) Yes No N/A
(a) Used exclusively for storage, food preparation, dishwashing, and activities
X
related to eating and food preparation activities
(b) Walls, floors are easily cleanable X
(c) Equipment and utensils are easily cleanable, durable, nontoxic, and kept clean X
(e) Equipment is easy to clean beneath, between and behind X
Furnishings and Personal Items 419-470-0040 Yes No N/A
(1) There is a bed with frame X
(1)(b) clean mattress in good condition, with a minimum thickness of five inches X
(1)(c) a pillow in good condition X
(1)(d) a private dresser, closet, or similar storage area for personal belongings that
X
is readily accessible
(2) Linens are in good repair. There is a waterproof mattress cover or mattress.
X
Linens are appropriate and towels and washcloths are provided
(3) Bedding is changed weekly or when soiled X
(4)&(5) Personal hygiene supplies and appropriate clothing are provided X
Food Services 419-470-0070 Yes No N/A
(1)(a) Meals are arranged daily, consistent with normal mealtimes that occur during
X
the hours of operation and provide snacks between mealtimes
(1)(b) Menus are prepared in advance in accordance with USDA guidelines,
X
provide a variety of foods and are adjusted for seasonal changes including snacks
(1)(b) Menus are kept for at least 6 months X
(1)(c) Drinking water is freely available X
(2)(a) Food is stored, prepared & served in a sanitary manner X
(2)(c) & (d) Food products are obtained from commercial suppliers (exception of
fruits & vegetables), unpasteurized juice is prohibited, and only Grade A X
pasteurized and fortified milk in appropriate container.
Residential Care Safety 419-470-0080 Yes No N/A Corrective Actions/Comments
(2) Written emergency plan that includes X
(a) Identifying the types of emergencies most likely to happen where the residential
X
care agency is located
(b) Identifying a place to meet for each type of emergency identified X
(c) Identifying an alternate shelter if necessary X
P a g e 6 | 14
Form Rev. 11/14/2023
(d) Ensuring access to necessary medications or medical equipment X
(e) How to help each child in care recover after a disaster X
(3) Telephone numbers for local police, fire department, poison control, after hours
medical advice and other appropriate emergency numbers must be posted near all X
telephones.
(4) Operative flashlights sufficient in number are readily available to staff Comment: This licensor recommended moving the
X box of flashlights to a more readily available space.
(5)(a) Evacuation drill occurs monthly under varying conditions, is retained 2 years Documentation of evacuation drills were inconsistent.
and contains:
(A) identify of person conducting drill Corrective Action:
(B) date & time The agency shall ensure the evacuation drill log form
(C) notification method includes all required elements noted in (A-H); ensure
X
(D) staff participating that evacuation drills occur monthly and are
(E) # of children & staff evacuated appropriately documented.
(F) special conditions simulated
(G) problems encountered
(H) time to complete
Umbrella Safety 419-400-0200 Yes No N/A
(5)(b) Vehicle has insurance policy, is smoke free, safe operating condition, and X
has first aid kit and fire extinguisher 2-A:10-BC
(1)(b)(A) Each vehicle used to transport a child in care must be: properly registered, X
covered by an insurance policy in full force and effect, maintained in safe operating
condition, and smoke-free.
(3) If a child-caring agency has a swimming pool on the premises that is accessible X
to children in care or if a child-caring agency plans to have children in care engage
in swimming, the child-caring agency must have and adhere to policies and
procedures that address, at a minimum, providing disclosures and obtaining
consents, assessing swimming ability of children in care, and ensuring the safety of
pool access.
(4)(a) The program protects children from potentially harmful items and materials. X
(4)(b) Direct supervision of children who do not have the ability to adjust and control X
water temperature
(4)(c) Light fixtures have protective covers unless designed to be used without one X
Medication 419-470-0100 Yes No N/A Corrective Actions and Comments
(3)&(7)(e) Medications have a prescription and are stored in the original container
X
with prescription label
(4)&(5) Herbal supplements and remedies, medical treatments, special diets,
physical therapy, physical aides or limitations have a written order signed by a
physician or qualified medical professional. A written order, signed by a physician X
or qualified medical professional, is also required before a restriction on diet or
physical activity is imposed.
(7)(a) Prescription medications that are unused and medications that are expired or Several bubble pack medications were observed to be
recalled may not be maintained with current medication and must be disposed of as X unsealed, however there were still pills tucked back in
described in agency disposal policy. the bubble and/or taped back in. The medication
P a g e 7 | 14
Form Rev. 11/14/2023
record did not provide a reasoning for any anomalies.
Medications that have been popped out of their
bubble packs and subsequently not administered to a
child in care must not be placed back in the original
container.
This concern was brought to the attention of the
Executive Director and the Nurse and immediately
began investigating.
Corrective Action:
• The agency shall ensure staff are retrained
and following procedures to dispose of
medications when a medication is refused,
missed or any other type of medication error
that results in a medication not being
administered as prescribed and to follow the
agency’s disposal policy.
• The agency shall ensure management
oversight occurs regularly to ensure proper
procedures are followed.
(7)(c) Medications are inaccessible to children and stored behind at least two
Comment: Requirements are met within the program
locking mechanisms. This does not apply to Naloxone.
medication room, however the storage of discontinued
medications in the Nurse’s office was not locked behind
two locking mechanisms at the time of my walk-thru.
X Typically, the drawer is locked, and the office is locked.
However, the drawer was unlocked at the time of the
walk-thru. Other staff have keys to unlock the office,
leaving a potential risk of mishandling of those
medications.
(8) Medications are disposed in accordance with state and federal law Comment: It is recommended that the collection of
medications to be disposed are stored in a separate
container in the medication cabinet and clearly marked
X
as “medications to be disposed.” While on-site, the
Nurse provided a labeled container in the cabinet.
(9) Written record of the disposal of medications is maintained and includes: Comment: The Nurse maintains discontinued
(a) description and amount medications in their office in a baggie labeled per each
(b) name child in care. However, there’s no corresponding record
(c) reason identifying the medications contained in that baggie.
X
(d) method Agency policy allows for return of discontinued
(e) staff & witness signature medications to the child’s parent/guardian.
• This licensor recommended that a record be
created and utilized to document each
P a g e 8 | 14
Form Rev. 11/14/2023
medication, the amount, the child’s name, and
the date at a minimum.
(10) Written record of the administration of medication includes: Medications that were not administered, refused,
(a) name missed or any other type of medication error must be
(b) description documented. Refer to (7)(c) above.
(c) dates and times
(d) missed doses Corrective Action:
(e) medication disposed • The agency shall ensure medication errors, or
(f) method of administration anomalies in documentation, are documented
(g) ID of person administering by adding a notation to the medication
X
(h) possible adverse reactions administration record.
(i) medication taken outside facility • The agency shall ensure staff are retrained
and following procedures for proper
documentation.
• The agency shall ensure management
oversight occurs regularly to ensure proper
procedures are followed.
Extracurricular, Enrichment, Cultural & Social Activities 419-470-0110 Yes No N/A
(2) Children have ongoing opportunities to participate in at least one age- X
appropriate or developmentally appropriate activity
Minimum Staffing Requirements 419-470-0130 Yes No N/A
(1)&(2) Supervision is adequate for the type of program, location, age and type of X
children, ability of supervisor to respond, electronic back-up systems.
Minimum ratios are maintained:
Ages 6 and older: 1:7; Overnight (staff awake) 1:10
(4)(a) When one staff on duty, there is additional staff immediately available with X
max response time of 30 minutes
(5) There is at least one on-site employee authorized to apply the reasonable and X
prudent parent standard
Sleeping Arrangements 419-470-0140 Yes No N/A
(1) Children are in separate bedrooms than adults, unless parent and child, or there X
is written approval from guardian/parent and licensing coordinator
(2) There is adequate supervision of children when sleeping X
(3) When assigning bedrooms a residential care agency must consider all of the X
following:
(a) Chronological age
(b) Developmental age
(c) Gender identity
(d) Personal history, including medical, mental health, behavioral health, and past
adverse experiences including any physical or sexual abuse
P a g e 9 | 14
Form Rev. 11/14/2023
Personnel Files 419-400-0120 Yes No N/A Comments
Staff Name/Position X
(3)(g) Date of Hire X
(3)(a) record of education, training, and previous employment X
(1)(b) & (3)(b) reference checks completed and documented X
(1)(a) & (3)(c) Background check completed and documented X A reminder was provided to initiate new background
checks at times of position changes.
(3)(d) Annual performance evaluations X
(3)(f) Record of personnel actions X
(3)(g) Termination date, reason for termination X
(3)(h) Current job description (1)(c) Employee meets minimum qualifications
X
stated in current job description
New Employee Orientation – Umbrella Requirements (30 days)
Yes No N/A Corrective Actions
419-400-0120(4)
(a) Agency policies and procedures X
(b) Ethical and professional guidelines X
(c) Suicide prevention and intervention X The agency shall ensure that all new employees
(under Calo Programs Missouri Inc.) complete this
training within 30 days of hire, regardless of their prior
employment.
(d) Attributes of population served X
(e) & (5)(a) to (c) Mandatory reporting that includes:
(a) legal definition of child abuse in ORS 418.257 and 419B.005
X
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to the employee
(f) Privacy laws X
(g) Emergency procedures X
New Employee Orientation – Residential 419-470-0120(1)
Yes No N/A Corrective Actions
(Prior to working alone and within 30 days)
(a) Discipline and behavior management including de-escalation, crisis prevention,
positive behavior management, and disciplinary techniques that are non-punitive X
in nature
(b) CPR and First Aid sufficient to retain a current certification X
(c) Universal precautions and hygiene X
(d) Application of the reasonable and prudent parent standard X
(e) Training on the agency’s policy on suicide prevention and suicide risk The agency shall ensure that all new employees
assessment tool (under Calo Programs Missouri Inc.) complete this
X training within 30 days of hire, regardless of their prior
employment.
Crisis Intervention Training Standards and Certification
Yes No N/A Corrective Actions/Comments
419-400-0160(4) (as applicable)
P a g e 10 | 14
Form Rev. 11/14/2023
(a)Complete a minimum of 12 hours of initial training in person from a certified
instructor, including but not limited to a minimum of six hours of training focused
X
on positive behavior support, nonviolent crisis intervention and other methods of
nonphysical intervention to support children in care during a crisis
(d) Receive a certificate that states:
(A) The dates during which the certification is current
(B) The type of restraint which the individual is certified to perform if applicable
(C) The type of training the individual is certified to conduct if applicable
X
(D) Any special endorsements earned by the individual
(E) The level of training
(F) The name of the certified instructor who conducted the training and
administered the assessment of proficiency.
(e) A certification issued:
(A) Must be personal to the individual certified by the training provider X
(B) May be valid for no more than two years with recertification
Ongoing Training Yes No N/A
419-470-0070(2)(b) Employees who handle food served to children have a valid
X
food handler’s card
419-400-0200 (1) Employees transporting children have: current driver’s license,
insurance, trained in emergency procedures and behavior management, and X
training for 15+ passenger vans if applicable)
419-470-0120 (2)(a) Environmental emergencies X
419-470-0120 (2)(b) Universal Precautions X
419-470-0120 (2)(c) Discipline and Behavior Management X
419-470-0120 (2)(d) Agency’s policy on suicide prevention and risk assessment tool X
419-470-0120 (3) Staff providing direct care must maintain current CPR/First Aid
X
certification
419-470-0120 (4) Designated staff authorized to apply reasonable and prudent
X
parent standard are trained in application of the standard
419-400-0120(5) Mandatory reporting (annually) that includes:
(a) legal definition of child abuse in ORS 418.257 and 419B.005
X
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to the employee
419-400-0160(4)(b) Receive continuing education (as applicable on crisis
X
intervention training) from a certified instructor on an annual basis
Children’s Records Yes No N/A
Health Services 419-470-0090
P a g e 11 | 14
Form Rev. 11/14/2023
(2) Medical history obtained within 30 days (significant findings, current
immunizations, history of surgical procedures-health issues-injuries, allergies, X
dental, vision, hearing, behavioral health, and physician orders)
(4)(a) to (f) Medical exams (3 in first year of life, 2,4,6,9,14) X
(g) Have a physical examination within the first 60 days after admission of a child
in care. Documentation of a physical examination having occurred within the X
calendar year will meet this requirement.
Consents 419-470-0160(1) Yes No N/A Corrective Actions
(a) Provide routine and emergency medical care X
(b) Use the discipline and behavior management system X
(c) Use restraint or seclusion (if applicable). Must specify the reasons for the
X
intervention and how staff are trained and supervised
(d) Restrict contact with persons outside of the agency X
(e) Allow access as defined in 419-400-0230 & 0240 X
(f) Impose a dress code The agency shall ensure consent to impose a dress
X code is obtained from the child in care’s
parent/guardian and properly documented.
(g) Apply the reasonable and prudent parent standard X
Disclosures 419-470-0160(2) Parent/guardian has acknowledged in writing: Yes No N/A Corrective Actions
(a) Information regarding personal or room searches and protocols for confiscation
X
of contraband
(b) Statement of Rights of Children and Parents/Guardians The agency shall ensure this disclosure is provided
X and properly documented indicating that the
parent/guardian has acknowledged.
(c) Any policies and procedures upon request The agency shall ensure this disclosure is provided
X and properly documented indicating that the
parent/guardian has acknowledged.
Authorizations 419-470-0160(3) Yes No N/A
(a) Disclose or exchange information with others X
(b) Child specific visitors X
(c) Visitation resources are pre-approved X
(d) Activity specific authorizations are pre-approved to allow children to participate
in potentially hazardous activities, including but not limited to using motorized yard X
equipment, swimming, and horseback riding.
Information about Children in Care 419-400-0190(1)
Yes No N/A Corrective Actions
Summary sheet contains the following:
(a)The name, gender, date of birth, religious preference, and previous address The agency shall ensure an entry is noted for
religious preference.
• While on-site, the agency discussed ways to
X
incorporate that into their electronic system in
the demographic page.
(b) Name and location of previous and current school The agency shall ensure this information is obtained
X
and documented.
P a g e 12 | 14
Form Rev. 11/14/2023
• While on-site, the agency discussed ways to
incorporate that into their electronic system in
the demographic page.
(c) Date of admission X
(d) Legal custody The agency shall ensure an entry is noted for legal
custody.
X • While on-site, the agency discussed ways to
incorporate that into their electronic system in
the demographic page.
(e) The name, address, and telephone number of:
(A) The child in care's parents.
(B) The child in care's legal guardian, if different than the parents, and a copy
X
of the document that provides for his or her authority over the child in care.
(C) Other persons significant to child
(D) Other professionals to be involved in service planning (if applicable)
Service Planning 419-470-0170(2) Yes No N/A Comments
(b) Intake document is completed the date child accepted into care (emergency
X
placement 48 hours)
(d) Assessment is completed within 30 days and contains relevant historical info.,
current behavioral observations, identified need for services, and how agency will X
provide services
(e) (A)&(B) Service plan within 60 days (parent, guardian and child actively Comment: The agency shall continue efforts to
involved). Describes how child’s issues will be addressed, anticipated outcomes, X ensure documentation is clear when the review with
and reviewed by child and guardian/parent. the child and parent/guardian occurs.
(e)(C)&(D) Service plan is reviewed quarterly and revised when information
X
indicates other services should be provided
Case Management 419-470-0170(3) Yes No N/A Corrective Actions
(a) Services are documented, progress toward achieving goals is tracked X
(c) Discharge planning evaluations and decisions are documented. The agency shall ensure discharge planning
X evaluations, decisions, etc. are captured and
documented.
(c) Discharge summary must include:
(A)Current medications
(B)Name of the physician or qualified medical professional who prescribed each
medication
(C)Any outstanding medical or other appointments X
(D)Summary of the child’s participation in the program and progress achieved.
(E)Results of evaluations
(F)Recommendations regarding services
(G)Discharge destination
(e) Follow up services X
(f) Incident Reports X
Records Relating to Restraint & Involuntary Seclusion Yes No N/A Corrective Actions
P a g e 13 | 14
Form Rev. 11/14/2023
419-400-0180 (12) Records X
419-400-0180(13)(e) Each child caring agency shall provide notice regarding how
to access the quarterly reports to the parents or guardians of children in care in This requirement is not met in its entirety. The
X
the program. The child caring agency shall provide the notice upon the child in agency shall update the notice and submit for review.
care’s admission and at least two times each year thereafter.
419-400-0190(1) Information provided to children in care relating to Restraint & This requirement is not met in its entirety. The
X
Involuntary Seclusion agency shall update the notice and submit for review.
Financial Records 419-470-0170(4) Yes No N/A Corrective Actions and Comments
Records contain date, amount, source, purpose, signatures A small amount of cash was discovered after a child’s
admission process, and it was placed in a baggie
labeled with the child’s name and stored in the office.
Corrective Action:
• The agency shall create a financial record log
to document any monies belonging to a child
in care. The form must include all elements
notes in this rule. Note: Typically, the
X
program does not allow cash, however a log
is required in the event
Comment: The agency has a process for in-program
earnings for each child in care which translates into
money on a debit card that’s specific to each child to
use on store outings. The agency provided
documentation outlining how the debit card system
works and how it’s tracked.
Personal Possessions Records 419-470-0170 (5) Yes No N/A
Individual written inventory of all personal possessions is maintained and updated
X
as needed
Records and Documentation 419-400-0140 Yes No N/A
(1) Stored safely X
(2) Permanent, legible, dated, and signed X
(3)&(4) Uniform in organization, readily identifiable and accessible, current, and
X
complete, containing all required info. No eraser tape or white out.
(7) Permanent registry for each child includes Name; Gender; Birth date; Names,
addresses of parents or guardians; Dates of admission; Placement upon X
discharge
Licensing Coordinator’s Signature: ________________________ Date: _1_2_/_2_8_/2_0_2__3_________
Manager Review: ______________________________________ Date: _1_2_-2_7_-_2_0_2_3_ ________
P age 14 | 14
Form Rev. 11/14/2023

agency_name: Calo Programs of Missouri, Inc. dba Embark Behavioral Health (EBH)

program_name: Embark

program_type: (RC) Residential Care Programs

report_type: License Renewals

view_code: RC

facility_type: Residential Care

board_chairperson: Russell Petrella

visit_date: November 6-7, 2023

licensing_coordinator: Robin DuVal

other_regulatory_agencies: Joint Commission Accreditation.

funding_sources: Commercial insurance.

average_length_of_stay: 65 days

use_of_seclusion_or_restraint: No. Interviews: Two youth were individually interviewed, ages 14 and 13, with stays of 7 weeks and 3 weeks, respectively. Both report feeling safe in the program and that they feel the program is helping them. They have regular contact with people on their approved contact list, have privacy and time isn't restricted. Youth described regular activities on and off-site. The food is good and plentiful. Neither youth report any issues getting medications as prescribed. School is going well, and they get help when needed. Youth report giving input on their treatment plan and feeling listened to. They report the program does well at the educational component and their therapists. If there was something they could change about the program, it would be changing the age-range to group the younger residents and older residents together and allow more freedoms. Two staff were individually interviewed and have worked in the program for almost 3 years and 6 months, respectively. Both described the types and frequency of training at time of hire and ongoing. They have regular staff meetings, have regular contact with their immediate supervisor, and management is responsive to concerns or suggestions made by staff. Staffing is sufficient for the current census. Forms of recreation for the youth, both on-site and off-site, were described. They described the ways to obtain information when a child enters the program. They report the program does well at building relationships with the youth, are attuned to their needs, and affirming to youth's gender fluidity. The program could improve on having more staff, staff consistency with boundaries within shifts, and improved communication. When asked if there was anything they could change about the program, they reported having more time in the morning for youth to be outside, more outdoor experiences, and more structure and staff consistency around areas of laundry and clean-up. Observations: The walk-through consisted of the youth bedrooms, dorm rooms, bathrooms, living rooms, kitchen, medication room. Areas observed were clean, odor-free, and in good condition.

program_challenges:
Current leadership challenge is visibility and marketing. There's a need to do more outreach to let Oregon families know this
program is an option for youth.

lawsuits:
none
P a g e 2 | 14


facility_name: Family Solutions - Cascade House Date of Unannounced: March 13, 2024

summary: Unannounced - 7 findings

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Licensee: Family Solutions – Cascade House and Willow House
Executive Director: Tom Johnson
Program Director(s): Dorothy Provencio
Date of Unannounced: May 13, 2021
Licensing Coordinator: Robin DuVal
Other Regulatory or Accrediting Agencies: Oregon Department of Human Services (ODHS) Child Welfare Treatment Services
Program Compliance: OAR 413-215-0001 to 413-215-0136 Licensing Umbrella Rules, and OAR 413-215-0501 to 413-215-0586, Licensing
Residential Care Agencies Rules.
Purpose: Per OAR 413-215-0101 (1) (b) Children’s Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings: Repeat Findings Comments
-Willow House 6-Mth Review 01/20/2021 Further Action
Needed
-Cascade House Unannounced Site Visit 11/3/2020 (no Findings)
413-215-0511(2)(a) &(c) Buildings are smoke free, clean and in good Yes☐ No
repair:
 The left front window nearest the front door has tape over the
cracked glass and furniture inside blocks access to the window.
The agency is aware and working on repair, including possible
other solutions for that window space.”
413-215-0551(10) Written record of the administration of medication Yes☐ No Willow House - Note: The Adverse Reaction binder shall be
includes: (h) possible adverse reactions: easily accessible to staff.
 The requirement is unmet for (10)(h) Adverse Reactions. The
agency shall ensure possible adverse reactions are listed for all
medications.”
1
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 200115)
413-215-0546(2)(e) Documentation of age appropriate instruction – Yes No☐ Willow House: Documentation of age appropriate
pregnancy prevention, nutrition, prevention of HIV & AIDS, and instruction is unmet. The agency shall implement a
prevention and treatment of sexually transmitted disease: systematic procedure to ensure this requirement is met.
 Documentation of age appropriate instruction is unmet. The This is a REPEAT FINDING.
agency shall ensure age appropriate instruction occurs and is
appropriately documented.
413-215-0581(1) Summary sheet contains the following: (a)The name, Yes No☐ Willow House: The summary sheet is missing religious
gender, date of birth, religious preference, and previous address(b) preference and name and location of previous and/or
Name and location of previous and current school: current school. The agency shall ensure the updated form
 The summary sheets are missing religious preference; and name capturing all requirements is implemented going forward.
and location of previous and/or current school. The agency shall This is a REPEAT FINDING.
ensure this information is captured and appropriately documented.
413-215-0581(4) Records contain date, amount, source, purpose, Yes☐ No
signatures:
 The agency shall update the form to include source and purpose
of deposits to and withdrawals from youths’ personal funds and
ensure signatures are obtained instead of initials.
413-215-0071(3)&(4) Uniform in organization, readily identifiable and Yes No☐ Willow House: Records are incomplete missing information
accessible, current, and complete, containing all required info. No as noted above.
eraser tape or white out:
 Youth records are incomplete missing information as noted above.
New Findings from Site Visit Comments
413-215-0511(2)(a) &(c) Buildings are At Willow House, several bedrooms were observed with large amounts of clothing, possessions, etc. strewn
smoke free, clean and in good repair: about the floors with minimal sight of the bare floor. The agency shall ensure cleanliness and safety from
potential hazards.
2
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 200115)
Interview Summary
Youth M. is 14 years old and has been at Willow House for approximately 6 months and reports the program is helping with anger issues, staff
are trusting, feels safe here, has contact with family and time isn’t limited, food is good and plentiful. Gives input into treatment plan and feels
listened to. No problems getting medications as ordered. Regular activities and outings were described. Doesn’t really like school in general and
they need additional explanation to help understand. Feels that staff really don’t understand their background and what led up to them being in
this program. Doesn’t like the peers here and that the program only serves one gender population.
Youth T. #1 is 14 years old and has been at Cascade House for approximately 4 months. It’s their first time being in a program and is still adjusting.
The program is kind of helping but described some peer and environment stressors. There’s a couple staff who are trusting and there when they
need it. Feels safe in the house but doesn’t like the neighborhood. Has contact with family and time isn’t limited. Hasn’t really thought about giving
input into their treatment plan. Dislikes the food but is a picky eater, and reports big meals are made for leftovers. Favorite thing about the program
is the friends that have been made. Least favorite is “everything”. Has school on-site but would rather be in-person at a school building. Regular
activities and outings were described.
Youth T. #2 is 13 years old and has been at Cascade House for approximately 3 weeks and reports the program is helping with coping techniques,
cussing, and to think before speaking. Staff are trusting, especially the therapist. It’s ok here, still adjusting and feels safe. Activities and outings
were described. Has regular phone contact with family and time isn’t limited. Food is good, gets enough and reports big meals are made for
leftovers. No problems getting medications as ordered. Frustrated that caseworker never answers or returns calls but is looking forward to their
upcoming team meeting. School is good and gets help. Feels there’s some unfair privileges, especially with the youth that have runaway and
returned, and peer boundaries and rules are unfair among peers. The program does well at teaching right and wrong.
Both youth at Cascade House shared some statements made by staff that they felt aren’t appropriate for the youth being served in the program.
This coordinator discussed the concerns with the House Manager, and the program is taking it seriously and is taking actions to correct.
Current census: 5 at Willow House and 6 at Cascade House.
Observations
Willow House: The program had good COVID-19 protocols and all staff wore face masks, as mandated statewide due to the COVID-19 pandemic.
Adequate food supply was evident by dry and canned goods on shelves and in multiple refrigerators and freezers. Several bedrooms were
observed with large amounts of clothing, possessions, etc. strewn about the floors with minimal sight of the bare floor, and a recommendation
was provided to utilize Collaborative Problem Solving techniques to encourage the youth to maintain a level of cleanliness and reduce risk of
safety hazards.
Cascade House: The program had good COVID-19 protocols and all staff wore face masks, as mandated statewide due to the COVID-19
pandemic. Adequate food supply was evident by dry and canned goods on shelves and in multiple refrigerators and freezers. The fire extinguisher
3
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 200115)
upstairs on A. side was missing from the mount, which was installed the following day. There are two egresses to the medication/staff office and
one door had the glass replaced with wood. The facility is an aging building and the program makes efforts to maintain good repair.
Corrective Actions and Timeframes:
Please submit the following to verify compliance.
Within 45 days of receipt of this report Family Solutions must submit a letter of verification indicating the agency is in compliance with the specific
rules cited above and describing how compliance will be maintained going forward. Along with the letter of verification, the agency must submit any
and all specific documentation requested in the body of this report. The letter of verification and any additional requested documents are to be emailed
directly to Robin DuVal, ROBIN.M.DuVal@dhsoha.state.or.us
6/1/2021
Licensing Coordinator’s Signature: ________________________ Date: ___________________
5-31-2021
Manager Review: ______________________________________ Date: __________________
4
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 200115)

agency_name: Family Solutions (FS)

report_type: Unannounced

licensee: Family Solutions - Cascade House and Willow House

executive_director: Tom Johnson

program_director: Dorothy Provencio

purpose:
Per OAR 413-215-0101 (1) (b) Children's Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings: Repeat Findings Comments
-Willow House 6-Mth Review 01/20/2021 Further Action
Needed
-Cascade House Unannounced Site Visit 11/3/2020 (no Findings)
413-215-0511(2)(a) &(c) Buildings are smoke free, clean and in good Yes[ ] No
repair:
- The left front window nearest the front door has tape over the
cracked glass and furniture inside blocks access to the window.
The agency is aware and working on repair, including possible
other solutions for that window space."
413-215-0551(10) Written record of the administration of medication Yes[ ] No Willow House - Note: The Adverse Reaction binder shall be
includes: (h) possible adverse reactions: easily accessible to staff.
- The requirement is unmet for (10)(h) Adverse Reactions. The
agency shall ensure possible adverse reactions are listed for all
medications."
1

413-215-0546(2)(e) Documentation of age appropriate instruction - Yes No[ ] Willow House: Documentation of age appropriate
pregnancy prevention, nutrition, prevention of HIV & AIDS, and instruction is unmet. The agency shall implement a
prevention and treatment of sexually transmitted disease: systematic procedure to ensure this requirement is met.
- Documentation of age appropriate instruction is unmet. The This is a REPEAT FINDING.
agency shall ensure age appropriate instruction occurs and is
appropriately documented.
413-215-0581(1) Summary sheet contains the following: (a)The name, Yes No[ ] Willow House: The summary sheet is missing religious
gender, date of birth, religious preference, and previous address(b) preference and name and location of previous and/or
Name and location of previous and current school: current school. The agency shall ensure the updated form
- The summary sheets are missing religious preference; and name capturing all requirements is implemented going forward.
and location of previous and/or current school. The agency shall This is a REPEAT FINDING.
ensure this information is captured and appropriately documented.
413-215-0581(4) Records contain date, amount, source, purpose, Yes[ ] No
signatures:
- The agency shall update the form to include source and purpose
of deposits to and withdrawals from youths' personal funds and
ensure signatures are obtained instead of initials.
413-215-0071(3)&(4) Uniform in organization, readily identifiable and Yes No[ ] Willow House: Records are incomplete missing information
accessible, current, and complete, containing all required info. No as noted above.
eraser tape or white out:
- Youth records are incomplete missing information as noted above.
New Findings from Site Visit Comments
413-215-0511(2)(a) &(c) Buildings are At Willow House, several bedrooms were observed with large amounts of clothing, possessions, etc. strewn
smoke free, clean and in good repair: about the floors with minimal sight of the bare floor. The agency shall ensure cleanliness and safety from
potential hazards.
2

Interview Summary
Youth M. is 14 years old and has been at Willow House for approximately 6 months and reports the program is helping with anger issues, staff
are trusting, feels safe here, has contact with family and time isn't limited, food is good and plentiful. Gives input into treatment plan and feels
listened to. No problems getting medications as ordered. Regular activities and outings were described. Doesn't really like school in general and
they need additional explanation to help understand. Feels that staff really don't understand their background and what led up to them being in
this program. Doesn't like the peers here and that the program only serves one gender population.
Youth T. #1 is 14 years old and has been at Cascade House for approximately 4 months. It's their first time being in a program and is still adjusting.
The program is kind of helping but described some peer and environment stressors. There's a couple staff who are trusting and there when they
need it. Feels safe in the house but doesn't like the neighborhood. Has contact with family and time isn't limited. Hasn't really thought about giving
input into their treatment plan. Dislikes the food but is a picky eater, and reports big meals are made for leftovers. Favorite thing about the program
is the friends that have been made. Least favorite is "everything". Has school on-site but would rather be in-person at a school building. Regular
activities and outings were described.
Youth T. #2 is 13 years old and has been at Cascade House for approximately 3 weeks and reports the program is helping with coping techniques,
cussing, and to think before speaking. Staff are trusting, especially the therapist. It's ok here, still adjusting and feels safe. Activities and outings
were described. Has regular phone contact with family and time isn't limited. Food is good, gets enough and reports big meals are made for
leftovers. No problems getting medications as ordered. Frustrated that caseworker never answers or returns calls but is looking forward to their
upcoming team meeting. School is good and gets help. Feels there's some unfair privileges, especially with the youth that have runaway and
returned, and peer boundaries and rules are unfair among peers. The program does well at teaching right and wrong.
Both youth at Cascade House shared some statements made by staff that they felt aren't appropriate for the youth being served in the program.
This coordinator discussed the concerns with the House Manager, and the program is taking it seriously and is taking actions to correct.
Current census: 5 at Willow House and 6 at Cascade House.
Observations
Willow House: The program had good COVID-19 protocols and all staff wore face masks, as mandated statewide due to the COVID-19 pandemic.
Adequate food supply was evident by dry and canned goods on shelves and in multiple refrigerators and freezers. Several bedrooms were
observed with large amounts of clothing, possessions, etc. strewn about the floors with minimal sight of the bare floor, and a recommendation
was provided to utilize Collaborative Problem Solving techniques to encourage the youth to maintain a level of cleanliness and reduce risk of
safety hazards.
Cascade House: The program had good COVID-19 protocols and all staff wore face masks, as mandated statewide due to the COVID-19
pandemic. Adequate food supply was evident by dry and canned goods on shelves and in multiple refrigerators and freezers. The fire extinguisher
3

upstairs on A. side was missing from the mount, which was installed the following day. There are two egresses to the medication/staff office and
one door had the glass replaced with wood. The facility is an aging building and the program makes efforts to maintain good repair.


summary: Unannounced - 08/13/2021

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Licensee: Adapt Deer Creek
Executive Director: Dr. Gregory Brigham
Program Director(s): Ronald Farley
Date of Unannounced: 8/13/2021
Licensing Coordinator: Mary Torres
Other Regulatory or Accrediting Agencies: Oregon Health Authority (OHA)
Purpose: Per OAR 413-215-0101 (1) (b) Children’s Care Licensing is required to perform at least one unannounced site visit a year
where children in care reside.
Previous Findings Repeat Comments
Findings
Further
Action
Needed
The program had no previous findings Yes☐ No☐
to review from the last Licensing on-
site inspection completed in
December of 2020.
New Findings from Site Visit Comments
There were no new findings from this
site visit
1
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Interview Summary
Program Director, Ron Farley, was interviewed and facilitated a tour of the campus.
Information gathered during site visit:
- The program currently has 6 youth, 3 males/3 females. A 7th resident is pending intake.
- The majority of referrals coming in to Adapt are not a good match for the program as the youths’ needs are much higher than
the program can accommodate. The program is receiving 3 - 4 referrals a week. With the new COVID surge, referral
numbers have decreased.
- A new electronic filing system was adopted, making intakes difficult to enter, but staff are doing their best to maneuver
through this computer system.
- Staff are grieving the unexpected death of a long-time employee. This employee had been with Adapt for 32 years.
- Youth are attending school Monday through Friday. An instructor from the local school district is on campus Tuesday,
Wednesday and Thursday. On Monday and Friday, Adapt staff assist residents with their school work. Youth are currently
wearing masks while in school as required by the Department of Education.
- There are three open staff positions. Two resident assistants (RA) and a counselor. One open position is a result of an out
of state move while two are a result of covering additional shifts related to under staffing. The program raised their entry level
rate to $15.15/hr., but employment interest remains low.
- Family on-site visits were suspended again due to COVID. Youth continue to have daily phone contact with their family and
participate in zoom visits on the weekends. Prior to the new COVID surge, the program had hosted four months of family
visits and had recently began allowing siblings, ages 12 years and older, to visit. When on-site visits were occurring,
everyone wore masks and no food was allowed.
- Some youth in program are vaccinated.
- Licensing recapped mandatory reporting, stressing the importance of reporting any suspected child abuse to the Child Abuse
Hotline rather than conducting an internal investigation.
Two youth were interviewed. Both report feeling safe in the program. One youth shared a recent incident where a power struggle
took place between staff and youth. This was described as an isolated incident and an uncommon occurrence for the staff involved.
This information was given to the Program Director at the time of the site visit. The Program Director was already aware of the
situation and has plans to look into the matter further. Neither youth enjoy the program’s meals that are prepared off site in an
industrial kitchen. One resident stated that the food was generally “not good” while the other said the food had “no flavor.” Youth
report getting enough to eat, however, as the facility has two kitchens available where residents can prepare quick meals and have
snacks throughout the day. Youth confirm daily phone calls and zoom calls on the weekends with family. Both youth shared that it
would be nice if daily call times could be increased to 15 minutes. Right now, residents are allowed only 10-minute phone calls.
Youth understand that when the program is full, that 10 minute calls allow everyone an opportunity to use the phone, but when
2
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 200115)
resident numbers are low, youth would like to see their phone times increased. Youth report possessing a good understanding of
their treatment goals while in program and have a sense of what their after care plan may look like. A program strength was
identified as staff’s consistency with enforcing rules. A program weakness was stated as staff “not listening” to youth. Youth
explained that staff will stop a youth from sharing during a conversation, encouraging them, instead, to talk to their counselor. Youth
acknowledge that at times speaking to a counselor is more appropriate, but youth may want to talk to staff knowing that their
counselor is immediately unavailable to them. Both youth identified the same staff member who does not exhibit the same level of
engagement as the rest of the staff. This staff member is said to be on their phone the majority of their shift time and does the “bare
minimum.” This information was also provided to the Program Director who is actively coaching this staff member.
Observations
Despite the uncommonly high temperatures, the facility was well air conditioned and comfortable.
The youths’ rooms have a supply of masks for youth to use as needed.
There were no new findings regarding the program’s physical campus.
Corrective Actions and Timeframes:
Please submit the following to verify compliance.
Within 45 days of receipt of this report Agency Name must submit a letter of verification indicating the agency is in compliance with the specific
rules cited above and describing how compliance will be maintained going forward. Along with the letter of verification, the agency must submit any
and all specific documentation requested in the body of this report. The letter of verification and any additional requested documents can be emailed
directly to Licensing Coordinator email address or sent by regular mail to the following address:
Department of Human Services
Children’s Care Licensing Program
Attn: Licensing Coordinator
201 High St. SE Suite 500
Salem, OR 97301
Licensing Coordinator’s Signature: ________________________ Date: _ _ _ _8_/2_5_/_2_0_2_1_ _______
Manager Review: ______________________________________ Date: __8_-_2_3__-2__0_2_1_______
3
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 200115)

licensee: Adapt Deer Creek

executive_director: Dr. Gregory Brigham

program_director: Ronald Farley

licensing_coordinator: Mary Torres

other_regulatory_agencies: Oregon Health Authority (OHA)

purpose:
Per OAR 413-215-0101 (1) (b) Children's Care Licensing is required to perform at least one unannounced site visit a year
where children in care reside.
Previous Findings Repeat Comments
Findings
Further
Action
Needed
The program had no previous findings Yes[ ] No[ ]
to review from the last Licensing on-
site inspection completed in
December of 2020.
New Findings from Site Visit Comments
There were no new findings from this
site visit
1

Interview Summary

interview_summary:
Program Director, Ron Farley, was interviewed and facilitated a tour of the campus.
Information gathered during site visit:
- The program currently has 6 youth, 3 males/3 females. A 7th resident is pending intake.
- The majority of referrals coming in to Adapt are not a good match for the program as the youths' needs are much higher than
the program can accommodate. The program is receiving 3 - 4 referrals a week. With the new COVID surge, referral
numbers have decreased.
- A new electronic filing system was adopted, making intakes difficult to enter, but staff are doing their best to maneuver
through this computer system.
- Staff are grieving the unexpected death of a long-time employee. This employee had been with Adapt for 32 years.
- Youth are attending school Monday through Friday. An instructor from the local school district is on campus Tuesday,
Wednesday and Thursday. On Monday and Friday, Adapt staff assist residents with their school work. Youth are currently
wearing masks while in school as required by the Department of Education.
- There are three open staff positions. Two resident assistants (RA) and a counselor. One open position is a result of an out
of state move while two are a result of covering additional shifts related to under staffing. The program raised their entry level
rate to $15.15/hr., but employment interest remains low.
- Family on-site visits were suspended again due to COVID. Youth continue to have daily phone contact with their family and
participate in zoom visits on the weekends. Prior to the new COVID surge, the program had hosted four months of family
visits and had recently began allowing siblings, ages 12 years and older, to visit. When on-site visits were occurring,
everyone wore masks and no food was allowed.
- Some youth in program are vaccinated.
- Licensing recapped mandatory reporting, stressing the importance of reporting any suspected child abuse to the Child Abuse
Hotline rather than conducting an internal investigation.
Two youth were interviewed. Both report feeling safe in the program. One youth shared a recent incident where a power struggle
took place between staff and youth. This was described as an isolated incident and an uncommon occurrence for the staff involved.
This information was given to the Program Director at the time of the site visit. The Program Director was already aware of the
situation and has plans to look into the matter further. Neither youth enjoy the program's meals that are prepared off site in an
industrial kitchen. One resident stated that the food was generally "not good" while the other said the food had "no flavor." Youth
report getting enough to eat, however, as the facility has two kitchens available where residents can prepare quick meals and have
snacks throughout the day. Youth confirm daily phone calls and zoom calls on the weekends with family. Both youth shared that it
would be nice if daily call times could be increased to 15 minutes. Right now, residents are allowed only 10-minute phone calls.
Youth understand that when the program is full, that 10 minute calls allow everyone an opportunity to use the phone, but when
2

resident numbers are low, youth would like to see their phone times increased. Youth report possessing a good understanding of
their treatment goals while in program and have a sense of what their after care plan may look like. A program strength was
identified as staff's consistency with enforcing rules. A program weakness was stated as staff "not listening" to youth. Youth
explained that staff will stop a youth from sharing during a conversation, encouraging them, instead, to talk to their counselor. Youth
acknowledge that at times speaking to a counselor is more appropriate, but youth may want to talk to staff knowing that their
counselor is immediately unavailable to them. Both youth identified the same staff member who does not exhibit the same level of
engagement as the rest of the staff. This staff member is said to be on their phone the majority of their shift time and does the "bare
minimum." This information was also provided to the Program Director who is actively coaching this staff member.

observations:
Despite the uncommonly high temperatures, the facility was well air conditioned and comfortable.
The youths' rooms have a supply of masks for youth to use as needed.
There were no new findings regarding the program's physical campus.


summary: Unannounced - 7 findings

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Residential Care
Licensee: Family Solutions – Cascade House Date of Unannounced: August 23, 2023
Executive Director: Dorothy Provencio Licensing Coordinator: Robin DuVal, accompanied by Katie Wyland with
Program Manager: Susan Shorey Child Welfare Treatment Services.
Program Director(s): Roy Lindsay
Other Regulatory or Accrediting Agencies: Oregon Health Authority (OHA) and Oregon Department of Human Services Child Welfare Treatment
Services (ODHS).
Purpose: Per OAR 419-400-0240(1)(b) Children’s Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Repeat
Previous Findings: Findings
Comments or Corrective Actions
License Renewal Site Visit 08/31/2022 Further Action
Needed
SB710 Requirements: Policy and Procedures; notifications to Yes☐ No This notification is provided to guardians and children in care
guardian and children in care. OAR 419-400-0180(8)(e), and documented as being provided.
(11)(e) and OAR 419-400-0190(1).
 No further corrective action is needed at this time.
 This licensor provided edits and recommendations to
the notification document for guardians and children in Note: The form had an outdated email extension for the
care. The agency shall ensure the notification is licensing contact. The agency staff person will update and
updated and implemented going forward. ensure the new form is utilized going forward.
Medication 419-470-0100(9) Written record of the disposal of Yes No☐ Requirement (9)(e) remains unmet: initials instead of
medications is maintained and includes: signatures; and several instances with only one staff person
(a) description and amount without a witness.
(b) name
(c) reason Some disposed medications are disposed on-site utilizing the
(d) method Rx Destroyer product, however other disposed medications
(e) staff & witness signature were in a bin labeled “disposal” with no tracking document
within said bin, creating a risk of mismanagement or theft.
1 of 6 | P a g e
Form Rev. 01/23/2023
 (9)(e) The agency shall ensure staff and witness
provide a signature, not initials. When speaking to several staff and the program manager,
there was a lack of clarity on the process of medication
Note: This licensor and staff discussed ways to update administration documentation and medication disposal and
documentation and processes. The agency is working on disposal documentation. There have been recent staff
updating policies and procedures to be clearer and reduce changes, and new hires that may not have received required
potential errors. training.
Corrective Action. The Agency shall:
1) Ensure staff and a witness provide a signature, not
initials.
2) Ensure two staff (one staff and one staff witness) are
disposing medications and signing the disposal
record.
3) Review medication policies and procedures to ensure
it meets requirements in related OARs and the
practices set forth by Family Solutions.
4) Ensure all staff who handle medications are provided
medication policies and procedures, are trained, and
demonstrate competency before administering and
disposing medications as well as proper
documentation.
5) Ensure management oversight for quality check and
assurances and any follow-up training needed.
**This is a repeat finding.**
2 of 6 | P a g e
Form Rev. 01/23/2023
Medication 419-470-0100(10) Written record of the Yes No☐ Requirements (10)(d) and (e) are unmet. There were several
administration of medication includes: blank areas on the medication administration record with no
(a) name corresponding notes to document the circumstances where
(b) description space is provided for such notes on the back of the sheet.
(c) dates and times
(d) missed doses When speaking to several staff and the program manager,
(e) medication disposed there was a lack of clarity on the process of medication
(f) method of administration administration documentation and medication disposal and
(g) ID of person administering disposal documentation. There have been recent staff
(h) possible adverse reactions changes, and new hires that may not have received required
(i) medication taken outside facility training.
 Requirements (10)(e) and (i) are unmet. The agency Corrective Action – The Agency shall:
shall ensure all requirements are included on the
medication administration record. 1) The agency shall ensure the written record of the
medication administration are filled out accurately with
Note: This licensor and staff discussed ways to update no blanks, indicating missed doses or medication
documentation and processes. The agency is working on disposed.
updating policies and procedures to be clearer and reduce  Medication errors, or anomalies in documentation or
potential errors. administration, can be documented by adding a
notation to the medication administration record.
2) Review medication policies and procedures to ensure
it meets requirements in related OARs and the
practices set forth by Family Solutions.
3) Ensure all staff who handle medications are provided
medication policies and procedures, are trained, and
demonstrate competency before administering and
disposing medications as well as proper
documentation.
4) Ensure management oversight for quality check and
assurances and any follow-up training needed.
**This is a repeat finding.**
3 of 6 | P a g e
Form Rev. 01/23/2023
Children’s Records Health Services 419-470-0090 Yes No 
(2)(e) Documentation of age-appropriate instruction – This rule changed effective 4/18/2023 and is now required
pregnancy prevention, nutrition, prevention of HIV & AIDS, and under 419-470-0090(3)(a) Health Services Medical exams.
prevention and treatment of sexually transmitted disease
 No further corrective action is needed at this time
 (2)(e) is unmet. The agency shall ensure age-
appropriate instruction is provided and appropriately
documented in each youth file. Repeat finding.
Financial Records 419-470-0170 (4) Records contain date, Yes☐ No Financial records are being signed by both staff and the child
amount, source, purpose, signatures. in care.
 Signatures were inconsistent. The agency shall ensure  No further corrective action is needed at this time.
signatures are regularly obtained.
Note: the administrative staff person recently implemented a
weekly quality check to verify accurate documentation and
initials when complete. This licensor recommended revising
the log form to include a column for this review and signature.
New Findings from Site Visit Corrective Actions
Physical Plant Requirements 419-470- All upstairs toilets had various levels of rings in the toilet indicating a deep cleaning and regular upkeep
0020(2)(c) All areas of buildings where was lacking. It’s recommended that the agency utilize Collaborative Problem Solving techniques to
children in care are present must be kept encourage the youth to meet cleaning expectations.
clean and in good repair. Major
appliances and heating, ventilation,  Corrective Action: The agency is ultimately responsible and must ensure agency staff are
plumbing, and electrical systems must be completing necessary cleaning.
functional and in good repair.
There is dark discolored flooring around one of the upstairs toilets indicating a potential water leak,
mold, rotting floor, or other unknown reason. Mold is a health hazard, and a rotting floor structure is
a safety concern.
 Corrective Action: The agency shall seek out a professional assessment and remedy the
problem.
4 of 6 | P a g e
Form Rev. 01/23/2023
Interview Summary
The program manager began a site tour with this licensor before attending the scheduled all-staff training. The current census is 6 with one
potential new intake soon. Katie Wyland interviewed two youth and three staff. This licensor interviewed one youth and the in-house schoolteacher
and met three newer staff and briefly talked with two longer term staff.
Youth Interviews: Youth reported wanting to do more activities and get out of the program more. They’ve spent most of the summer break sitting
around watching TV and playing video games in the downstairs main living room. They’re not allowed to use the upstairs recreation room until
after 3pm. Outings have included swimming, the park, or drives. They reported only two outings in the last two weeks. There’s no structured daily
physical activity time. Staff aren’t following the outing or activity schedule that’s posted. Groups haven’t been happening. School starts next week,
so they’re hoping for more daily structure. There are staff that are trusting. With the recent staffing changes, it feels disorganized. Food is described
as good, but there’s a lot of frozen meals and approximately two cooked meals per week. Phone calls with approved contact persons occur at the
end of each day for 15 minutes per youth, but it’s a tight schedule to start/stop for the next youth to make a call. Phone calls occur at the kitchen
table which provides semi-privacy as youth and staff might be walking thru or doing chores. One of the therapists recently left the agency, and
the youth are seeing the other one, but it’s reported their approach is more of a hands-off, listening type rather than helping them process through
feelings or providing tools to work through feelings.
Staff Interviews: Staff report that the youth need more routine and structure, and that there’s been too much sitting watching TV and playing
video games during the day. This is due to not having enough staff, especially due to the recently implemented staffing ratio for outings where if
two youth go on an outing there must be two staff to accompany them, which means all youth go on the outing or there is no outing. Some youth
lose outing privileges, due to safety concerns, which contributes to the staffing/outing dilemma. It was reported the funds for outings are not always
sufficient, and there doesn’t seem to be oversight of those funds or sufficient funds for the types of outings that may cost more. One staff reports
that youth are going on outings 4-5 times a week, just not on day shift, and outings include YMCA for swimming (M, W & F), drives, bowling and,
if funds allow, to the movies or coffee shop.
There’s been recent staff changes and the atmosphere among coworkers feels stressed. Schedules are all over the place. Hands-on training for
new staff isn’t happening as thoroughly i.e., showing a new staff person how to do a proper room check requires two staff to leave the floor, which
is nearly impossible to accommodate; staff either don’t know the house rules or they’re not consistent with the house rules; and only receiving a
5-minute training on BRS service documentation.
Staff report various levels of feeling comfortable going to management with concerns as well as mixed feedback about issues getting resolved or
not. Staff expressed a desire to have the program manager be more involved on the floor on a regular basis, especially during times of staff
changes, training, new client intakes and during times when client behaviors are challenging to manage.
5 of 6 | P a g e
Form Rev. 01/23/2023
Observations
The facility is an aging building, was originally built as a house, has original or aging bathrooms and some areas appear more worn down. The
agency works at keeping it maintained and clean. A couple maintenance issues are noted above in “New Findings”. Youth bedrooms were
observed and were relatively clean and tidy. Food was observed in the cupboards and in refrigerators and freezers. The walk-through consisted
of the classroom, and all rooms, bathrooms, and common areas on the first and second floor of the residential side of the building. It was smokey
outside due to wildfires, so the youth were inside finishing up breakfast and then in the living room either watching tv or playing video games.
Staff had a scheduled training (in-person and virtual) soon after this licensor arrived, and accommodations were made to continue the
unannounced visit.
Corrective Actions and Timeframes: Please submit the following to verify compliance.
Within 45 days of receipt of this report Family Solutions must submit a letter of verification indicating the agency is in compliance with the specific
rules cited above and describing how compliance will be maintained going forward. Along with the letter of verification, the agency must submit any
and all specific documentation requested in the body of this report. The letter of verification and any additional requested documents can be emailed
directly to robin.m.duval@dhsoha.state.or.us.
Licensing Coordinator’s Signature: ________________________ Date: _9_/1_2_/_2_0_2_3_ __________
Manager Review: ______________________________________ Date: _9_-_1_2_-2__0_2_3_ ________
6 of 6 | P a g e
Form Rev. 01/23/2023

licensee: Family Solutions - Cascade House Date of Unannounced: August 23, 2023

program_director: Roy Lindsay

purpose:
Per OAR 419-400-0240(1)(b) Children's Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Repeat
Previous Findings: Findings
Comments or Corrective Actions
License Renewal Site Visit 08/31/2022 Further Action
Needed
SB710 Requirements: Policy and Procedures; notifications to Yes[ ] No This notification is provided to guardians and children in care
guardian and children in care. OAR 419-400-0180(8)(e), and documented as being provided.
(11)(e) and OAR 419-400-0190(1).
- No further corrective action is needed at this time.
- This licensor provided edits and recommendations to
the notification document for guardians and children in Note: The form had an outdated email extension for the
care. The agency shall ensure the notification is licensing contact. The agency staff person will update and
updated and implemented going forward. ensure the new form is utilized going forward.
Medication 419-470-0100(9) Written record of the disposal of Yes No[ ] Requirement (9)(e) remains unmet: initials instead of
medications is maintained and includes: signatures; and several instances with only one staff person
(a) description and amount without a witness.
(b) name
(c) reason Some disposed medications are disposed on-site utilizing the
(d) method Rx Destroyer product, however other disposed medications
(e) staff & witness signature were in a bin labeled "disposal" with no tracking document
within said bin, creating a risk of mismanagement or theft.
1 of 6 | P a g e

- (9)(e) The agency shall ensure staff and witness
provide a signature, not initials. When speaking to several staff and the program manager,
there was a lack of clarity on the process of medication
Note: This licensor and staff discussed ways to update administration documentation and medication disposal and
documentation and processes. The agency is working on disposal documentation. There have been recent staff
updating policies and procedures to be clearer and reduce changes, and new hires that may not have received required
potential errors. training.
Corrective Action. The Agency shall:
1) Ensure staff and a witness provide a signature, not
initials.
2) Ensure two staff (one staff and one staff witness) are
disposing medications and signing the disposal
record.
3) Review medication policies and procedures to ensure
it meets requirements in related OARs and the
practices set forth by Family Solutions.
4) Ensure all staff who handle medications are provided
medication policies and procedures, are trained, and
demonstrate competency before administering and
disposing medications as well as proper
documentation.
5) Ensure management oversight for quality check and
assurances and any follow-up training needed.
**This is a repeat finding.**
2 of 6 | P a g e

Medication 419-470-0100(10) Written record of the Yes No[ ] Requirements (10)(d) and (e) are unmet. There were several
administration of medication includes: blank areas on the medication administration record with no
(a) name corresponding notes to document the circumstances where
(b) description space is provided for such notes on the back of the sheet.
(c) dates and times
(d) missed doses When speaking to several staff and the program manager,
(e) medication disposed there was a lack of clarity on the process of medication
(f) method of administration administration documentation and medication disposal and
(g) ID of person administering disposal documentation. There have been recent staff
(h) possible adverse reactions changes, and new hires that may not have received required
(i) medication taken outside facility training.
- Requirements (10)(e) and (i) are unmet. The agency Corrective Action - The Agency shall:
shall ensure all requirements are included on the
medication administration record. 1) The agency shall ensure the written record of the
medication administration are filled out accurately with
Note: This licensor and staff discussed ways to update no blanks, indicating missed doses or medication
documentation and processes. The agency is working on disposed.
updating policies and procedures to be clearer and reduce - Medication errors, or anomalies in documentation or
potential errors. administration, can be documented by adding a
notation to the medication administration record.
2) Review medication policies and procedures to ensure
it meets requirements in related OARs and the
practices set forth by Family Solutions.
3) Ensure all staff who handle medications are provided
medication policies and procedures, are trained, and
demonstrate competency before administering and
disposing medications as well as proper
documentation.
4) Ensure management oversight for quality check and
assurances and any follow-up training needed.
**This is a repeat finding.**
3 of 6 | P a g e

Children's Records Health Services 419-470-0090 Yes No
(2)(e) Documentation of age-appropriate instruction - This rule changed effective 4/18/2023 and is now required
pregnancy prevention, nutrition, prevention of HIV & AIDS, and under 419-470-0090(3)(a) Health Services Medical exams.
prevention and treatment of sexually transmitted disease
- No further corrective action is needed at this time
- (2)(e) is unmet. The agency shall ensure age-
appropriate instruction is provided and appropriately
documented in each youth file. Repeat finding.
Financial Records 419-470-0170 (4) Records contain date, Yes[ ] No Financial records are being signed by both staff and the child
amount, source, purpose, signatures. in care.
- Signatures were inconsistent. The agency shall ensure - No further corrective action is needed at this time.
signatures are regularly obtained.
Note: the administrative staff person recently implemented a
weekly quality check to verify accurate documentation and
initials when complete. This licensor recommended revising
the log form to include a column for this review and signature.
New Findings from Site Visit Corrective Actions
Physical Plant Requirements 419-470- All upstairs toilets had various levels of rings in the toilet indicating a deep cleaning and regular upkeep
0020(2)(c) All areas of buildings where was lacking. It's recommended that the agency utilize Collaborative Problem Solving techniques to
children in care are present must be kept encourage the youth to meet cleaning expectations.
clean and in good repair. Major
appliances and heating, ventilation, - Corrective Action: The agency is ultimately responsible and must ensure agency staff are
plumbing, and electrical systems must be completing necessary cleaning.
functional and in good repair.
There is dark discolored flooring around one of the upstairs toilets indicating a potential water leak,
mold, rotting floor, or other unknown reason. Mold is a health hazard, and a rotting floor structure is
a safety concern.
- Corrective Action: The agency shall seek out a professional assessment and remedy the
problem.
4 of 6 | P a g e

Interview Summary
The program manager began a site tour with this licensor before attending the scheduled all-staff training. The current census is 6 with one
potential new intake soon. Katie Wyland interviewed two youth and three staff. This licensor interviewed one youth and the in-house schoolteacher
and met three newer staff and briefly talked with two longer term staff.
Youth Interviews: Youth reported wanting to do more activities and get out of the program more. They've spent most of the summer break sitting
around watching TV and playing video games in the downstairs main living room. They're not allowed to use the upstairs recreation room until
after 3pm. Outings have included swimming, the park, or drives. They reported only two outings in the last two weeks. There's no structured daily
physical activity time. Staff aren't following the outing or activity schedule that's posted. Groups haven't been happening. School starts next week,
so they're hoping for more daily structure. There are staff that are trusting. With the recent staffing changes, it feels disorganized. Food is described
as good, but there's a lot of frozen meals and approximately two cooked meals per week. Phone calls with approved contact persons occur at the
end of each day for 15 minutes per youth, but it's a tight schedule to start/stop for the next youth to make a call. Phone calls occur at the kitchen
table which provides semi-privacy as youth and staff might be walking thru or doing chores. One of the therapists recently left the agency, and
the youth are seeing the other one, but it's reported their approach is more of a hands-off, listening type rather than helping them process through
feelings or providing tools to work through feelings.
Staff Interviews: Staff report that the youth need more routine and structure, and that there's been too much sitting watching TV and playing
video games during the day. This is due to not having enough staff, especially due to the recently implemented staffing ratio for outings where if
two youth go on an outing there must be two staff to accompany them, which means all youth go on the outing or there is no outing. Some youth
lose outing privileges, due to safety concerns, which contributes to the staffing/outing dilemma. It was reported the funds for outings are not always
sufficient, and there doesn't seem to be oversight of those funds or sufficient funds for the types of outings that may cost more. One staff reports
that youth are going on outings 4-5 times a week, just not on day shift, and outings include YMCA for swimming (M, W & F), drives, bowling and,
if funds allow, to the movies or coffee shop.
There's been recent staff changes and the atmosphere among coworkers feels stressed. Schedules are all over the place. Hands-on training for
new staff isn't happening as thoroughly i.e., showing a new staff person how to do a proper room check requires two staff to leave the floor, which
is nearly impossible to accommodate; staff either don't know the house rules or they're not consistent with the house rules; and only receiving a
5-minute training on BRS service documentation.
Staff report various levels of feeling comfortable going to management with concerns as well as mixed feedback about issues getting resolved or
not. Staff expressed a desire to have the program manager be more involved on the floor on a regular basis, especially during times of staff
changes, training, new client intakes and during times when client behaviors are challenging to manage.
5 of 6 | P a g e

Observations
The facility is an aging building, was originally built as a house, has original or aging bathrooms and some areas appear more worn down. The
agency works at keeping it maintained and clean. A couple maintenance issues are noted above in "New Findings". Youth bedrooms were
observed and were relatively clean and tidy. Food was observed in the cupboards and in refrigerators and freezers. The walk-through consisted
of the classroom, and all rooms, bathrooms, and common areas on the first and second floor of the residential side of the building. It was smokey
outside due to wildfires, so the youth were inside finishing up breakfast and then in the living room either watching tv or playing video games.
Staff had a scheduled training (in-person and virtual) soon after this licensor arrived, and accommodations were made to continue the
unannounced visit.