facility_name: Parry Center

summary: License Renewals - 22 findings

raw_content:
Licensed Child Caring Agency Site Visit Report
Residential Care
Licensee: Trillium Family Services Date of site visit: August 24-25, 2021
Executive Director: Kim Scott Licensing Coordinator: Todd Cooley
Board Chairperson: Eric Larsen
Other Regulatory or Accrediting Agencies: OHA
Program Compliance: The program was found to be compliant or will be compliant with OAR 413-215-0001 to 413-215-0131, Licensing Umbrella
Rules, and OAR 413-215-0501 to 413-215-0586, Licensing Residential Care Agencies Rules. Personnel records were reviewed and compliance
with required background checks was documented for employees in all programs.
Program Description(s): Serve children and adolescents, typically ages 5 – 17 at Parry Center for Children (PCC) and typically ages 12 – 17 at
the Children’s Farm Home (CFH), who are struggling with mental health challenges and are in need of 24-hour residential treatment. Provide secure
and nurturing healing environment with locked facility, access to fenced and open recreation areas, therapeutic activities aimed at increasing social
and emotional well-being, opportunities for home visits and community outings if appropriate. 24-hour supervision and intervention by trained staff
and 24-hour crisis support.
Sender House young adult independent living group home is a voluntary community based residential home. It serves youth with significant mental
health concerns that are being transitioned out of or being diverted from a hospital, residential, corrections, or foster care system. The program is
designed to help young people transition into adulthood by meeting their developmental, psychosocial, and physical needs as emerging adults with
significant mental health needs.
Program type and services: On-site services include psychologist and medical physicianfor additional assessment, as needed, medication
management with an assigned child psychiatrist, school instruction facilitated by licensed Public School teachers in our on-site school building
during school year, individual, family, and group counseling utilizing evidence-based interventions such as DBT (Dialectical Behavior Therapy) and
CPS (Collaborative Problem Solving), targeting healthy coping strategies and community/home success, and nursing services.
Subacute Treatment offers brief and intensive on-site psychiatric services that stabilize a young person after a significant emotional or behavioral
incident with the goal of achieving behavioral and mental health stabilization in order to prepare each child for the next phase of care. Subacute
services provide more intensive care than what is offered through Trillium’s Psychiatric Residential Treatment Services.
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 03/25/2021)
The Secure Children’s Inpatient Program (SCIP) and the Secure Adolescent Inpatient Program (SAIP) are designed for children and adolescents
who need longer term support and intense therapy services. Trillium is the only provider of Secure Inpatient treatment for children and adolescents
in Oregon. This service is considered to be a state hospital level of care and therefore all referrals must come through the state’s Health Systems
Division. Children participate in individual and family therapy, therapeutic skills groups in the milieu, and school in a contained classroom. This
program is highly supervised due to the intensity of the children’s needs.
Sender House utilizes a client centered and strength-cased approach. The clinical team incorporates a very positive and collaborative engagement
process, with trauma informed care, collaborative problem solving, motivational interviewing, leading interventions and supports. The clients have
24-hour mental health supports with a minimum of 2-4 hours a day of independent living skills training from a QMHA qualified staff. All clients work
with Linn County Mental Health for therapy and psychiatric services.
Capacity and Age Range:
PCC – 48 ages 5-17
CFH – 70 ages 5-17
Sender House – 4 ages 17-24 (licensed for ages 17-20)
Funding sources:
For all programs: OHA, OYA, OHP (all CCOs) and private insurance
Contracts and sources for referrals: For all programs
Contracts:
 CareOregon (Columbia Pacific CCO, Jackson Care Connect)
 CareOregon (Health Share of Oregon)
 Cascade Health Alliance
 GOBHI (Eastern Oregon CCO)
 InterCommunity Health Network CCO
 Options for Southern Oregon (AllCare Josephine, Jackson and Douglas counties)
 PacificSource Community Solutions
 SW Oregon IPA (Advanced Health CCO (Western Oregon Advanced Health))
 Trillium Community Health Plan
 Umpqua Health Alliance
 Yamhill County Care Organization
Referrals:
 Hospitals
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 Emergency departments
 Outpatient treatment teams (therapist, psychiatrist, pediatrician, DD services)
 CCO care coordinators
 County Wraparound facilitators
 Commercial insurance companies
 Oregon Youth Authority
 Other residential providers
 Direct contact from family/guardian
 Direct contact from DHS caseworker
 Internal referral from other levels of TFS care
Average length of stay based on program provided information:
PCC – SIP 274 days, PRTS 65 days, Subacute 31 days
CFH – SIP 166 days, PRTS 165 days, Subacute 43 days
Sender House – 575 days
Average daily population served based on program provided information:
PCC – 53
CFH – 70
Sender House – 4
Number of children served annually based on program provided information:
PCC – 250
CFH – 350
Sender House – 6
Use of seclusion or restraint:
PCC – Use of seclusion and NCI
CFH – Use of seclusion and NCI
Sender House – No restraint or seclusion, NCI trained
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Interviews, Observations:
PCC: A walkthrough of spaces and common areas used by clients was conducted. Overall, the facility was clean and in good repair. There was
noticeable black substance presumed to be mold or mildew present in shower areas of two of the units as noted in the report. Three client
interviews were also conducted as part of this process.
Client interviews: First of three clients stated they had been at the program for almost two months. During their stay they said they had plenty of
opportunities to talk with family on the phone but liked to see them in person more. They have weekly meetings with their therapist and have lots of
favorite staff they are comfortable talking with if they have any concerns. School was currently on break, but the client stated school was okay.
They do lots of activities and their favorites were Minecraft and ball tag. Client said the food was good and favorites were the nachos and pizza.
There are plenty of snacks available and they don’t ever get hungry. Client enjoys daily groups and they enjoyed the relaxation group best. They
feel safe in the program and have staff they can talk to at any time if they are not feeling safe.
Client two has been at the program for about a month and stated they feel safe on the unit. Client identified Abe, Remy and Apollo as their favorite
staff and can talk to them about any concerns they have. They said they are fed plenty of food and particularly enjoy the Wednesday snack of an
ice cream bar. Client sees their therapists a couple of times a week. They said they regularly receive visits from family and have a chance to call
them every day. Their favorite activities are riding bikes and being able to go to MOD, which is a video game place. There was nothing they could
think of to change, and they reiterated their love of Wednesday snack and going to MOD.
Client three has been at the program around three months. Client stated they see their therapist twice a week. They also said they get to see their
mother every Wednesday and make daily phone calls. Client said school was fun, but they were not doing a good job of keeping up on credits.
They said they get to go outside for activities every day and also play a lot of cards. When asked about food they said some is really good and
some sucks but overall they could do a better job. They always were offered enough food and snacks were available. Client stated staff were nice.
Client also relayed when they are anxious, they sometimes have personal issues with staff because their faces change and appear to look like their
bio-mom. Client said Parry Center does a really good job with having advocates. Client stated they are assigned two staff advocates (front and
back end of each week) who do a really great job of checking in with youth. They said it makes them feel very supported knowing they have these
staff that are there for them specifically.
CFH: A walkthrough of spaces and common areas used by clients was conducted. Overall, the facility was clean and in good repair. Cottages are
on a schedule for updates, with the Powers Cottage almost done. Mallett is one of the older cottages and is in queue for updates and also has an
ongoing, intermittent foul odor issue in the basement space. There have been several investigations into the source of the odor and some success
at remediating the odor, but then it returns. Work is still ongoing on this problem.
Three clients were also interviewed at Children’s Farm Home and came from various cottages. The first client has been at the program for over a
year. They feel safe and comfortable in the program and attend daily groups. They meet with Dr. Adler once a week and their therapist 2-3 times a
week. Client couldn’t comment on the overall quality of food as they were currently on a special diet. School is their favorite thing, and they are
currently in 10th grade and doing very well. They like to hang out at the barn and felt there were enough different activities for them to participate in.
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In their cottage they have speakers in their bedrooms that can be used for phone calls. They said the speakers are terrible and the system for
phone calls doesn’t work very well. They didn’t like that in SAIP they were not allowed any clothes in their room. They understood not having
shoelaces but didn’t like they could not have any of their clothes either. Client stated they have access to all of their clothes and will pick out what
they want to wear from their personal items’ locker. Client said staff did a really good job with their interventions when youth get escalated.
The second client interviewed has been at the program for 20 months. They stated they have felt safe and comfortable during their time there.
Client said the food was terrible, but there are plenty of snacks and alternatives to keep them from being hungry. They have weekly visits from their
dad and have daily phone calls with him. Client really enjoys riding bikes and likes fixing them even better. The program has accommodated their
desire to fix bikes by providing time, tools, and assistance in repairing campus bicycles. Client stated CFH could do better at communication
between staff on different shifts. Sometimes there are inconsistent enforcement of rules and staff will tell youth different things depending on the
shift. Client also stated they need to do better at retaining staff because it is hard to connect with a staff and then they leave and there are always
new faces. They said the program does a really good job with the daily groups and enjoys participating in them.
The last client interviewed has been in the program around three months. They stated they feel mostly safe themselves but had several concerns
about other clients. They stated personally they have issues around receiving PRN medication where staff say they will get it, but actually do it
maybe 50% of the time. Client will ask staff for a PRN and staff don’t get it when they say they will. They also said staff were inconsistent with
boards and they witnessed a staff who was new to the cottage provide a peer with pens and make-up when they were not supposed to. Another
peer is lactose intolerant and still allowed to consume lactose if they want to. Client also stated they have seen holds that seem pretty inhumane
but wouldn’t elaborate on what made them inhumane. Client stated they get weekly visits from family and make calls daily. They said snacks are
always available and the food is decent. Client felt most of the staff were very kind and caring.
The above concerns noted by the client were addressed with management and most of the items observed were due to the clients perspective and
not having all of the information about their peers treatment plans and history.
Sender: A walkthrough of the house and outbuildings was conducted, along with interviews of two clients. The program was clean, in good repair,
and had a fully stocked kitchen. The two clients interviewed had been at the program for four months and 8 months. Both clients were over 18 and
were not extremely talkative. Both said they really liked the program, felt safe and the food was good. They said the staff were very encouraging
and were helping with resumes and job searches. One of the clients was actively looking for work and was on their way to drop off
resumes/applications as soon as we finished talking. The other was currently working on school as a sophomore at the community college with a
focus on psychology and the desire to help others. They also were working on a resume and planned to find a part time job. There were no
complaints or feedback on things the program could do to improve.
Program Strengths per program:
PCC – We have added Program Supervisors to the PCC campus, to provide additional support and training to our milieu, especially in
the swing time hours. We also add a Campus Operations manager, to support the Campus Ops. As far as successes, I would echo
what Jamie wrote. We have continued to serve children in PRTS, Subacute, SCIP, and Day Treatment, throughout the pandemic, and
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managed through power outages, heat waves, and fires. At this point, we also have a full management team for the Parry Center, with
every Clinical Program Manager filled, after having to restructure with a Program Manager for the past year, due to an inability to recruit
a Clinician. We continue to develop a very cohesive leadership team!
West 1
West 1 has adapted treatment structure and therapeutic interventions to accommodate for extraordinary circumstances brought on by
the COVID-19 pandemic (i.e. addressing the impact of increased isolation on adolescents).
West 2
Staff demonstrate excellence in rapport building and supporting clients in identifying skills that attend to their trauma histories. Staff have
worked to understand and implement agency policy with consistency. Staff have developed positive inter-team communication skills.
North 1
Consistent focus on trauma-informed care and individualized treatment planning, practice of experiential, sensory-oriented, creative
groups and experiences throughout each week, family-centered and inclusive treatment approach
North 2
The program has done well with managing a high level of physical acuity (aggression) safely, with low instances of injury to staff and
clients. The culture has been strong, in terms of retaining staff despite the fast paced and high energy environment. As such, we benefited
from strong staffing during the pandemic, and navigating safely through the wildfires, a COVID outbreak, snowstorms, and recently the
heat wave. There have been several major success stories with some of our youngest Secure Inpatient clients, who have been able to
return to community placements primarily with their families, when initially upon referral it was thought that they would not be able to
return home. The program has come to have a heavy focus on integrating the parent(s) into treatment.
CFH – We are really proud of a lot we were able to do, as a campus, even in the midst of the pandemic and significant staffing shortage.
The leadership team has continually worked to maintain hope for the future, planning for the future and engaging in change that really
gets us to where we want to be, rather than staying stuck in the crisis. We also continued to try to creatively engage our youth within the
realms of our COVID guidelines and were able to successfully do at least two campus wide 5k events. We were able to continue working
with different universities to offer in person internships and had our first round of a bachelor’s level Intern program where we had 8 interns
during spring term, 7 who were hired as Skills Trainers at the end of their internship. As a leadership team, we made some thoughtful
and hard decisions to consolidate one program and move the remaining four programs to nine clients, each, in order to best and most
safely serve our youth and staff with the staffing shortage.
Cummings:
Adjusted to the world of Covid- 19 and all of the limitations on outings and activities and doctor visits, wrap meetings, treatment reviews
and at times family visits via Zoom. Solid working relationship of the Cummings Clinical Team with primary psychiatrist Dr Kyle Bernheim,
and Clinical Program Manager Tina Hendrickson and the Child and Family Therapists working with clients in the unit. Cummings was
able to flex to temporarily living in the Powers building to allow for some physical plan upgrades of new flooring and paint in many areas.
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The Cummings program was able to absorb clients and staff when the decision was made to close the FE building. We are continuing to
be a blended unit of generally 1/3 SAIP and 2/3 PRTS and Subacute, thus being a step down from SAIP (Redwood and Sequoia) and a
step up in securing when needed for Mallett.
The Program Supervisor Model is serving the Cummings well by adding some consistency across all teams in many areas from how
things are managed.
Mallet:
Our strengths are that we are working hard to pull DBT skills together with attachment focused treatment that uses a trauma informed
lens to make sure that we are meeting our clients where they are functioning. Our leadership team (CPM, therapists and program
supervisor) is a cohesive machine working to support staff and clients. This is important to make sure that everyone is getting what they
need. We also work with our staff from the lens of the Brene Brown book Dare to Lead to support building connection and working to
retain good staff. Our staff are knowledgeable and creative. They care deeply about the kids that they work with. The staff on the Mallett
unit work well together and are willing to support the other units on campus.
Powers:
Since the new program supervisor position was developed – the Powers program supervisor have been working on facilitating additional
support to staff, especially in areas of new hires, team development and assisting with growth and change conversations; increasing staff
Relias compliance; and more consistent facilitation of scheduled individual and group supervision. With Powers still closed due to low
staffing resources, the time has allowed for more focus on milieu programming and development through EBP lens.
Redwood:
We are adjusting to the structure of the new building and some of the differences in milieu management with split milieus. Since the new
program supervisor position was developed – the program supervisors at Redwood have been working on facilitating additional group
trainings, increasing staff Relias compliance, and more consistent facilitation of scheduled individual and group supervision. We have
also been working on more consistent structure around PODs and skills trainer led groups, including assigning staff for each shift and
working with staff to order supplies for PODs in advance and pre-plan activities a month ahead.
Sequoia:
We have been rolling out our Onyx Programming in the last year to provide increase structure for clients needing shorter chunks of time
between transitions and more mindfulness centered activities. We have consistent prescheduled supervisions with our Program
Supervisor role; since the rollout, we have seen an increase in prescheduled and predictable individual supervisions for our employees
as a result. We are also providing time for planning groups and activities; each team gets an hour of time biweekly to plan for upcoming
groups and activities. We have seen this be helpful in many ways, including having quite a bit of activities supplies on hand to keep
clients engaged.
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Sender House – Program continues to be a leader within the young adult treatment system and improve on treatment outcomes and
effectiveness with stabilizing and improving client’s mental health functioning, building resiliency, and assisting client’s with moving out
into community living on their own. Staff’s growth with their clinical skills with this particular population and treatment philosophy has been
exciting to watch, and it is very evident with client’s success. This is a very effective program.
Program Challenges per program: Agency wide our programs are generally operating at 100% of physical capacity, at all levels of care. We
maintain pending referral lists for all levels of care and age groups, and for day treatment, residential and subacute programs children may wait up
to 4 weeks for admission availability. Due to the ongoing nationwide staff shortages in psychiatry, nursing, direct care, and qualified mental health
providers we have had to keep our beds lower to continue to meet the needs of our clients and families. Additionally, with the ongoing COVID
pandemic resources are further stressed, and refusal to vaccinate has led to ongoing challenges, as well as overall staff burnout. Furthermore, we
continue to see rising acuity in referrals and limited resources for children waiting for or discharging from care.
PCC
North 1
50-60% staffing for months and continuing to struggle with hiring any new staff; team as a whole has been in significant staffing transition and
attempting to train supervisors, skills trainers, and a new therapist at the same time; requiring a lot of support from the greater campus to support
crisis interventions
North 2
Despite strong staffing through most of the pandemic, the staffing crisis in 2021 has had an impact and several seasoned staff have left recently,
requiring an extensive focus on training and developing a new work force. Staff fear and anxiety levels were high during the pandemic, mostly
concerning the changing COVID protocols and varying degrees of personal fear of COVID infection. School has been a major challenge since the
pandemic, as there have also been numerous iterations of distanced learning, most of which has had a major impact on our young learners and
their academic progress. Also, there has been issues related to a sense of divide between the leadership team and some staff, and a major focus
within the team has been promoting safety, democracy, and open communication.
West 1
We are continuing to adjust to our new EHR to make sure that we are implementing best practice and meeting top quality standards through our
documentation. Ongoing training will support us in meeting this goal.
West 2
Continue to work on how to avoid reinforcing maladaptive behaviors. Staff continue to focus on developing strategies to support staff with their
work/life balance.
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CFH
Cummings:
We are working on increasing staff adherence to unit rules and structure supported by having new STSs and STs in the program. Increasing
opportunities for connections with CFTs and STSs and STs to support clients with their therapeutic goals. Building in more opportunities for
mastery, to have as a genuine goal for each client to be striving toward improving or learning skills that are a bit of reach and that they enjoy, like
guitar or gardening or art.
Mallet:
Our areas for growth are in continuing to work with our staff to understand that feedback is an important part of the work that we do. This means
that feedback can be given to management and clients can give us feedback. We would like to help our staff learn that constructive
criticism/feedback/suggestions are not a personal attack but rather to help them gain insight so that they can continue to grow and change. There
has been a fear about change and concerns about scarcity of resources that can cause staff to feel like they don't have what they need, and we are
still working to figure out how to best support them.
Powers: Not currently utilized
We continue to work on ordering supplies and organizing the new space. With the new role of program supervisor, they are still working on how to
most effectively target areas to increase staff retention, staff training, and staff development.
Redwood:
With the new program supervisor role and the change in the schedules of these supervisors, they are still working on how to meet the group
supervision requirements most effectively for those they supervise. We are also continuing to work on organizing the new space and to work with
staff on documentation in IRs and shift notes.
Sequoia:
Some areas of focus of us are: Facilitation of strong programming; we are currently working with our employees on how to run effective
groups and activities to improve programming. Cleanliness and organization of staff areas; we have been working on improving our
organization of staff areas to reduce clutter and make it easier to access supplies and necessities. Documentation of Incident Reports;
we are doing a lot of follow up with individuals on how to write proper and thorough incident reports using the ABIO format and including
enough information.
Sender House – The continued navigation of state Medicaid system and partners to ensure program stays financially viable. Trying to grow
services to another program to add young adult beds to state system to help manage referral overflow.
Changes that have occurred in the last 2 years per program: Agency wide, we restructured a good portion of our residential staffing
model to address the trends we have experienced and researched as it relates to recruitment and retention. This includes moving
some of the scheduled positions on each of the residential programs to be filled by campus operations on calls (approximately 30% of
the shift), rather than having all positions filled with set-scheduled skills trainers. We also restructured the STS position, removing the
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Skills Trainer supervisory duties and having it focus specifically on the facilitation of the day to day shift programming. We also created
the Program Supervisor position, who is responsible for the direct supervision of the Skills Trainers and STSs and is supervised by the
Program Managers. Lastly, we have added the position of Med Aide, who will focus on medication administration in all of the programs,
including SIP.
CFH – Powers and Francis Elizabeth (FE) cottages are not currently housing any youth.
Lawsuits: No
Grievances and complaints filed in the last two years: Grievances were provided and are on file with CCLP.
Corrective Actions and Timeframes: Please submit the following to verify compliance.
Within 45 days of receipt of this report Trillium Family Services 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 Todd Cooley, todd.cooley@dhsoha.state.or.us or sent by regular mail to the following address:
Department of Human Services, Children’s Care Licensing Program
Attn: Todd Cooley
201 High St SE, Suite 500
Salem, OR 97301
Exceptions: Bedroom window egress exception on file with CCLP
Changes in License: Powers and FE cottages have not served youth in over 6 months and will be removed from the license. Redwood (new
construction) is added. Powers, FE and Redwood are all on the CFH campus.
Summary of Review
Program and Services Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0011(2) Completed
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Program and services are in scope of license
X
Governance of the Agency Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0021 Completed
(1)(a) Minimum of 5 board members X
(2)(f) Formally evaluate the exec. Director’s
X
performance annually
(2)(g) Approves annual budget X
(2)(h) Obtain and review an annual
independent financial review or audit of X
financial records.
(2)(k) Written quality improvement program X
(2)(l) Meeting minutes X
Executive Director or Program Director Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0021 Completed
(3)(a) knowledge of requirements for
providing care and treatment appropriate to X
programs
(3)(g) Approval from BCU X
Discipline, Behavior Management, and Corrective Action
Yes No N/A Corrective Actions/Comments
Suicide Prevention 413-215-0076 Completed
(3) Agency uses appropriate and positive
methods of behavior management and
X
nationally recognized non-violent crisis
intervention
(3)(b)(C) Agency does not use chemical and
mechanical restraint (excluding medically X
necessary devices/prescriptions)
(3)(c) Agency uses appropriate time-out
rooms (adequate space, heat, light and
ventilation and is not capable of locking) and X
documents use in child’s record when
applicable
(3)(e) Agency uses seclusion
X
appropriately/consistent with policy
(4) Agency has adequate plan in place to
X
respond to suicidal behavior/warning signs
Contractors (if applicable) Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0061(6) Completed
(a) Agency ensures the contractor meets the
requirements of this rule and Chapter 413 X
division 215
(b)(B) Contract includes the following:
X
(i) Services provided
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(ii) Contractor fees
(iii) Disclosure of information from contractor
to agency
(iv) Lines of authority
(v) Adherence to rules, including background
check
(vi) Any liability of the agency for acts of the
contractor, rights of indemnity and limitations
on liability
Supplemental Information Provided by Corrective Action
Yes No N/A Corrective Actions/Comments
CCA Completed
Documents as indicated on the form titled - Not all Certificates of Occupancy have been received
“Renewal Licensing Required Documents” - PCC does not have a current Environmental Health
Inspection
X
- No conflict of interest policy meeting requirements of
licensing rule
Documents as indicated on form titled
“Required Financial Documents and X
Information”
All required policies and procedures as
X
identified in the “Umbrella Rules”
All required policies and procedures as
X
identified in “Agency Type Specific Rules”
Physical Plant Corrective Action
Yes No N/A Corrective Actions/Comments
Completed
413-215-0046(3)(a) Foster Rights Posted (if
X
children in DHS custody)
413-215-0051(1) Sufficient safe space,
X
equipment, and office equipment
413-215-0091(12) License is posted in
X
common area at each facility
413-215-0001(5)(d), 0516(4(a)(I) & 0521(1)
X
Adequate furnishings and personal items
413-215-0511(2)(a) &(c) Buildings are
X
smoke free, clean and in good repair
413-215-0511(2)(d) Rooms are free of
X
harmful drafts, odors, and excessive noise
413-215-0511(2)(e) Rooms are adequate in
X
size and arrangement
413-215-0511(2)(f) System provides a
continuous supply of hot and cold water to X
taps located throughout the facility
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413-215-0511(2)(h) Building is well
ventilated and room temperature is within a X
normal comfort range
413-215-0516(1) All parts of the facility
X
ensure the safety of children
Room and Space Requirements Corrective Action
Yes No N/A Corrective Actions/Comments
Bedrooms 413-215-0516(3) Completed
(a) Adequate furnishings and personal items X
(b) Separate from rooms used for dining,
X
living, laundry, kitchen, and storage
(c) Outside room with window allowing
X
egress from building
(d) Ceiling at least 90 inches X
(e) Minimum 60 SF per bed X
(f) No more than 25 if dorm style X
(g) Permanently wired fixtures X
(h) Window covering X
(i) Beds are 3 feet apart and maintained to
X
ensure safety
Room and Space Requirements Corrective Action
Yes No N/A Corrective Actions/Comments
Bathrooms 413-215-0516(4) Completed
(a)(A)&(B) 1:8 ratio for toilets and sinks X
(a)(D) Hot and cold running water, soap, and
X
approved hand drying options
(a)(E) 1:10 ratio for shower or bathtub X
PCC – Black mold or mildew present in West 1 and West 2
(a)(E) Individual privacy X
shower areas
(a)(F) Window covering X
(a)(G) Permanently wired fixtures X
CFH – Black mold or mildew present in Sequoia bathroom
(a)(H) Adequate ventilation X
(b)&(c) Wooden racks on floors are
prohibited and impervious shower mats are X
disinfected & dried daily
Room and Space Requirements Corrective Action
Yes No N/A Corrective Actions/Comments
Kitchen 413-215-0516(6) Completed
(a) Used exclusively for storage, food
preparation, dish washing and activities X
related to eating
(b) Walls, floors are easily cleanable X
(c) Equipment and utensils are easily
X
cleanable, durable, nontoxic, and kept clean
(e) Equipment is easy to clean beneath,
X
between and behind
Room and Space Requirements Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0516 Completed
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(2) There is a separate living room or lounge
X
area – 15 SF minimum per child
(5) There is a separate dining room with
capacity for ½ of children in care and 15 SF X
per child in care
(7) Laundry is separate from living areas,
X
kitchen and dining
(8) Separate storage areas are provided for
food, kitchen supplies, utensils, clean linens,
soiled linens and clothing, cleaning supplies X
and equip, poisons, chemicals, outdoor
recreational and maintenance equipment
(9) Outdoor activity area is protected from
vehicles and other hazards and of a size and
X
availability appropriate to the age and needs
of children in care
(11) & 413-215-0076(3)(c)(C)Time out rooms
have adequate space, heat, light and X
ventilation and is not capable of locking
Furnishings and Personal Items Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0521 Completed
(1) There is a bed with frame, clean mattress
and pillow and personal storage (dresser, X
closet)
(2) Linens are in good repair. There is a
waterproof mattress cover or mattress.
X
Linens are appropriate and towels and
washcloths are provided
(3) Bedding is changed weekly or when
X
soiled
(4)&(5) Personal hygiene supplies and
X
appropriate clothing are provided
Food Services Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0536(1)&(2) Completed
(1)(a) Meals are arranged daily, consistent
with normal mealtimes that occur during the X
hours of operation
(1)(b) Menus are prepared in advance in
accordance with USDA guidelines, provide a
X
variety of foods and are adjusted for
seasonal changes.
(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
X
sanitary manner
14
(2)(c) & (d) Food products are obtained from
commercial suppliers (exception of fruits &
vegetables), unpasteurized juice is X
prohibited, and only Grade A pasteurized
and fortified milk in appropriate container.
Safety Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0541 Completed
(2)(a) Written emergency plan X
(2)(b) Telephone numbers for local police
X
and fire are posted near all telephones
(2)(c) Operative flashlights sufficient in
X
number are readily available to staff
(3)(a) Evacuation drill occurs monthly under
- Each office had an emergency kit and at least one
varying conditions, is retained 2 yrs and
operational flashlight. However, many of the flashlights
contains;
present and easily accessible were not operational and
(A) identify of person conducting drill
needed the batteries replaced. For comment only, not a
(B) date & time
corrective action.
(C) notification method X
(D) staff participating
(E) # of children & staff evacuated
(F) special conditions simulated
(G) problems encountered
(H) time to complete
Safety – Transportation Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0541 Completed
(5)(b) Vehicle has insurance policy, is smoke
free, safe operating condition, and has first X
aid kit and fire extinguisher 2-A:10-BC
Medication Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0551 Completed
(3)&(7)(e) Medications have a prescription
and are stored in the original container with X
prescription label
(4)&(5) Herbal supplements and remedies,
medical treatments, special diets, physical
therapy, physical aides or limitations have a X
written order signed by a physician or
qualified medical professional.
(7)(c) Medications are inaccessible to
X
children
(8) Medications are disposed in accordance
X
with state and federal law
(9) Written record of the disposal of
medications is maintained and includes: X
(a) description and amount
15
(b) name
(c) reason
(d) method
(e) staff & witness signature
(10) Written record of the administration of
medication includes:
(a) name
(b) description
(c) dates and times
(d) missed doses X
(e) medication disposed
(f) method of administration
(g) ID of person administering
(h) possible adverse reactions
(i) medication taken outside facility
Extracurricular, Enrichment, Cultural &
Corrective Action
Social Activities Yes No N/A Corrective Actions/Comments
Completed
413-215-0554
(2) Children have ongoing opportunities to
participate in at least one age-appropriate or X
developmentally appropriate activity
Minimum Staffing Requirements Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0561 Completed
(1)&(2) Supervision is adequate for the type
of program, location, age and type of
children, ability of supervisor to respond,
electronic back-up systems.
Minimum ratios are maintained:
Under 30 months of age: 1:4 X
30 months to ˃ 6 yrs or non-ambulatory: 1:6
PCC and CFH – Only program managers and very few
Ages 6 and older: 1:7
others had received Prudent Parent training. This was not
sufficient to ensure there was always an on-site person
Overnight (staff awake)
trained in applying the Prudent Parent standard.
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
Separation of Residents Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0566 Completed
16
(1) Children are in separate bedrooms than
adults, unless parent and child, or there is
X
written approval from guardian/parent and
licensing coordinator
(2) There is adequate supervision of children
if both males and females are served by the X
program
Personnel Files Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0061 Completed
Staff Name/Position X
(3)(g) Date of Hire X
(3)(a) record of education, training and
X
previous employment
(1)(b) & (3)(b) reference checks completed
X
and documented
(1)(a) & (3)(c) Background check completed
and documented X Sender - missing one performance evaluation
(3)(d) Annual performance evaluations X
(3)(f) Record of personnel actions X
(3)(g) Termination date, reason for
X
termination
(3)(h) Current job description (1)(c)
Employee meets minimum qualifications X
stated in current job description
New Employee Orientation – Umbrella
Corrective Action
Requirements (30 days) Yes No N/A Corrective Actions/Comments
Completed
413-215-0061(4)
(a) Agency policies and procedures X
(b) Ethical and professional guidelines X
(c) Organizational lines of authority X
(d) Attributes of population served X
(e) & (5)(a) to (c) Mandatory reporting that
includes:
(a) legal definition of child abuse ORS
X
419B.005, Oregon Laws 2016, chapter 106,
section 36
(b) legal responsibility to immediately report
17
(c) legal responsibility to report is personal to
the employee
(f) Privacy laws X
(g) Emergency procedures X
New Employee Orientation – Residential
Corrective Action
(30 days) Yes No N/A Corrective Actions/Comments
Completed
413-215-0556
(1)(a) Discipline and behavior management
including de-escalation, crisis prevention,
positive behavior management, and X
disciplinary techniques that are non-punitive
in nature
(1)(b) Restraint and seclusion (if applicable) X
Ongoing Training Corrective Action
Yes No N/A Corrective Actions/Comments
Completed
413-215-0536(2)(b) Employees who handle
food served to children have a valid food X
handler’s card
413-215-0541(5)(a) Employees transporting
children have: current driver’s license,
insurance, trained in emergency procedures X
and behavior management, and training for
15+ passenger vans if applicable)
413-215-0556(2)(a) Environmental
X
emergencies
413-215-0556(2)(b) Universal Precautions X
413-215-0556(2)(c) Discipline and Behavior PCC - One staff had an expired CPR certification
X
Management
413-215-0556(3) Staff providing direct care
Sender - Only 2020 Prudent Parent documented for all staff
must maintain current CPR/First Aid X
certification
413-215-0556(4) Designated staff authorized
to apply reasonable and prudent parent
X
standard are trained in application of the
standard
413-215-0061(5) Mandatory reporting
(annually) that includes:
(a) legal definition of child abuse ORS
X
419B.005, Oregon Laws 2016, chapter 106,
section 36
(b) legal responsibility to immediately report
18
(c) legal responsibility to report is personal to
the employee
Comments:
Children’s Records Corrective Action
Yes No N/A Corrective Actions/Comments
Completed
Health Services
413-215-0546
(2) Medical history obtained within 30 days
(significant findings, current immunizations,
history of surgical procedures-health issues- X
injuries, allergies, dental, vision, hearing,
behavioral health, and physician orders)
(2)(e) Documentation of age appropriate
instruction – pregnancy prevention, nutrition,
prevention of HIV & AIDS, and prevention X
and treatment of sexually transmitted
disease
(4)(a) to (f) Medical exams (3 in first year of
life, 2,4,6,9,14) X
Consents Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0576(1) Completed
(a) Provide routine and emergency medical
X
care
(b) Use the discipline and behavior
X
management system
(c) Use restraint or seclusion (if applicable).
Must specify the reasons for the intervention X PCC – 2 of 5 files were missing documentation of all
and how staff are trained and supervised consents
(d) Restrict contact with persons outside of
X CFH - 2 of 5 files were missing documentation of all consents
the agency
(e) Allow access as defined in 413-215-0091
X
& 0101
(f) Impose a dress code X
(g) Apply the reasonable and prudent parent
X
standard
19
Disclosures
Corrective Action
413-215-0576(2) Parent/guardian has Yes No N/A Corrective Actions/Comments
Completed
acknowledged in writing:
(a) Information regarding personal or room
searches and protocols for confiscation of X PCC – 2 of 5 files were missing documentation of all
contraband disclosures
(b) Statement of Rights of Children and
X
Parents/Guardians CFH - 2 of 5 files were missing documentation of all
(c) Any policies and procedures upon disclosures
X
request
Authorizations Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0576(3) Completed
(a) Disclose or exchange information with
X PCC – 2 of 5 files were missing documentation of activity
others
specific authorizations
(b) Child specific visitors X
(c) Visitation resources are pre-approved X CFH – 3 of 5 files were missing authorization to disclose or
exchange info with others and activity specific authorization.
(d) Activity specific authorizations are pre-
1 of 5 files did not have documentation for
approved to allow children to participate in
authorization of child specific visitors or pre-approval of
potentially hazardous activities, including but X
visitation resources.
not limited to using motorized yard
equipment, swimming, and horseback riding.
Information about Children in Care
Corrective Action
413-215-0581(1) Summary sheet contains Yes No N/A Corrective Actions/Comments
Completed
the following:
(a)The name, gender, date of birth, religious
X
preference, and previous address
(b) Name and location of previous and
X
current school
(c) Date of admission X
(d) Legal custody X
(e) The name, address, and telephone
number of:
(A) The child in care's parents.
(B) The child in care's legal guardian, if
different than the parents, and a copy of
X
the document that provides for his or her
authority over the child in care.
(C) Other persons significant to child
(D) Other professionals to be involved in
service planning (if applicable)
Service Planning Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0581(2) Completed
20
(b) Intake document is completed the date
child accepted into care (emergency X
placement 48 hours)
(d) Assessment is completed within 30 days
and contains relevant historical info., current
behavioral observations, identified need for X
services, and how agency will provide
services
Sender not reviewed quarterly
(e) (A)&(B) Service plan within 60 days
(parent, guardian and child actively
involved). Describes how child’s issues will X
be addressed, anticipated outcomes and
reviewed by child and guardian/parent.
(e)(C)&(D) Service plan is reviewed quarterly
and revised when information indicates other X
services should be provided
Case Management Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0581(3) Completed
(a) Services are documented, progress
X
toward achieving goals is tracked
(b)-(d) discharge planning and instructions X
(f) Incident Reports X
Financial Records Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0581(4) Completed
Records contain date, amount, source,
X
purpose, signatures
Personal Possessions Records Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0581(5) Completed
CFH – 2 of 5 files had no documentation of individual written
Individual written inventory of all personal
inventories
possessions is maintained and updated as X
needed
Sender – No documentation of individual written inventories
Records and Documentation Corrective Action
Yes No N/A Corrective Actions/Comments
413-215-0071 Completed
(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.
21
(7) Permanent registry for each child
includes:
Name
Gender
X
Birth date
Names, addresses of parents or guardians
Dates of admission
Placement upon discharge
Comments:
9-29-2021
Licensing Coordinator’s Signature: ________________________ Date: ___________________
9-27-2021
Manager Review: ______________________________________ Date: __________________
22

program_name: Parry Center

facility_type: Residential Care

board_chairperson: Eric Larsen

other_regulatory_agencies: OHA

program_description:
Serve children and adolescents, typically ages 5 - 17 at Parry Center for Children (PCC) and typically ages 12 - 17 at
the Children's Farm Home (CFH), who are struggling with mental health challenges and are in need of 24-hour residential treatment. Provide secure
and nurturing healing environment with locked facility, access to fenced and open recreation areas, therapeutic activities aimed at increasing social
and emotional well-being, opportunities for home visits and community outings if appropriate. 24-hour supervision and intervention by trained staff
and 24-hour crisis support.
Sender House young adult independent living group home is a voluntary community based residential home. It serves youth with significant mental
health concerns that are being transitioned out of or being diverted from a hospital, residential, corrections, or foster care system. The program is
designed to help young people transition into adulthood by meeting their developmental, psychosocial, and physical needs as emerging adults with
significant mental health needs.

program_services:
On-site services include psychologist and medical physicianfor additional assessment, as needed, medication
management with an assigned child psychiatrist, school instruction facilitated by licensed Public School teachers in our on-site school building
during school year, individual, family, and group counseling utilizing evidence-based interventions such as DBT (Dialectical Behavior Therapy) and
CPS (Collaborative Problem Solving), targeting healthy coping strategies and community/home success, and nursing services.
Subacute Treatment offers brief and intensive on-site psychiatric services that stabilize a young person after a significant emotional or behavioral
incident with the goal of achieving behavioral and mental health stabilization in order to prepare each child for the next phase of care. Subacute
services provide more intensive care than what is offered through Trillium's Psychiatric Residential Treatment Services.

The Secure Children's Inpatient Program (SCIP) and the Secure Adolescent Inpatient Program (SAIP) are designed for children and adolescents
who need longer term support and intense therapy services. Trillium is the only provider of Secure Inpatient treatment for children and adolescents
in Oregon. This service is considered to be a state hospital level of care and therefore all referrals must come through the state's Health Systems
Division. Children participate in individual and family therapy, therapeutic skills groups in the milieu, and school in a contained classroom. This
program is highly supervised due to the intensity of the children's needs.
Sender House utilizes a client centered and strength-cased approach. The clinical team incorporates a very positive and collaborative engagement
process, with trauma informed care, collaborative problem solving, motivational interviewing, leading interventions and supports. The clients have
24-hour mental health supports with a minimum of 2-4 hours a day of independent living skills training from a QMHA qualified staff. All clients work
with Linn County Mental Health for therapy and psychiatric services.

capacity_age_range: PCC - 48 ages 5-17 CFH - 70 ages 5-17 Sender House - 4 ages 17-24 (licensed for ages 17-20)

contracts_and_referrals:
For all programs
Contracts:
- CareOregon (Columbia Pacific CCO, Jackson Care Connect)
- CareOregon (Health Share of Oregon)
- Cascade Health Alliance
- GOBHI (Eastern Oregon CCO)
- InterCommunity Health Network CCO
- Options for Southern Oregon (AllCare Josephine, Jackson and Douglas counties)
- PacificSource Community Solutions
- SW Oregon IPA (Advanced Health CCO (Western Oregon Advanced Health))
- Trillium Community Health Plan
- Umpqua Health Alliance
- Yamhill County Care Organization
Referrals:
- Hospitals
2
- Emergency departments
- Outpatient treatment teams (therapist, psychiatrist, pediatrician, DD services)
- CCO care coordinators
- County Wraparound facilitators
- Commercial insurance companies
- Oregon Youth Authority
- Other residential providers
- Direct contact from family/guardian
- Direct contact from DHS caseworker
- Internal referral from other levels of TFS care

use_of_seclusion_or_restraint: PCC - Use of seclusion and NCI CFH - Use of seclusion and NCI Sender House - No restraint or seclusion, NCI trained 3

interviews_observations:
PCC: A walkthrough of spaces and common areas used by clients was conducted. Overall, the facility was clean and in good repair. There was
noticeable black substance presumed to be mold or mildew present in shower areas of two of the units as noted in the report. Three client
interviews were also conducted as part of this process.
Client interviews: First of three clients stated they had been at the program for almost two months. During their stay they said they had plenty of
opportunities to talk with family on the phone but liked to see them in person more. They have weekly meetings with their therapist and have lots of
favorite staff they are comfortable talking with if they have any concerns. School was currently on break, but the client stated school was okay.
They do lots of activities and their favorites were Minecraft and ball tag. Client said the food was good and favorites were the nachos and pizza.
There are plenty of snacks available and they don't ever get hungry. Client enjoys daily groups and they enjoyed the relaxation group best. They
feel safe in the program and have staff they can talk to at any time if they are not feeling safe.
Client two has been at the program for about a month and stated they feel safe on the unit. Client identified Abe, Remy and Apollo as their favorite
staff and can talk to them about any concerns they have. They said they are fed plenty of food and particularly enjoy the Wednesday snack of an
ice cream bar. Client sees their therapists a couple of times a week. They said they regularly receive visits from family and have a chance to call
them every day. Their favorite activities are riding bikes and being able to go to MOD, which is a video game place. There was nothing they could
think of to change, and they reiterated their love of Wednesday snack and going to MOD.
Client three has been at the program around three months. Client stated they see their therapist twice a week. They also said they get to see their
mother every Wednesday and make daily phone calls. Client said school was fun, but they were not doing a good job of keeping up on credits.
They said they get to go outside for activities every day and also play a lot of cards. When asked about food they said some is really good and
some sucks but overall they could do a better job. They always were offered enough food and snacks were available. Client stated staff were nice.
Client also relayed when they are anxious, they sometimes have personal issues with staff because their faces change and appear to look like their
bio-mom. Client said Parry Center does a really good job with having advocates. Client stated they are assigned two staff advocates (front and
back end of each week) who do a really great job of checking in with youth. They said it makes them feel very supported knowing they have these
staff that are there for them specifically.
CFH: A walkthrough of spaces and common areas used by clients was conducted. Overall, the facility was clean and in good repair. Cottages are
on a schedule for updates, with the Powers Cottage almost done. Mallett is one of the older cottages and is in queue for updates and also has an
ongoing, intermittent foul odor issue in the basement space. There have been several investigations into the source of the odor and some success
at remediating the odor, but then it returns. Work is still ongoing on this problem.
Three clients were also interviewed at Children's Farm Home and came from various cottages. The first client has been at the program for over a
year. They feel safe and comfortable in the program and attend daily groups. They meet with Dr. Adler once a week and their therapist 2-3 times a
week. Client couldn't comment on the overall quality of food as they were currently on a special diet. School is their favorite thing, and they are
currently in 10th grade and doing very well. They like to hang out at the barn and felt there were enough different activities for them to participate in.
4
In their cottage they have speakers in their bedrooms that can be used for phone calls. They said the speakers are terrible and the system for
phone calls doesn't work very well. They didn't like that in SAIP they were not allowed any clothes in their room. They understood not having
shoelaces but didn't like they could not have any of their clothes either. Client stated they have access to all of their clothes and will pick out what
they want to wear from their personal items' locker. Client said staff did a really good job with their interventions when youth get escalated.
The second client interviewed has been at the program for 20 months. They stated they have felt safe and comfortable during their time there.
Client said the food was terrible, but there are plenty of snacks and alternatives to keep them from being hungry. They have weekly visits from their
dad and have daily phone calls with him. Client really enjoys riding bikes and likes fixing them even better. The program has accommodated their
desire to fix bikes by providing time, tools, and assistance in repairing campus bicycles. Client stated CFH could do better at communication
between staff on different shifts. Sometimes there are inconsistent enforcement of rules and staff will tell youth different things depending on the
shift. Client also stated they need to do better at retaining staff because it is hard to connect with a staff and then they leave and there are always
new faces. They said the program does a really good job with the daily groups and enjoys participating in them.
The last client interviewed has been in the program around three months. They stated they feel mostly safe themselves but had several concerns
about other clients. They stated personally they have issues around receiving PRN medication where staff say they will get it, but actually do it
maybe 50% of the time. Client will ask staff for a PRN and staff don't get it when they say they will. They also said staff were inconsistent with
boards and they witnessed a staff who was new to the cottage provide a peer with pens and make-up when they were not supposed to. Another
peer is lactose intolerant and still allowed to consume lactose if they want to. Client also stated they have seen holds that seem pretty inhumane
but wouldn't elaborate on what made them inhumane. Client stated they get weekly visits from family and make calls daily. They said snacks are
always available and the food is decent. Client felt most of the staff were very kind and caring.
The above concerns noted by the client were addressed with management and most of the items observed were due to the clients perspective and
not having all of the information about their peers treatment plans and history.
Sender: A walkthrough of the house and outbuildings was conducted, along with interviews of two clients. The program was clean, in good repair,
and had a fully stocked kitchen. The two clients interviewed had been at the program for four months and 8 months. Both clients were over 18 and
were not extremely talkative. Both said they really liked the program, felt safe and the food was good. They said the staff were very encouraging
and were helping with resumes and job searches. One of the clients was actively looking for work and was on their way to drop off
resumes/applications as soon as we finished talking. The other was currently working on school as a sophomore at the community college with a
focus on psychology and the desire to help others. They also were working on a resume and planned to find a part time job. There were no
complaints or feedback on things the program could do to improve.

lawsuits: No

excerpt:
Documents as indicated on the form titled
“Renewal Licensing Required Documents” - Not all Certificates of Occupancy have been received
- PCC does not have a current Environmental Health
Inspection
- No conflict of interest policy meeting requirements of
licensing rule

excerpt:
All required policies and procedures as
identified in the “Umbrella Rules”

excerpt:
(5) There is at least one on-site employee
authorized to apply the reasonable and
prudent parent standard

excerpt: (3)(d) Annual performance evaluations

excerpt:
Staff providing direct care
must maintain current CPR/First Aid
certification

excerpt:
Designated staff authorized
to apply reasonable and prudent parent
standard are trained in application of the
standard

excerpt:
PCC – 2 of 5 files were missing documentation of all
consents
CFH - 2 of 5 files were missing documentation of all consents

excerpt:
(b) Use the discipline and behavior
management system

excerpt:
(c) Use restraint or seclusion (if applicable).
Must specify the reasons for the intervention
and how staff are trained and supervised

excerpt:
(d) Restrict contact with persons outside of
the agency

excerpt:
(e) Allow access as defined in 413-215-0091
& 0101

excerpt: (f) Impose a dress code

excerpt:
(g) Apply the reasonable and prudent parent
standard

excerpt:
(a) Information regarding personal or room
searches and protocols for confiscation of
contraband PCC – 2 of 5 files were missing documentation of all
disclosures
CFH - 2 of 5 files were missing documentation of all
disclosures

excerpt:
(b) Statement of Rights of Children and
Parents/Guardians

excerpt:
(c) Any policies and procedures upon
request

excerpt:
(a) Disclose or exchange information with
others PCC – 2 of 5 files were missing documentation of activity
specific authorizations
CFH – 3 of 5 files were missing authorization to disclose or
exchange info with others and activity specific authorization.
1 of 5 files did not have documentation for
authorization of child specific visitors or pre-approval of
visitation resources.

excerpt: (b) Child specific visitors

excerpt:
(d) Activity specific authorizations are pre-
approved to allow children to participate in
potentially hazardous activities, including but
not limited to using motorized yard
equipment, swimming, and horseback riding.

excerpt:
(e)(C)&(D) Service plan is reviewed quarterly
and revised when information indicates other
services should be provided

excerpt:
Individual written inventory of all personal
possessions is maintained and updated as
needed CFH – 2 of 5 files had no documentation of individual written
inventories
Sender – No documentation of individual written inventories


state: OR

summary: Unannounced - 3 findings

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Licensee: Trillium Family Services – Parry Center
Executive Director: Kim Scott, CEO
Program Director(s): Amy McAdams
Date of Unannounced: December 20, 2022
Licensing Coordinator: Aubrey Kelly
Other Regulatory or Accrediting Agencies: OHA, Joint Commission
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
2021 Unannounced Site Visit 12-09-2021 – Findings
Parry Center Further Action
Needed
413-215-0576(2) Parent/guardian has Yes☐ No Three client files reviewed contained the required disclosure.
acknowledged in writing: (c) Any policies
and procedures upon request:
PCC – 2 of 5 files were missing
documentation of all disclosures
Files reviewed did not contain the consent.
The program shall ensure all required
consents are signed by the legal guardian.
413-215-0576(3) (b) Child specific visitors: Yes☐ No Three client files reviewed contained the required authorization.
PCC – 2 of 5 files were missing
documentation of activity specific
authorizations
1
(rev. 07/21/2022)
Files reviewed did not contain the consent.
The program shall ensure all required
consents are signed by the legal guardian.
413-215-0576(3) (c) Visitation resources Yes☐ No Three client files reviewed contained the required authorization.
are pre-approved:
PCC – 2 of 5 files were missing
documentation of activity specific
authorizations
Files reviewed did not contain the consent.
The program shall ensure all required
consents are signed by the legal guardian.
New Findings from Site Visit Comments
None
Interview Summary
Client #1: They have been here for 2 months. They have previously been at Unity and Randall’s. They like it here, there are ups and
downs. Groups are fun, they like the art and active groups. They don’t like when peers are fighting and arguing. Their favorite staff
is Clara, she listens. They feel safe here and gets phone calls and visits with family. The food is better than they expected, they get
enough to eat. They have not been in any restraints since being at the program. Staff keeps them safe when other peers are
freaking out. They like school, the program allows lots of breaks during school. They would not change anything about the program.
Client #2: They have been here for 1 week. They previously were at Albertina Kerr and really liked it there. They have phone calls
and visits with family. They like the staff here, they are very nice. Their favorite staff is Rich. They don’t like one staff because they
are sarcastic. The food is food, they get enough to eat. They feel safe here.
2
Observations
The program was clean and home-like. Staff de-escalated clients effectively during the site visit.
Corrective Actions and Timeframes:
Please submit the following to verify compliance.
Within 45 days of receipt of this report Trillium – Parry Center 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 Aubrey.J.Kelly@dhsoha.state.or.us.
Licensing Coordinator’s Signature: ________________________ Date: _1_2_-_2_8_-2__0_2_2_ ________
Manager Review: ______________________________________ Date: _1_2_-_2_8_-_2_0_2_2_ _______
3

agency_name: Trillium Family Services (TFS)

program_type: (RC) Residential Care Programs

report_type: Unannounced

view_code: RC

licensee: Trillium Family Services - Parry Center

executive_director: Kim Scott, CEO

program_director: Amy McAdams

visit_date: December 20, 2022

licensing_coordinator: Aubrey Kelly

other_regulatory_agencies: OHA, Joint Commission

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
2021 Unannounced Site Visit 12-09-2021 - Findings
Parry Center Further Action
Needed
413-215-0576(2) Parent/guardian has Yes[ ] No Three client files reviewed contained the required disclosure.
acknowledged in writing: (c) Any policies
and procedures upon request:
PCC - 2 of 5 files were missing
documentation of all disclosures
Files reviewed did not contain the consent.
The program shall ensure all required
consents are signed by the legal guardian.
413-215-0576(3) (b) Child specific visitors: Yes[ ] No Three client files reviewed contained the required authorization.
PCC - 2 of 5 files were missing
documentation of activity specific
authorizations
1

Files reviewed did not contain the consent.
The program shall ensure all required
consents are signed by the legal guardian.
413-215-0576(3) (c) Visitation resources Yes[ ] No Three client files reviewed contained the required authorization.
are pre-approved:
PCC - 2 of 5 files were missing
documentation of activity specific
authorizations
Files reviewed did not contain the consent.
The program shall ensure all required
consents are signed by the legal guardian.
New Findings from Site Visit Comments
None
Interview Summary
Client #1: They have been here for 2 months. They have previously been at Unity and Randall's. They like it here, there are ups and
downs. Groups are fun, they like the art and active groups. They don't like when peers are fighting and arguing. Their favorite staff
is Clara, she listens. They feel safe here and gets phone calls and visits with family. The food is better than they expected, they get
enough to eat. They have not been in any restraints since being at the program. Staff keeps them safe when other peers are
freaking out. They like school, the program allows lots of breaks during school. They would not change anything about the program.
Client #2: They have been here for 1 week. They previously were at Albertina Kerr and really liked it there. They have phone calls
and visits with family. They like the staff here, they are very nice. Their favorite staff is Rich. They don't like one staff because they
are sarcastic. The food is food, they get enough to eat. They feel safe here.
2
Observations
The program was clean and home-like. Staff de-escalated clients effectively during the site visit.

excerpt:
413-215-0576(3) (c) Visitation resources Yes[ ] No Three client files reviewed contained the required authorization.
are pre-approved:
PCC - 2 of 5 files were missing
documentation of activity specific
authorizations
Files reviewed did not contain the consent.
The program shall ensure all required
consents are signed by the legal guardian.
New Findings from Site Visit Comments
None
None


facility_name: Trillium Family Services - Parry Center (Portland Date of site visit: May 6th, 2025 Campus)

summary: Unannounced - 17 findings

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Licensee: Trillium Family Services, Parry Center
Executive Director: Kim Scott, CEO
Program Director(s): Amy McAdams
Date of Unannounced: 12.09.2021
Licensing Coordinator: Kelly Aubrey
Other Regulatory or Accrediting Agencies: OHA, Joint Commission
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
License Renewal 08/24/2021 Findings
Further Action
Needed
Documents as indicated on the form titled Yes☐ No Completed. No further action is required.
“Renewal Licensing Required Documents”
PCC does not have a current
Environmental Health Inspection
413-215-0561(5) There is at least one on-site Yes☐ No Staff are continuing to be trained in the prudent parent standard. No further action is
employee authorized to apply the reasonable required.
and prudent parent standard:
PCC and CFH – Only program managers and
very few others had received Prudent Parent
training. This was not sufficient to ensure
there was always an on-site person trained in
applying the Prudent Parent standard.
413-215-0556(3) Staff providing direct care Yes☐ No CPR certifications were current for the 5 staff files reviewed. No further action is required.
must maintain current CPR/First Aid
certification:
PCC - One staff had an expired CPR
certification
1
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 200115)
413-215-0576(1) (a) Provide routine and Yes☐ No Files reviewed contained this consent. No further action is required.
emergency medical care:
PCC – 2 of 5 files were missing
documentation of all consents
413-215-0576(1) (b) Use the discipline and Yes☐ No Files reviewed contained this consent. No further action is required.
behavior management system:
PCC – 2 of 5 files were missing
documentation of all consents
413-215-0576(1) (c) Use restraint or seclusion Yes☐ No Files reviewed contained this consent. No further action is required.
(if applicable). Must specify the reasons for
the intervention and how staff are trained and
supervised:
PCC – 2 of 5 files were missing
documentation of all consents
413-215-0576(1) (d) Restrict contact with Yes☐ No Files reviewed contained this consent. No further action is required.
persons outside of the agency:
PCC – 2 of 5 files were missing
documentation of all consents
413-215-0576(1) (e) Allow access as defined Yes☐ No Files reviewed contained this consent. No further action is required.
in 413-215-0091 & 0101:
PCC – 2 of 5 files were missing
documentation of all consents
413-215-0576(1)(f) Impose a dress code: Yes☐ No Files reviewed contained this consent. No further action is required.
PCC – 2 of 5 files were missing
documentation of all consents
413-215-0576(1) (g) Apply the reasonable Yes☐ No Staff are continuing to be trained on the prudent parent standard. No further action is
and prudent parent standard: required.
PCC – 2 of 5 files were missing
documentation of all consents
413-215-0576(2) Parent/guardian has Yes☐ No Files reviewed contained this disclosure. No further action is required.
acknowledged in writing:(a) Information
regarding personal or room searches and
protocols for confiscation of contraband:
PCC – 2 of 5 files were missing
documentation of all disclosures
2
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 200115)
413-215-0576(2) Parent/guardian has Yes☐ No Files reviewed contained this disclosure. No further action is required.
acknowledged in writing: (b) Statement of
Rights of Children and Parents/Guardians:
PCC – 2 of 5 files were missing
documentation of all disclosures
413-215-0576(2) Parent/guardian has Yes No☐ Files reviewed did not contain the consent. The program shall ensure all required consents
acknowledged in writing: (c) Any policies and are signed by the legal guardian.
procedures upon request:
PCC – 2 of 5 files were missing
documentation of all disclosures
413-215-0576(3) (a) Disclose or exchange Yes☐ No Files reviewed contained this disclosure. No further action is required.
information with others:
PCC – 2 of 5 files were missing
documentation of activity specific
authorizations
413-215-0576(3) (b) Child specific visitors: Yes No☐ Files reviewed did not contain the consent. The program shall ensure all required consents
are signed by the legal guardian.
PCC – 2 of 5 files were missing
documentation of activity specific
authorizations
413-215-0576(3) (c) Visitation resources are Yes No☐ Files reviewed did not contain the consent. The program shall ensure all required consents
pre-approved: are signed by the legal guardian.
PCC – 2 of 5 files were missing
documentation of activity specific
authorizations
413-215-0576(3) (d) Activity specific Yes☐ No Files reviewed contained this disclosure. No further action is required.
authorizations are pre-approved to allow
children to participate in potentially hazardous
activities, including but not limited to using
motorized yard equipment, swimming, and
horseback riding:
PCC – 2 of 5 files were missing
documentation of activity specific
authorizations
3
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 200115)
New Findings from Site Visit Comments
None
Interview Summary
Client #1: They are 10 years old, has been in foster homes and Jasper Mtn. They like it here, been here for over 1 year. They feel
like they are helping. They feel like they are safe here and staff helps them to stay safe. The food is really good but they don’t drink
milk because it gives them the farts. Favorite staff is Jessica, she’s really nice. They speak with their caseworker on the phone.
Client #2: They are 16 years old. They have been in several other programs. They have spoke with family on a regular basis. They
wish they could have cereal for breakfast, they are a very picky eater. They feel safe here, though they have anxiety here also.
Observations
The program was clean and well taken care of.
Corrective Actions and Timeframes:
Please submit the following to verify compliance.
Within 45 days of receipt of this report Trillium Family Services, Inc. – Parry Center 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 Aubrey Kelly at AUBREY.J.KELLY@dhsoha.state.or.us or sent by regular mail to the following
address:
Department of Human Services
Children’s Care Licensing Program
Attn: Aubrey Kelly
201 High St. SE Suite 500
Salem, OR 97301
4
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 200115)
12.20.2021
Licensing Coordinator’s Signature: ________________________ Date: ___________________
Manager Review: ______________________________________ Date: _1_2_/2_0_/_2_1_ __________
5
I:\LICENSING\CCLU Forms & Templates\Site Visit Checklists (rev. 200115)

licensee: Trillium Family Services, Parry Center

licensing_coordinator: Kelly Aubrey

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
License Renewal 08/24/2021 Findings
Further Action
Needed
Documents as indicated on the form titled Yes[ ] No Completed. No further action is required.
"Renewal Licensing Required Documents"
PCC does not have a current
Environmental Health Inspection
413-215-0561(5) There is at least one on-site Yes[ ] No Staff are continuing to be trained in the prudent parent standard. No further action is
employee authorized to apply the reasonable required.
and prudent parent standard:
PCC and CFH - Only program managers and
very few others had received Prudent Parent
training. This was not sufficient to ensure
there was always an on-site person trained in
applying the Prudent Parent standard.
413-215-0556(3) Staff providing direct care Yes[ ] No CPR certifications were current for the 5 staff files reviewed. No further action is required.
must maintain current CPR/First Aid
certification:
PCC - One staff had an expired CPR
certification
1

413-215-0576(1) (a) Provide routine and Yes[ ] No Files reviewed contained this consent. No further action is required.
emergency medical care:
PCC - 2 of 5 files were missing
documentation of all consents
413-215-0576(1) (b) Use the discipline and Yes[ ] No Files reviewed contained this consent. No further action is required.
behavior management system:
PCC - 2 of 5 files were missing
documentation of all consents
413-215-0576(1) (c) Use restraint or seclusion Yes[ ] No Files reviewed contained this consent. No further action is required.
(if applicable). Must specify the reasons for
the intervention and how staff are trained and
supervised:
PCC - 2 of 5 files were missing
documentation of all consents
413-215-0576(1) (d) Restrict contact with Yes[ ] No Files reviewed contained this consent. No further action is required.
persons outside of the agency:
PCC - 2 of 5 files were missing
documentation of all consents
413-215-0576(1) (e) Allow access as defined Yes[ ] No Files reviewed contained this consent. No further action is required.
in 413-215-0091 & 0101:
PCC - 2 of 5 files were missing
documentation of all consents
413-215-0576(1)(f) Impose a dress code: Yes[ ] No Files reviewed contained this consent. No further action is required.
PCC - 2 of 5 files were missing
documentation of all consents
413-215-0576(1) (g) Apply the reasonable Yes[ ] No Staff are continuing to be trained on the prudent parent standard. No further action is
and prudent parent standard: required.
PCC - 2 of 5 files were missing
documentation of all consents
413-215-0576(2) Parent/guardian has Yes[ ] No Files reviewed contained this disclosure. No further action is required.
acknowledged in writing:(a) Information
regarding personal or room searches and
protocols for confiscation of contraband:
PCC - 2 of 5 files were missing
documentation of all disclosures
2

413-215-0576(2) Parent/guardian has Yes[ ] No Files reviewed contained this disclosure. No further action is required.
acknowledged in writing: (b) Statement of
Rights of Children and Parents/Guardians:
PCC - 2 of 5 files were missing
documentation of all disclosures
413-215-0576(2) Parent/guardian has Yes No[ ] Files reviewed did not contain the consent. The program shall ensure all required consents
acknowledged in writing: (c) Any policies and are signed by the legal guardian.
procedures upon request:
PCC - 2 of 5 files were missing
documentation of all disclosures
413-215-0576(3) (a) Disclose or exchange Yes[ ] No Files reviewed contained this disclosure. No further action is required.
information with others:
PCC - 2 of 5 files were missing
documentation of activity specific
authorizations
413-215-0576(3) (b) Child specific visitors: Yes No[ ] Files reviewed did not contain the consent. The program shall ensure all required consents
are signed by the legal guardian.
PCC - 2 of 5 files were missing
documentation of activity specific
authorizations
413-215-0576(3) (c) Visitation resources are Yes No[ ] Files reviewed did not contain the consent. The program shall ensure all required consents
pre-approved: are signed by the legal guardian.
PCC - 2 of 5 files were missing
documentation of activity specific
authorizations
413-215-0576(3) (d) Activity specific Yes[ ] No Files reviewed contained this disclosure. No further action is required.
authorizations are pre-approved to allow
children to participate in potentially hazardous
activities, including but not limited to using
motorized yard equipment, swimming, and
horseback riding:
PCC - 2 of 5 files were missing
documentation of activity specific
authorizations
3

New Findings from Site Visit Comments
None
Interview Summary
Client #1: They are 10 years old, has been in foster homes and Jasper Mtn. They like it here, been here for over 1 year. They feel
like they are helping. They feel like they are safe here and staff helps them to stay safe. The food is really good but they don't drink
milk because it gives them the farts. Favorite staff is Jessica, she's really nice. They speak with their caseworker on the phone.
Client #2: They are 16 years old. They have been in several other programs. They have spoke with family on a regular basis. They
wish they could have cereal for breakfast, they are a very picky eater. They feel safe here, though they have anxiety here also.
Observations
The program was clean and well taken care of.

excerpt:
413-215-0576(3) (d) Activity specific Yes[ ] No Files reviewed contained this disclosure. No further action is required.
authorizations are pre-approved to allow
children to participate in potentially hazardous
activities, including but not limited to using
motorized yard equipment, swimming, and
horseback riding:
PCC - 2 of 5 files were missing
documentation of activity specific
authorizations
3
New Findings from Site Visit Comments
None
None