summary: Unannounced - 21 findings

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Licensee: Washington County Juvenile Department
Shelter Manager: LaRoy LaBonte
Juvenile Services Supervisor: Martha Villegas
Date of Unannounced: December 13, 2022
Licensing Coordinator: Todd Cooley
Other Regulatory or Accrediting Agencies: Oregon Department of Education (ODE), Oregon Health Authority (OHA), Oregon Department of
Human Services (ODHS)
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
Governance of the Agency Yes☐ No Quality Improvement Policy and Procedure submitted by the program via email on 8/22/22.
413-215-0021
(2)(k) Written quality improvement program
A copy of the program’s quality improvement
plan was not submitted to Licensing for
review.
CORRECTIVE ACTION: Submit a copy of the
program’s quality improvement plan to
Licensing.
Executive Director or Program Director Yes☐ No The program requested a new criminal background check on 8/1922 for the Shelter
413-215-0021 Manager. Approved results were forwarded to Licensing on 10/3/22 via email.
(3)(g) Approval from BCU
1
(rev. 200115)
A new criminal background check is required
for the Shelter Manager for the new licensing
period.
CORRECTIVE ACTION: Request and submit
a copy of the Shelter Manager’s newly
approved background check for this new
licensing period.
Supplemental Information Provided by CCA Yes☐ No The program has submitted copies of ongoing email correspondence with the City of
Documents as indicated on the form titled Hillsboro in an attempt to obtain a Certificate of Occupancy for the program but a certificate
“Renewal Licensing Required Documents” for the building could not be located.
- Certification of Occupancy was not
submitted
CORRECTIVE ACTION:
- Submit copy of Certificate of
Occupancy
Supplemental Information Provided by CCA Yes☐ No An approved copy of the program’s Environmental Health Inspection, citing no violations,
Documents as indicated on the form titled was submitted via email on 8/22/22.
“Renewal Licensing Required Documents”
- Submitted Environmental Health
Inspection was incomplete.
CORRECTIVE ACTION:
- Resubmit completed inspection form
that is signed, dated, and indicates if
the inspection was approved or not
approved.
All required policies and procedures as Yes☐ No The program submitted two documents, Article 13 Ethical Standards and 6.4.5 Harkins
identified in the “Umbrella Rules” House Staff Boundaries and Expectations, via email on 8/22/22. that outline situations
related to a potential conflict of interest.
- Conflict of Interest was not submitted
for review.
CORRECTIVE ACTION:
- Submit copy of Conflict-of-Interest
Policy
All required policies and procedures as Yes☐ No The program submitted a revised copy of 6.2.1 Harkins House Responsibilities Youth and
identified in the “Umbrella Rules” Parental Rights via email on 8/22/22. This policy was revised as requested, however, the
specific right that speaks to a resident’s right to privacy was not included in the revised
- Youth and Parent Rights requires version. This right must be added and the policy resubmitted to Licensing. Licensing
modification. received the updated policy 11/15/2022 with right to privacy language.
(rev. 07/21/2022)
CORRECTIVE ACTION:
- Revise 6.2.1 Youth and Parent Rights
to include highlighted information.
413-215-0046 Licensing Umbrella
Rules: Children and Families Rights
Policy and Grievance Procedures
(Amended 1/1/19)
.
(b) The child in care's right to privacy.
All required policies and procedures as Yes☐ No The program submitted a revised copy of 6.2.4 Grievance Policy that now meets Licensing
identified in the “Umbrella Rules” Rule.
- Grievance Policy requires
modification.
CORRECTIVE ACTION:
- Revise 6.2.4 Grievance Policy to
include elements of the Licensing
Rule that are missing from the current
policy.
All required policies and procedures as Yes☐ No The program submitted a revised copy of 6.4.3 Procedures for Mandatory Reporting
identified in the “Umbrella Rules” Information that now meets Licensing Rule.
- Mandatory Reporting Policy requires
modification.
CORRECTIVE ACTION:
- Revise 6.4.3 Mandatory Reporting
Policy to include elements of the
Licensing Rule that are missing
from the current policy.
Physical Plant Yes☐ No The program submitted a work order request to facilities for the repair of damaged
413-215-0511(2)(a) &(c) Buildings are smoke windowsills and submitted pictures of the completed work on 8/31/22. The completion of
free, clean and in good repair this work will be verified at a subsequent site visit.
Window sills located in the wellness room and Both windowsills were inspected on 12/13/22 and were in good condition.
in bedroom #281 located in the blue dorm are
damaged and/or have etched in
words/symbols associated with gang
affiliation.
(rev. 07/21/2022)
CORRECTIVE ACTION: Repair damaged
window sills and submit photos of repaired
areas
Physical Plant Yes☐ No The program submitted ongoing correspondence with the county’s Facilities and Parks
413-215-0511(2)(h) Building is well ventilated Services Division to address ongoing HVAC concerns at Harkins House. Facilities has
and room temperature is within a normal assessed the system and determined that given the building’s age and design, the system
comfort range is functioning as expected. While the county continues to explore a long-term solution to
include the possibility of upgrading the HVAC system should funds become available,
Staff report that during the summer, the Facilities and Park Services Division is making portable cooling units available to the
facility’s air conditioner does not effectively program during the summer months.
cool the facility.
CORRECTIVE ACTION: Address concern
with facilities to resolve or improve the
facility’s cooling system.
Room and Space Requirements Yes☐ No A work order to assess the bathroom’s ventilation system was submitted. An email dated
Bathrooms 413-215-0516(4) 8/22/22, documents a facility tech replacing a motor for an exhaust fan that resulted in the
(a)(H) Adequate ventilation system working appropriately now. Completion of this work will be verified at a subsequent
site visit.
The bathroom and shower areas do not
appear to have a working ventilation system. Bathroom ventilation appeared adequate during walkthrough on 12/13/22.
CORRECTIVE ACTION: Follow up with
facilities and explore ventilation options for the
bathrooms and shower areas.
Safety Yes No The program submitted drills for the last licensing period Jan. 2020 – July 2022. The drill
413-215-0541 sheets were missing required information as per the licensing rule to include special
3)(a) Evacuation drill occurs monthly conditions simulated and problems encountered. In reviewing the drill sheets, the program
missed 3 monthly drills in 2020, 2 monthly drills in 2021 and 3 drills in 2022.
Evacuation drills were not submitted for
review On 9/1/22, the program emailed a revised version of the fire drill sheets to include
conditions simulated and problems encountered. In an attempt to ensure that the drills are
CORRECTIVE ACTION: Submit a copy of completed on a monthly basis, the evacuation sheets have been prefilled with each month
evacuation drills for 2020 thru May of 2022. as a reminder for the drills to be completed on a regular basis.
During the unannounced the evacuation drills were reviewed and there was no
documentation of a drill being conducted in November 2022
-Repeat finding
Medication Yes☐ No☐ The program reports that adverse reactions have been added to the youth’s MARS.
413-215-0551 Compliance in this area will be monitored at a subsequent site visit.
(10) Written record of the administration of
medication includes:
(h) possible adverse reactions
(rev. 07/21/2022)
The program’s existing medication logs
maintained for each youth does not reflect
possible adverse reactions related to the
medication being taken.
CORRECTIVE ACTION: Develop a process
where possible adverse reactions are
documented on youths’ medication logs.
New Employee Orientation – Umbrella Yes☐ No The program has submitted a New Employee Training Checklist that will be implemented
Requirements (30 days) to ensure the completion and documentation of New Employee Orientation training
413-215-0061(4) required by Licensing Rule. Compliance in this area will be monitored at a subsequent site
visit.
(a) Agency policies and procedures
There have been no new hires since the last review and this item was unable to be
One out of three new hire files did not reflect reviewed. Follow-up will continue at the next unannounced.
training in the following areas:
- Agency policies and procedures
CORRECTIVE ACTION: Ensure that new
hires are receiving the required training and
the completed training is appropriately
documented in their respective personnel file.
New Employee Orientation – Umbrella Yes☐ No The program has submitted a New Employee Training Checklist that will be implemented
Requirements (30 days) to ensure the completion and documentation of New Employee Orientation training
413-215-0061(4) required by Licensing Rule. Compliance in this area will be monitored at a subsequent site
visit.
(b) Ethical and professional guidelines
There have been no new hires since the last review and this item was unable to be
One out of three new hire files did not reflect reviewed. Follow-up will continue at the next unannounced.
training in the following areas:
- Ethical and professional guidelines
CORRECTIVE ACTION: Ensure that new
hires are receiving the required training and
the completed training is appropriately
documented in their respective personnel file.
New Employee Orientation – Umbrella Yes☐ No The program has submitted a New Employee Training Checklist that will be implemented
Requirements (30 days) to ensure the completion and documentation of New Employee Orientation training
413-215-0061(4) required by Licensing Rule. Compliance in this area will be monitored at a subsequent site
visit.
(c) Organizational lines of authority
There have been no new hires since the last review and this item was unable to be
One out of three new hire files did not reflect reviewed. Follow-up will continue at the next unannounced.
training in the following areas:
- Organizational lines of Authority
(rev. 07/21/2022)
CORRECTIVE ACTION: Ensure that new
hires are receiving the required training and
the completed training is appropriately
documented in their respective personnel file.
New Employee Orientation – Umbrella Yes☐ No The program has submitted a New Employee Training Checklist that will be implemented
Requirements (30 days) to ensure the completion and documentation of New Employee Orientation training
413-215-0061(4) required by Licensing Rule. Compliance in this area will be monitored at a subsequent site
visit.
(d) Attributes of population served
There have been no new hires since the last review and this item was unable to be
One out of three new hire files did not reflect reviewed. Follow-up will continue at the next unannounced.
training in the following areas:
- Attributes of Population Served
CORRECTIVE ACTION: Ensure that new
hires are receiving the required training and
the completed training is appropriately
documented in their respective personnel file.
New Employee Orientation – Umbrella Yes☐ No The program has submitted a New Employee Training Checklist that will be implemented
Requirements (30 days) to ensure the completion and documentation of New Employee Orientation training
413-215-0061(4) required by Licensing Rule. Compliance in this area will be monitored at a subsequent site
visit.
(e) Privacy laws
There have been no new hires since the last review and this item was unable to be
One out of three new hire files did not reflect reviewed. Follow-up will continue at the next unannounced.
training in the following areas:
- Privacy Laws
CORRECTIVE ACTION: Ensure that new
hires are receiving the required training and
the completed training is appropriately
documented in their respective personnel file.
Ongoing Training Yes☐ No The program reports updating their electronic training system through NeoGov with staff’s
413-215-0556(2)(c) Discipline and Behavior completed training so that employees are alerted regarding required annual training.
Management Compliance in this area will be monitored during subsequent site visit.
One out of two established staff members did The unannounced review was too close in proximity to the site review to determine
not reflect completion of required annual ongoing compliance in this area. Follow-up to be done on next review.
training in the following areas:
- Discipline and Behavior Management
CORRECTIVE ACTION: Ensure that
employees are receiving the required annual
training and the completed training is
(rev. 07/21/2022)
appropriately documented in their respective
personnel file.
Ongoing Training Yes☐ No The program reports losing their two CPR/1st aid instructors due to staff turnover. Two new
413-215-0556(3) Staff providing direct care trainers have been identified to provide in house training in these two areas. In addition,
must maintain current CPR/First Aid the program is updating their electronic training system through NeoGov with staff’s
certification completed training so that employees are alerted regarding required annual training.
Compliance in this area will be monitored during subsequent site visit.
One out of two established staff members did
not reflect completion of required annual The unannounced review was too close in proximity to the site review to determine
training in the following areas: ongoing compliance in this area. Follow-up to be done on next review.
- CPR/1st Aid
CORRECTIVE ACTION: Ensure that
employees are receiving the required annual
training and the completed training is
appropriately documented in their respective
personnel file.
Ongoing Training Yes☐ No The program reports updating their electronic training system through NeoGov with staff’s
413-215-0061(5) Mandatory reporting completed training so that employees are alerted regarding required annual training.
(annually) that includes: Compliance in this area will be monitored during subsequent site visit.
(a) legal definition of child abuse ORS
419B.005, Oregon Laws 2016, chapter 106, The unannounced review was too close in proximity to the site review to determine
section 36 ongoing compliance in this area. Follow-up to be done on next review.
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to
the employee
One out of two established staff members did
not reflect completion of required annual
training in the following areas:
- Mandatory Reporting
CORRECTIVE ACTION: Ensure that
employees are receiving the required annual
training and the completed training is
appropriately documented in their respective
personnel file.
Children’s Records Yes☐ No The program has re-established this instruction through the county’s Health and Human
Health Services Services. A representative from this agency provides this instruction to youth on a
413-215-0546 quarterly basis. Documentation of this instruction will be kept in the youth’s respective
(2)(e) Documentation of age-appropriate files. Compliance in this area will be monitored in a subsequent site visit.
instruction – pregnancy prevention, nutrition,
prevention of HIV & AIDS, and prevention and Given there is no frequency requirement for this training and the close proximity to the site
treatment of sexually transmitted disease review, this item will be followed up on at the next review.
(rev. 07/21/2022)
Confirmation regarding the documentation of
age-appropriate instruction could not be found
after the review of youth files.
CORRECTIVE ACTION: Create a process
where age-appropriate instruction in the areas
listed is documented in the youth’s respective
files.
Consents Yes☐ No The program confirmed via email dated 9/15/22, that this consent is located in the
413-215-0576(1) program’s Voluntary Placement Agreement form that was revised on 8/11/22.
(a) Provide routine and emergency
medical care
Consent to provide routine and emergency
medical care could not be located in the
program’s intake packet.
CORRECTIVE ACTION: Demonstrate that
this consent exists within the program’s intake
process. If one does not exist, create, and
implement the required consent.
Authorizations Yes☐ No The program’s Assumption and Risk and Release of Liability form has been revised to
413-215-0576(3) include this authorization related to potentially hazardous activities. This form is available
(d) Activity specific authorizations are pre- in both English and Spanish.
approved to allow children to participate in
potentially hazardous activities, including but
not limited to using motorized yard equipment,
swimming, and horseback riding.
Authorization for pre-approved potentially
hazardous activities could not be found in the
youth files reviewed.
CORRECTIVE ACTION: Create an
authorization related to potentially hazardous
activities and ensure this authorization is
signed at the time of intake by the youth
and/or legal guardian.
Information about Children in Care Yes☐ No The program’s client face sheet has been modified to include religious preference as well
413-215-0581(1) Summary sheet contains as gender identity.
the following:
(rev. 07/21/2022)
(a)The name, gender, date of birth, religious
preference, and previous address
There is no designated space to capture a
youth’s religious preference on the youth’s
summary sheet.
CORRECTIVE ACTION: Modify the existing
summary/face sheet to include religious
preference.
The program was advised to forward all Yes☐ No The program has forwarded their most recent critical events to Licensing for review.
critical events documented in incident reports
to Licensing as required by rule effective
immediately. See related licensing rule for
reference.
413-215-0091 Licensing Umbrella Rules:
Responsibilities of Licensees (Amended
1/1/19)
A licensee is responsible to do all of the
following:
(11) Notify the Department in the following
circumstances:
(b) Within one business day if a critical event
occurs. As used in this section, "critical event"
means a significant event occurring in the
operation of a child-caring agency that is
considered likely to cause complaints,
generate concerns, or come to the attention of
the media, law enforcement agencies, first
responders, Child Protective Services, or
other regulatory agencies. Compliance with
this notification requirement does not satisfy
mandatory child abuse reporting requirements
under ORS 419B.005 to 419B.045.
The program provides a consent intake form Yes☐ No As per an email sent on 8/19/22, the program has updated the Voluntary Placement
in Spanish for their monolingual Spanish Agreement and has had this intake packet translated into Spanish for monolingual,
speaking youth and families. A review of Spanish speaking guardians.
these Spanish forms indicate that some
information is missing and does not match the
English consent intake forms provided to
English speaking and/or bilingual youth and
families.
CORRECTIVE ACTION: Review the
translated forms and ensure the document
(rev. 07/21/2022)
holds that same information that is provided to
English.
New Findings from Site Visit Comments
None
Interview Summary
During the unannounced review three youth and one staff were interviewed.
The first youth interviewed had been in the program just over four months and had previously been in the program for about four months within the preceding
year. Youth felt safe in the program and stated there were multiple staff they felt comfortable addressing any problems or concerns with. School was going
good, and youth stated they are on track to finish a year early. The food is good, and the youth stated they enjoy participating in meal prep and working in the
kitchen. Youth said they get at least one hour of rec time each day and goes on outings to the gym where they like to lift heavy weights. Youth noted some
concern around staffing during med pass as one staff will be downstairs administering meds while there is one staff for each side upstairs. During this time it
is at the discretion of the staff whether youth can be in the common area or if they need to stay in there rooms for downtime due to ratios. Youth also stated
they previously had “unlimited” phone calls while on level 5, but that had recently changed to a strict one ten-minute phone call to family each day. Youth
expressed frustration around this because they are very close to their family and it is a good support system for them. This client also had the perception that
some of the staff “targeted” or supervised more closely the Hispanic clients as compared to the white clients. Youth stated overall the program was fine and a
lot of the staff were really good about checking in with youth.
Youth two and three felt more comfortable being interviewed at the same time and provided similar responses to each other. They have been in the program
for 2 ½ months and 1 ½ months respectively. Both stated they felt safe in the program and had multiple staff across different shifts they could talk to if they
had issues. They said the food was awesome during the week, but on the weekends, a lot of the same stuff is served. Youth two stated his family was
involved in his treatment and discharge planning while youth three stated their mother wasn’t very involved, but staff kept her updated on what was discussed.
When asked about rec both stated they would love to have a heavy bag or speed bag on campus (both are types of punching bags). They also mentioned
that they liked to go to the gym, but it hasn’t happened as frequently as it once did. It used to be a weekly trip and now only is occurring maybe twice a month.
They were unsure if it was a staffing issue or just a time issue. These clients also commented on the phone usage and stated it recently went from unlimited
to once a day for 10-minutes. Youth stated concerns over a particular staff, Henry, whom they stated was disrespectful towards them and their peers. When
asked for examples one stated Henry would imply during conversations that he would fight them. This was in the context of telling a story about an incident
outside of the program the client had with another youth, where Henry implied he would have handled it differently and referenced them both going to DEL,
Donald E. Long (Multnomah County Juvenile Detention) which the client took to mean Henry would have fought him and landed them both in detention if
Henry was the other youth. The other example was during a phone call in which Henry asked the client to wrap their phone call because they were at the 10-
minute limit. Henry again asked the client to wrap it up, and when the call didn’t end immediately, Henry hung up the phone. The other concern both of these
clients had was around leisure time and the movies/TV they were allowed to watch. They said they could only watch PG movies with the exception of Marvel
movies, and they only had access to Kids Netflix. They thought this was unreasonable given the average age of the clients being around 15-17. The clients
also said certain staff, identifying David and Sidney/Sindey, in particular as being very good about checking in with them.
(rev. 07/21/2022)
The staff interviewed had been at the program just over a year in both JC1 and JC2 roles. Staff had a lot of concerns, not serious, but items that should be
addressed by management to improve workplace conditions. Most of the concern revolved around overall training and communication. There has been a lot
of turnover the past year and as people leave, promotions to fill the vacant spot is typically internal. These changes occurred without a whole lot of training or
guidance for those acquiring the new positions. Staff felt they have adequate staffing, but the lack of communication on assignments and duties creates a lot
of stress and makes it more difficult to do their jobs. Staff stated that with better organization and communication the daily routines would be just fine with the
staff they currently have. With current schedules and staff to youth ratios, they said prioritizing Individual Skills Building (ISB) with the youth can be a
challenge due to time. Staff felt they had a very solid group of staff that are capable of working well together and just needed some clear guidance from
management in order for things to run more smoothly. When asked if the outings were being limited due to lack of staffing, it was relayed time was an issue,
but there are staff who are reluctant to take clients on outings for their own reasons. Training was also discussed, and they felt training was not as strong as it
could be, and due to turnover, it felt like there was a push to get staff on the floor sooner rather than later.
Observations
Overall, the program was clean and in good repair. There were some items strewn about the living quarters as the clients were in the process of decorating
their doors for the holidays. The boy’s bathroom had garbage cans overflowing with paper towels, but chores are normally conducted after school, which was
currently in session during the review.
All concerns noted in the above interviews will be addressed with upper management. The program director is currently on vacation and licensing would like
to meet with both the program manager and supervisor at the same time. These concerns or follow-up will be around the topics of phone calls, outing
consistency, training, communication on all levels, and the individual concerns around the one staff identified.
Corrective Actions and Timeframes:
Please submit the following to verify compliance.
Within 45 days of receipt of this report Washington County Juvenile Department 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 at todd.cooley@odhsoha.oregon.gov.
.
Licensing Coordinator’s Signature: ________________________ Date: _1_2_-2_1_-_2_0_2_2_ _________
Manager Review: ______________________________________ Date: _1_2_-_1_9_-_2_0_2_2_ _______
(rev. 07/21/2022)

report_type: Unannounced

visit_date: December 13, 2022

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
Governance of the Agency Yes[ ] No Quality Improvement Policy and Procedure submitted by the program via email on 8/22/22.
413-215-0021
(2)(k) Written quality improvement program
A copy of the program's quality improvement
plan was not submitted to Licensing for
review.
CORRECTIVE ACTION: Submit a copy of the
program's quality improvement plan to
Licensing.

interview_summary:
During the unannounced review three youth and one staff were interviewed.
The first youth interviewed had been in the program just over four months and had previously been in the program for about four months within the preceding
year. Youth felt safe in the program and stated there were multiple staff they felt comfortable addressing any problems or concerns with. School was going
good, and youth stated they are on track to finish a year early. The food is good, and the youth stated they enjoy participating in meal prep and working in the
kitchen. Youth said they get at least one hour of rec time each day and goes on outings to the gym where they like to lift heavy weights. Youth noted some
concern around staffing during med pass as one staff will be downstairs administering meds while there is one staff for each side upstairs. During this time it
is at the discretion of the staff whether youth can be in the common area or if they need to stay in there rooms for downtime due to ratios. Youth also stated
they previously had "unlimited" phone calls while on level 5, but that had recently changed to a strict one ten-minute phone call to family each day. Youth
expressed frustration around this because they are very close to their family and it is a good support system for them. This client also had the perception that
some of the staff "targeted" or supervised more closely the Hispanic clients as compared to the white clients. Youth stated overall the program was fine and a
lot of the staff were really good about checking in with youth.
Youth two and three felt more comfortable being interviewed at the same time and provided similar responses to each other. They have been in the program
for 2 ½ months and 1 ½ months respectively. Both stated they felt safe in the program and had multiple staff across different shifts they could talk to if they
had issues. They said the food was awesome during the week, but on the weekends, a lot of the same stuff is served. Youth two stated his family was
involved in his treatment and discharge planning while youth three stated their mother wasn't very involved, but staff kept her updated on what was discussed.
When asked about rec both stated they would love to have a heavy bag or speed bag on campus (both are types of punching bags). They also mentioned
that they liked to go to the gym, but it hasn't happened as frequently as it once did. It used to be a weekly trip and now only is occurring maybe twice a month.
They were unsure if it was a staffing issue or just a time issue. These clients also commented on the phone usage and stated it recently went from unlimited
to once a day for 10-minutes. Youth stated concerns over a particular staff, Henry, whom they stated was disrespectful towards them and their peers. When
asked for examples one stated Henry would imply during conversations that he would fight them. This was in the context of telling a story about an incident
outside of the program the client had with another youth, where Henry implied he would have handled it differently and referenced them both going to DEL,
Donald E. Long (Multnomah County Juvenile Detention) which the client took to mean Henry would have fought him and landed them both in detention if
Henry was the other youth. The other example was during a phone call in which Henry asked the client to wrap their phone call because they were at the 10-
minute limit. Henry again asked the client to wrap it up, and when the call didn't end immediately, Henry hung up the phone. The other concern both of these
clients had was around leisure time and the movies/TV they were allowed to watch. They said they could only watch PG movies with the exception of Marvel
movies, and they only had access to Kids Netflix. They thought this was unreasonable given the average age of the clients being around 15-17. The clients
also said certain staff, identifying David and Sidney/Sindey, in particular as being very good about checking in with them.

The staff interviewed had been at the program just over a year in both JC1 and JC2 roles. Staff had a lot of concerns, not serious, but items that should be
addressed by management to improve workplace conditions. Most of the concern revolved around overall training and communication. There has been a lot
of turnover the past year and as people leave, promotions to fill the vacant spot is typically internal. These changes occurred without a whole lot of training or
guidance for those acquiring the new positions. Staff felt they have adequate staffing, but the lack of communication on assignments and duties creates a lot
of stress and makes it more difficult to do their jobs. Staff stated that with better organization and communication the daily routines would be just fine with the
staff they currently have. With current schedules and staff to youth ratios, they said prioritizing Individual Skills Building (ISB) with the youth can be a
challenge due to time. Staff felt they had a very solid group of staff that are capable of working well together and just needed some clear guidance from
management in order for things to run more smoothly. When asked if the outings were being limited due to lack of staffing, it was relayed time was an issue,
but there are staff who are reluctant to take clients on outings for their own reasons. Training was also discussed, and they felt training was not as strong as it
could be, and due to turnover, it felt like there was a push to get staff on the floor sooner rather than later.

observations:
Overall, the program was clean and in good repair. There were some items strewn about the living quarters as the clients were in the process of decorating
their doors for the holidays. The boy's bathroom had garbage cans overflowing with paper towels, but chores are normally conducted after school, which was
currently in session during the review.
All concerns noted in the above interviews will be addressed with upper management. The program director is currently on vacation and licensing would like
to meet with both the program manager and supervisor at the same time. These concerns or follow-up will be around the topics of phone calls, outing
consistency, training, communication on all levels, and the individual concerns around the one staff identified.

previous_findings:
Repeat Comments
Findings
Further Action
Needed
Governance of the Agency Yes[ ] No Quality Improvement Policy and Procedure submitted by the program via email on 8/22/22.
413-215-0021
(2)(k) Written quality improvement program
A copy of the program's quality improvement
plan was not submitted to Licensing for
review.
CORRECTIVE ACTION: Submit a copy of the
program's quality improvement plan to
Licensing.
Executive Director or Program Director Yes[ ] No The program requested a new criminal background check on 8/1922 for the Shelter
413-215-0021 Manager. Approved results were forwarded to Licensing on 10/3/22 via email.
(3)(g) Approval from BCU
1

A new criminal background check is required
for the Shelter Manager for the new licensing
period.
CORRECTIVE ACTION: Request and submit
a copy of the Shelter Manager's newly
approved background check for this new
licensing period.
Supplemental Information Provided by CCA Yes[ ] No The program has submitted copies of ongoing email correspondence with the City of
Documents as indicated on the form titled Hillsboro in an attempt to obtain a Certificate of Occupancy for the program but a certificate
"Renewal Licensing Required Documents" for the building could not be located.
- Certification of Occupancy was not
submitted
CORRECTIVE ACTION:
- Submit copy of Certificate of
Occupancy
Supplemental Information Provided by CCA Yes[ ] No An approved copy of the program's Environmental Health Inspection, citing no violations,
Documents as indicated on the form titled was submitted via email on 8/22/22.
"Renewal Licensing Required Documents"
- Submitted Environmental Health
Inspection was incomplete.
CORRECTIVE ACTION:
- Resubmit completed inspection form
that is signed, dated, and indicates if
the inspection was approved or not
approved.
All required policies and procedures as Yes[ ] No The program submitted two documents, Article 13 Ethical Standards and 6.4.5 Harkins
identified in the "Umbrella Rules" House Staff Boundaries and Expectations, via email on 8/22/22. that outline situations
related to a potential conflict of interest.
- Conflict of Interest was not submitted
for review.
CORRECTIVE ACTION:
- Submit copy of Conflict-of-Interest
Policy
All required policies and procedures as Yes[ ] No The program submitted a revised copy of 6.2.1 Harkins House Responsibilities Youth and
identified in the "Umbrella Rules" Parental Rights via email on 8/22/22. This policy was revised as requested, however, the
specific right that speaks to a resident's right to privacy was not included in the revised
- Youth and Parent Rights requires version. This right must be added and the policy resubmitted to Licensing. Licensing
modification. received the updated policy 11/15/2022 with right to privacy language.

CORRECTIVE ACTION:
- Revise 6.2.1 Youth and Parent Rights
to include highlighted information.
413-215-0046 Licensing Umbrella
Rules: Children and Families Rights
Policy and Grievance Procedures
(Amended 1/1/19)
.
(b) The child in care's right to privacy.
All required policies and procedures as Yes[ ] No The program submitted a revised copy of 6.2.4 Grievance Policy that now meets Licensing
identified in the "Umbrella Rules" Rule.
- Grievance Policy requires
modification.
CORRECTIVE ACTION:
- Revise 6.2.4 Grievance Policy to
include elements of the Licensing
Rule that are missing from the current
policy.
All required policies and procedures as Yes[ ] No The program submitted a revised copy of 6.4.3 Procedures for Mandatory Reporting
identified in the "Umbrella Rules" Information that now meets Licensing Rule.
- Mandatory Reporting Policy requires
modification.
CORRECTIVE ACTION:
- Revise 6.4.3 Mandatory Reporting
Policy to include elements of the
Licensing Rule that are missing
from the current policy.
Physical Plant Yes[ ] No The program submitted a work order request to facilities for the repair of damaged
413-215-0511(2)(a) &(c) Buildings are smoke windowsills and submitted pictures of the completed work on 8/31/22. The completion of
free, clean and in good repair this work will be verified at a subsequent site visit.
Window sills located in the wellness room and Both windowsills were inspected on 12/13/22 and were in good condition.
in bedroom #281 located in the blue dorm are
damaged and/or have etched in
words/symbols associated with gang
affiliation.

CORRECTIVE ACTION: Repair damaged
window sills and submit photos of repaired
areas
Physical Plant Yes[ ] No The program submitted ongoing correspondence with the county's Facilities and Parks
413-215-0511(2)(h) Building is well ventilated Services Division to address ongoing HVAC concerns at Harkins House. Facilities has
and room temperature is within a normal assessed the system and determined that given the building's age and design, the system
comfort range is functioning as expected. While the county continues to explore a long-term solution to
include the possibility of upgrading the HVAC system should funds become available,
Staff report that during the summer, the Facilities and Park Services Division is making portable cooling units available to the
facility's air conditioner does not effectively program during the summer months.
cool the facility.
CORRECTIVE ACTION: Address concern
with facilities to resolve or improve the
facility's cooling system.
Room and Space Requirements Yes[ ] No A work order to assess the bathroom's ventilation system was submitted. An email dated
Bathrooms 413-215-0516(4) 8/22/22, documents a facility tech replacing a motor for an exhaust fan that resulted in the
(a)(H) Adequate ventilation system working appropriately now. Completion of this work will be verified at a subsequent
site visit.
The bathroom and shower areas do not
appear to have a working ventilation system. Bathroom ventilation appeared adequate during walkthrough on 12/13/22.
CORRECTIVE ACTION: Follow up with
facilities and explore ventilation options for the
bathrooms and shower areas.
Safety Yes No The program submitted drills for the last licensing period Jan. 2020 - July 2022. The drill
413-215-0541 sheets were missing required information as per the licensing rule to include special
3)(a) Evacuation drill occurs monthly conditions simulated and problems encountered. In reviewing the drill sheets, the program
missed 3 monthly drills in 2020, 2 monthly drills in 2021 and 3 drills in 2022.
Evacuation drills were not submitted for
review On 9/1/22, the program emailed a revised version of the fire drill sheets to include
conditions simulated and problems encountered. In an attempt to ensure that the drills are
CORRECTIVE ACTION: Submit a copy of completed on a monthly basis, the evacuation sheets have been prefilled with each month
evacuation drills for 2020 thru May of 2022. as a reminder for the drills to be completed on a regular basis.
During the unannounced the evacuation drills were reviewed and there was no
documentation of a drill being conducted in November 2022
-Repeat finding
Medication Yes[ ] No[ ] The program reports that adverse reactions have been added to the youth's MARS.
413-215-0551 Compliance in this area will be monitored at a subsequent site visit.
(10) Written record of the administration of
medication includes:
(h) possible adverse reactions

The program's existing medication logs
maintained for each youth does not reflect
possible adverse reactions related to the
medication being taken.
CORRECTIVE ACTION: Develop a process
where possible adverse reactions are
documented on youths' medication logs.
New Employee Orientation - Umbrella Yes[ ] No The program has submitted a New Employee Training Checklist that will be implemented
Requirements (30 days) to ensure the completion and documentation of New Employee Orientation training
413-215-0061(4) required by Licensing Rule. Compliance in this area will be monitored at a subsequent site
visit.
(a) Agency policies and procedures
There have been no new hires since the last review and this item was unable to be
One out of three new hire files did not reflect reviewed. Follow-up will continue at the next unannounced.
training in the following areas:
- Agency policies and procedures
CORRECTIVE ACTION: Ensure that new
hires are receiving the required training and
the completed training is appropriately
documented in their respective personnel file.
New Employee Orientation - Umbrella Yes[ ] No The program has submitted a New Employee Training Checklist that will be implemented
Requirements (30 days) to ensure the completion and documentation of New Employee Orientation training
413-215-0061(4) required by Licensing Rule. Compliance in this area will be monitored at a subsequent site
visit.
(b) Ethical and professional guidelines
There have been no new hires since the last review and this item was unable to be
One out of three new hire files did not reflect reviewed. Follow-up will continue at the next unannounced.
training in the following areas:
- Ethical and professional guidelines
CORRECTIVE ACTION: Ensure that new
hires are receiving the required training and
the completed training is appropriately
documented in their respective personnel file.
New Employee Orientation - Umbrella Yes[ ] No The program has submitted a New Employee Training Checklist that will be implemented
Requirements (30 days) to ensure the completion and documentation of New Employee Orientation training
413-215-0061(4) required by Licensing Rule. Compliance in this area will be monitored at a subsequent site
visit.
(c) Organizational lines of authority
There have been no new hires since the last review and this item was unable to be
One out of three new hire files did not reflect reviewed. Follow-up will continue at the next unannounced.
training in the following areas:
- Organizational lines of Authority

CORRECTIVE ACTION: Ensure that new
hires are receiving the required training and
the completed training is appropriately
documented in their respective personnel file.
New Employee Orientation - Umbrella Yes[ ] No The program has submitted a New Employee Training Checklist that will be implemented
Requirements (30 days) to ensure the completion and documentation of New Employee Orientation training
413-215-0061(4) required by Licensing Rule. Compliance in this area will be monitored at a subsequent site
visit.
(d) Attributes of population served
There have been no new hires since the last review and this item was unable to be
One out of three new hire files did not reflect reviewed. Follow-up will continue at the next unannounced.
training in the following areas:
- Attributes of Population Served
CORRECTIVE ACTION: Ensure that new
hires are receiving the required training and
the completed training is appropriately
documented in their respective personnel file.
New Employee Orientation - Umbrella Yes[ ] No The program has submitted a New Employee Training Checklist that will be implemented
Requirements (30 days) to ensure the completion and documentation of New Employee Orientation training
413-215-0061(4) required by Licensing Rule. Compliance in this area will be monitored at a subsequent site
visit.
(e) Privacy laws
There have been no new hires since the last review and this item was unable to be
One out of three new hire files did not reflect reviewed. Follow-up will continue at the next unannounced.
training in the following areas:
- Privacy Laws
CORRECTIVE ACTION: Ensure that new
hires are receiving the required training and
the completed training is appropriately
documented in their respective personnel file.
Ongoing Training Yes[ ] No The program reports updating their electronic training system through NeoGov with staff's
413-215-0556(2)(c) Discipline and Behavior completed training so that employees are alerted regarding required annual training.
Management Compliance in this area will be monitored during subsequent site visit.
One out of two established staff members did The unannounced review was too close in proximity to the site review to determine
not reflect completion of required annual ongoing compliance in this area. Follow-up to be done on next review.
training in the following areas:
- Discipline and Behavior Management
CORRECTIVE ACTION: Ensure that
employees are receiving the required annual
training and the completed training is

appropriately documented in their respective
personnel file.
Ongoing Training Yes[ ] No The program reports losing their two CPR/1st aid instructors due to staff turnover. Two new
413-215-0556(3) Staff providing direct care trainers have been identified to provide in house training in these two areas. In addition,
must maintain current CPR/First Aid the program is updating their electronic training system through NeoGov with staff's
certification completed training so that employees are alerted regarding required annual training.
Compliance in this area will be monitored during subsequent site visit.
One out of two established staff members did
not reflect completion of required annual The unannounced review was too close in proximity to the site review to determine
training in the following areas: ongoing compliance in this area. Follow-up to be done on next review.
- CPR/1st Aid
CORRECTIVE ACTION: Ensure that
employees are receiving the required annual
training and the completed training is
appropriately documented in their respective
personnel file.
Ongoing Training Yes[ ] No The program reports updating their electronic training system through NeoGov with staff's
413-215-0061(5) Mandatory reporting completed training so that employees are alerted regarding required annual training.
(annually) that includes: Compliance in this area will be monitored during subsequent site visit.
(a) legal definition of child abuse ORS
419B.005, Oregon Laws 2016, chapter 106, The unannounced review was too close in proximity to the site review to determine
section 36 ongoing compliance in this area. Follow-up to be done on next review.
(b) legal responsibility to immediately report
(c) legal responsibility to report is personal to
the employee
One out of two established staff members did
not reflect completion of required annual
training in the following areas:
- Mandatory Reporting
CORRECTIVE ACTION: Ensure that
employees are receiving the required annual
training and the completed training is
appropriately documented in their respective
personnel file.
Children's Records Yes[ ] No The program has re-established this instruction through the county's Health and Human
Health Services Services. A representative from this agency provides this instruction to youth on a
413-215-0546 quarterly basis. Documentation of this instruction will be kept in the youth's respective
(2)(e) Documentation of age-appropriate files. Compliance in this area will be monitored in a subsequent site visit.
instruction - pregnancy prevention, nutrition,
prevention of HIV & AIDS, and prevention and Given there is no frequency requirement for this training and the close proximity to the site
treatment of sexually transmitted disease review, this item will be followed up on at the next review.

Confirmation regarding the documentation of
age-appropriate instruction could not be found
after the review of youth files.
CORRECTIVE ACTION: Create a process
where age-appropriate instruction in the areas
listed is documented in the youth's respective
files.
Consents Yes[ ] No The program confirmed via email dated 9/15/22, that this consent is located in the
413-215-0576(1) program's Voluntary Placement Agreement form that was revised on 8/11/22.
(a) Provide routine and emergency
medical care
Consent to provide routine and emergency
medical care could not be located in the
program's intake packet.
CORRECTIVE ACTION: Demonstrate that
this consent exists within the program's intake
process. If one does not exist, create, and
implement the required consent.
Authorizations Yes[ ] No The program's Assumption and Risk and Release of Liability form has been revised to
413-215-0576(3) include this authorization related to potentially hazardous activities. This form is available
(d) Activity specific authorizations are pre- in both English and Spanish.
approved to allow children to participate in
potentially hazardous activities, including but
not limited to using motorized yard equipment,
swimming, and horseback riding.
Authorization for pre-approved potentially
hazardous activities could not be found in the
youth files reviewed.
CORRECTIVE ACTION: Create an
authorization related to potentially hazardous
activities and ensure this authorization is
signed at the time of intake by the youth
and/or legal guardian.
Information about Children in Care Yes[ ] No The program's client face sheet has been modified to include religious preference as well
413-215-0581(1) Summary sheet contains as gender identity.
the following:

(a)The name, gender, date of birth, religious
preference, and previous address
There is no designated space to capture a
youth's religious preference on the youth's
summary sheet.
CORRECTIVE ACTION: Modify the existing
summary/face sheet to include religious
preference.
The program was advised to forward all Yes[ ] No The program has forwarded their most recent critical events to Licensing for review.
critical events documented in incident reports
to Licensing as required by rule effective
immediately. See related licensing rule for
reference.
413-215-0091 Licensing Umbrella Rules:
Responsibilities of Licensees (Amended
1/1/19)
A licensee is responsible to do all of the
following:
(11) Notify the Department in the following
circumstances:
(b) Within one business day if a critical event
occurs. As used in this section, "critical event"
means a significant event occurring in the
operation of a child-caring agency that is
considered likely to cause complaints,
generate concerns, or come to the attention of
the media, law enforcement agencies, first
responders, Child Protective Services, or
other regulatory agencies. Compliance with
this notification requirement does not satisfy
mandatory child abuse reporting requirements
under ORS 419B.005 to 419B.045.
The program provides a consent intake form Yes[ ] No As per an email sent on 8/19/22, the program has updated the Voluntary Placement
in Spanish for their monolingual Spanish Agreement and has had this intake packet translated into Spanish for monolingual,
speaking youth and families. A review of Spanish speaking guardians.
these Spanish forms indicate that some
information is missing and does not match the
English consent intake forms provided to
English speaking and/or bilingual youth and
families.
CORRECTIVE ACTION: Review the
translated forms and ensure the document

holds that same information that is provided to
English.
New Findings from Site Visit Comments
None

excerpt:
413-215-0091 Licensing Umbrella Rules:
Responsibilities of Licensees (Amended
1/1/19)
A licensee is responsible to do all of the
following:
(11) Notify the Department in the following
circumstances:
(b) Within one business day if a critical event
occurs. As used in this section, "critical event"
means a significant event occurring in the
operation of a child-caring agency that is
considered likely to cause complaints,
generate concerns, or come to the attention of
the media, law enforcement agencies, first
responders, Child Protective Services, or
other regulatory agencies. Compliance with
this notification requirement does not satisfy
mandatory child abuse reporting requirements
under ORS 419B.005 to 419B.045.
The program provides a consent intake form Yes[ ] No As per an email sent on 8/19/22, the program has updated the Voluntary Placement
in Spanish for their monolingual Spanish Agreement and has had this intake packet translated into Spanish for monolingual,
speaking youth and families. A review of Spanish speaking guardians.
these Spanish forms indicate that some
information is missing and does not match the
English consent intake forms provided to
English speaking and/or bilingual youth and
families.
CORRECTIVE ACTION: Review the
translated forms and ensure the document
holds that same information that is provided to
English.
New Findings from Site Visit Comments
None
None


state: OR

facility_name: Harkins House

summary: Unannounced - 1 finding

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Residential Care
Licensee: Washington County Juvenile Department – Harkins House
Shelter Manager: Anna Markovich
Juvenile Services Supervisor: Martha Villegas
Date of Unannounced: 10-03-2023
Licensing Coordinator: Todd Cooley
Other Regulatory or Accrediting Agencies: Oregon Department of Education (ODE), Oregon Health Authority (OHA), Oregon Department of
Human 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.
Previous Findings Repeat Comments
Unannounced Site Visit 12/13/2022 Findings
Further Action
Needed
Safety Yes No☐
413-215-0541
3)(a) Evacuation drill occurs monthly
Evacuation drills were not submitted for - Program still utilizing the older form that was missing space for special conditions
review and problems encountered. They are currently using the comments column to
document problems encountered. Recommended changing the title of the
CORRECTIVE ACTION: Submit a copy of comments column and adding special conditions.
evacuation drills for 2020 thru May of 2022. - Harkins House was missing a fire drill for July 2023
The program submitted drills for the last Corrective Action – Update fire drill form and provide a plan for consistently
licensing period Jan. 2020 – July 2022. The conducting monthly fire drills.
drill sheets were missing required information
as per the licensing rule to include special
conditions simulated and problems
encountered. In reviewing the drill sheets, the
1 |P ag e
Form Rev. 01/23/2023
program missed 3 monthly drills in 2020, 2
monthly drills in 2021 and 3 drills in 2022.
On 9/1/22, the program emailed a revised
version of the fire drill sheets to include
conditions simulated and problems
encountered. In an attempt to ensure that the
drills are completed on a monthly basis, the
evacuation sheets have been prefilled with
each month as a reminder for the drills to be
completed on a regular basis.
During the unannounced the evacuation drills
were reviewed and there was no
documentation of a drill being conducted in
November 2022
-Repeat finding
New Findings from Site Visit Comments
No new findings.
Interview Summary
Two clients were interviewed during the unannounced visit and both had been at the program for 4-5 months. The first client was discharging the following
day after having completed the program successfully and was returning to their family. The client was not very talkative but stated they thought the program
was helpful in providing them the tools to succeed when returning home. They felt safe and comfortable during their time in the program. They received
plenty to eat and said there are always seconds available and snacks throughout the day. Client was able to earn 6 credits towards school which helped them
start to catch up for when they returned to public school. They had plenty of time to use the phone to contact family and earned progressively longer visits
with family from visits to day passes to overnight passes to weekend passes. Client stated they felt the groups were really good and they did a good job
overall of running the program.
The other client interviewed was having a discharge meeting and would be exiting the program to home in 2-3 weeks. They had the same opportunities to
earn progressively longer visits and routinely went on weekend passes. Client felt like they had input into their treatment and was aware of their goals. They
stated school was really good and it was easy to get caught up on credits there. Client said all of the staff are nice and they feel comfortable talking with them
if they have concerns. Client also stated the food was good and said seconds were available as well as fruit for snacks throughout the day. Client felt like
they did a lot more outings over the summer going to places like the pool, park and museums, but have not done as much since school started. They said
they get daily rec where they can go outside and play basketball or volleyball. Client also participated in the co-op program they have with a local farm. Client
was able to earn money and work off community service hours all while learning about farm operations. Client said the farm plants and harvests a lot of
2 |P ag e
Form Rev. 01/23/2023
produce. Client said they get plenty of phone calls and time to talk with family. Client stated staff manage the program really well and specifically thought the
case managers were really good.
Observations
Overall the program was in good condition and repair. Some of the cleaning that was the responsibility of the clients needed some work. The floors of the
visiting room had crumbs and wrappers from youth eating in that area and not cleaning up. The trash bins in both bathrooms were overflowing with paper
towels and need to be changed out. The bathrooms were clean, but messy. The kitchen, classroom, bedrooms and other common areas all looked
presentable and clean.
There were no concerns noted or new licensing violations found during the visit.
Corrective Actions and Timeframes:
Please submit the following to verify compliance.
Within 45 days of receipt of this report Washington County Juvenile Harkins House 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@odhsoha.oregon.gov
Licensing Coordinator’s Signature: ________________________ Date: _1_0_-_0_4_-2__0_2_3_________
Manager Review: ______________________________________ Date: _1_0_-_4_-2_0_2_3_ _________
3 | P a g e
Form Rev. 01/23/2023

agency_name: Washington Cty. Juvenille Dept. (WCJD)

program_name: Harkins House

program_type: (RC) Residential Care Programs

view_code: RC

facility_type: Residential Care

licensee: Washington County Juvenile Department - Harkins House Shelter Manager: Anna Markovich Juvenile Services Supervisor: Martha Villegas

licensing_coordinator: Todd Cooley

purpose:
Per OAR 419-400-0240 (1)(b) Children's Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Comments
Unannounced Site Visit 12/13/2022 Findings
Further Action
Needed
Safety Yes No[ ]
413-215-0541
3)(a) Evacuation drill occurs monthly
Evacuation drills were not submitted for - Program still utilizing the older form that was missing space for special conditions
review and problems encountered. They are currently using the comments column to
document problems encountered. Recommended changing the title of the
CORRECTIVE ACTION: Submit a copy of comments column and adding special conditions.
evacuation drills for 2020 thru May of 2022. - Harkins House was missing a fire drill for July 2023
The program submitted drills for the last Corrective Action - Update fire drill form and provide a plan for consistently
licensing period Jan. 2020 - July 2022. The conducting monthly fire drills.
drill sheets were missing required information
as per the licensing rule to include special
conditions simulated and problems
encountered. In reviewing the drill sheets, the

program missed 3 monthly drills in 2020, 2
monthly drills in 2021 and 3 drills in 2022.
On 9/1/22, the program emailed a revised
version of the fire drill sheets to include
conditions simulated and problems
encountered. In an attempt to ensure that the
drills are completed on a monthly basis, the
evacuation sheets have been prefilled with
each month as a reminder for the drills to be
completed on a regular basis.
During the unannounced the evacuation drills
were reviewed and there was no
documentation of a drill being conducted in
November 2022
-Repeat finding
New Findings from Site Visit Comments
No new findings.
Interview Summary
Two clients were interviewed during the unannounced visit and both had been at the program for 4-5 months. The first client was discharging the following
day after having completed the program successfully and was returning to their family. The client was not very talkative but stated they thought the program
was helpful in providing them the tools to succeed when returning home. They felt safe and comfortable during their time in the program. They received
plenty to eat and said there are always seconds available and snacks throughout the day. Client was able to earn 6 credits towards school which helped them
start to catch up for when they returned to public school. They had plenty of time to use the phone to contact family and earned progressively longer visits
with family from visits to day passes to overnight passes to weekend passes. Client stated they felt the groups were really good and they did a good job
overall of running the program.
The other client interviewed was having a discharge meeting and would be exiting the program to home in 2-3 weeks. They had the same opportunities to
earn progressively longer visits and routinely went on weekend passes. Client felt like they had input into their treatment and was aware of their goals. They
stated school was really good and it was easy to get caught up on credits there. Client said all of the staff are nice and they feel comfortable talking with them
if they have concerns. Client also stated the food was good and said seconds were available as well as fruit for snacks throughout the day. Client felt like
they did a lot more outings over the summer going to places like the pool, park and museums, but have not done as much since school started. They said
they get daily rec where they can go outside and play basketball or volleyball. Client also participated in the co-op program they have with a local farm. Client
was able to earn money and work off community service hours all while learning about farm operations. Client said the farm plants and harvests a lot of

produce. Client said they get plenty of phone calls and time to talk with family. Client stated staff manage the program really well and specifically thought the
case managers were really good.
Observations
Overall the program was in good condition and repair. Some of the cleaning that was the responsibility of the clients needed some work. The floors of the
visiting room had crumbs and wrappers from youth eating in that area and not cleaning up. The trash bins in both bathrooms were overflowing with paper
towels and need to be changed out. The bathrooms were clean, but messy. The kitchen, classroom, bedrooms and other common areas all looked
presentable and clean.
There were no concerns noted or new licensing violations found during the visit.

new_findings: No new findings.

excerpt:
413-215-0541
3)(a) Evacuation drill occurs monthly
Evacuation drills were not submitted for - Program still utilizing the older form that was missing space for special conditions
review and problems encountered. They are currently using the comments column to
document problems encountered. Recommended changing the title of the
CORRECTIVE ACTION: Submit a copy of comments column and adding special conditions.
evacuation drills for 2020 thru May of 2022. - Harkins House was missing a fire drill for July 2023
The program submitted drills for the last Corrective Action - Update fire drill form and provide a plan for consistently
licensing period Jan. 2020 - July 2022. The conducting monthly fire drills.
drill sheets were missing required information
as per the licensing rule to include special
conditions simulated and problems
encountered. In reviewing the drill sheets, the
program missed 3 monthly drills in 2020, 2
monthly drills in 2021 and 3 drills in 2022.
On 9/1/22, the program emailed a revised
version of the fire drill sheets to include
conditions simulated and problems
encountered. In an attempt to ensure that the
drills are completed on a monthly basis, the
evacuation sheets have been prefilled with
each month as a reminder for the drills to be
completed on a regular basis.
During the unannounced the evacuation drills
were reviewed and there was no
documentation of a drill being conducted in
November 2022
-Repeat finding
New Findings from Site Visit Comments
No new findings.
No new findings.


summary: Unannounced - 1 finding

raw_content:
Licensed Child Caring Agency Unannounced Site Visit Report
Residential Care
Licensee: Washington County Juvenile Department – Harkins House
Juvenile Services Director: Ray Cameron
Residential Manager: Anna Markovich
Date of Unannounced: February 29, 2024
Licensing Coordinator: Todd Cooley
Other Regulatory or Accrediting Agencies: Oregon Department of Education (ODE), Oregon Health Authority (OHA), Oregon Department of
Human 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.
Previous Findings Repeat Comments
Unannounced Site Visit 12/13/2022 Findings
Further Action
Needed
Safety Yes☐ No✓
413-215-0541
3)(a) Evacuation drill occurs monthly
The fire drill log was reviewed. Drills were consistently conducted in the time
CORRECTIVE ACTION:
since the last unannounced visit. The fire drill log was complete and included all
required information.
Corrective Action – Update fire drill form to
include special conditions/problems
encountered, and provide a plan for
consistently conducting monthly fire drills.
New Findings from Site Visit Comments
No new findings.
1 | P age
Form Rev. 01/23/2023
Interview Summary
During the course of the unannounced visit two clients were interviewed about their experience at Harkins House. Neither client had any prior experience with
other programs and based their comments solely on Harkins House.
- Harkins House was comfortable and safe.
- Staff were nice and fair. One stated their case manager was the first person to actually listen and believe them.
- Food is great and enjoyed the opportunity to learn some culinary skills while prepping and cooking meals.
- School is good and credits have been much easier to catch up on than while in public school.
- Daily phone calls with plenty of time to talk with those on approved list.
- Lots of basketball and outside rec each day. Harkins has an outdoor covered area for basketball/volleyball and other activities.
- Groups have been good helping to reach out to individuals.
- Would like more time for “rec” outside of the program such as walks.
- Felt staff could communicate better when consequences are given; have additional conversations around why there was a consequence.
- Appreciated there was a lot of 1:1 time with staff for those clients who are struggling.
- Staff really care and were okay staying late to help out clients instead of just passing on to the next shift.
- One client stated they came in with an attitude, but did a 180 and really embraced the program and help being provided.
Observations
Overall, the program was in good condition and repair. Some of the cleaning that was the responsibility of the clients again needed some work, but I was
informed I had arrived just prior to client “chores”, which included tidying up the restrooms. The kitchen, classroom, bedrooms and other common areas all
looked presentable and clean.
There was some ongoing HVAC work being done and it is close to completion. The skylights had also been repaired since the last visit.
There were no concerns noted or new licensing violations found during the visit.
Corrective Actions and Timeframes:
Please submit the following to verify compliance.
Within 45 days of receipt of this report Washington County Juvenile Harkins House 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@odhsoha.oregon.gov
Licensing Coordinator’s Signature: ________________________ Date: _0_3_-1_1_-_2_0_2_4__________
Manager Review: ______________________________________ Date: _2_-8_-_2_0_2_4___________
2 | P age
Form Rev. 11/14/2023

licensee: Washington County Juvenile Department - Harkins House

visit_date: February 29, 2024

purpose:
Per OAR 419-400-0240 (1)(b) Children's Care Licensing is required to perform at least one unannounced site visit a year where children
in care reside.
Previous Findings Repeat Comments
Unannounced Site Visit 12/13/2022 Findings
Further Action
Needed
Safety Yes[ ] No✓
413-215-0541
3)(a) Evacuation drill occurs monthly
The fire drill log was reviewed. Drills were consistently conducted in the time
CORRECTIVE ACTION:
since the last unannounced visit. The fire drill log was complete and included all
required information.
Corrective Action - Update fire drill form to
include special conditions/problems
encountered, and provide a plan for
consistently conducting monthly fire drills.
New Findings from Site Visit Comments
No new findings.

Interview Summary
During the course of the unannounced visit two clients were interviewed about their experience at Harkins House. Neither client had any prior experience with
other programs and based their comments solely on Harkins House.
- Harkins House was comfortable and safe.
- Staff were nice and fair. One stated their case manager was the first person to actually listen and believe them.
- Food is great and enjoyed the opportunity to learn some culinary skills while prepping and cooking meals.
- School is good and credits have been much easier to catch up on than while in public school.
- Daily phone calls with plenty of time to talk with those on approved list.
- Lots of basketball and outside rec each day. Harkins has an outdoor covered area for basketball/volleyball and other activities.
- Groups have been good helping to reach out to individuals.
- Would like more time for "rec" outside of the program such as walks.
- Felt staff could communicate better when consequences are given; have additional conversations around why there was a consequence.
- Appreciated there was a lot of 1:1 time with staff for those clients who are struggling.
- Staff really care and were okay staying late to help out clients instead of just passing on to the next shift.
- One client stated they came in with an attitude, but did a 180 and really embraced the program and help being provided.
Observations
Overall, the program was in good condition and repair. Some of the cleaning that was the responsibility of the clients again needed some work, but I was
informed I had arrived just prior to client "chores", which included tidying up the restrooms. The kitchen, classroom, bedrooms and other common areas all
looked presentable and clean.
There was some ongoing HVAC work being done and it is close to completion. The skylights had also been repaired since the last visit.
There were no concerns noted or new licensing violations found during the visit.

excerpt:
413-215-0541
3)(a) Evacuation drill occurs monthly
The fire drill log was reviewed. Drills were consistently conducted in the time
CORRECTIVE ACTION:
since the last unannounced visit. The fire drill log was complete and included all
required information.
Corrective Action - Update fire drill form to
include special conditions/problems
encountered, and provide a plan for
consistently conducting monthly fire drills.
New Findings from Site Visit Comments
No new findings.
No new findings.