Child Caring Agencies and Facilities

5933+++05/11/2023+++TerrDCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: ______Crossroads___________________________________________________ TIME OF VISIT (FROM - TO): __________________________ DATE: ___5-11-23_______________ AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: Program Director List of Areas / Topics covered during visit: • Census - 8 - However one youth was scheduled to be discharged on 5-12-23 and another was possibly leaving the following week. The program had a new (male) admission. One of the female residents has remained out of the program for several weeks. • Other residents are in various levels of program compliance. • There are currently 2 staff openings however 2 additional staff positions have been added. Currently looking to fill 4 positions. • Both apartments had an ample supply of food. Refrigerators/freezers and cabinets all had food items. It was recommended that secure containers be purchased for flour, sugar, cereal, etc. as this may help improve organization and cleaner storage of the items. • The curtain rods in one bedroom were bent (Girl's apt.). In another bedroom curtains were help up by push pins. • The door frame in one bedroom was cracked (Girl's apt.). A repair order has reportedly been submitted. • One of the bedrooms in the girl's apartment is small in size (one half of a divided larger room) and is significantly cluttered due to many belongings and limited storage area. • The bathroom in the boy's apartment was in need of painting. • Several youth were observed in the program. • The involvement by DCF Licensing will end (June 2023) with the conversion to a SILS program. Corrective Actions implemented as a result of previous visit: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Areas of regulatory non-compliance identified during this visit: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Terri Bohara 5-19-23 ______________________________ _________________ Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5919+++03/15/2023+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: ____Crossroads _____________________________________________ TIME OF VISIT (FROM - TO): __________________________ DATE: ___3-15-23_______________ AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title JB Program Director List of Areas / Topics covered during visit: • Census - 7. A couple referrals were received but did not result in placements. • There is one part time staff opening. Existing staff have been picking up open shifts. A full-time staff will be going out on maternity leave. • The program TLC's are currently organizing the Life skills groups. Written Monthly reports have reportedly improved however overall documentation that captures programming and contacts with residents continues to be a challenge, but staff continue to work on it. • A stone facade has been installed around the lower portion of the house. • Security cameras have been installed around the exterior of the house with additional cameras to be added. The cameras cover most of the area around the outside of the house. The recording feature has not been set up yet. The monitor for the cameras is in the staff office. • "Panic" buttons have also been purchased for the house. The buttons are on a lanyard and can be worn around the neck. If pushed for approx. 3 seconds they will automatically connect to the police department. • A room on the main floor has been set up with 3 computers for residents. • Two residents are reportedly rarely at the program. They are spending time at the homes of friends and do not participate in the program offerings. • One resident will turn 22 this year. Two residents will be turning 21 this year. • Walk through of apartments. • The kitchens in the girl's apartment were in need of cleaning. The refrigerator had food spills and uncovered food in it. The microwave had food splatter on the surfaces. Dirty dishes were in the sink area. The freezer and refrigerator were full of food items. • Several bedrooms in the girl's apartment had piles of clothing, some clean, some dirty. One room had very little open space due to clutter (clothing). There was evidence of food in the bedrooms. Beds were not made, and trash cans were full. One resident was present. • The bathroom in the girl's apartment had a dirty toilet and sink top. Bathroom rugs were in need of washing. • The walls in the boy's apartment were "scuffed" up and dirty in several locations. • The toilet and bathroom carpets in the boy's bathroom were dirty. • The refrigerator and freezer had food items. • Floors throughout both apartments were in need of cleaning. • One of the bedrooms in the boy's apartment had clothing scattered and piled throughout the room. There was also a pile of clothing. There was a foul odor in the room. • Both apartments were dark with little natural light in areas. According to the PD residents prefer to keep bedrooms and other areas dark. • A chore list is posted that identifies what is expected of residents in each room of the apartments. Corrective Actions implemented as a result of previous visit: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Areas of regulatory non-compliance identified during this visit: Section 17a-145-64. Personnel policies and procedures. • Four staff do not have current CPR certification. • Five staff do not have current restraint training certification. Section 17a-145-73. Sleeping accommodations. • Bedrooms in the girl's apartment had clothing piled up and on the floor. One bedroom in particular had very little open space available. • Evidence of food and food containers were observed in the bedrooms in the girl's apartment. • One bedroom in the boy's apartment had clothing on the floor and piled in a basket. The room had a foul odor (dirty clothing). • Trash cans in several rooms were full and in need of emptying. Section 17a-145-74. Lavatory facilities. Toilet articles and linens. • The sink and toilet in the girl's bathroom were dirty and in need of cleaning. • The toilet in the boy's bathroom was dirty and in need of cleaning. • Bathroom rugs in both apartments were dirty and in need of washing. Section 17a-145-76. Kitchens, equipment, food handling. • The refrigerator and freezer in the girl's apartment had food spills and was in need of cleaning. • The microwave in the girl's apartment was dirty with food splatter and in need of cleaning. • The floors in the kitchen were in need of cleaning. • The walls in the boy's apartment (kitchen and hallway) were marked with "scuff" marks and food spills. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Terri Bohara 3-17-23 ______________________________ _________________ Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5834+++11/29/2022+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: ____Crossroads_____________________________________________________ TIME OF VISIT (FROM - TO): __________________________ DATE: ___11-29-22_______________ AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: JD - Program Director L R-P - Sr. Director Community Services List of Areas / Topics covered during visit: • Current census is 8. Both apartments are full. • There are 2 full-time TLC positions open. Open shifts are being covered by per diem staff. The PD indicated that holiday coverage was not a concern. Four staff still need restraint training (HWC). • PP was out for approx. a month and just recently returned. During that time the PD covered her responsibilities. • Discussion regarding the process for obtaining groceries for residents. Residents are given a Walmart gift card for $120 every other week for groceries. Shopping trips to Walmart are every other week however if residents run out of items additional gift cards are provided and staff will assist with getting additional items and transportation. • There is a Community dinner every Sunday prepared by staff. Sometimes staff will do "take-out" as an alternative. Staff maintain an activity calendar for the residents. • Cleaning supplies are purchased weekly (approx.) by staff. A downstairs closet had an ample supply. • Feminine hygiene products are kept by individual residents in addition to a supply on the main floor of the house. • Areas of the house have been cleaned out to allow for additional storage. It was suggested that storage totes be provided to residents to alleviate some of the clutter in individual bedrooms. It was also recommended that lock boxes be provided to residents to secure valuable items. • Staff meetings are reportedly being held monthly while resident meetings are being held weekly. • Tour of apartments. There was ample food in both apartments. Residents from both apartments interviewed. There was a range of both cooking abilities and interest in meal preparation. It was suggested that staff take a more active role in making sure that residents are purchasing a more well rounded diet (less processed foods and more fruits and vegetables). Staff should also assist with menu planning and shopping lists. • Suggested revisions to the program manual were provided. Corrective Actions implemented as a result of previous visit: • The wooden porch railings have been replaced with new (secure)vinyl railings. • The stairs leading to the back parking lot have been redone. The new stairs are newly surfaced and level. • The flooring in the boy's bathroom has been repaired. Areas of regulatory non-compliance identified during this visit: Section 17a-145-64 Personnel policies and procedures. • Not all staff have completed required training/re-certifications. Currently there are 6 staff who need to be certified in CPR and 6 staff who need to be certified in Handle with Care. Please submit a service development plan to address the above referenced areas of non-compliance within 30 days of receipt of this report. The service development plan must be submitted to the attention of the undersigned at the address listed above. Terri Bohara 12-9-22 ______________________________ _________________ Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5748+++07/13/2022+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: ____Crossroads_____________________________________________________ TIME OF VISIT (FROM - TO): _____Morning/Afternoon___________DATE: _____7-13-22_____________ AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: JB - Program Director LR - Senior Director PP - Vocational/Educational AP - DCF (QA) List of Areas / Topics covered during visit: • Census is 7. There have been several new admissions. • The program has been able to fill several staff positions and is close to being fully staffed. This has allowed the PD and Educational/Vocational specialist to focus on the responsibilities of their positions and address issues that have been identified. • A review of 3 personnel files was conducted on 7-6-22. One file did not have an indication that the employee received the Personnel policies. All three files did not contain documentation of CPR certification or completed restraint training. • Weekly/Monthly schedules have been developed and staff and house meetings have been added on an ongoing basis. Activities are scheduled by staff with input from residents. They are working on diversifying the activities. • The request for bond monies has been submitted to DCF and is awaiting approval. • Work continues on formalizing a QA process so that documentation is reviewed on a regular basis to assure that timelines and requirements are met. • As of 8-1-22 the house will transition to age 18 and over. • No physical plant repairs have been made since the last visit. A contractor hired by the agency had to stop temporarily due to medical issues. • Templates to document contact between the agency and DCF and staff/client contacts have been developed. Currently the program meets the monthly contact requirement (Monthly reports) and the quarterly reports (treatment plans). • Completion of LIST assessments for new admissions as well as ongoing assessments continue. The program is attempting to address a different domain each month. • Two residents are working in the community. One had an interview. Two of the male residents are not working or seeking employment. • A review of the case record for a newly admitted resident. The placement agreement and the admission information (family/medical/social) were in the record. • Blinds were being installed in the bedroom of one resident during the visit. One resident did not have an air conditioner in his room. A follow up email was sent to ask that one be installed prior to an expected heat wave if not done already. It is to be installed on 7-19-22. Corrective Actions implemented as a result of previous visit: • Blinds have been installed in the resident's bedroom. Areas of regulatory non-compliance identified during this visit: Section 17a-145-63 Chief administrative officer. • The porch railing and the lead abatement have not been completed. A request for bond monies has been submitted to the department. Section 17a-145-64 Personnel policies and procedures. • Three files were reviewed on 7-6-22. • All three files did not have documentation of CPR certification. • All three files did not have documentation of restraint training (certification). • One file did not have documentation of receipt of the personnel policies. Section 17a-145-73. Sleeping accommodations. • The hole in the bedroom wall (girls apt.) has not yet been repaired. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Terri Bohara 7-19-22 ______________________________ _________________ Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5747+++06/13/2022+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: ______Crossroads___________________________________________________ TIME OF VISIT (FROM - TO): _____Afternoon_________DATE: _____6-13-22_____________ AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: JB - Program Director List of Areas / Topics covered during visit: • Census - 5 • Two staff have started, one is pending and one is waiting on background checks. The program is down 3 staff. The goal is to have 3 more staff med certified by the end of the month. Risking connections will be starting in July for 6 weeks (3 hrs/virtual). Handle With Care training will start once the new staff come on board. • All treatment plans have reportedly been done but documentation regarding contact with DCF and sending of the treatment plans is not being fully captured. • The List assessments are being done and some have been completed. One resident refuses to cooperate and the one on the new resident is in the process. • The PD confronted one resident on the front porch (holding a bottle of wine and a "bong"). He turned over the bottle of wine but left with the "bong". • The Educational/Vocational specialist has a new schedule (Sunday-Thursday). She is now focusing more on the educational/vocational issues of the residents. • Physical plant tour. There is a hole in the wall in one of the bedrooms in the girl's apartment (off of the kitchen). The recently vacated room was in need of cleaning. A new couch was purchased for the girl's apartment and a love seat for the boy's apartment. A broken chair remains in the boy's apartment. Beds in a couple of the bedrooms in the boy's apartment did not have sufficient bed linens (missing pillowcase/sheets). There were broken blinds in one bedroom. The stairs to the front porch area have nails popping up. A side railing on the porch is loose and there is evidence of rotting wood. The cement top coat on stairs leading to the parking lot is coming off. • A (virtual) meeting was held on 6-29-22 to discuss ongoing concerns at the program. In attendance were DCF representatives (Ted Sanford; Skye Garafalo; Amita Patel; Terri Bohara) and Access Agency representatives (Peter DiBiasi; Luis Perez; Jolene Berard). Topics included insufficient funding/lack of funding increases; staff roles; documentation requirements; physical plant issues; scheduling; program expectations for staff and residents; the program operational manual, admissions into the program and the impact that Covid and staffing shortages have had on the program. It was agreed that the cost estimates for identified repairs would be submitted to the department for possible bond monies approval. It was also agreed that the department would prioritize areas to be addressed in order to focus the program efforts as well as establish time lines for completion/submission. Corrective Actions implemented as a result of previous visit: • See note above regarding efforts made by the agency/staff to address issues. Areas of regulatory non-compliance identified during this visit: Section 17a-145-63 Chief administrative officer. • The nails on the side porch steps are popping up. • A side railing on the porch is loose and the wood is rotted in spots. • The cement covering the back steps (leading to the parking area) is flaking off. Section 17a-145-73 Sleeping accommodations. • There is a hole in the wall of one of the bedrooms (girls apartment). • There was insufficient bed linens in two bedrooms (missing pillow case/sheets). • Broken blinds in one bedroom. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Terri Bohara 7-8-22 ______________________________ _________________ Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5693+++04/19/2022+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM:____Crossroads______ TIME OF VISIT (FROM - TO): ________ DATE: __4-19-22________________ AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: JB - Program Director List of Areas / Topics covered during visit: • Sufficient staffing remains a concern. There are approx. 3 staff openings. Current staff (including per diem staff) are covering. Contract negotiations are currently occurring. • Census - 3 boys with another admission planned for 4/21/22. Two girls with no pending admissions. • Bedrooms in the girl's apartment had clothing on the floor and food (partially eaten) with one resident leaving items throughout the living room. • The girl's apartment had a strong odor of marijuana. The lone resident acknowledged use. A lighter and rolling papers were removed by the PD. • The sub flooring in the boy's bathroom shows signs of possible rot (soft/springy when stepped on. • There were no pillow cases on pillows in one residents room. The resident reported he washes his pillows infrequently and prefers not using pillow cases. • A broken full length mirror was removed from the girls bathroom by the PD. • Review of MAR for one client. There were multiple days where medication was not given (no notation). • On 4-11-22 there was a notation that "No PM meds - no med cert staff". • Three staff did not countersign full signatures on the back of the MAR to identify corresponding initials. Corrective Actions implemented as a result of previous visit: • New couches have been purchased for both apartments. • Kitchen counter (new facing) has been repaired in the kitchen in the boy's apartment. • Rooms in both apartments have been painted. A hole in the wall (Bedroom in girl's apt.) still needs to be repaired. • All but 2 staff are reportedly now trained in CPR. • All but 1 staff have now completed Handle with Care. • The sink in the girls bathroom has been replaced. Areas of regulatory non-compliance identified during this visit: Section 17a-145-73 Sleeping accommodations. • Bedrooms in the girl's apartment had clothing on the floor and food in the rooms. • There was a hole in the wall in one of the bedrooms in the girl's apartment. Section 17a-145-74. Lavatory facilities. Toilet articles and linens. • The sub-flooring in the boy's bathroom is showing signs of possible rot. The floor does not solidly support weight (Spongey in areas) and the linoleum is coming up in places. Section 17a-145-75. Health and medical treatment. Administration of first aid. Prescription medication. Administration of medicine or treatment. Written records. Storage of drugs, medicines and instruments. Sick room, telephone. • A review of an MAR for no corresponding signatures for initials of staff. • The MAR noted that on 4-11-22 no PM meds were administered because there were no med cert staff. • There days in which no meds were given and there was no notation indicating the reason. Please submit a service development plan to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Terri Bohara 4-22-22 ______________________________ _________________ Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

5967+++06/26/2023+++Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Esther House TIME OF VISIT (FROM - TO): 1:00 pm to 2:30 pm DATE: 6/26/2023 AGENCY PERSONNEL WHO PARTICIPATED: Job Title Esther House Direct Care Staff List of Areas / Topics covered during visit: • Discussion of the current census, which is 1, and the LBC for Esther House is 4. • Discussion of Esther House's current staffing levels, vacant positions, and hiring activities. • Discussion with Esther House staff regarding the status of Esther House's milieu, the clinical programming, and summer activities for the residents. • Inspection of the Esther House physical plant to assess the cleanliness of the home, as well as to ensure there are no health or safety concerns. Corrective Actions implemented as a result of previous visit: • Not applicable. Areas of regulatory non-compliance identified during this visit: • None at the time of this quarterly visit. Patrick Hughes 6/26/23 Regulatory Consultant Date|5891+++03/15/2023+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Esther House TIME OF VISIT (FROM - TO): 12:45 pm to 1:45 pm DATE: 3/15/2023 AGENCY PERSONNEL WHO PARTICIPATED: Job Title Adelbrook Director of Group Homes Esther House Supervisor List of Areas / Topics covered during visit: • Discussion of the current census, which is 2, with 1 resident currently hospitalized and the LBC for Esther House is 4. • Discussion of Esther House's current staffing levels, vacant positions, and hiring activities. • Discussion with Esther House staff regarding the status of Esther House's milieu, the clinical programming, and activities for the residents. • Observations and discussion with the 1 resident home at the time of this quarterly visit, and observations of the interactions between Esther House staff and the Esther House resident. • Inspection of the Esther House physical plant to assess the cleanliness of the home, as well as to ensure there are no health or safety concerns. Corrective Actions implemented as a result of previous visit: • Not applicable. Areas of regulatory non-compliance identified during this visit: • None at the time of this quarterly visit. Patrick Hughes 3/21/23 Regulatory Consultant Date|5868+++12/28/2022+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Esther House TIME OF VISIT (FROM - TO): 3:30pm DATE: 12/28/2022 AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title ND Director of Group Homes NY Esther House co-supervisor List of Areas / Topics covered during visit: • Current census is 2 and the licensed bed capacity is 4. One resident is currently hospitalized. There was one discharge this quarter to a DMHAS program. There is one pending referral for Esther House. • The one resident currently in Esther House is doing well and preparing to discharge home to her mother. • Currently Esther House is fully staffed with no vacant positions. • Observation of the residents in the milieu; The one resident home was having free time at the time of the visit. The Esther resident reported to be doing well and is very excited to be discharging home in the next few weeks. She reported the Esther House staff are nice to her and treat her well. • Physical plant inspection of the facility; Esther House was clean, organized and nicely decorated with no health or safety concerns observed. Corrective Actions implemented as a result of previous visit: • Not applicable Areas of regulatory non-compliance identified during this visit: • None at the time of this quarterly visit. Patrick Hughes 2/8/2023 Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5820+++09/26/2022+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Esther House TIME OF VISIT (FROM - TO): 1:00pm DATE: 9/26/2022 AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title ND Director of Group Homes NY Esther House co-supervisor List of Areas / Topics covered during visit: • Current census is 3 and the licensed bed capacity is 4. One resident who was briefly hospitalized (5days) has returned to Esther House. • The residents of Esther House are doing well individually and as a group. The girls are out in the community often and have recently attended the Big E, the Durham Fair, and the Bristol Mum Fair. • Currently Esther House is fully staffed with no vacant positions. • Physical plant inspection of the facility; Esther House was clean, organized and nicely decorated with no health or safety concerns observed. • Observation of the residents in the milieu; two residents were home at the time of this quarterly visit. Both girls reported they were doing well and reported the staff at Esther House are nice. One resident reported she recently had her senior pictures taken and was very excited about this. Both residents appeared comfortable in their surrounding and all interactions between the staff and residents were friendly and professional. Corrective Actions implemented as a result of previous visit: • Not applicable Areas of regulatory non-compliance identified during this visit: • None at the time of this quarterly visit. Patrick Hughes 9/26/22 Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5728+++06/01/2022+++June 6, 2022 Alyssa Goduti / President & CEO Adelbrook Community Services Inc. 60 Hicksville Road Cromwell, CT 06416 RE: CCF # 88 Esther House Dear Ms. Goduti, We conducted a relicensing visit of your agency's program on June 1, 2022. This inspection determined your agency's program is in compliance with the Regulations for the Operation of Child Caring Agencies and Facilities; Sections 17a-145-48 through 17a-145-98, as well as DCF Guidelines for the Administration of Medication by Certified Staff. The Department has determined that your agency has met the requirements for a regular license. This license is effective as of August 16, 2022 and is valid for twenty-four months. We thank you and your staff for your cooperative participation in the review process. Sincerely, Patrick Hughes Patrick Hughes Regulatory Consultant Department of Children and Families 505 Hudson Street Hartford, CT 06106 (p) 860-550-6552 (f) 860-550-6665 patrick.hughes@ct.gov|5667+++03/16/2022+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Esther House TIME OF VISIT (FROM - TO): 2:00pm DATE: 3/16/2022 AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title ND Director of Group Homes NY Esther House co-supervisor PW Esther House co-supervisor List of Areas / Topics covered during visit: • Current census is 3 and the licensed bed capacity is 5. One resident is currently hospitalized, but it is anticipated that she will return to Esther House this Friday. • Discussed progress of the 3 Esther House residents and the status of the Esther House milieu. • Discussed Esther House employment vacancies and hiring updates. • Discussed the lessening of covid-19 restrictions and activities scheduled for the residents. • Physical plant inspection of the facility; no health or safety concerns observed. • Observation of the residents in the milieu; one resident was home from school and was napping in her room and was not disturbed. A second resident returned from school and briefly said hello to this worker before meeting with an Esther House staff. Corrective Actions implemented as a result of previous visit: • Not applicable Areas of regulatory non-compliance identified during this visit: • None at the time of this quarterly visit. Patrick Hughes 3/25/22 Regulatory Consultant Date|

5973+++08/02/2023+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Potter House TIME OF VISIT (FROM - TO): 2:45 pm to 4:00 pm DATE: August 2, 2023 AGENCY PERSONNEL WHO PARTICIPATED: Job Title Adelbrook Director of Group Homes Potter House Supervisor List of Areas / Topics covered during visit: • Discussion of the current census (4), and the LBC is 4. • Discussion of Potter House's current staffing levels, vacant positions, and hiring activities. • Discussion with Potter House staff regarding the status of Potter House's milieu, the clinical programming, and summer activities for the residents. • Observations and conversation with Potter House residents and observations of the interactions between Potter House staff and the Potter House residents. • Inspection of the Potter House physical plant to assess the cleanliness of the home, as well as to ensure there are no health or safety concerns. Corrective Actions implemented as a result of previous visit: • Not applicable. Areas of regulatory non-compliance identified during this visit: • None at the time of this quarterly visit. Patrick Hughes 8/8/23 Regulatory Consultant Date|5928+++05/08/2023+++May 15, 2023 Alyssa Goduti / President & CEO Adelbrook Community Services Inc. 60 Hicksville Road Cromwell, CT 06416 RE: CCF # 66 Potter House Dear Ms. Goduti, We conducted a relicensing visit of your agency's program on May 8th and May 10th. This inspection determined your agency's program is in compliance with the Regulations for the Operation of Child Caring Agencies and Facilities; Sections 17a-145-48 through 17a-145-98, as well as DCF Guidelines for the Administration of Medication by Certified Staff. The Department has determined that your agency has met the requirements for a regular license. This license is effective as of June 20, 2023, and is valid for twenty-four months. We thank you and your staff for your cooperative participation in the review process. Sincerely, Patrick Hughes Patrick Hughes Regulatory Consultant Department of Children and Families 505 Hudson Street Hartford, CT 06106 (p) 860-550-6552 (f) 860-550-6665 patrick.hughes@ct.gov|5890+++03/15/2023+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Potter House TIME OF VISIT (FROM - TO): 3:10 pm 4:15pm DATE: 3/15/2023 AGENCY PERSONNEL WHO PARTICIPATED: Job Title Adelbrook Director of Group Homes Potter House Supervisor Potter House Direct Care Worker List of Areas / Topics covered during visit: • Discussion of the current census which is 3 and the LBC is 4. • Discussion of Potter House's current staffing levels, vacant positions, hiring activities. • Discussion with Potter House staff regarding the status of Potter House's milieu, and the clinical programming and activities for the residents. • Observations and discussions with the 3 residents of Potter House, and observations of interactions between the residents as well as the interactions between Potter House staff and residents. • Inspection of the Potter House physical plant to assess the cleanliness of the home, as well as to ensure there are no health or safety concerns. Corrective Actions implemented as a result of previous visit: • Not applicable. Areas of regulatory non-compliance identified during this visit: • None at the time of this quarterly visit. Patrick Hughes 3/20/23 Regulatory Consultant Date|5862+++12/28/2022+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Potter House TIME OF VISIT (FROM - TO): 3:30 pm DATE: 12/28/2022 AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title ND Adelbrook Director of Group Homes List of Areas / Topics covered during visit: • Current census is 1 and the licensed bed capacity is 4. There are 2 current referrals for Potter House, one referral is currently at the Adelbrook residential program, while the other is currently at Susan Wayne Center. Once their school placements have been finalized admission dates can be scheduled. • The lone resident at the Potter House group home is doing well. For clinical services and recreation activities the Potter House resident joins with the 2 other Adelbrook Group Homes. • Potter House currently has a good level of staffing. There are two fulltime direct care vacancies. One of the former employees has moved to a per-diem position with Potter House. • At the time of this licensing visit the 1 Potter House resident was home relaxing having free time. This regulatory consultant spoke with her, and she reported to be doing well at Potter House and is treated nicely by the Potter House staff. She did not have any concerns for her safety or well-being. • Physical plant inspection of the facility; The group home was neat, orderly, and well decorated with no health or safety concerns noted. Corrective Actions implemented as a result of previous visit: • Not applicable Areas of regulatory non-compliance identified during this visit: • None at the time of this quarterly visit. Patrick Hughes 2/8/23 Regulatory Consultant Date|5821+++09/26/2022+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Potter House TIME OF VISIT (FROM - TO): 3:45 pm DATE: 09/26/2022 AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title ND Adelbrook Director of Group Homes List of Areas / Topics covered during visit: • Current census is 1 and the licensed bed capacity is 4. There are 2 current referrals for Potter House that need to have their school placements finalized before an admission date can be scheduled. One longtime resident was discharged to a DMHAS young adult program this quarter. • Currently there is only 1 resident in the Potter House group home. This resident is doing well at Potter House. For clinical services and recreation activities the Potter House resident joins with the 2 other Adelbrook Group Homes. • Potter House has filled the vacant co-supervisor and vacant clinician Potter House has 1 vacant full time direct care position and 1 vacant awake overnight position. • At the time of this licensing visit the 1 Potter House resident was home relaxing having free time. This regulatory consultant spoke with her, and she reported to be doing well at Potter House and is treated nicely by the Potter House staff. She did not have any concerns for her safety or well-being. During this quarterly visit all interactions observed between staff and the Potter House resident were friendly and professional. • Physical plant inspection of the facility; The group home was neat, orderly, and well decorated with no health or safety concerns noted. Corrective Actions implemented as a result of previous visit: • Not applicable Areas of regulatory non-compliance identified during this visit: • None at the time of this quarterly visit. Patrick Hughes 9/26/22 Regulatory Consultant Date|5729+++06/01/2022+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Potter House TIME OF VISIT (FROM - TO): 3:45pm DATE: 6/1/2022 AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title ND Adelbrook Director of Group Homes List of Areas / Topics covered during visit: • Current census is 2 and the licensed bed capacity is 4. There are 2 current referrals for the open beds at Potter House. • Discussed progress of the 2 Potter House residents and the status of the Potter House milieu. Both residents are doing well overall at Potter House, however one resident is scheduled to discharge in the coming weeks and is having some difficulties. Both girls are participating in events and activities with the residents from the other 2 Adelbrook group homes. The most recent activity is weekly group swimming lessons. • Discussed Potter House employment vacancies and hiring updates. Hiring has improved for Potter House with most positions filled. Potter House has a pool of per-diem staff to cover the vacant shifts. • At the time of this licensing visit one resident was home. The resident was upset and kept stating that she wanted to leave. This resident is scheduled to leave the group home later this month. She was unable to tell this writer why she wanted to leave but she did say she was safe and did not have any concerns for her safety or well-being. The resident was being loud and threatening harm to the staff but did not act on this. The direct care staff and the clinician were patient, and calm as they talked with and supported the resident. By the time this writer ended the quarterly visit the resident was calm. • Physical plant inspection of the facility; The group home was neat and orderly with no health or safety concerns noted. Corrective Actions implemented as a result of previous visit: • Not applicable Areas of regulatory non-compliance identified during this visit: • None at the time of this quarterly visit. Patrick Hughes 7/6/22 Regulatory Consultant Date|5668+++03/16/2022+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Potter House TIME OF VISIT (FROM - TO): 3:30pm DATE: 3/16/2022 AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title ND Adelbrook Director of Group Homes FM Potter House direct care staff List of Areas / Topics covered during visit: • Current census is 2 and the licensed bed capacity is 5. There are no current referrals for the open Potter House beds. • Discussed progress of the 2 Potter House residents and the status of the Potter House milieu. • Discussed Potter House employment vacancies and hiring updates. • Discussed the lessening of covid-19 restrictions and activities scheduled for the residents. • Physical plant inspection of the facility; no health or safety concerns observed. • Observation of the residents in the milieu; Both residents were home. One resident was outside walking with a staff member. This resident was excited to report she has an upcoming birthday. She appeared comfortable in her surroundings and did not report any concerns for her safety or well-being. The second resident was inside watching television. She reported to be doing well and has been at Potter House for approximately one month. She reported prior to Potter House she was living in her home. She reported she likes being at Potter House and did not report any concerns for her safety or well-being. Corrective Actions implemented as a result of previous visit: • Not applicable Areas of regulatory non-compliance identified during this visit: • None at the time of this quarterly visit. Patrick Hughes 3/28/22 Regulatory Consultant Date|

5972+++08/02/2023+++6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Isaiah House TIME OF VISIT (FROM - TO): 1:00 pm to 2:30 pm DATE: August 2, 2023 AGENCY PERSONNEL WHO PARTICIPATED: Job Title Adelbrook Director of Group Homes Isaiah House Supervisor List of Areas / Topics covered during visit: • Discussion of the current census, which is 3, and the LBC is 4. • Discussion of Isaiah House's current staffing levels, vacant positions, and hiring activities. • Discussion with Isaiah House staff regarding the status of Isaiah House's milieu, the clinical programming, and summer activities for the residents. • Observations and conversation with Isaiah House residents and observations of the interactions between Isaiah House staff and the Isaiah House residents. • Inspection of the Isaiah House physical plant to assess the cleanliness of the home, as well as to ensure there are no health or safety concerns. Corrective Actions implemented as a result of previous visit: • Not applicable. Areas of regulatory non-compliance identified during this visit: • None at the time of this quarterly visit. Patrick Hughes 8/7/23 Regulatory Consultant Date|5930+++05/10/2023+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Isaiah House TIME OF VISIT (FROM - TO): 2:00 pm to 3:30 pm DATE: 5/10/2023 AGENCY PERSONNEL WHO PARTICIPATED: Job Title Adelbrook Director of Group Homes Isaiah House Direct Care Staff List of Areas / Topics covered during visit: • Discussion of the current census, which is 1, and the LBC is 4. • Discussion of Isaiah House's current staffing levels, vacant positions, and hiring activities. • Discussion with Isaiah House staff regarding the status of Isaiah House's milieu, the clinical programming, and activities for the residents. • Inspection of the Isaiah House physical plant to assess the cleanliness of the home, as well as to ensure there are no health or safety concerns. Corrective Actions implemented as a result of previous visit: • Not applicable. Areas of regulatory non-compliance identified during this visit: • None at the time of this quarterly visit. Patrick Hughes 5/16/23 Regulatory Consultant Date|5892+++03/15/2023+++505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Isaiah House TIME OF VISIT (FROM - TO): 2:00 pm to 3:00 pm DATE: 3/15/2023 AGENCY PERSONNEL WHO PARTICIPATED: Job Title Adelbrook Director of Group Homes Isaiah House Direct Care Staff List of Areas / Topics covered during visit: • Discussion of the current census, which is 1, and the LBC is 4. • Discussion of Isaiah House's current staffing levels, vacant positions, and hiring activities. • Discussion with Isaiah House staff regarding the status of Isaiah House's milieu, the clinical programming, and activities for the residents. • Observations and conversation with the Isaiah House resident and observations of the interactions between Isaiah House staff and the Isaiah House resident. • Inspection of the Isaiah House physical plant to assess the cleanliness of the home, as well as to ensure there are no health or safety concerns. Corrective Actions implemented as a result of previous visit: • Not applicable. Areas of regulatory non-compliance identified during this visit: • None at the time of this quarterly visit. Patrick Hughes 3/21/23 Regulatory Consultant Date|5869+++12/28/2022+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Isaiah House TIME OF VISIT (FROM - TO): 2:15 pm DATE: 12/28/22 AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title ND Adelbrook Director of Group Homes List of Areas / Topics covered during visit: Current census. The current census at Isaiah House is 1 and the licensed bed capacity is 4. There have been 2 discharges this quarter at Isaiah House to DMHAS programs. There is an admission scheduled for tomorrow (12/29/22). Milieu / Resident progress. The Isaiah House resident is doing well at Isaiah House. For clinical services and recreation activities the Potter House resident joins with the 2 other Adelbrook Group Homes. Staffing Isaiah House has sufficient staff to cover all shifts. There are 2 full time direct care staff openings. Isaiah House has a large pool of per-diem staff and can cover any vacant shifts when they arise. Observations / Interviews During this quarterly visit the lone Isaiah House resident was home and sick in bed with a cold. This regulatory consultant quickly said hello to the resident from the doorway of her bedroom. The resident said hello back and reported she was doing okay and was just resting. She did not report any concerns regarding her safety or well-being. Physical Plant Inspection All areas of Isaiah House were observed during this quarterly visit. Isaiah House was clean, orderly, and nicely decorated with no health or safety concerns noted. Corrective Actions implemented as a result of previous visit: Not applicable Areas of regulatory non-compliance identified during this visit: None at the time of this quarterly visit. Patrick Hughes 2/8/23 Regulatory Consultant Date|5822+++09/26/2022+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Isaiah House TIME OF VISIT (FROM - TO): 2:30 pm DATE: 9/26/22 AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title ND Adelbrook Director of Group Homes List of Areas / Topics covered during visit: Current census. The current census at Isaiah House is 2 and the licensed bed capacity is 4. There was one discharge this quarter with the resident moving to therapeutic foster care. There was also a new voluntary admission to Isaiah House during this quarter. There are no current referrals for the open Isaiah House beds. Milieu / Resident progress. The long-term Isaiah House resident is doing well at Isaiah House, and the newly admitted Isaiah House resident has been doing better of late. The residents have been out in the community often for recreation and therapeutic activities. The newly admitted Isaiah House resident has an assigned DMHAS worker who is assisting Isaiah House with finding a school placement for the new resident. Staffing Hiring has improved for Isaiah House over the last quarter. There are 2 full time direct care staff openings. Isaiah House has a pool of per-diem staff and are able to cover any vacant shifts. Observations / Interviews During this quarterly visit both residents (K & A) were home and having free time in the living/ dining room area. This regulatory consultant spoke with both residents. Resident K reported to be doing well and was very happy and proud of her new haircut. She reported she is treated well by the Isaiah staff and denied any concerns for her safety or well-being. Resident K was a little shy, but she reported to be doing well at Isaiah House and reported the staff are nice to her. She did not report any concerns for her safety or well-being. During this quarterly visit both residents appeared comfortable in their surroundings and all interactions observed were friendly. Physical Plant Inspection All areas of Isaiah House were observed during this quarterly visit. Isaiah House was clean, orderly, and nicely decorated with no health or safety concerns noted. Corrective Actions implemented as a result of previous visit: Not applicable Areas of regulatory non-compliance identified during this visit: None at the time of this quarterly visit. Patrick Hughes 9/26/22 Regulatory Consultant Date|5730+++06/01/2022+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Isaiah House TIME OF VISIT (FROM - TO): 2:30pm DATE: 6/1/2022 AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title ND Adelbrook Director of Group Homes List of Areas / Topics covered during visit: • Current census is 2 and the licensed bed capacity is 4. There has been 1 discharge since the last quarterly visit. There is 1 pending referral for Isaiah House. • Discussed progress of the 2 Isaiah House residents and the status of the Isaiah House milieu. Both residents are doing well at Isaiah House recently the girls are participating in events and activities with the residents from the other 2 Adelbrook group homes. The most recent activity is weekly group swimming lessons. • Discussed Isaiah House employment vacancies and hiring updates. Hiring has improved for Isaiah House with most positions filled. Isaiah has a pool of per-diem staff to cover the vacant shifts. • Physical plant inspection of the facility; The group home was neat and orderly with no health or safety concerns noted. • Observation of the residents in the milieu; 1 resident was home, while the other resident was at a medical appointment. The one resident who was home was walking on the treadmill in the living room off the kitchen, supervised by an Isaiah House staff. She reported she is doing well at Isaiah House and that school gets out on June 20th. This resident appeared comfortable in her surroundings and did not report any concerns for her safety or well-being. Corrective Actions implemented as a result of previous visit: • Not applicable Areas of regulatory non-compliance identified during this visit: • None at the time of this quarterly visit. Patrick Hughes 6/7/22 Regulatory Consultant Date|5664+++03/16/2022+++March 24, 2022 Alyssa Goduti / President & CEO Adelbrook Community Services Inc. 60 Hicksville Road Cromwell, CT 06416 Re: Licensing Inspection for Isaiah House / CCF # 79 Regulatory Consultants: Patrick Hughes, Jimmy Moore. Dear Ms. Goduti, On March 16th and March 17th, a biennial re-licensing inspection was conducted at Isaiah House. This inspection was conducted to determine the compliance of this agency with the Regulations for Child Placing Agencies; Sections 17a-145-48 through 17a-145-98, as well as the DCF Guidelines for the Administration of Medication by Certified Staff. The licensing inspection determined that your agency has met the requirements for a regular license. This license is effective as of April 18, 2022 and is valid for twenty-four months. We thank you and your staff for your cooperative participation in the review process. Sincerely, Patrick Hughes Patrick Hughes Regulatory Consultant Department of Children and Families 505 Hudson Street Hartford, CT 06106 (p) 860-550-6552 (f) 860-550-6665 patrick.hughes@ct.gov|

5998+++09/07/2023+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Backcountry Wellness Residential Group Home TIME OF VISIT (FROM - TO): 10:00am to 1:30pm DATE: 9/7/23 AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: CEO Program Director Nurse Care Coach Clients (5) List of Areas / Topics covered during visit: This was a scheduled quarterly Licensing visit to obtain a program update and tour the physical plant. A meeting was held with the CEO and Program Director. Topics discussed included: • LBC is 6. Current census is 5 with 1 admission pending. • Discussed most recent admission. • Staffing vacancies (1 Care Coach). • 4 calls to emergency services during this quarter. • Discussed upcoming licensing inspection. • Discussed recreation/outings. • Recent projects-garden • Discussed meals/nutrition Milieu Observation: • Clients observed eating lunch and participation in educational programming. • Met with clients as a group and one individually to discuss safety/well-being and the program. Physical Plant: • Toured facilitated with Program Director and CEO. No safety concerns observed and the home was clean and maintained well. Corrective Actions implemented as a result of previous visit: A service development plan was submitted to DCF by Backcountry Wellness Residential group home following a June 2023 Licensing visit that addressed regulatory citations. The plan was accepted by the Department. Areas of regulatory non-compliance identified during this visit: NA Please submit a service development plan to address the above referenced areas of non-compliance within 30 days of receipt of this report. The service development plan must be submitted to the attention of the undersigned at the address listed above. No service development plan is required for this Licensing visit. James Funaro Date: 9-8-23 Regulatory Consultant A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM Cc: File, Program Director|5945+++06/15/2023+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Backcountry Wellness Residential Group Home TIME OF VISIT (FROM - TO): 11am-3:15pm DATE: 6-15-23 AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: CEO Program Director Care Coach Nurse Therapist (2) Clients (5) List of Areas / Topics covered during visit: This was a scheduled quarterly visit to obtain an update on the program and tour the physical plant to determine regulatory compliance. Additionally, a semi-annual personnel file review was conducted as well as a case record review for regulatory compliance. A meeting was held with the CEO and Program Director. Topics discussed included: • Census = 6. Program is full. • Pending discharges and referrals • Staffing vacancies = 0 • No calls for emergency services this quarter • Recreation outings • Listing group therapy on client treatment plans • Treatment plan review frequency and documentation • Garden • Visitors list • Use of periodic telehealth for therapy • Case record documentation • 'Rock Ceremony' scheduled for today for client that will discharge soon A meeting was held with the program Nurse. Topics discussed included: • Documentation of physical exams, dental exams, vision exams in client case records Milieu Observation: • Teacher observed overseeing educational programming • Clients observed eating snack and lunch Physical Plant: • Tour facilitated by Program Director. All areas appeared exceptionally clean and organized. • One sink out of order in a second floor bathroom with two sinks. Replacement reportedly on order. Personnel File Review: • Two personnel files of new employees were reviewed remotely. See 'Areas of Regulatory Non-Compliance' below. Case Record Review: • Two client case records were reviewed remotely. See 'Areas of Regulatory Non-Compliance' below. Client Interviews: • A group interview was conducted with five residents. • All reported they feel safe in the program. • All report therapy and staff are very helpful. Areas of regulatory non-compliance identified during this visit: Section 46a-154. Internal monitoring, training and development of policies and procedures required and subject to state agency inspection. 1. One personnel file (BP) did not contain evidence of restraint training provided by the facility. Section 17a-145-94 Medical, Dental, Nursing Care. Two client case records were reviewed. The following deficiencies were noted: 1. Case record for one client (C.) does not contain documentation of a physical exam, dental exam, or vision exam. 2. Case record for one client (H.) does not contain documentation of a physical exam. Please submit a service development plan to address the above referenced areas of non-compliance within 30 days of receipt of this report. The service development plan must be submitted to the attention of the undersigned at the address listed above. Kathleen Forsythe, LCSW Date: 6-16-23 Regulatory Consultant A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM Cc: Program Director|5882+++03/09/2023+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Backcountry Wellness Residential Group Home TIME OF VISIT (FROM - TO): 11:45am - 1:30pm DATE: 3-9-23 AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: Program Director Cook Teacher Direct Care Staff Clients (6) Nurse List of Areas / Topics covered during visit: This was an unannounced quarterly Licensing visit to obtain an update on the program and to tour the physical plant. A meeting was held with the Program Director. The following topics were discussed: • Census = 6 females; 6 referrals on the waiting list; discharges in past three months; length of stays; • No incidents for restraint, AWOL, hospital visits, call for emergency services in the past three months; • No staff vacancies; • Additional nurse recently hired for evenings and weekends; • Cleaning crew on site three days per week; bathroom cleaning schedule; disinfection process after discharges • Infection control procedures for beds; • Holiday celebration activities; • Family involvement in program; • Treatment planning and review process; • Fire drill schedule; • Storage of water cooler bottles; • Biennial re-licensing inspection scheduled for Fall 2023. The Program Director facilitated a tour of the physical plant: • All areas appeared exceptionally clean and organized; • Third floor/attic door found unsecured - corrected during visit; • Storage lockers scheduled for installation on first floor. A meeting was held with the program nurse. Topics discussed: • Medication access, storage, destruction; Over-the counter medication & expiration date audits; • Documenting medication administration; • Medication refrigerator. Milieu Observation: • Lunch prep & serving; • Interview with Cook; • Educational programming; • Group interview conducted with six clients. Corrective Actions implemented as a result of previous visit: Not applicable. Areas of regulatory non-compliance identified during this visit: None. Please submit a service development plan to address the above referenced areas of non-compliance within 30 days of receipt of this report. The service development plan must be submitted to the attention of the undersigned at the address listed above. - No service development plan is required following the Licensing visit. Kathleen Forsythe, LCSW Date: 3-10-23 Regulatory Consultant A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM Cc: File Program Director|5833+++12/08/2022+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Backcountry Wellness, LLC - Residential Group Home TIME OF VISIT (FROM - TO): 10:30am-1:00pm DATE: 12-8-22 AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: Chief Executive Officer Program Director Clients (5) Care Coach LPN day nurse Therapist Therapist/Culinary Director List of Areas / Topics covered during visit: This was a scheduled quarterly Licensing visit to obtain an update on the program and to tour the physical plant. Additionally, a semiannual personnel file review was conducted. A meeting was held with the CEO and Program Director. The following areas were discussed: • Census = 6 females; program is full with a waiting list; • Staff vacancies = 0 • Neighborhood; • Amended license issued last month to serve an age range of 11-20 years of age; • Group home approaching the one-year anniversary of opening; • Average length of stay and discharge planning; • Joint Commission accreditation awarded to Backcountry Wellness group home and outpatient psychiatric clinic for children last month for a three-year period; • Psychiatrist coverage; • Emergency planning, disaster/evaluation drills, future purchase of a house generator; • Culinary Director recently completed a graduate professional counseling degree and licensure and carries a small caseload in the group home; • Marketing, tracking referral sources; Milieu Observation: Observed and conducted brief interviews with five residents in the kitchen while they finished morning snack. Residents explained the meal and snack schedule and routine. All five residents reported enjoying their stay at the group home very much. Two residents who had been in a placement prior to BCW group home reported that the BCW program was "the best" they had ever been in. Residents cited friendly staff, beautiful home, and helpful program as to what they liked best about BCW. Residents were later observed studying quietly during the educational program. One client was observed meeting with a therapist in a private room. Physical Plant tour: All areas appeared extremely clean and organized. Discussed driveway repairs/additional parking area scheduled for 2023, and closing off unused bathroom in basement. Personnel File review: A semi-annual personnel file review was conducted. Three personnel files were reviewed of new staff hired since July 2022. No regulatory deficiencies noted. Corrective Actions implemented as a result of previous visit: N/A Areas of regulatory non-compliance identified during this visit: None. Kathleen Forsythe, LCSW Date: 12-8-22 Regulatory Consultant A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM Cc: Program Director|5779+++09/07/2022+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Backcountry Wellness Residential Group Home TIME OF VISIT (FROM - TO): 10:30am-2:00pm DATE: 9-7-22 AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: o CEO o Program Director o Culinary Director o Care Coach o Clients (3) List of Areas / Topics covered during visit: This was a scheduled bimonthly visit to the group home for monitoring the program during its initial provisional license period. Discussions: • Current census = 3 • Meeting with CEO • Pursuing Joint Commission accreditation • Clinical coverage at the group home • Financial audit • Interstate compact requirements • Meeting with Program Director for program update • Restraint refresher training • Group therapies (family, DBT, medical, body image, art expression, cooking, etc.) • Structured program schedule reviewed • Utilization of office space • Milieu observation • Menus • Physical plant tour: all areas observed to be clean, organized and beautifully decorated • Client interviews during lunch • Fire drill documentation reviewed • Driveway appearance • Determination made to remove provisional license status and issue regular license Corrective Actions implemented as a result of previous visit: • Completed service development plan submitted by BCW after last Licensing visit which addressed areas of criminal history background checks, DCF protective services background checks, physical exams, and TB testing during hire process for new staff. Areas of regulatory non-compliance identified during this visit: None. Kathleen Forsythe, LCSW Date: 9-8-22 Regulatory Consultant A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM Cc: Program Director|5735+++07/12/2022+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Backcountry Wellness Residential Group Home TIME OF VISIT (FROM - TO): 11:00am-2:15pm DATE: 7-12-22 AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: Chief Executive Officer Program Director Regional Program Director Clients (5) Property Manager DCF Regulatory Consultant List of Areas / Topics covered during visit: This was a scheduled Licensing visit to conduct a semiannual personnel file review and tour the physical plant for determination in issuing a continued provisional license. • Meeting with CEO • Semiannual personnel file review • Program update meeting with Program Director and Regional Program Director • Milieu observation/client interview meeting • Physical Plant tour Corrective Actions implemented as a result of previous visit: N/A Areas of regulatory non-compliance identified during this visit: 17a-145-63 Chief Executive Officer. • The facility failed to secure the results of a criminal history background check through the Connecticut State Police prior to the employee assuming duties for two employees (DV, RBo). • The facility failed to secure the results of a child protective services background check through DCF prior to hire for two employees (MM, SBP). 17a-145-64 Personnel Policies and Procedures. • The facility failed to secure evidence of a physical exam that was conducted immediately prior to assuming duties for four employees (AR, RBo, RBy, SBP). • The facility failed to secure the results of TB testing that was conducted immediately prior to assuming duties for four employees (AR, RBo, RBy SBP). Please submit a service development plan to address the above referenced areas of non-compliance within 30 days of receipt of this report. The service development plan must be submitted to the attention of the undersigned at the address listed above. Kathleen Forsythe, LCSW Date: 7-13-22 Regulatory Consultant A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM Cc: Program Director Regional Program Director|5692+++05/04/2022+++Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Backcountry Wellness Residential Group Home__________________ TIME OF VISIT (FROM - TO): 10:30am-2:00pm__________ DATE: _5-4-22_______ AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: CEO Property Manager Chef Program Director Day LPN Nurse Care Coaches (2) One male and Three female clients List of Areas / Topics covered during visit: This was a scheduled visit to obtain a program update, tour the physical plant and interview clients. One case record review was conducted remotely after the visit. This new program is currently in a second provisional license period while the Dept. continues to monitor activities. Discussions: • Menu review & documentation; grocery delivery; food storage; Registered Dietician menu approval • Welcome visit from neighbor • Program daily schedule • Recreation activities • Improvements to the physical plant; addition of doors on dining room • Enhancing privacy on windows • Garden installation and driveway expansion proposed for summer • Feedback given to Property Manager during physical plant tour • Window screens; privacy film • Age range of clients served • Case overview on client M. • Client interviews • One case record review Observation • Lunch activities • Physical Plant Corrective Actions implemented as a result of previous visit: • Window privacy film added to bathrooms Areas of regulatory non-compliance identified during this visit: None Kathleen Forsythe, LCSW ______________________________ ___5-6-22_______ Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM Cc: J. Zweiman|5654+++02/24/2022+++NAME OF FACILITY / PROGRAM: Backcountry Wellness Residential Group Home TIME OF VISIT (FROM - TO): 11:00am - 1:30pm DATE: 2-24-22 AGENCY PERSONNEL WHO PARTICIPATED: Job Title CEO Property Manager Nurse Teacher Program Director Regional Program Director DCF Regulatory Consultant DCF Clinical Nurse Coordinator List of Areas / Topics covered during announced visit: • Census • Physical plant inspection • Client interviews • Case record review • Food storage • Medication storage • Program nurse responsibilities • Intake assessments • Program activities since group home opened in January 2022 Corrective Actions implemented as a result of previous visit: N/A Areas of regulatory non-compliance identified during this visit: None. Kathleen Forsythe, LCSW 3-11-22 ______________________________ _________________ Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

5879+++12/12/2022+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: _Bridge Family Center / MOP TIME OF VISIT (FROM - TO): ___12pm_______________________ DATE: ___12/12/2022 AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title KM Education Coordinator DE Program Director List of Areas / Topics covered during visit: . • Census 10. • Physical plant inspection of the Group Home. • Discussed the programing challenges and resident's treatment and compliance. • Some residents in community, ie, work. • Discussed staffing of shifts. • Program in the process of remodeling the medication room and purchased a new medication cabinet. • Controlled medication count for three residents was completed. The count is correct. • DE is the new Program Director. Corrective Actions implemented as a result of previous visit: Section 17a-145-63. At the time of the visit, Apartment 4 had a strong odor of marijuana emanating from one of the bedrooms. Director Residential Services noted this youth is 18, and regularly smokes marijuana, but holds down a job. A bong was found inside the closet, but the Director returned the bong, but felt to remove it abruptly would escalate the youth. Youth was not present during the visit. Licensing reminded the Director that all drug paraphernalia, including lighters, matches, cigarettes are not allowed. Director Residential Services subsequently met with residents and staff and prior to the meeting drafted a policy and procedure on drugs and drug paraphernalia. According to Director Residential Services, the bong was removed. Licensing will follow up. Completed. Areas of regulatory non-compliance identified during this visit: Section 17a-145-75. Health and medical treatment. Section d Evidence: At the time of the visit, the assigned medication certified staff member was not in possession of the medication keys. The medication keys were found inside the lock box. The med keys include access to regular medications and controlled medication. Per Medication Administration training, the assigned staff member authorized to administer medication to youth are required to carry the medication keys during the shift. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Thomas S. Cuchara ___1-18-23_______ Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5803+++09/01/2022+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: _Bridge Family Center / MOP TIME OF VISIT (FROM - TO): ___12pm_______________________ DATE: ___9/1/2022 AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title KM Education Coordinator MR Director of Residential Services List of Areas / Topics covered during visit: . • Census 9. Program expects another admission 9/2/22. • Physical plant inspection of the Group Home. See below. • Discussed the programing challenges and resident's treatment and compliance. • Some residents in community, ie, work. • Discussed staffing of shifts. Corrective Actions implemented as a result of previous visit: Section 17a-145-63. Chief administrative officer. Completed. Evidence of mouse dropping found under the sink in Apartments 1 and Apartment 5. This is a repeat citation. Areas of regulatory non-compliance identified during this visit: Section 17a-145-63. At the time of the visit, Apartment 4 had a strong odor of marijuana emanating from one of the bedrooms. Director Residential Services noted this youth is 18, and regularly smokes marijuana, but holds down a job. A bong was found inside the closet, but the Director returned the bong, but felt to remove it abruptly would escalate the youth. Youth was not present during the visit. Licensing reminded the Director that all drug paraphernalia, including lighters, matches, cigarettes are not allowed. Director Residential Services subsequently met with residents and staff and prior to the meeting drafted a policy and procedure on drugs and drug paraphernalia. According to Director Residential Services, the bong was removed. Licensing will follow up. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Thomas S. Cuchara ___10/6/2022_______ Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5760+++07/25/2022+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: _Bridge Family Center / MOP TIME OF VISIT (FROM - TO): ___1:15pm_______________________ DATE: ___7/25/2022 AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title KM Education Coordinator List of Areas / Topics covered during visit: • Census is 8 and LBC 11. 11 males. • Physical plant inspection of the Group Home. See below. • Discussed the programing challenges and resident's treatment and compliance. • Some residents in community, ie, work. • Spoke to one resident and he states he likes staff and living at MOP. • Discussed staffing of shifts. Corrective Actions implemented as a result of previous visit: Section 17a-145-73. Sleeping accommodation. Apartment 4. Professionally cleaned and painted. Completed. Areas of regulatory non-compliance identified during this visit: Section 17a-145-63. Chief administrative officer Evidence of mouse dropping found under the sink in Apartments 1 and Apartment 5. This is a repeat citation. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Thomas S. Cuchara ___7/27/2022_______ Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5759+++04/19/2022+++ Margaret Hann, Executive Director 5/12/2022 The Bridge Family Center, Inc. 1022 Farmington Avenue West Hartford, CT 06107 Re: 2022 Licensing Inspection for MOP GH Regulatory Consultants: Tom Cuchara and Pat Hughes Dear Ms. Hann, On 4/19/22, 4/20/22 and 5/6/22 a biennial re-licensing inspection was conducted at MOP GH. This inspection was conducted to determine the compliance of this agency with the Regulations for Operation of Child-Caring Agencies and Facilities 17a-145-48 to 17a-145-98. Below are listed the areas of regulatory non-compliance which were identified during the re-licensing inspection. Please review the areas identified and submit a service development plan to address each area. The plan must be submitted within 30 days of receipt of this letter and should identify: 1. the steps to be taken to correct the non-compliance; and 2. the date the correction(s) will be completed. Also included in the report are recommendations. Recommendations are meant to highlight areas that are not currently areas of non-compliance, but may become non-compliant if actions are not taken. Recommendations are also made in order to enhance program functioning. Recommendations do not require the submission of a service development plan. The areas of non-compliance identified are as follows: Section 17a-145-66. Health, sanitation, fire safety, and zoning approval. • As part of the licensing process the Manchester Health Department conducted an inspection of the MOP to determine health code compliance. The visit found numerous and consistent health code violations in five apartments. It is the DCF expectation each violation be addressed satisfactorily and DCF Licensing will follow up at the next quarterly visit. • As part of the licensing visit the Manchester Fire Department conducted an inspection of the MOP to determine fire code compliance. The program was cited for several violations which were addressed prior to the DCF Licensing inspection. Please provide an update on all outstanding Fire Code violations. 17a-145-75. Health and medical treatment. Section(b,c,e) Evidence: All medical records are disorganized and unable to find the documents. Face-sheet-no date of admission. Medication certification-disorganized. Medication room is very small, no space to check the medication administration Kardex, cluttered with binders on shelf, and no room for turning. b) Based on the review of the records the facility failed to do Quarterly Review of Policies and Procedures on March 2021. c) The physician failed to review the orders for one of six files reviewed. e) Standing Orders: PRN order must contain specific time intervals for administration. Six files reviewed did not have evidence of specific time intervals. Section 17a-145-93. Medical, dental and nursing care. Evidence: Based on the review of the clinical records the facility failed to maintain Immunization Records. There is no evidence of the recent physical exam, last dental hygiene exam, and last eye examination for one client. • One client was admitted a few months ago, but there is no evidence of medical records, including annual physical exam, immunization record, dental hygiene, and eye exam during the review of clinical records. • No immunization records available during the review of clinical records for one client. • No nurses note for 6 client files reviewed. DCF Medication Administration. 17a-6(g)-15(a-g) Evidence: • Based on the review of the DCF date entry system the facility failed to submit the monthly summaries. • Based on the review of the training records the facility failed to provide annual epi pen training in 2022. • Based on the review of the training records the facility failed to provide Annual Observation of Medication Administration Skills for one staff member. Once licensing has reviewed and accepted the service development plan and has determined that your agency is in compliance with the regulations a decision on the issuance of a regular twenty-four month license for the program will be made. Until DCF makes this decision the current license will remain in effect. Please be advised that failure to submit an acceptable service development plan within the specified time frame may lead to licensing action up to and including revocation. Please forward a copy of your service development plan to your assigned DCF Program Development and Oversight Coordinator (PDOC) if applicable. Should you have any questions or comments regarding the contents of this report please do not hesitate to call me at (860) 550-6310 or (203)675-6975. Sincerely, _______________________________________ Thomas S. Cuchara, Regulatory Consultant Copy: Executive Director Licensing File|

5981+++07/27/2023+++DCF-3034 1/2013 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY/PROGRAM: CHR/ Brook House Group Home TIME OF VISIT (FROM - TO): 11:45am to 1:30pm DATE: July 27, 2023 AGENCY PERSONNEL WHO PARTICIPATED: Job Title Brook House Program Director Areas / Topics covered during visit: The census was five females at the time of the quarterly visit and the group home's licensed capacity is five. The program reported that there were two part-time staff vacancies and both positions are expected to be filled soon. A walkthrough of the physical plant was conducted with the director and several deficiencies were identified. Corrections implemented as a result of previous visit: N/A Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning) N/A Areas of regulatory non-compliance identified during this visit: Section 17a-145-74: Lavatory facilities: Upon inspection of the physical plant, the upstairs' bathroom ceiling (in the shower area) contained a small black stain and it needs to be addressed. Section 17a-145-77. Dining areas and supervision: Upon inspection of the physical plant, one of the dining room's walls contained two large repair patches and they need to be addressed. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Penny Woodward, LCSW August 14, 2023 Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5931+++05/02/2023+++May 23, 2023 Community Health Resources 2 Waterside Crossing Windsor, CT. 06095 Re: Bi-annual licensing inspection was conducted at the Community Health Resources Brook House Group Home located in Enfield, CT, Consultants: Penny Woodward and Patrick Hughes. On 5/2/23 and 5/3/23, a bi-annual re-licensing inspection was conducted at the Brook House Program to determine compliance with Regulations for Operation of Child-Caring Agencies and Facilities 17a-145-48 through 17a-145-98, as well as the DCF Guidelines for the Administration of Medication by certified staff. DCF has determined that the program is in compliance with all applicable regulatory provisions except those itemized below. Please review areas identified and submit a service development plan to address each area. The plan must be submitted within 30 days of receipt of this letter and should identify: 1. Steps to be taken to correct the non-compliance. 2. The date correction(s) will be completed. The areas of non-compliance are as follows: Section 17a-145-61: Written policies and procedures. (Evidence) Upon review of the program manual, some of the group home's policies were outdated and did not always reflect current practices. Section 17a-145-63: Chief administrative officer. (Evidence) Upon review of milieu documentation, clients were reported to be smoking at the facility while under the supervision of staff and the lack of intervention at the time of the incident by the program did not ensure the safety of residents at the group home. Section 17a-145-73: Sleeping accommodations. (Evidence) Upon inspection of the physical plant, bedroom three contained a wall that had noticeable scuff marks and it needs to be addressed. Bedroom six's ceiling contained a large indentation from a recent construction project and it needs to be addressed. Section 17a-145-74: Lavatory Facilities. (Evidence) Upon inspection of the physical plant, the second-floor bathroom contained cracked waterproof sealant around the shower area and it needs to be addressed. Section 17a-145-86: Instruction in safety procedure. Supervision. (Evidence) Upon review of fire drill records for 2021, a first shift drill was conducted on the second shift and it had not been done according to regulatory requirements. A first shift drill was not conducted by the program in the second quarter as required by regulations. Section 17a-145-98: Case records. (Evidence) Upon inspection of case records, all clients did not have placement agreements as required by regulations. Once a finding is made that your agency has satisfactorily addressed the regulatory compliance issues, and all required supplementary materials have been received, the Department of Children and Families will be prepared to issue a regular license. Failure to submit a plan of correction or successfully implement a plan will result in the refusal to renew the license. Should you have any questions or comments regarding the contents of this report, please do not hesitate to call me at (959) 255-0615. Sincerely, Penny Woodward Penny Woodward, LCSW Regulatory Consultant Department of Children and Families 505 Hudson Street Hartford, CT. 06016 Phone: 959-255-0615 Fax: 860-550-6665 penny.woodward@ct.gov|5918+++03/21/2023+++DCF-3034 1/2013 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: CHR/Brook House Group Home TIME OF VISIT (FROM - TO): 10:30am to 12:00pm DATE: March 21, 2023 AGENCY PERSONNEL WHO PARTICIPATED: Job Title Brook House Program Director Areas / Topics covered during visit: The census was four females at the time of the quarterly visit and the group home's licensed bed capacity is five. The program reported that there was one part-time vacancy and the agency expects to fill the position soon. A walkthrough of the physical plant was conducted with the Brook House Director and it was confirmed that the facility was being maintained according to regulatory standards. Corrections implemented as a result of previous visit: N/A Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning) N/A Areas of regulatory non-compliance identified during this visit: N/A Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Penny Woodward, LCSW April 18, 2023 Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

6000+++08/30/2023+++ 9/8/23 Re: Bi-annual licensing inspection at the Mills House Group Home located in Windsor, CT. Regulatory Consultants: Penny Woodward and Patrick Hughes. On 8/30/23 and 8/31/23, a bi-annual inspection was conducted at the Mills House Group Home to determine compliance with Regulations for Operation of Child-Caring Agencies and Facilities 17a-145-48 through 17a-145-98, as well as the DCF Guidelines for the Administration of Medication by certified staff. DCF has determined that the program is in compliance with all applicable regulatory provisions except those itemized below. Please review areas identified and submit a service development plan to address each area. The plan must be submitted within 30 days of receipt of this letter and should identify: 1. Steps to be taken to correct the non-compliance. 2. The date correction(s) will be completed. Section 17a-145-63: Chief administrative officer. (Evidence) Upon inspection of the physical plant, the front patio contained wood flooring that was rotted and in disrepair and it needs to be addressed. Section 17a-145-64: Personnel policies and procedure. (Evidence) Upon review of personnel files, one record contained a CT State Police check that was completed after the employee's hire date and one file contained a CT DCF check that was completed after the employee's hire date. Section 17a-145-71: Living room lounge. (Evidence) Upon review of the physical plant, the first floor and second floor lounges' ceilings contained unpainted areas from the removal of electronic devices and they need to be addressed. Section 17a-145-73: Sleeping accommodations. (Evidence) Upon inspection of the physical plant, the ceilings in bedrooms two and four contained unpainted areas from the removal of electronic devices and they need to be addressed. Section 17a-145-74: Lavatory facilities. (Evidence) Upon inspection of the physical plant, bathroom one contained a vent light that had not been properly cleaned and it needs to be addressed. Section: 17a-145-98: Case records. (Evidence) Upon review of case records, one file did not contain a discharge summary that included information on who the client was discharged to as required by regulations. Once a finding is made that your agency has satisfactorily addressed the regulatory compliance issues, and all required supplementary materials have been received, the Department of Children and Families will be prepared to issue a regular license. Failure to submit a plan of correction or successfully implement a plan will result in the refusal to renew the license. Please contact me as soon as the regulatory violations have been addressed. Should you have any questions or comments regarding the contents of this report please do not hesitate to call me at (959) 255-0615. Sincerely, Penny Woodward, LCSW Regulatory Consultant Cc: File|5959+++05/25/2023+++DCF-3034 1/2013 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: CHR /Mills House Group Home TIME OF VISIT (FROM - TO): 11:30pm to 1:00pm DATE: May 25, 2023 AGENCY PERSONNEL WHO PARTICIPATED: Job Title Program Director Areas / Topics covered during visit: The program census was one male youth and one transgender youth and the group home's licensed bed capacity is four. The program reported that there were two part-time vacancies and the agency expects to fill positions soon. A walkthrough of the physical plant was conducted with the group home director and no citations were identified. Corrections implemented as a result of previous visit: N/A Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning) N/A Areas of regulatory non-compliance identified during this visit: N/A Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Penny Woodward, LCSW May 26, 2023 Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5921+++03/21/2023+++DCF-3034 1/2013 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. DCF-3034 1/2013 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: CHR /Mills House Group Home TIME OF VISIT (FROM - TO): 12:30pm to 1:30pm DATE: March 21, 2023 AGENCY PERSONNEL WHO PARTICIPATED: Job Title Program Director Areas / Topics covered during visit: The group home census was one male youth and one transgender youth and the program's licensed bed capacity is four. The program reported that there was one part-time vacancy, one full-time vacancy and a candidate has been selected to fill the full-time position. A walkthrough of the physical plant was conducted with the director and no citations were identified. Corrections implemented as a result of previous visit: N/A Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning) N/A Areas of regulatory non-compliance identified during this visit: N/A Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Penny Woodward, LCSW April 18, 2023 Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5852+++11/29/2022+++DCF-3034 1/2013 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: CHR /Mills House Group Home TIME OF VISIT (FROM - TO): 10:30pm to 11:00pm DATE: November 29, 2022 AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title N/A Program Director Areas / Topics covered during visit: The Department of Children and Families conducted a scheduled quarterly inspection visit at the Mills House Program on November 29, 2022. Topics covered during the quarterly visit included staffing and training, physical plant inspection and medication administration system. Physical plant: A walkthrough of the facility was conducted with the group home director to confirm the program was following and in compliance with regulatory requirements. Corrections implemented as a result of previous visit: N/A Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning) N/A Areas of regulatory non-compliance identified during this visit: N/A Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Penny Woodward, LCSW January 5, 2023 Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5784+++09/01/2022+++DCF-3034 1/2013 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: CHR /Mills House Group Home TIME OF VISIT (FROM - TO): 10:30pm to 12:00pm DATE: September 1, 2022 AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title N/A Program Director Areas / Topics covered during visit: The Department of Children and Families conducted a scheduled quarterly inspection visit at the Mills House Program on September 1, 2022. Topics covered during the quarterly visit included staffing and training, physical plant inspection and medication administration system. Physical plant: A walkthrough of the facility was conducted with the program director to confirm the program was following and in compliance with regulatory requirements. Corrections implemented as a result of previous visit: N/A Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning) N/A Areas of regulatory non-compliance identified during this visit: N/A Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Penny Woodward, LCSW September 23, 2022 Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5743+++05/24/2022+++DCF-3034 1/2013 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: CHR /Mills House Group Home TIME OF VISIT (FROM - TO): 11:00pm to 12:30pm DATE: May 24, 2022 AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title N/A Program Director Areas / Topics covered during visit: The Department of Children and Families conducted a scheduled quarterly inspection visit at the Mills House Group Home on May 24, 2022. Topics covered during the quarterly visit included staffing and training, physical plant inspection, and medication administration system. Physical plant: During the quarterly visit a walkthrough of the facility was conducted with the director and citations were identified. Please see citations that are listed below in the area of regulatory non-compliance section. Corrections implemented as a result of previous visit: N/A Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning) N/A Areas of regulatory non-compliance identified during this visit: 17a-145-74. Lavatory facilities: The second-floor bathroom contained a window frame that was misaligned and a clogged sink and they need to be addressed. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Penny Woodward, LCSW June 28, 2022 Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5690+++03/22/2022+++ DCF-3034 1/2013 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Mills House Program TIME OF VISIT: (FROM–TO) Afternoon DATE: 3/22/22 AGENCY PERSONNEL WHO PARTICIPATED: Name Job TitleN/A Program Director Areas / Topics covered during visit: The Department of Children and Families conducted a scheduled quarterly inspection visit at the Mills House Group Home Program on March 22, 2022. Topics covered during the quarterly visit included program census, supervision of residents, staffing, physical plant inspection and medication administration system. Physical plant: A walkthrough of the physical plant with the program director was conducted; deficiencies were identified and discussed with the director. Corrections implemented as a result of previous visit: N/A Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning) N/A Areas of regulatory non-compliance identified during this visit: N/A Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Penny Woodward, LCSW April 18, 2022 Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5688+++03/22/2021+++ DCF-3034 1/2013 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Mills House Program TIME OF VISIT: (FROM–TO) Afternoon DATE: 3/22/22 AGENCY PERSONNEL WHO PARTICIPATED: Name Job TitleN/ Program Director Areas / Topics covered during visit: The Department of Children and Families conducted a scheduled quarterly inspection visit at the Mills House Group Home Program on March 22, 2022. Topics covered during the quarterly visit included program census, supervision of residents, staffing, physical plant inspection and medication administration system. Physical plant: A walkthrough of the physical plant with the program director was conducted; deficiencies were identified and discussed with the director. Corrections implemented as a result of previous visit: N/A Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning) N/A Areas of regulatory non-compliance identified during this visit: N/A Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Penny Woodward, LCSW April 18, 2022 Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

5997+++08/10/2023+++DCF-3034 1/2013 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: CHR / Grant House Group Home TIME OF VISIT (FROM - TO): 11:30am to 1:30pm DATE: August 10, 2023 AGENCY PERSONNEL WHO PARTICIPATED: Job Title Program Director Supervisor Areas / Topics covered during visit: The census consisted of two youths and the group home's licensed bed capacity is five. Topics covered during the quarterly visit included milieu changes, clinical services, menu planning, nursing services, staffing changes and medication administration coverage at the facility for all three shifts. A walkthrough of the physical plant with the program supervisor was conducted and no citations were identified. Corrections implemented as a result of previous visit: N/A Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning) N/A Areas of regulatory non-compliance identified during this visit: N/A Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Penny Woodward, LCSW September 7, 2023 Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5958+++06/22/2023+++DCF-3034 1/2013 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: CHR / Grant House Group Home TIME OF VISIT (FROM - TO): 11:25am to 1:00pm DATE: June 22, 2023 AGENCY PERSONNEL WHO PARTICIPATED: Job Title Program Director Service Director Areas / Topics covered during visit: The program census consisted of two male youths and the group home's licensed bed capacity is five. Topics covered during the quarterly visit included clients' behavioral issues, staffing, physical plant inspection and medication administration system. A walkthrough of the facility with the group home supervisor was conducted; areas of improvements were discussed and reviewed with program. Corrections implemented as a result of previous visit: N/A Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning) Due to pervasive behavioral issues of both residents currently placed in the program it is recommended that current milieu services be evaluated to ensure resources are appropriate to meet the needs of youths at the facility. Areas of regulatory non-compliance identified during this visit: N/A Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Penny Woodward, LCSW June 28, 2022 Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5880+++01/26/2023+++DCF-3034 1/2013 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: CHR / Grant House Group Home TIME OF VISIT (FROM - TO): 10:30am to 11:30am DATE: January 26, 2023 AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title N/A Program Director N/A Service Director Areas / Topics covered during visit: The Department of Children and Families conducted a scheduled quarterly inspection visit at the Grant House Group Home on January 26, 2023. Topics covered during the quarterly visit included staffing and training, physical plant inspection and medication administration system. Physical plant: A walkthrough of the facility was conducted with the program director to confirm the group home was complying with regulatory standards. Corrections implemented as a result of previous visit: N/A Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning) N/A Areas of regulatory non-compliance identified during this visit: N/A Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Penny Woodward, LCSW February 17, 2023 Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5850+++11/17/2022+++ DCF-3034 1/2013 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: CHR / Grant House Program TIME OF VISIT: (FROM–TO): 11:30pm to 1:15pm DATE: 11/17/22 AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title N/A Service Director N/A Supervisor Areas / Topics covered during visit: The Department of Children and Families conducted a scheduled quarterly inspection visit at the Grant House Program on November 17, 2022. Topics covered during the quarterly visit included milieu services, staffing and training, a physical plant inspection and medication administration system. Physical plant: During the quarterly visit a walkthrough of the physical plant was conducted with the program supervisor to confirm the group home was complying with regulatory standards. Corrections implemented as a result of previous visit: N/A Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning) N/A Areas of regulatory non-compliance identified during this visit: N/A Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Penny Woodward, LCSW December 19, 2022 Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5785+++08/30/2022+++ DCF-3034 1/2013 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: CHR / Grant House Program TIME OF VISIT: (FROM–TO): 11:30pm to 1:00pm DATE: 8/30/22 AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title N/A Service Director N/A Supervisor Areas / Topics covered during visit: The Department of Children and Families conducted a scheduled quarterly inspection visit at the Grant House Program on August 30, 2022. Topics covered during the quarterly visit included physical plant inspection and staffing and training. Physical plant: A walkthrough of the physical plant was conducted with the service director and program supervisor to confirm the program was following and in compliance with regulatory requirements. Corrections implemented as a result of previous visit: N/A Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning) N/A Areas of regulatory non-compliance identified during this visit: N/A Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Penny Woodward, LCSW September 23, 2022 Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5740+++05/17/2022+++ DCF-3034 1/2013 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: CHR / Grant House Program TIME OF VISIT: (FROM–TO): 12:30pm to 2:00pm DATE: 5/17/22 AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title N/A Program Director N/A Service Director Areas / Topics covered during visit: The Department of Children and Families conducted a scheduled quarterly inspection visit at the Grant House Program on May 17, 2022. Topics covered during the quarterly visit included program information and a physical plant inspection. Physical plant: During the quarterly visit a walkthrough of the physical plant was conducted with program representatives. Please see citation that is listed below in the area of regulatory non-compliance section. Corrections implemented as a result of previous visit: N/A Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning) N/A Areas of regulatory non-compliance identified during this visit: Section 17a-145-73: Residents’ bedrooms were not clean or well organized and the citation needs to be addressed. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Penny Woodward, LCSW_ June 17 , 2022 Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5685+++04/08/2022+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Boys and Girls Village/Safe Haven residential treatment program TIME OF VISIT (FROM - TO): 10:05 -- 11:30 DATE: 4-7-22 AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title Executive Director Director of Residency Services Milieu Coordinator List of Areas / Topics covered during visit: Verified LBC and census. Noted which residents were home and not in school. Inspected the entire program. Reviewed full time vacancies. Corrective Actions implemented as a result of previous visit: Not applicable. Areas of regulatory non-compliance identified during this visit: None. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. A plan of correction does not need to be filed. Regulatory Consultant Date James Richard Moore, LMSW 4-7-22 A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

6003+++09/21/2023+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: CJR, Winchester House TGH TIME OF VISIT (FROM - TO): 9:45am to 11:30pm DATE: 9/21/23 AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: COO Program Director House Supervisor List of Areas / Topics covered during visit: This was a scheduled quarterly Licensing visit to obtain a program update and tour the physical plant. A meeting was held with the COO, Program Director and house supervisor. Topics discussed included: • LBC is 4. Current census is 2. One resident discharged this quarter. • Staffing vacancies (1 first shift, 1 second shift, two third shift). Discussed coverage and no temp agencies utilized for coverage. New recruiter hired for CJR. • New clinician hired and started on 9/10/23. • 2 calls to emergency services during this quarter. One police involved and one for ED medical assessment with resident transported from school setting. • No AWOLS, no calls to fire dept and no restraints since the last Licensing visit. • Discussed peer relations and activities. • Current client education planning/settings and client employment. • Recent projects-staff office construction completed, slider door replaced and future project to replace front walkway. • Discussed new procedures for nursing/medical oversight. • PNMI & QRTP audits. Milieu Observation: • Observed positive client interaction with direct care staff. • Met with client to discuss experience in the program and overall safety and well-being. Physical Plant: • Tour facilitated with House Supervisor. No safety concerns observed, and the home was very clean and maintained well. Corrective Actions implemented as a result of previous visit: NA Areas of regulatory non-compliance identified during this visit: NA Please submit a service development plan to address the above referenced areas of non-compliance within 30 days of receipt of this report. The service development plan must be submitted to the attention of the undersigned at the address listed above. No service development plan is required for this Licensing visit. James Funaro Date: 9-22-23 Regulatory Consultant A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM Cc: File, Program Director, COO|5952+++06/07/2023+++ June 26, 2023 Mr. Daniel Rezende President & CEO Connecticut Junior Republic, Inc. 550 Goshen Road PO Box 161 Litchfield, CT 06759 Re: Winchester House Relicensing Inspection License #: CCF/GH 105 Licensing Consultants: Kathleen Forsythe, Patrick Hughes, Kathleen DiTuccio Dear Mr. Rezende, On June 7, 2023, a biennial re-licensing inspection was conducted for the CJR Winchester group home, located at 131 Ashley Rd., Winchester, CT. This inspection was conducted to determine the compliance of this program with the Regulations of the Connecticut Department of Children and Families Child Caring Regulations 17a-145-48 through 17a-145-124, the DCF Medication Administration Guidelines and the DCF Nursing Standards. Listed below/on the attached service development plan are the areas of DCF regulatory non-compliance which were identified during the re-licensing inspection. Please review the areas identified and complete a service development plan (SDP) to address each area of noncompliance. The completed service development plan must be submitted to the assigned Regulatory Consultant within 30 days of receipt of this emailed report. The areas of regulatory noncompliance are as follows: 17a-145-64 Personnel Policies and Procedures. Two personnel files were reviewed. The following deficiencies was noted: • One personnel file (APV) did not contain evidence of TB testing results dated immediately prior to assuming duties. • Evidence of CPR certification does not contain the name of the program authorizing the certification (i.e. American Red Cross, Heart Saver, etc.). 17a-145-75 Health and Medical Treatment. Administration of First Aid. Prescription Medication. Administration of Medicine or Treatment. Written Records. Storage of Drugs, Medicines, and Instruments. Sick Room, Telephone. c) Standing orders for the current two residents expired 6-1-23. c) An epi-pen for a current resident stored in the medication room expired in March 2023. c) Eleven (11) empty prescription bottles for a current resident were found in the locked medication cabinet and an unlocked drawer. d) The roster of medication administration certified staff posted in the medication room is not current. d) Evidence of quarterly training for medication certified staff was not found for the first quarter of 2023. d) Evidence of an annual skills assessment for three staff (WD, RE, BG) was not found for 2022, and thus far in 2023. d) Evidence of training for medication administration certified staff in the second quarter of 2022 does not contain a complete date. h) A list of posted emergency and poison information numbers was not found in the medication room. 17a-145-86 Instructions in Safety Procedures. Supervision. Fire drill evacuation reports were reviewed for the licensed period. The following deficiencies were noted: • 2022: A first shift drill report in the 4th quarter did not contain evidence that children participated in the drill. • 2023: A first shift drill report for the 1st quarter did not contain evidence that children participated in the drill. ****************************************************************************** Once the Licensing Unit has reviewed and accepted the completed service development plan and has determined that your agency is in compliance with the regulations, a decision on the issuance of a regular twenty-four month license for the program will be made. Until DCF makes this decision, the current license will remain in effect. Should you have any questions or comments regarding the contents of this report please do not hesitate to contact me at (860) 937-7551. Sincerely, Kathleen Forsythe Kathleen Forsythe, LCSW Regulatory Consultant Dept. of Children and Families cc: File Director of Residential Services Program Director|5897+++03/23/2023+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: The Connecticut Junior Republic, Inc. - Winchester Group Home TIME OF VISIT (FROM - TO): 12:00pm-1:30pm DATE: 3-23-23 AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: Program Director Program Shift Supervisor Clinician 3 Youth Care Workers List of Areas / Topics covered during visit: This was an unscheduled quarterly Licensing visit to obtain an update on the program and tour the physical plant. Meeting held with Program Director and Clinician. Topics discussed: • Current census = 1; LBC = 4; 1 pending admission; • Staffing: Current staff vacancies = 1 on first shift, 2 on second shift, 2 on third shift; vacancies covered with perdiem staff and overtime; • Biennial relicensing inspection: scheduled for June 2023; application and materials due dates; case records and medical information not in an electronic health record; proper storage of closed case records; • Search policy; use of hand-held electronic wand; • CJR rebranding; official name change from Connecticut Junior Republic to CJR; new dragonfly logo and mission statement; new tag line: 'Nurturing Change. Creating Possibilities'; • Program Clinician recently acquired licensure; • Winter weather, snow removal, two brief power losses, automatic generator activated. Physical plant inspection: • All areas appeared clean and organized; • Recent improvements include new laminate wood flooring on first floor, second floor hallway and staff area; purchase of five new beds, three armoires, new stove, and new loveseat; • New office and utility closet under construction in basement with fire marshal inspections; • Client at school; direct care staff cleaning the home during Licensing visit. Corrective Actions implemented as a result of previous visit: N/A Areas of regulatory non-compliance identified during this visit: None. Please submit a service development plan to address the above referenced areas of non-compliance within 30 days of receipt of this report. The service development plan must be submitted to the attention of the undersigned at the address listed above. - A service development plan is not required for this Licensing visit. Kathleen Forsythe, LCSW ______________________________ Date: 3-24-23 Regulatory Consultant A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM Cc: Director of Residential Services Program Director|5831+++12/02/2022+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: The Connecticut Junior Republic, Inc. - Winchester Group Home TIME OF VISIT (FROM - TO): 10:45p-12:45pm DATE: 12-1-22 AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: Program Director Program Shift Supervisor Youth Care Worker List of Areas / Topics covered during visit: This was a scheduled quarterly Licensing visit to obtain an update on the program, tour the physical plant, and conduct a semiannual personnel file review. Meeting held with Program Director and Shift Supervisor. Topics discussed: • Census = 0. One client was placed in the program for September - November before decompensating. Client was sent to the hospital for evaluation and stabilization, and ultimately discharged to a higher level of care. • Incident data for the quarter • Property destruction by former client • Changing profile of referrals to the group home • Planned admission of a youth from a PRTF; recent transitional visits; possible utilization of behavior management system from client's current placement to assist in the transition to the group home • Group home's QRTP status, aftercare services, application needed to reduce LBC • Semiannual personnel file review was scheduled, however no new hires since last review in June 2022 • Current staff vacancies include two first and one second shift full time positions • Recent physical plant upgrades to the group home, which included a new roof, new stove and refrigerator, ceiling fans replaced with overhead lights. Contractors on site during the visit to activate water dispenser in new refrigerator. • Planned upgrades will include new flooring on first and second floors, ceiling lights on second floor, armoires in bedrooms, office in basement, new roof on shed Tour of physical plant. All areas appeared clean and organized. No regulatory deficiencies noted. Corrective Actions implemented as a result of previous visit: N/A Areas of regulatory non-compliance identified during this visit: None. Kathleen Forsythe, LCSW ______________________________ Date: 12-2-22 Regulatory Consultant A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM Cc: Director of Residential Services Program Director|5786+++09/28/2022+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Connecticut Junior Republic, Inc. - Winchester House Group Home TIME OF VISIT (FROM - TO): 9:00am-10:00am DATE: 9-28-22 AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: Program Director Clinical Therapist List of Areas / Topics covered during visit: This was a scheduled quarterly Licensing visit to obtain an update on the program and to tour the physical plant. This visit was conducted virtually due to COVID concerns. Areas discussed: • Census: 1; client admitted earlier this month • Overview of new client's history, school assignment, job search, discharge plan • Referrals • Staff vacancies: one first shift, one second shift, two third shift • Staff recruitment activities, radio advertising, hiring incentives • New universal Medication Administration program for DCF programs effective this fall • Access to medications • New purchases and updates to the group home in the past quarter • Virtual physical plant tour: all areas appeared clean and organized. Closets needed in two vacant bedrooms. Corrective Actions implemented as a result of previous visit: Not applicable. Areas of regulatory non-compliance identified during this visit: None. Kathleen Forsythe, LCSW Date: 9-28-22 Regulatory Consultant A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM Cc: File Director of Residential Services Program Director|5713+++06/17/2022+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Connecticut Junior Republic, Inc. - Winchester House Group Home TIME OF VISIT (FROM - TO): 11:30am-1:00pm DATE: 6-17-22 AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: Program Director Clinical Therapist List of Areas / Topics covered during visit: This was a scheduled quarterly Licensing visit to obtain an update on the program and to tour the physical plant. • Census: 0 • Referrals • Staff vacancies • Staffing levels • New purchases • Aftercare services for most recent discharge • Medication administration certified staff • Physical plant tour • Quality Residential Treatment Program • Semiannual personnel file review Corrective Actions implemented as a result of previous visit: Not applicable. Areas of regulatory non-compliance identified during this visit: None. Kathleen Forsythe, LCSW Date: 6-20-22 Regulatory Consultant A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM Cc: File Director of Residential Services Program Director|5657+++03/17/2022+++Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Connecticut Junior Republic, Inc. - Winchester House Group Home TIME OF VISIT (FROM - TO): 11:00am-1:10pm DATE: 3-17-22 AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: Clinical Social Worker Direct Care Worker (2) DCF Regulatory Consultant List of Areas / Topics covered during visit: • Unannounced quarterly Licensing visit • Tour of physical plant • Census • Program referrals • Client behaviors during the quarter • Independent living skills training topics • Recent client discharge • Aftercare procedures • Food storage • Select new appliances • Client privacy • Two new leased vehicles for group home Corrective Actions implemented as a result of previous visit: N/A Areas of regulatory non-compliance identified during this visit: None. Kathleen Forsythe, LCSW 3-17-22 ______________________________ _________________ Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM Cc: Director of Residential Services Program Director Clinical Social Worker|

5961+++07/12/2023+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: CT Clinical Services d/b/a Turnbridge - Extended Care Program North Haven TIME OF VISIT (FROM - TO): 1:30pm-3:00pm DATE: 7-12-23 AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: • Program Director • Nurse • Food Services Worker • Client List of Areas / Topics covered during visit: This was a scheduled quarterly Licensing visit to obtain an update on the program and tour the physical plant. Meeting held with The Program Director and the day Nurse on duty. Topics discussed included: • Census: Program is at capacity with seven male and seven female residents • Incidents/significant events that occurred in the past three months • Staff vacancies: 0 • Safety checks during awake and overnight hours; staff stations and duties on overnight shift • Interstate compact forms for out-of-state clients • Recreation • Proposed new residential program in New Haven • Proposed garage renovation • Client search procedures • Client supervision procedures Tour of physical plant. All areas observed to be very clean and organized. • New alarms installed on emergency exit doors Interview with male resident. Topics discussed: • Safety • Staff & peer relationships • Helpfulness of program • Food quality Milieu observation: dinner prep, one client having snack in kitchen; evening nurse on duty in the Medication room Personnel file review: • Five (5) personnel files were reviewed remotely. See Areas of Regulatory Noncompliance below. Corrective Actions implemented as a result of previous visit: N/A Areas of regulatory non-compliance identified during this visit: 17a-145-22 Personnel Policies and Procedures. • One file (N.) contained evidence of a physical exam and TB testing results completed after hire. • One file (N.) did not contain the results of an out-of-state child protective services background check from NY. • One file (M.) did not contain the results of an out-of-state child protective services background check from NY. • One file (A). contained evidence of a criminal history background check through the CT State Police completed after hire. Please submit a service development plan to address the above referenced areas of non-compliance within 30 days of receipt of this report. The service development plan must be submitted to the attention of the undersigned at the address listed above. Kathleen Forsythe, LCSW Date: 7-14-23 Regulatory Consultant A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM Cc: Program Director|5922+++04/25/2023+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 F Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: CT Clinical Services d/b/a Turnbridge - Extended Care Program North Haven TIME OF VISIT (FROM - TO): 10:00am -1:50pm DATE: 4-26-23 AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: • Program Director • Nurse • Support Staff • Food Services Director • Client List of Areas / Topics covered during visit: This was a scheduled quarterly Licensing visit to obtain an update on the program and tour the physical plant. Meeting held with The Program Director and the Nurse on duty. Topics discussed included: • census - program is full with seven male and seven female residents length of stay • weekly Clinical rounds • incidents/significant events that occurred in the past three months, EMS calls, hospital visits, etc. • program schedule • staff vacancies = 0 • 30 minute safety checks; staff stations on overnight shift • ensure case records include incident reports • medication administration certified staff • medication errors for the quarter; Medication now distributed out of Nursing office; Dutch-style door installed Tour of physical plant. All areas observed to be clean and organized. Discussion included: • privacy film has been added to lower half of bedroom windows • locks and alarms on emergency exit doors tested • soda machine in Kitchen • storage area for resident personal items • water temperature Interview with female resident. Topics discussed: • Resident safety • Recreation/leisure activities on and off site • Menus, snacks • Peer relationships • Staff helpfulness • Off-site clinical programming • Staff supervision • Bedtime routine • chores Milieu observation: Lunch and dinner prep, two clients returning from day programming and eating lunch. Case record review: Two case records were reviewed remotely after the site visit. Corrective Actions implemented as a result of previous visit: N/A Areas of regulatory non-compliance identified during this visit: N/A Please submit a service development plan to address the above referenced areas of non-compliance within 30 days of receipt of this report. The service development plan must be submitted to the attention of the undersigned at the address listed above. -No service development plan is required following this Licensing visit. Kathleen Forsythe, LCSW Date: 4-28-23 Regulatory Consultant A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM Cc: Program Director|5845+++01/12/2023+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: CT Clinical Services d/b/a Turnbridge - Adolescent Extended Care Program, North Haven, CT TIME OF VISIT (FROM - TO): 12:15pm-2:45pm DATE: 1-12-23 AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: Program Director Kitchen Manager Kitchen Assistant Maintenance Worker Direct Care Worker List of Areas / Topics covered during visit: This was an unannounced quarterly Licensing visit to tour the physical plant and obtain a program update. A meeting was held with the Program Director. Topics discussed: • Census = 14 • Average length of stay • Incidents • Recent COVID cases with staff and one client • Headcount process, frequency, recording • Laundry schedule • Security camera monitoring; staff stations • Call from Executive Vice President with Regulatory Consultant • Age/over census waiver form Milieu Observation A tour of the physical plant was facilitated by the Program Director: • All common areas appeared very clean and organized; Male bedrooms appeared unkempt. • House interior temperature • Food storage in kitchen and food storage room • New Dutch-style door installed in Nursing office • Emergency exit security • Hygiene products stored in showers • Storage room with unsecured door in basement • Storage of mops/brooms Corrective Actions implemented as a result of previous visit: N/A Areas of regulatory non-compliance identified during this visit: No regulatory deficiencies were noted during the visit. Kathleen Forsythe, LCSW Date: 1-13-23 Regulatory Consultant A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM Cc: Executive Vice President File|5835+++12/12/2022+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: CT Clinical Services d/b/a Turnbridge - Extended Care Program, North Haven, CT TIME OF VISIT (FROM - TO): morning DATE: 12-12-22 AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: Executive Vice President List of Areas / Topics covered during visit: This was a scheduled semiannual personnel file review of staff hired since July 2022. The review was conducted remotely. One personnel file was reviewed. Corrective Actions implemented as a result of previous visit: N/A Areas of regulatory non-compliance identified during this visit: No regulatory deficiencies were noted during the review. Kathleen Forsythe, LCSW Date: 12-14-22 Regulatory Consultant A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM Cc: Executive Vice President File|5796+++10/25/2022+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: _CT Clinical Services d/b/a Turnbridge - North Haven program TIME OF VISIT (FROM - TO): 10:30am- 1:30pm DATE: 10-25-22 AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: Program Director APRN Chef Culinary Assistant List of Areas / Topics covered during visit: This was a scheduled quarterly Licensing visit to tour the physical plant, as well as obtain an update on the program since the relicensing inspection conducted in July 2022. Discussion included: • Census = 14 (7 males, 7 females). The program is full. • Staffing: Staff to client ratios, staffing schedule, staffing vacancies (none), staff supervision procedures including bed checks, staff stations on the overnight shift, camera monitoring. • Program: Resident daily schedule/routine, fall recreation activities, academics, clinical services provided at Turnbridge OPCC, police involvement for two incidents of AWOL, medical incidents, 136 report, search procedures, telephone procedures, drug testing procedures. • Food Services: Menu cycles, menu posting and approval process, food storage in refrigerators and supply storeroom, snack availability, refrigerator/freezer temperatures, ensuring food safety when transporting meals to OPCC. Lunch on this date was plentiful and attractively presented. • Nursing: Nursing coverage, APRN and RN responsibilities, drug testing procedures, water availability in nursing office. • Physical plant tour: All areas of the home appeared clean, organized, attractive and decorated for the season. Discussed enhancing client privacy on exterior windows, enhancing infection control procedures in shared bathrooms, and wall decor. Residents were observed returning from clinical day program. One client was observed to be resting in bed due to mild illness. A registered nurse was on duty in the home. Corrective Actions implemented as a result of previous visit: A service development plan to address regulatory deficiencies noting during the relicensing inspection was accepted by the Department and a renewed license was issued in August 2022. Areas of regulatory non-compliance identified during this visit: No regulatory deficiencies were noted during this visit. Kathleen Forsythe, LCSW Date: 10-28-22 Regulatory Consultant A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM Cc: Executive Vice President Program Director|5754+++07/26/2022+++July 28, 2022 Dr. Christopher Cutter, PhD. Executive Director -Turnbridge Adolescent Programs CT Clinical Services, Inc. 189 Orange Street New Haven, CT 06510 Re: Turnbridge NORTH HAVEN extended care License #: CCF/GH # 168 Regulatory Consultants: Kathleen Forsythe & Terri Bohara Dear Dr. Cutter, On July 26-27, 2022, a biennial re-licensing inspection was conducted for the Turnbridge North Haven co-ed extended care residential program, located at 600 Middletown Ave., North Haven, CT. This inspection was conducted to determine the compliance of this program with the Regulations of the Connecticut Department of Children and Families Operation of Child-Caring Agencies and Facilities Regulations 17a-145-48 through 17a-145-124. Additionally, an onsite review was conducted by DCF Nurse Consultant Anna Cherian, RN, MSN, FNP-BC on 6-30-22 to determine the program’s compliance with the DCF Medication Administration Guidelines and the DCF Nursing Standards. A copy of the nursing review site visit summary report is included with this report. Listed below are the areas of DCF regulatory non-compliance which were identified during the re-licensing inspection. Please review the areas identified and complete a service development plan (SDP) to address each area of noncompliance. The completed service development plan and applicable supporting documentation must be submitted to the assigned Regulatory Consultant within 30 days of receipt of this emailed report. The areas of regulatory noncompliance are as follows: 17a-145-64 Personnel Policies and Procedures. A review of documentation in seven (7) personnel files identified the following deficiencies: • Seven (7) files did not contain evidence that the employee received a physical examination immediately prior to assuming duties (KP, NR, AK, CT, CB, DC, MR). • Three files did not contain evidence that TB testing results were obtained immediately prior to assuming duties (AK, DC, MR). • Evidence of current CPR training was missing in two files (CB, DC). • CT State Police criminal history background check results were obtained after the hire date in three files (AK, CB, NR). • DCF protective services background check results were obtained after the hire date in four files (KP, NR, CB, DC). 17a-145-75 Health and Medical Treatment. Administration of First Aid. Prescription Medication. Administration of Medicine or Treatment. Written Records. Storage of Drugs, medicines, and Instruments. Sick Room, Telephone. b) Evidence of a physician's quarterly review of required policies (administration of first aid; care of residents with minor illness, injuries or special conditions; administration or use by residents of patent medicines) was not found as follows: 2020: 4th quarter 2021: 2nd, 3rd, & 4th quarters 2022: 2nd quarter 17a-145-86 Instructions in Safety Procedures. Supervision. Based on a review of fire drill evacuation records for the North Haven Residential program for the licensed period, it was found that the facility did not have documentation of fire drills as follows: 2020: 1st shift: 4th quarter 2nd shift: 3rd quarter 3rd shift: 3rd 7 4th quarters 2021: 1st shift: 1st, 2nd, 3rd, 4th quarters 3rd shift: 1st, 2nd, 3rd, 4th quarters 2022; 1st shift: 2nd quarter 3rd shift: 1st & 2nd quarters 814e - Physical Restraint, Medication & Seclusion of Persons Receiving Care, Education or Supervision in an Institution or Facility: 46a-154 Internal Monitoring, Training and Development of Policies and Procedures Required and Subject to State Agency Inspection. • Written policy on seclusion was not provided for review. • Written policy addressing restraint does not include all elements listed in the statute. ********************************************************************************************* Once the Licensing Unit has reviewed and accepted the service development plan and has determined that your agency is in compliance with the regulations, a decision on the issuance of a regular twenty-four month license for the program will be made. Until DCF makes this decision, the current license will remain in effect. Should you have any questions or comments regarding the contents of this report please do not hesitate to contact me at (860) 937-7551. Sincerely, Kathleen Forsythe _________________________ Kathleen Forsythe, LCSW Regulatory Consultant Cc: Adolescent Program Director, Executive Vice President, Executive Director of Residential Services|

5974+++06/08/2023+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: ____Discovery Practice Management / Fairfield GH __________ TIME OF VISIT (FROM - TO): __1pm to 2:30pm___ DATE: _____6/8/23__________ AGENCY PERSONNEL WHO PARTICIPATED: Job Title Program Director List of Areas / Topics covered during visit: • Census is 6. LBC 6. Five females and one male. • Physical plant inspection of the Group Home. No concerns. • Discussed the programing challenges and resident's treatment and compliance. • One case reviewed. See below. • Discussed staffing of shifts. Program has two clinicians, but one resigned. Clinician is covering, but stated a new clinician is hired and soon to begin working at the Group Home. Corrective Actions implemented as a result of previous visit: NO SDP from last visit. Areas of regulatory non-compliance identified during this visit: No SDP required. Section 17a-145-48. Definitions. Section(e) Program did not adhere to this regulation. Section 17a-145-58. Waiver of requirements. Program did not address this regulation. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Thomas S. Cuchara, 6/8/23 Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5903+++01/26/2023+++ John Peloquin, CEO 3/3/23 Discovery Practice Management 4281 Katella Avenue, Suite #111 Los Alamitos, CA 90720 Re: Licensing Inspection for Fairfield GH Regulatory Consultants: Tom Cuchara, Keith Bryan & Pat Hughes Dear Mr. Peloquin, On 1/26/23 and 1/27/23 a biennial re-licensing inspection was conducted at 615 Mine Hill Road, Fairfield, CT. This inspection was conducted to determine the compliance of this facility with the Regulations for Operation of Child-Caring Agencies and Facilities 17a-145-48 through 17a-145-98, as well as the DCF Guidelines for the Administration of Medication by Certified Staff and the DCF Nursing Standards. Below are listed the areas of regulatory non-compliance which were identified during the re-licensing inspection. Please review the areas identified and submit a Service Development Plan to address each area. The plan must be submitted within 30 days of receipt of this letter and should identify: 1. the steps to be taken to correct the non-compliance; and 2. the date the correction(s) will be completed. The areas of non-compliance are listed on the attached DCF Licensing Report form. Please use this form to submit the Service Development Plan as well. Also included in the report are recommendations. Recommendations are meant to highlight areas that are not currently areas of non-compliance, but may become non-compliant if actions are not taken. Recommendations do not require the submission of a plan of a Service Development Plan. Section 17a-145-64. Personnel policies and procedures. Evidence: Three personnel files reviewed. Restraint: One file did not have evidence of restraint training. M.V. Medication Administration: DCF Reg: 17a145-75 (d) and 17a -6(g) - 16 (c) Evidence: 1. Based on the review of the training records the facility failed to provide quarterly training from 2021 and 2022. • No documentation found that the med certified staff attended training for two years. 2. Program did not submit a DCF-2272 Monthly Medication Administration Program Supervision and Review to DCF Risk Management. 3. Based on the review of the DCF Data entry system the facility failed to submit the monthly summaries from 07/2021 to January 2023. 4. Annual Observation of Medication Administration Skills Once a year the facility nurse must observe medication certified staff performing the DCF medication administration procedure. This must be documented using the DCF-2275 DCF Medication Administration Program Procedure Checklist and placed in the employee file. 5. Based on the review of the records the facility failed to do Medication Administration Skills Once a year. 6. The following medication administration certified staff members' annual skills verification not done. M.C., L.R., M.V., N.R., A.F. 7. Quarterly Review of Policies and Procedures Quarterly. The supervising registered nurse or licensed medical person will document a review of the facility’s medication policies and a review of the continuing education offered related to medication administration. • Based on the review of the records the facility failed to review the quarterly policy. RN Signature: Missing-January 2022. MD and RN signature missing for 10/01/22 and 01/26/21. 8. Mandatory Annual Epi-pen & Inhaler & Training for all staff Based on the review of the training records the facility failed to provide annual epi-pen-asthma training. • This training must be provided at least annually and whenever necessary to maintain a safe environment for children. • Documentation shall be maintained listing staff who have been successfully trained and deemed competent to administer Epi-pens and emergency inhalers. • Annual epi-pen & asthma training missing in 2021 & 2022 Once licensing has reviewed and accepted the Service Development Plan and has determined that your agency is in compliance with the regulations a decision on the issuance of a regular twenty-four month license for the program will be made. Until DCF makes this decision the current license will remain in effect. Should you have any questions or comments regarding the contents of this report please do not hesitate to call me at (203) 675-6975. Sincerely, _______________________________________ Thomas S. Cuchara, Regulatory Consultant Copy: file|5859+++12/27/2022+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: ____Discovery Practice Management_________________ TIME OF VISIT (FROM - TO): _______1pm_______________ DATE: _____12/27/2022____ AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title JG Program Director MT Medical Quality Manager CB RN Supervisor Fairfield and Stamford LR Program Administrator List of Areas / Topics covered during visit: • Census is 6. 5 females & 1 male. LBC 6. • Physical plant inspection of the Group Home. • Discussed the programing challenges and resident's treatment and compliance. • Discussed on-going training with staff. • Discussed staffing of shifts. No staff vacancies. Corrective Actions implemented as a result of previous visit: No SDP from previous visit. Areas of regulatory non-compliance identified during this visit: No SDP required. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Thomas S. Cuchara 12/27/2022 Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5816+++09/22/2022+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: ____Discovery Practice Management- Fairfield GH_______________ TIME OF VISIT (FROM - TO): _______12pm_______________ DATE: _____9/22/2022____ AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title LR Program Administrator List of Areas / Topics covered during visit: • Census is 6. 6 females. LBC 6. • Physical plant inspection of the Group Home. LR noted all bedrooms have been painted, new dining room table, carpets, and furniture for the living room. • Discussed the programing challenges and resident's treatment and compliance. • Discussed on-going training with staff. • Discussed staffing of shifts. LR reports one part-time open vacant position opened. • One client discharge record reviewed and in compliance. Corrective Actions implemented as a result of previous visit: No SDP from previous visit. Areas of regulatory non-compliance identified during this visit: No SDP required. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Thomas S. Cuchara 11/10/22 Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5815+++06/27/2022+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: ____Discovery Practice Management_________________ TIME OF VISIT (FROM - TO): _______1:30pm_______________ DATE: _____6/27/2022____ AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title LR Program Administrator List of Areas / Topics covered during visit: • Census is 6. 6 females. LBC 6. • Physical plant inspection of the Group Home. • Discussed the programing challenges and resident's treatment and compliance. • Discussed on-going training with staff. • Discussed staffing of shifts. LR reports no vacancies. However, LR is the new PD. • One client record reviewed and in compliance. Corrective Actions implemented as a result of previous visit: No SDP from previous visit. Areas of regulatory non-compliance identified during this visit: No SDP required. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Thomas S. Cuchara 8/8/2022 Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5677+++03/30/2022+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: ____Discovery Practice Management_________________ TIME OF VISIT (FROM - TO): _______9:30am___________________ DATE: _____3/30/2022____ AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title LD Program Director List of Areas / Topics covered during visit: • Census is 6. 6 females. LBC 6. • Physical plant inspection of the Group Home. • Discussed the programing challenges and resident's treatment and compliance. • Discussed on-going training with staff. • Discussed staffing of shifts. Corrective Actions implemented as a result of previous visit: No SDP from previous visit. Areas of regulatory non-compliance identified during this visit: No SDP required. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Thomas S. Cuchara 4/8/2022 Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

5905+++03/02/2023+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Boys and Girls Village / STAR TIME OF VISIT (FROM - TO): __1pm__________ DATE: 3/2/23 AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title OT Program Director WS Milieu Staff List of Areas / Topics covered during visit: • Census is 5. • At the time of the visit there was one youth in the program. He is a new admission. • Physical plant inspection was conducted and in compliance. • Discussed the programing, resident safety, juggling room challenges. • Discussed staffing of shifts. No staff vacancies on all three shifts. • Reviewed medication. • One case record reviewed. Corrective Actions implemented as a result of previous visit: n/a Areas of regulatory non-compliance identified during this visit: Medication Administration: • The sheet used to document key exchanges calendar dates are predated. The document has room for only signatures of staff handing the key off to the oncoming shift. The document does not have sufficient space to accommodate multiple key exchanges for each shift. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Thomas S. Cuchara ___3/24/23_______ Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5904+++09/13/2022+++ John Peloquin, CEO 11/3/2022 Discovery Practice Management 4281 Katella Avenue, Suite #111 Los Alamitos, CA 90720 Re: Licensing Inspection for Southport GH Regulatory Consultants: Tom Cuchara & Penny Woodward Dear Mr. Peloquin, On 9/13/22 and 9/14/22 a biennial re-licensing inspection was conducted at 1320 Mill Hill Road, Southport, CT. This inspection was conducted to determine the compliance of this facility with the Regulations for Operation of Child-Caring Agencies and Facilities 17a-145-48 through 17a-145-98, as well as the DCF Guidelines for the Administration of Medication by Certified Staff and the DCF Nursing Standards. Below are listed the areas of regulatory non-compliance which were identified during the re-licensing inspection. Please review the areas identified and submit a Service Development Plan to address each area. The plan must be submitted within 30 days of receipt of this letter and should identify: 1. the steps to be taken to correct the non-compliance; and 2. the date the correction(s) will be completed. The areas of non-compliance are listed on the attached DCF Licensing Report form. Please use this form to submit the Service Development Plan as well. Also included in the report are recommendations. Recommendations are meant to highlight areas that are not currently areas of non-compliance, but may become non-compliant if actions are not taken. Recommendations do not require the submission of a plan of a Service Development Plan. Section 17a-145-64. Personnel policies and procedures. Evidence: 15 personnel files reviewed. CPR: Missing CPR certification, OS, DL, AM, MG, JT Restraint: missing KN, JT, OS,HB Section17a-145-75. Health and medical treatment. section(b) Evidence: At the time of the licensing review there was no evidence the physician signed off on the medical policy and procedures. DCF Regulation 17a-6(g)-15 (a - g) Administration of the Medication Training Program. Evidence: 1) Mandatory Training for All Staff • Annual Emergency Medication Administration - Epi-pens and Asthma Rescue Medication. • This training must be provided at least annually and whenever necessary to maintain a safe environment for children. • Violation 1 Based on the review of the training records the facility failed to provide annual EpiPen / inhaler training in 2021. 2) Annual Observation of Medication Administration Skills Once a year the facility nurse must observe medication certified staff performing the DCF medication administration procedure. This must be documented using the DCF-2275 DCF Medication Administration Program Procedure Checklist and placed in the employees file. • Violation 2 Based on the review of the training records the facility failed to provide Annual Observation of Medication Administration Skills for one of the staff members. • Staff Member, A. P. missing the Annual Observation of Medication Administration Skills in July 2022. 3) DCF Medication Administration Regulation. Submit a DCF-2272 Monthly Medication Administration Program Supervision and Review to DCF Risk Management. • Violation3 Based on the review of the DCF Data system the facility failed to provide DCF-2272 from June 2021 to July 2022. 4) DCF Reg: 17a-6(g) -16 (c): "Day programs and residential facilities shall provide continuing education on administration of medication to trained person staff members." Facility nurses and/or appropriate personnel must offer continuing education opportunities for DCF medication certified staff. The facility nurse must document on a quarterly basis all continued education opportunities offered in the past 3 months. See Forms section for suggested form to document quarterly offerings. • Violation4 Based on the review of the training records the facility failed to provide quarterly training in 2021 and 2022. 5) Quarterly Review of Policies and Procedures Quarterly, the supervising registered nurse or licensed medical person will document a review of the facility’s medication policies and a review of the continuing education offered related to medication administration. Forms for documentation of these reviews are available on line and in the Forms section of this handbook (see Quarterly Review of Medication Policy and Procedures by Licensed Nurse and Quarterly Review of Medication Administration Continuing Education). Documentation of these reviews is to be kept at the facility and made available to the DCF upon request. • Violation 5 Based on the review of the policy records the facility failed to review the Quarterly Review of Policies and Procedures Quarterly. Once licensing has reviewed and accepted the Service Development Plan and has determined that your agency is in compliance with the regulations a decision on the issuance of a regular twenty-four month license for the program will be made. Until DCF makes this decision the current license will remain in effect. Should you have any questions or comments regarding the contents of this report please do not hesitate to call me at (860) 550-6310 or 203-675-6975. Sincerely, _______________________________________ Regulatory Consultant Copy: file|5678+++03/30/2022+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: ____Center of Discovery / Southport __________ TIME OF VISIT (FROM - TO): _________1:30pm____ DATE: _____3/30/2022___________ AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title AP Executive Director List of Areas / Topics covered during visit: • Census is 6. 6 females. LBC 6. • Physical plant inspection of the Group Home. See below. • Discussed the programing challenges and resident's treatment and compliance. • Discussed on-going training with staff. • Discussed staffing of shifts. • Met new RN • Spoke with youth briefly before group. Residents stated they like program and staff. Corrective Actions implemented as a result of previous visit: No SDP from previous visit. Areas of regulatory non-compliance identified during this visit: Physical Plant: The basement rug has numerous stains and tears visible. A work order was submitted. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Thomas S. Cuchara, _____4/7/22____________ Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

5975+++06/08/2023+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: ____Discovery Practice Management / Stamford __________ TIME OF VISIT (FROM - TO): 8:40am to 11:15am___ DATE: _____6/8/23__________ AGENCY PERSONNEL WHO PARTICIPATED: Job Title Milieu Manager Tech 4 List of Areas / Topics covered during visit: • Census is 12. LBC 12. Eleven females and one male. • Physical plant inspection of the Group Home. See below. • Discussed the programing challenges and resident's treatment and compliance. • One case reviewed and found no concerns. • Discussed staffing of shifts. No vacancies. Corrective Actions implemented as a result of previous visit: NO SDP from last visit. Areas of regulatory non-compliance identified during this visit: Section 17a-145-76. Kitchen, equipment, food-handling. Items were identified in the kitchen that need to be addressed. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Thomas S. Cuchara, 8/8/23 Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5902+++01/24/2023+++ John Peloquin, CEO 3/3/2023 Discovery Practice Management 4281 Katella Avenue, Suite #111 Los Alamitos, CA 90720 Re: Licensing Inspection for Stamford GH Regulatory Consultants: Tom Cuchara, Keith Bryan & Pat Hughes Dear Mr. Peloquin, On 1/24/23 and 1/25/23 a biennial re-licensing inspection was conducted at 929 Newfield Avenue, Stamford, CT. This inspection was conducted to determine the compliance of this facility with the Regulations for Operation of Child-Caring Agencies and Facilities 17a-145-48 through 17a-145-98, as well as the DCF Guidelines for the Administration of Medication by Certified Staff and the DCF Nursing Standards. Below are listed the areas of regulatory non-compliance which were identified during the re-licensing inspection. Please review the areas identified and submit a Service Development Plan to address each area. The plan must be submitted within 30 days of receipt of this letter and should identify: 1. the steps to be taken to correct the non-compliance; and 2. the date the correction(s) will be completed. The areas of non-compliance are listed on the attached DCF Licensing Report form. Please use this form to submit the Service Development Plan as well. Also included in the report are recommendations. Recommendations are meant to highlight areas that are not currently areas of non-compliance, but may become non-compliant if actions are not taken. Recommendations do not require the submission of a plan of a Service Development Plan. Section 17a-145-64. Personnel policies and procedures. Evidence: Twelve files reviewed. CPR: Three files did not have evidence of CPR training. S.H., M.R., C.B. Restraint: Four files did not have evidence of restraint training. S.H., M.R., C.B., G.P. Medication Administration: DCF Reg: 17a145-75 (d) and 17a -6(g) - 16 (c) Evidence: 1. Based on the review of the training records the facility failed to provide quarterly training from 2021 and 2022. No documentation that the med certified staff attended to training for two years. 2. Submit a DCF-2272 Monthly Medication Administration Program Supervision and Review to DCF Risk Management. 3. Based on the review of the DCF Data entry system the facility failed to submit the monthly summaries from 07/2021 to January 2023. • Annual Observation of Medication Administration Skills Once a year the facility nurse must observe medication certified staff performing the DCF medication administration procedure. This must be documented using the DCF-2275 DCF Medication Administration Program Procedure Checklist and placed in the employee's file. 4. Based on the review of the records the facility failed to do Medication Administration Skills Once a year. • Evidence: The following medication administration certified staff members' annual skills verification not done. M.C., L., R., M.V., N.R., A.F. 5. Quarterly Review of Policies and Procedures Quarterly, the supervising registered nurse or licensed medical person will document a review of the facility’s medication policies and a review of the continuing education offered related to medication administration. 6. Based on the review of the records the facility failed to review the quarterly policy. • Missing-January 2022 • 10/01/22 No MD signature/nurse • 01/26/21-no MD signature 7. Mandatory Annual Epi-pen & Inhaler & Training for all staff • This training must be provided at least annually and whenever necessary to maintain a safe environment for children. • Documentation shall be maintained listing staff who have been successfully trained and deemed competent to administer Epi-pens and emergency inhalers. 8. Based on the review of the training records the facility failed to provide annual epi-pen-asthma training. Evidence: Annual epi-pen & asthma training missing in 2021 & 2022. Once licensing has reviewed and accepted the Service Development Plan and has determined that your agency is in compliance with the regulations a decision on the issuance of a regular twenty-four month license for the program will be made. Until DCF makes this decision the current license will remain in effect. Should you have any questions or comments regarding the contents of this report please do not hesitate to call me at (203) 675-6975. Sincerely, __Thomas S. Cuchara_______________________________ Thomas S. Cuchara Regulatory Consultant Copy: file|5858+++12/22/2022+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Discovery Practice Management / Discovery Mood and Anxiety Program/ Stamford TIME OF VISIT (FROM - TO): 11:45am DATE: 12/22/2022 AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title KA Facility Manager List of Areas / Topics covered during visit: • Census is 10 LBC 12. 7 females and 3 males. • Physical plant inspection of the Group Home. No concerns. • Discussed the programing and resident's treatment and compliance. • No staff vacancies. KA reported the Agency hired a nursing supervisor, 10/22, to cover Stamford and Fairfield. • Medication Administration review of control medication found documentation correct. • Residents observed attending group with staff. No concerns. Corrective Actions implemented as a result of previous visit: Section 17a-145-76. Kitchens, equipment, food-handling. Completed. • The dishwasher was removed due repair needed. The handy man will assess repair needs. Licensing will follow up on next visit. • Several kitchen floor tiles were found to be broken and present as a tripping hazard. Areas of regulatory non-compliance identified during this visit: No SDP required. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Thomas S. Cuchara __2/3/2023______________ Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5818+++09/22/2022+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Discovery Practice Management / Discovery Mood and Anxiety Program/ Stamford TIME OF VISIT (FROM - TO): 9:30am DATE: 9/22/2022 AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title M Program Director KA Facility Manager List of Areas / Topics covered during visit: • Census is 12 LBC 12. 4 males and 8 females. • Physical plant inspection of the Group Home. No concerns. • Discussed the programing and resident's treatment and compliance. • Residents observed attending group with staff. No concerns. Corrective Actions implemented as a result of previous visit: No SDP last quarter Areas of regulatory non-compliance identified during this visit: Section 17a-145-76. Kitchens, equipment, food-handling. • The dishwasher was removed due repair needed. The handy man will assess repair needs. Licensing will follow up on next visit. • Several kitchen floor tiles were found to be broken and present as a tripping hazard. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Thomas S. Cuchara __11/10/2022______________ Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5817+++06/27/2022+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Discovery Practice Management / Discovery Mood and Anxiety Program/ Stamford TIME OF VISIT (FROM - TO): 9:30am DATE: 9/22/2022 AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title M Program Director KA Facility Manager List of Areas / Topics covered during visit: • Census is 12 LBC 12. 4 males and 8 females. • Physical plant inspection of the Group Home. No concerns. • Discussed the programing and resident's treatment and compliance. • Residents observed attending group with staff. No concerns. Corrective Actions implemented as a result of previous visit: No SDP last quarter Areas of regulatory non-compliance identified during this visit: Section 17a-145-76. Kitchens, equipment, food-handling. • The dishwasher was removed due repair needed. The handy man will assess repair needs. Licensing will follow up on next visit. • Several kitchen floor tiles were found to be broken and present as a tripping hazard. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Thomas S. Cuchara __11/10/2022______________ Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5672+++03/08/2022+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Discovery Practice Management / Discovery Mood and Anxiety Program TIME OF VISIT (FROM - TO): 1pm DATE: 3/8/2022 AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title MA Program Director LR Facility Manager List of Areas / Topics covered during visit: • Census is 11 and LBC 12. 7 females and 4 males. • Physical plant inspection of the Group Home. See below. • Discussed the programing and resident's treatment and compliance. • Residents observed attending group with staff. • Discussed staffing of shifts. Corrective Actions implemented as a result of previous visit: No SDP last quarter Areas of regulatory non-compliance identified during this visit: Physical Plant: Window on the third-floor hallway is damaged. A work order was created. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Thomas S. Cuchara ___4/1/2022______________ Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

5898+++03/23/2023+++DCF-3034 1/2013 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: FCA / 10 Harmony TIME OF VISIT (FROM - TO): 10:45am-1:15pm DATE: 3/23/23 AGENCY PERSONNEL WHO PARTICIPATED: Job Title Program Director Program Coordinator Areas / Topics covered during visit: Current Census= 3, LBC 5. One youth is inpatient. Staffing: No vacancies. Physical Plant Inspection: No concerns Client Files: Reviewed 2 client files. Found no concerns Corrections implemented as a result of previous visit: N/A Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning) N/A Areas of regulatory non-compliance identified during this visit: N/A Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Thomas S. Cuchara 3/28/23 ______________________________ _________________ Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5860+++12/28/2022+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Family & Children's Aid / 10 Harmony GH TIME OF VISIT (FROM - TO): __12:30pm _____________________ DATE: ___12/28/2022____ AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title CH Program Director SC Program Coordinator List of Areas / Topics covered during visit: • Census is 3, but one youth is in the hospital and scheduled to discharged to a hire level of care. • At the time of the visit there was no youth in the program. They are at school. • An evening visit to see the physical plant was completed. • Discussed the programing and working effective client in a group home. Corrective Actions implemented as a result of previous visit: Areas of regulatory non-compliance identified during this visit: NONE. No SDP. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Thomas S. Cuchara 2/3/2023_______ Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5684+++04/20/2022+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Family & Children's Aid/10 Harmony Girls' Group Home TIME OF VISIT (FROM - TO): 11:15 am -- 12:15 pm DATE: 4-20-22 AGENCY PERSONNEL WHO PARTICIPATED: Job Title CH Program Director EK Program Coordinator List of Areas / Topics covered during visit: Verified census and LBC. Reviewed the resident's circumstances and response to the program so far. Inspected all common areas, the bedrooms, and med room, staff office, and clinician's office. Verified med keys were being carried appropriately by a med cert staff. Corrective Actions implemented as a result of previous visit: Not applicable. Areas of regulatory non-compliance identified during this visit: None. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. A plan of correction does not have to be filed. James Richard Moore, LMSW April 21, 2022 Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

5969+++06/21/2023+++7/11/2023 Donna Swanson, Executive Director Focus Center for Autism 326 Albany Turnpike, PO Box 452 Canton, CT 06019 Re: CCF/ GH # 103 Dear Ms. Swanson, On June 21, 2023, a biennial licensing inspection was conducted at your facility. This inspection was conducted to determine the compliance of this facility with the Regulations for Operation of Child-Caring Agencies and Facilities 17a-145-48 through 17a-145-98, as well as the DCF Guidelines for the Administration of Medication by Certified Staff. Below are the areas of regulatory non-compliance which were identified during the re-licensing inspection. Please review the areas of non-compliance identified on the enclosed Service Development Plan and submit your responses on the enclosed Service Development Plan to address each area. The plan must be submitted within 30 days of receipt of this letter and should identify: 1. the steps to be taken to correct the non-compliance; and 2. the date the correction(s) will be completed. The areas of non-compliance are listed on the attached DCF Licensing Service Development Plan. Once the licensing unit has reviewed and accepted your plan of correction and has determined that your agency is in compliance with the regulations a decision will be made regarding the issuance of a regular 24-month license. Please be advised that failure to submit an accepted plan of correction within the timeframe specified may lead to a licensing action, up to and including revocation. Until the Department renders a decision your current license will remain in effect. Sincerely, Patrick Hughes DCF Regulatory Consultant Licensing Unit DCF LICENSING UNIT INSPECTION REPORT Date of Licensing Visit: June 21, 2023 Date Licensing Report Received by Facility: July 12, 2023 License Type: CCF License No. #: # 103 Date Service Development Plan Submitted to Licensing Unit: Corporate Name: Focus Center for Autism Corporate Address: 326 Albany Turnpike, PO Box 452, Canton, CT 06019 Program Name: Shannon House Program Address: 18 Shannon Drive, Barkhamsted, CT 06063 Person Submitting Plan (Name and Title): Person Approving Plan (Name and Title): Date: Statute/ Licensing Regulation # Non-Compliance Citation Plan of Correction/Service Development Plan A System to Prevent Re-Occurrence Completion Date Title Responsible to Monitor Plan 17a-145-98 Case records. Reports. Confidentiality The clinical notes have not been entered into the case records in a timely manner. At the time of the relicensing inspection, several months of clinical notes had not been entered into the case records. August 29, 2023 Donna Swanson, Executive Director Focus Center for Autism 326 Albany Turnpike PO Box 452 Canton, CT 06019 Re: Shannon House CCF # 103 Dear Ms. Swanson, We visited your agency program on June 21st and June 22nd, 2023, for a biennial licensing inspection. This inspection was conducted to determine the compliance of this program with the Regulations for the Operation of Child Caring Agencies and Facilities; Sections 17a-145-48 through 17a-145-98, as well as DCF Guidelines for the Administration of Medication by Certified Staff. We received your agency's service development plan. The plan submitted by you addresses the areas of non-compliance identified in the inspection report. The Department accepts the service development plan and has determined that your agency has met the requirements for a regular license. This license is effective as of August 21, 2023 and is valid for twenty-four months. We thank you and your staff for your cooperative participation in the review process. Sincerely, Patrick Hughes Patrick Hughes Regulatory Consultant Department of Children and Families 505 Hudson Street Hartford, CT 06106 (p) 860-550-6552 (f) 860-550-6665 patrick.hughes@ct.gov|5888+++03/08/2023+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Shannon House TIME OF VISIT (FROM - TO): 3:00 pm DATE: March 8, 2023 AGENCY PERSONNEL WHO PARTICIPATED: Job Title Shannon House Supervisor Shannon House Direct Care Staff List of Areas / Topics covered during visit: Census The Shannon House census is 3 and the licensed bed capacity (LBC) is 4. There are no current referrals for the vacant bed at Shannon House. Staffing There have been several new staff hired this quarter at Shannon House. Shannon House continues to hire for their vacant positions. Shannon House is currently able to fill all shifts at Shannon House. Program / Milieu The Shannon House residents are doing well this quarter with very few incidents. The residents are friendly with each other and are out in the community often. At the time of this quarterly visit all 3 residents were home and at the kitchen table having a snack. All 3 residents were in good spirits and were talkative with this regulatory consultant. All reported to be doing well and did not have any concerns for their safety or well-being. All interactions observed between Shannon House staff and the residents were friendly and professional. Physical Plant During this quarterly visit a physical plant inspection was conducted. Shannon House was clean, orderly, and nicely decorated with no health or safety concerns observed. Corrective Actions implemented as a result of previous visit: Not Applicable. Areas of regulatory non-compliance identified during this visit: Not at the time of this quarterly visit. Patrick Hughes 3/16/23 Regulatory Consultant Date|5867+++12/20/2022+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Shannon House TIME OF VISIT (FROM - TO): 1:30 pm DATE: December 20, 2022 AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title LE Shannon House Program Director RA Shannon House Clinician List of Areas / Topics covered during visit: • Current census is 3 and the licensed bed capacity is 4. Currently one resident is hospitalized. Shannon House has a few referrals from Solnit North's PRTF, and Children's Center of Hamden's PRTF. • Discussion of the residents' progress in the program and the program's milieu. The two long term residents continue to do well. The third and most recently admitted resident is currently hospitalized. Shannon House staff have been keeping in weekly contact with the hospitalized resident. The Shannon House clinician has continued to hold weekly counseling sessions with the resident. The resident is expected to return to Shannon House next week. • Discussion of Shannon House's staffing and hiring. Shannon House is currently able to fill all shifts at Shannon House. Shannon House recently hired a new 2nd shift staff and a new 1st shift staff. • Physical plant inspection of the Group Home; Shannon House was clean, orderly and nicely decorated with no health or safety concerns observed. • Observation of the residents; at the time of this visit the residents were returning from their school programs. The residents were having free time and checking in with their staff. Both residents appeared comfortable with staff and the interactions observed were friendly and professional. • During the visit this regulatory consultant had brief conversations with both residents. Both residents appeared to be in good spirits and were friendly and comfortable talking to this writer. Both residents reported to be doing well at Shannon House and did not report any concerns for their safety or well-being. Corrective Actions implemented as a result of previous visit: • Not Applicable. Areas of regulatory non-compliance identified during this visit: • Not at the time of this quarterly visit. Patrick Hughes 2/9/23 Regulatory Consultant Date|5805+++09/29/2022+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Shannon House TIME OF VISIT (FROM - TO): 1:00 pm DATE: September 29, 2022 AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title LE Shannon House Program Director RA Shannon House Clinician List of Areas / Topics covered during visit: • Current census is 3 and the licensed bed capacity is 4. There was one admission a month ago to Shannon House. This admission is a Voluntary Services admission with no DCF involvement. • Discussion of the residents' progress in the program and the program's milieu. The new resident has had some difficulties adjusting but has been improving. The two long term residents continue to do well. The addition of the third resident has been helpful to the milieu. • Discussion of Shannon House's staffing and hiring. The 1st and 3rd shifts are fully staffed, however currently there are vacancies for second shift and the weekend shifts. Shannon House continues to interview applicants however only a small percentage of the applicants follow through with their interviews. The vacant shifts are being covered by the full-time supervisors, the Shannon House per-diem staff and the Shannon house management and clinical teams. • Physical plant inspection of the Group Home; Shannon House was clean, orderly and nicely decorated with no health or safety concerns observed. • Observation of the residents; at the time of this visit the residents were returning from their school programs. The residents were having free time and checking in with their staff. All the residents appeared comfortable with staff and the interactions observed were friendly and professional. • During the visit this regulatory consultant had brief conversations with all 3 residents. All appeared to be in good spirits and were friendly and comfortable talking to this writer. All 3 residents reported to be doing well at Shannon House and did not report any concerns for their safety or well-being. Corrective Actions implemented as a result of previous visit: • Not Applicable. Areas of regulatory non-compliance identified during this visit: • Not at the time of this quarterly visit. Patrick Hughes 9/29/22 Regulatory Consultant Date|5731+++06/09/2022+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Shannon House TIME OF VISIT (FROM - TO): 2:45pm DATE: 6/9/2022 AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title LE Shannon House Program Director RA Shannon House Clinician List of Areas / Topics covered during visit: • Current census is 2 and the licensed bed capacity is 4. There is one current voluntary placement referral for Shannon House. • Discussion of the residents' progress in the program and the program's milieu. Both boys are doing well at Shannon House with only a few minor issues now and then. • Discussion of Shannon House's staffing and hiring. 1st and 3rd shifts are fully staffed, however currently there are no full time second shift direct care staff. The shifts are being covered by the full-time supervisors, the Shannon House per-diem staff and the clinical team. • Physical plant inspection of the Home; no health or safety concerns observed. • Observation of the residents; at the time of this visit both had returned from their school programs. One resident was watching Anime while the other residents was talking with the staff. Both appeared comfortable with staff and in the group home. • Interview with both residents; both residents reported to be doing well at Shannon House and did not report any concerns for their safety or well-being. Corrective Actions implemented as a result of previous visit: • Not Applicable. Areas of regulatory non-compliance identified during this visit: • Not at the time of this quarterly visit. Patrick Hughes 7/6/22 Regulatory Consultant Date|5663+++03/10/2022+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Shannon House TIME OF VISIT (FROM - TO): 2:00pm DATE: 3/10/2022 AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title LE Shannon House Program Director RA Shannon House Clinician List of Areas / Topics covered during visit: • Current census is 2 and the licensed bed capacity is 5. • Discussion of the residents' progress in the program and the program's milieu. • Discussion of Shannon House's staffing and hiring. • Discussion of changes to covid-19 protocols within Shannon House • Physical plant inspection of the Home; no health or safety concerns observed. • Observation of the residents; at the time of this visit both had returned from their school programs. Both appeared comfortable with staff and in the group home. • Interview with both residents; both residents reported to be doing well at Shannon House and did not report any concerns for their safety or well-being. Corrective Actions implemented as a result of previous visit: • Not Applicable. Areas of regulatory non-compliance identified during this visit: • Not at the time of this quarterly visit. Patrick Hughes 3/23/22 Regulatory Consultant Date|

5717+++03/29/2022+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Gilead / Anchorage Home TIME OF VISIT (FROM - TO): First / Second shift_ DATE: _3/29/22___________ AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: Program Director Two direct care staff List of Areas / Topics covered during visit: Three youth were residing in the home and they were at the home during the site visit on spring vacation. The program is down 3 staffing positions, there was a full time second shift Friday through Monday, second shift Saturday through Wednesday and a part time second shift Friday through Saturday staff position available. The agency's nurse was out on medical leave and the program was being covered by a per diem nurse. Corrective Actions implemented as a result of previous visit: Section 17a-145-73. Sleeping accommodations; Section 17a-145-74. Lavatory facilities. Toilet articles and linens, were responded to satisfactorily. Areas of regulatory non-compliance identified during this visit: Section 17a-145-73. Sleeping accommodations (a) Sleeping accommodations for each child shall have adequate area, spacing and equipment in accordance with the child's age and needs. Bedrooms shall contain a window unless there is a 24-hour ventilation system approved by the state or local health department. Heating facilities shall be sufficient to maintain a room temperature consistent with existing department of health services' guidelines. Separate sleeping quarters shall be provided for children of the opposite sex six years of age or over. The facility shall provide each such child with a single bed with adequate linens and covers suitable for the temperature, and a locker, dresser or other storage space for the child's private use conveniently located in or near the child's sleeping room. The bedroom with the en suite bath needed cleaning. Section 17a-145-74. Lavatory facilities. Toilet articles and linens The en suite bath needed cleaning. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. _Keith Bryan____________ ____3/29/22__ Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

5814+++09/19/2022+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: GBAPP / Housing for Success TIME OF VISIT (FROM - TO): __12:30pm______________________ DATE: __9/19/22____ AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title JV Program Director List of Areas / Topics covered during visit: • Census is 4. One female and three male. LBC 8. • Physical plant inspection of the Group Home. See below. • Discussed the programing and resident's treatment and compliance. • One resident at home during the visit. The other residents were in school. • Fire Drills reviewed. In compliance. • Discussed staffing of shifts and security of building. Corrective Actions implemented as a result of previous visit: Areas of regulatory non-compliance identified during this visit: Section 17a-145-76. Kitchen, Equipment, food-handling. • First floor: At the time of the licensing visit the dishwasher on the first floor was found to be broken. Program noted that a new one will be ordered if it cannot be fixed. • Second floor: The light in the oven range above stove does not work. The oven range and stove is found to be dirty/tacky to touch and should be cleaned. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Thomas S. Cuchara ___11/10/2022_______ Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5711+++06/07/2022+++DCF-3034 1/2013 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Greater Bridgeport Adolescent Program Housing for Success 1470 Barnum Ave. Suite 301 Bridgeport, CT 06610 DCF license CCF-GH 108 TIME OF VISIT (FROM - TO): morning DATE: June 7, 2022 AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title Director of Youth Services Areas / Topics covered during visit: This was an unannounced visit to determine compliance with Regulations for Operation of Child Caring Facilities Sections 17a-145-48 through 17a-145-98, as well as the DCF Guidelines for the administration of medication by certified staff. A review of the fire drills and program’s physical plant was conducted. No regulatory deficiencies were identified. The apartments were clean, and well organized. The atmosphere was reported to be stable and no major disruptions have occurred in the last quarter. Corrections implemented as a result of previous visit: N/A Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning) N/A. Areas of regulatory non-compliance identified during this visit: N/A Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. _Maria L Tapia___________________ _6/17/2022_________ Regulatory Consultant Date Maria L. Tapia, BSN-RN, MSW-L.C.S.W Regulatory Consultant Office of Legal Affairs Department of Children and Families 505 Hudson St. Hartford, Ct 06106 860-550-6500 fax: 860-550-6665 maria.tapia@ct.gov Cc: File A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5650+++02/24/2022+++DCF-3034 1/2013 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Greater Bridgeport Adolescent Program Housing for Success 1470 Barnum Ave. Suite 301 Bridgeport, CT 06610 DCF license CCF-GH 108 TIME OF VISIT (FROM - TO): morning DATE: February 24, 2022 AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title Director of Youth Services Areas / Topics covered during visit: This was an unannounced visit to determine compliance with Regulations for Operation of Child Caring Facilities Sections 17a-145-48 through 17a-145-98, as well as the DCF Guidelines for the administration of medication by certified staff. The program census was reportedly two; 1 female and 1 male. In the last three months, 3 AWOL’s were reported and no hospitalizations. The atmosphere was reported to be stable and no major disruptions have occurred in the last quarter. A review of the program’s physical plant was conducted. No regulatory deficiencies were identified. The apartments were clean, and well organized. Corrections implemented as a result of previous visit: N/A Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning) N/A. Areas of regulatory non-compliance identified during this visit: N/A Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. _Maria L Tapia___________________ _3/9/2022_________ Regulatory Consultant Date Maria L. Tapia, BSN-RN, MSW-L.C.S.W Regulatory Consultant Office of Legal Affairs Department of Children and Families 505 Hudson St. Hartford, Ct 06106 860-550-6500 fax: 860-550-6665 maria.tapia@ct.gov Cc: File A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

5996+++08/08/2023+++DCF-3034 1/2013 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: JRI/ Chesterfield Group Home Program TIME OF VISIT (FROM - TO): 11:00 am to 12:30pm DATE: August 8, 2023 AGENCY PERSONNEL WHO PARTICIPATED: Job Title Program Director Areas / Topics covered during visit: The census was three males at the time of the quarterly visit and the group home's licensed bed capacity remains at four. The program reported that the therapist’s position has been filled and there is one full-time residential counselor vacancy. Recreational activities, menu planning, the milieu, medical and nursing services were discussed and reviewed with the program director. A walkthrough of the physical plant was conducted with the group home director and no citations were identified. Corrections implemented as a result of previous visit: N/A Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning) N/A Areas of regulatory non-compliance identified during this visit: N/A Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Penny Woodward, LCSW September 6, 2023 Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5955+++05/18/2023+++/2013 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: JRI/ Chesterfield Group Home Program TIME OF VISIT (FROM - TO): 11:30am to 12:30pm DATE: May 18, 2023 AGENCY PERSONNEL WHO PARTICIPATED: Job Title : Program Director Areas / Topics covered during visit: The census was three at the time of the quarterly visit and the group home's licensed bed capacity remains at four. The program reported that the vacant clinical case manager position has been filled and the new employee will start in the month of July. A walkthrough of the physical plant was conducted with the program director and one citation was identified please see information below. Corrections implemented as a result of previous visit: N/A Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning) N/A Areas of regulatory non-compliance identified during this visit: Section 17a-145-73. Sleeping accommodations: A walkthrough of the physical plant was conducted and bedroom seven's door frame was broken and it needs to be repaired. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Penny Woodward, LCSW ____June 16, 2023___ Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5915+++03/10/2023+++DCF-3034 1/2013 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: JRI/ Chesterfield Group Home Program TIME OF VISIT (FROM - TO): 11:30am to 1:00pm DATE: March 10, 2023 AGENCY PERSONNEL WHO PARTICIPATED: Job Title Program Director Division Director Areas / Topics covered during visit: The census was three at the time of the quarterly visit and the group home's licensed bed capacity is four. The program reported that there was a clinician vacancy and a candidate has been selected to fill the vacant position. A walkthrough of the physical plant was conducted with the program director and no deficiencies were identified. Corrections implemented as a result of previous visit: N/A Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning) N/A Areas of regulatory non-compliance identified during this visit: N/A Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Penny Woodward, LCSW April 6, 2023 Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5830+++11/02/2022+++November 16, 2022 Justice Resource Institute 160 Gould Street. Suite 300 Needham, MA. 02494 On November 1st and 2nd, a biennial re-licensing inspection was conducted at the Chesterfield Group Home to determine compliance with Regulations for Operation of Child Caring Agencies and Facilities Sections 17a-145-48 through 17a-145-98, as well as the DCF Guidelines for the Administration of Medication by certified staff. DCF has determined that the program is in compliance with all applicable regulatory provisions except those itemized below: Please review areas identified and submit a plan of correction to address each area. The service development plan must be submitted within 30 days of receipt of this letter and should identify: 1. The steps to be taken to correct the non-compliance. 2. The date the correction(s) will be completed. The areas of non-compliance identified are as follows: Section 17a-145-61: Written policies and procedures. Evidence: Upon review of the program manual, the following policies were outdated or did not reflect current group home practices. The telephone policy, waived testing policy and supervision policy. The outdated information must be amended or removed. Evidence: Upon review of the program manual, there was no written policy on the discharge of a youth from the group home program. Evidence: Upon review of the program manual, personnel policies did not include information that required a new employee to have criminal checks, TB and physical health exams completed prior to being hired. Section 17a-145-63: Chief administrative officer. Evidence: Upon review of staffing information, the program did not always ensure that there was the required amount of staffing on the third shift. Section 17a-145-74: Lavatory facilities. Evidence: Upon inspection of the physical plant, the second-floor bathroom ceiling contained repair marks and it needs to be addressed. Section 17a-145-75: Health and medical treatment. Evidence: Upon review of the medication administration system the following violations were identified during the inspection visit: The controlled medication box was not double locked or stored in an appropriate location. The medication key for controlled medications was not being kept on a second ring as required by regulations. The program did not always ensure that non-medication certified staff did not have access to medication keys. Nursing assessments for two residents had not been completed within the required time frame. The program did not always complete monthly reviews of physician orders in 2021.There was no documentation confirming that staff attended mandated quarterly and annual trainings for medication topics in 2022. The program nurse did not always conduct annual observations of medication administration and skills tests in 2022. For additional information please refer to the DCF Nurse’s report and medication administration guidelines. Section 17a-145-76: Kitchen, equipment. Evidence: Upon inspection of the physical plant, the oven contained an excessive amount of grease and food stains and it needs to be addressed. Section 17a-145-77: Dining areas and supervision. Evidence: Upon inspection of the dining room area, the floor contained an excessive number of scratches and scuffmarks and it needs to be addressed. Section 17a-145-97: Discharge of child. Evidence: Upon review of a discharge record, documentation did not identify the person the youth was discharged to as required by regulation. Once licensing has reviewed and accepted the service development plan and has determined that your agency is in compliance with the regulations a decision on the issuance of a regular twenty-four-month license for the program will be made. Until DCF makes this decision the current license will remain in effect. Please be advised that failure to submit an acceptable service development plan within the specified time frame may lead to a licensing action up to and including revocation. Should you have any questions or comments regarding the contents of this report please do not hesitate to call me at (959) 255-0615. Sincerely, Penny Woodward Penny Woodward, LCSW DCF Regulatory Consultant Copy: File|5776+++08/09/2022+++DCF-3034 1/2013 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: JRI/ Chesterfield Group Home Program TIME OF VISIT (FROM - TO): 11:30am to 1:00pm DATE: August 9, 2022 AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title N/A Program Director Areas / Topics covered during visit: The Department of Children and Families conducted a scheduled quarterly inspection visit at the Chesterfield Group Home Program on August 9, 2022. Topics covered during the quarterly visit included staffing and training, physical plant inspection, milieu services, medication administration system and the fall bi-annual inspection visit. Physical plant: A walkthrough of the physical plant was conducted with the group home director to confirm that the facility was in compliance with regulatory standards. Corrections implemented as a result of previous visit: N/A Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning) N/A Areas of regulatory non-compliance identified during this visit: N/A Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Penny Woodward, LCSW September 2, 2022 Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5737+++05/09/2022+++DCF-3034 1/2013 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: JRI/ Chesterfield Group Home Program TIME OF VISIT (FROM - TO): 11:30am to 1:00pm DATE: May 9, 2022 AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title N/A Program Director Areas / Topics covered during visit: The Department of Children and Families conducted a scheduled quarterly inspection visit at the Chesterfield Program On May 9, 2022. Topics covered during the quarterly visit included staffing and training, physical plant inspection, milieu services and medication administration system. Physical plant: A walkthrough of the facility was conducted with the director; areas of improvement were identified and discussed with the program representative. Some of the rooms had missing window screens and they need to be replaced. The outside patio deck surface contained chipping paint and it needs to be addressed. Corrections implemented as a result of previous visit: N/A Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning) N/A Areas of regulatory non-compliance identified during this visit: N/A Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Penny Woodward, LCSW June 17, 2022 Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5682+++03/18/2022+++ DCF-3034 1/2013 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Chesterfield Group Home TIME OF VISIT: (FROM–TO): Morning to Afternoon DATE: 3/18/22 AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title N Program Director Areas / Topics covered during visit: The Department of Children and Families conducted a scheduled quarterly inspection visit at the Chesterfield Group Home Program on March 18, 2022. Topics covered during the quarterly visit included program census, staffing and training, physical plant inspection and medication administration system. Physical plant: A walkthrough of the physical plant with the program director was conducted; deficiencies were identified and discussed with the director. Corrections implemented as a result of previous visit: N/A Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning) N/A Areas of regulatory non-compliance identified during this visit: N/A Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Penny Woodward, LCSW April 18, 2022 Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

5988+++08/17/2023+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Klingberg Family Centers, Inc. - WEBSTER HOUSE TIME OF VISIT (FROM - TO): 10:00am-1:20pm DATE: 8-17-23 AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: • Program Supervisor • Asst. Program Supervisor • Clinical Director • Clients List of Areas / Topics covered during visit: This was a scheduled quarterly Licensing visit to obtain an update on the program, tour the physical plant, and conduct a personnel file review. A meeting was held with the Clinical Director and Program Supervisors. Areas of discussion included: • Census = 6 (2 male, 4 female); LBC= 7 • Staff vacancies: Vacant Program Director position to be shared with another Klingberg home; 1 FT & 1 PT direct care staff positions; use of one temp agency staff 2-3 times per week; Program Director transitioned to program Clinical Director. • Sunsetting of PNMI reviews effective this month. • Incidents in the past quarter; Fire Dept. responded to sprinkler alarm. • Status reports on residents. • Client vocational and education placements; summer school. • Summer rec and leisure activities. • Life skills training activities. • Family involvement; discharge planning. • No video cameras in program. • Donations from building supply store for garden project. • Campus swimming pool. Milieu observation: • Staff/client interactions. • Lunch; menu discussion. • One family visiting a new resident. Physical Plant tour: • Supervisory staff facilitated tour of physical plant. • All areas appeared very clean and well organized. • Dining area floor is chipped and warped; Stained/ripped carpeting in common area; Replacement of both reportedly on hold. • Discussion on use of multipurpose lounge; improving appearance. • Worn appearance of kitchen cabinets. • Suggested door alarms on exit doors to enhance client safety. • Beautiful floor beds and vegetable garden in front of house. • Damage observed in several areas of exterior siding. • No water at sink in one bathroom. See 'Areas of regulatory Non-compliance' below. Interviews with four clients. • One concern reported that Clinical Director has followed up on earlier this week. Personnel file review/meeting with HR Admin Assistant. Topics discussed included: • DDS registry checks. • Securing background safety checks and physical exam information from temp agency for a regularly scheduled temp staff. • HR intern. • Personnel file review: Two personnel files were reviewed: See 'Areas of Regulatory Noncompliance' below. Corrective Actions implemented as a result of previous visit: - Not applicable. Areas of regulatory non-compliance identified during this visit: 17a-101. Protection of children from abuse. Mandated reporters. Educational and training programs. • The personnel file of one employee (SD) hired in March 2023 does not contain evidence of training on mandatory reporter requirements. 17a-131. Cardiopulmonary resuscitation training required for persons who directly supervise children. • The personnel file of one employee (CE) hired in May 2023 does not contain evidence of CPR certification. 17a-145-67 Water Supply. Sewage and garbage facilities. • The sink in one client bathroom does not have running water. 46a-154. Internal monitoring, training and development of policies and procedures required and subject to state agency inspection. • The personnel files of two employees (CE, SD) do not contain evidence of restraint/seclusion training. Please submit a service development plan to address the above referenced areas of non-compliance within 30 days of receipt of this report. The service development plan must be submitted to the attention of the undersigned at the address listed above. Kathleen Forsythe, LCSW Date: 8-18-23 Regulatory Consultant A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM Cc: Sr. Director of Community-Based Programs|5926+++05/04/2023+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Klingberg Family Centers, Inc. - WEBSTER HOUSE TIME OF VISIT (FROM - TO): 10:30am-2:30pm DATE: 5-4-23 AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: Program Supervisor Director of Nursing Senior Director of Community-Based Programs Client Youth Development Specialist Certified Nurse's Aid List of Areas / Topics covered during visit: This was a scheduled quarterly Licensing visit to obtain an update on the program, tour the physical plant, and conduct a sample record review. A meeting was held with the Program Supervisor and the Senior Director of Community-Based programs. Areas of discussion included: • Census: 5 (3 females, 2 males) • Staffing: o Program Director scheduled to return from leave next week o One part-time direct care worker vacancy o Nursing positions are full o Clinician position remains vacant - clinical duties covered by Sr. Director of Community-based programs and Program Director o Periodic use of temp agency staff • Recent client referral to program • Incidents in the past quarter • Video surveillance cameras o two exterior camera locations o possible installation of interior cameras • Update on each client • Life skills training for older teen client • Staff appreciation activities • New wooden garden bed built by school employee Milieu observation: • Staff client interactions • Staff supervision station • Another DCF rep onsite conducting scheduled PNMI review Physical Plant tour: • All areas were observed to be very clean and well organized. • Dining area tile floor appears worn - staff reported that carpet and tile flooring in the home are scheduled for replacement this year when federal funding is released. • Doorbell at front door has been repaired • Suggested door alarms on exit doors to enhance client safety Client Interview. Discussion included: • life skill training areas • vocation interests • discharge planning, transitioning to DMHAS in the future • food • relationships with peers and staff • community outings, rec activities with client from another Klingberg group home Case Record review: One client case record was reviewed after site visit. No regulatory deficiencies noted. Corrective Actions implemented as a result of previous visit: - A service development plan was submitted to DCF by Webster House program following a February 2023 Licensing visit that addressed regulatory citations related to the physical plant. The plan was accepted by the Department. Areas of regulatory non-compliance identified during this visit: None. Please submit a service development plan to address the above referenced areas of non-compliance within 30 days of receipt of this report. The service development plan must be submitted to the attention of the undersigned at the address listed above. - No service development plan is required for this Licensing visit. Kathleen Forsythe, LCSW Date: 5-9-23 Regulatory Consultant A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM Cc: Sr. Director of Community-Based Programs Program Director Program Supervisor|5873+++02/09/2023+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Klingberg - WEBSTER HOUSE TIME OF VISIT (FROM - TO): 1:00pm-3:00pm DATE: 2-9-23 AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: Director of Clinical Services Program Supervisor Clients (3) Assistant Supervisor Registered Nurse List of Areas / Topics covered during visit: This was an unannounced quarterly Licensing visit to the Webster House to tour the physical plant and obtain a program update. Physical plant tour conducted by a Youth Development Specialist (YDS): • Interior areas appeared clean and organized; sections of carpet are dirty (See 'Areas of Regulatory Non-compliance' below) • Privacy curtain, shade, etc. missing from window in bedroom #8 (See 'Areas of Regulatory Non-compliance' below) • Doorbell at front entrance remains non-functional • Storage room contains damaged mattress Interview with Program Nurse • Meals; menus • Mask wearing no longer required on unit Milieu Observation: • One resident relaxing in bedroom • Three residents returning from school • 1:1 staff supervision with one resident • Staff/resident interactions • Director of Medical Services in the milieu Meeting held with Director of Clinical Services. Topics discussed: • Current census = 5 residents (2 males, 3 females) • 1:4 ratio • Newest resident admitted since last Licensing; prone to wandering • No cameras or door alarms on the unit • One resident diagnosed with COVID last month (mild symptoms) • One resident in remission from cancer is doing well • Housekeeping cleaning service two hours per day Monday through Friday • Off-site recreation activities • Life skills training • Group therapy • Staff vacancies: program therapist remains vacant; two part-time YDS positions vacant; use of two temporary staffing agencies when needed (Delta-T and Visiting Angels); recently hired 3rd shift YDS • Two new televisions on unit • Conversion of a YDS position to a certified nurse's aide position • One resident stopped attending college classes; daily programming for the resident; discharge planning; paid mentorship at 'Huneebee Project' & transportation; undocumented status • Dietician/resident monthly meetings; Menus • No major incidents in the past quarter requiring emergency services • Program security: lack of cameras, non-functioning doorbell • Hair care for residents Interviews with two residents • One resident explained removing window covering • One resident not attending a school/work program; daily routine Corrective Actions implemented as a result of previous visit: N/A Areas of regulatory non-compliance identified during this visit: Section 17a-145-73. Sleeping accommodations. • A window in a female resident's bedroom (#8) does not contain curtains, shades, blinds etc. on the lower half of the window to ensure privacy. Section 17a-145-77. Dining areas and supervision. • Carpeting near dining area contains large stains. Please submit a service development plan to address the above referenced area of non-compliance within 30 days of receipt of this report. The service development plan must be submitted to the attention of the undersigned at the address listed above. Kathleen Forsythe, LCSW Date : 2-10-23 Regulatory Consultant A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM Cc: Director of Clinical Services|5825+++11/21/2022+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Klingberg Comprehensive Services, Inc. - WEBSTER HOUSE TIME OF VISIT (FROM - TO): 12:00p-2:00pm DATE: 11-21-22 AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: Director of Clinical Services Program Supervisor HR Benefits Coordinator List of Areas / Topics covered during visit: This was a scheduled quarterly Licensing visit to obtain an update on the program, tour the physical plant, and conduct a semiannual personnel file review. Meeting held with the Webster House Director of Clinical Services. Topics discussed: • Census (4) • Client events since last Licensing visit (medical, academic, vocational, recreation, incidents, etc.) • Staffing vacancies: 3 direct care workers, 1 overnight Registered Nurse, 1 Therapist • Planned Thanksgiving celebration • Director of Clinical Services interim coverage of Therapist duties, therapy schedules • Bed check frequency • Adding video surveillance for enhance client safety • Non-functioning doorbell at front door; planned entrance security upgrade • Individual client schedules • Covid status and mask requirement in group home; infection control procedures • Tour of the physical plant; condition of flooring in common area Personnel File Review: • Semiannual personnel file review conducted. Two personnel files were reviewed. No regulatory deficiencies noted. Corrective Actions implemented as a result of previous visit: • A Service Development Plan (SDP) was submitted by the agency on 9-30-22 as a follow up to the August 2022 Relicensing inspection. The SDP was accepted by the Department. Areas of regulatory non-compliance identified during this visit: None. Kathleen Forsythe, LCSW Date: 11-23-22 Regulatory Consultant A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM Cc: Director of Clinical Services|5775+++09/01/2022+++September 1, 2022 Dr. Steven A. Girelli, PhD. President/CEO Klingberg Comprehensive Services, Inc. 370 Linwood Street New Britain, CT 06052 Re: License #: CCF/GH/131 Webster Dear Dr. Girelli, On August 16th and September 1st, 2022, a biennial re-licensing inspection was conducted for the Webster House Group Home, located at 60 State Street, New Britain, CT. This inspection was conducted to determine the compliance of this program with the Regulations of the Connecticut Department of Children and Families Operation of Child-Caring Agencies and Facilities Regulations 17a-145-48 through 17a-145-124. Additionally, an onsite review was conducted by DCF Nurse Consultant Anna Cherian, RN, MSN, FNP-BC on 6-22-22 to determine the program’s compliance with the DCF Medication Administration Guidelines and the DCF Nursing Standards. A copy of the nursing review site visit summary report is included with this report. Listed below are the areas of DCF regulatory non-compliance which were identified during the re-licensing inspection. Please review the areas identified and complete a service development plan (SDP) to address each area of noncompliance. The plan must be submitted within 30 days of receipt of this letter and should identify: 1. the steps to be taken to correct the non-compliance; and 2. the date the correction(s) will be completed. The areas of non-compliance identified are as follows: 17a-131 Cardiopulmonary Resuscitation Training Required for Persons Who Directly Supervise Children. • Two personnel files reviewed (JS, IS) did not contain evidence of CPR training. Chapter 814e Physical Restraint, Medication and Seclusion of Persons Receiving Care, Education or Supervision in a School, Institution or Facility. 46a-154 Internal monitoring, training and development of Policies and procedures required and subject to state agency Inspection. • One personnel file reviewed (JS) did not contain evidence of physical restraint training. ****************************************************************************** Once the Licensing Unit has reviewed and accepted the service development plan and has determined that your agency is in compliance with the regulations, a decision on the issuance of a regular twenty-four month license for the program will be made. Until DCF makes this decision the current license will remain in effect. Should you have any questions or comments regarding the contents of this report please do not hesitate to contact me at (860) 937-7551. Sincerely, Kathleen Forsythe _________________________ Kathleen Forsythe, LCSW Regulatory Consultant Cc: Senior Director of Community Based programs Director of Clinical Services File|5705+++06/01/2022+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Klingberg - WEBSTER HOUSE TIME OF VISIT (FROM - TO): 10:30am-2:30pm DATE: 6-1-22 AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: Director of Clinical Services Program Supervisor Assistant Program Supervisor Assistant Plant Director Director of Health Services HR Administrative Assistant List of Areas / Topics covered during visit: This was a scheduled quarterly visit for the newly assigned Regulatory Consultant to tour the program and conduct a semi-annual personnel file review. Discussions were held in the following areas: • Introduction of group home management team • Current renovation of group home to add a bedroom and an ADA compliant bathroom • Restraint and seclusion data from past quarter • Hospital visits • Fire watch status report • Staff vacancies and use of a staffing agency • New DCF Physical Plant checklist • Reasonable Prudent Parent Standard • Physical plant tour, tour of area under renovation when clients are not in the building • Grocery delivery, food storage, menu development & Dietician approval • Storage of client personal belongings in bedrooms • Window screens • Use of Multiplacement Lounge (MPL) • Biannual relicensing inspection scheduled for August 2022; application materials and due dates reviewed • Semi-annual personnel file conducted; 9 files reviewed Corrective Actions implemented as a result of previous visit: N/A Areas of regulatory non-compliance identified during this visit: 17a-145-64 Personnel Policies and Procedures • One personnel file (AF) did not contain evidence of TB testing results. • One file (JF) contained TB testing results obtained six months prior to hire rather than immediately prior to hire. • Four files (KD, AR, SF, MB) did not contain evidence of CPR certification. • Six files (MG, JF, AR, JJ, AF, MB) did not contain evidence of restraint training certification. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Kathleen Forsythe, LCSW 6-2-22 ______________________________ _________________ Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM Cc: Director of Clinical Services|5676+++03/29/2022+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: _Klingberg Family Center / Webster House __________ TIME OF VISIT (FROM - TO): ______2pm____________________ DATE: ___3/29/22_____ AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title LC Program Director List of Areas / Topics covered during visit: • Census is 5. LBC 6. One 1:1. • Physical plant inspection of the Group Home. No concerns. • Two residents I spoke to state they really like living at Webster House and staff treat them well. • Discussed the programing and resident's treatment and compliance. Corrective Actions implemented as a result of previous visit: No SDP Areas of regulatory non-compliance identified during this visit: No Service Development Plan required. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Thomas S. Cuchara 4/6/2022 ______________________________ _________________ Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

5977+++08/10/2023+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Klingberg Family Centers (KFC) / Phoenix House Group Home TIME OF VISIT (FROM - TO): 10:00am - 12:20pm DATE: 8-10-23 AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: Senior Director of Community-Based Services Program Supervisor Lead Youth Development Specialist Client (D) List of Areas / Topics covered during visit: This was a scheduled quarterly Licensing Visit to obtain updates on the program and tour the physical plant. Meeting was held with: Senior Director, Program Supervisor and Lead YDS. Topics discussed included: • Census 3 females. LBC =4 • Proposed addition of bedroom in lower level • Incidents during past quarter • Medication Refrigerator • Program updates • Video cameras in common areas; Quality Assurance Measures • Recreation Activities • Discharge Planning • Program Vehicles • Life Skills Training • Klingberg selected as recipient of My Life My Choice Training by outside vendor • Two (2) Phoenix House participated in Train the Trainer for Love 146 Training • Staff Recruitment and Retention Initiatives • Nursing Care Plan for one (1) client • Fire Extinguisher installed in Cleaning supply Closet • Staffing Vacancies: 2.5 Youth Development Specialists, Program Director and Clinician. Senior Leadership is serving as Program Director and Clinician. Use of one (1) temp agency staff. Physical Plant: Staff facilitated a tour of the interior/exterior of the physical plant. All areas appear clean and organized. Rear Fence removal to be scheduled. Milieu: Two clients were observed in the home, observed leaving with staff on off-campus recreation activity. Client Interview: One (1) client interviewed, reported satisfaction with program and no concerns reported. Corrective Actions implemented as a result of previous visit: Not applicable Areas of regulatory non-compliance identified during this visit: Not applicable Please submit a service development plan to address the above referenced areas of non-compliance within 30 days of receipt of this report. - No service development plan is required following this Licensing visit. Amita Patel, LMSW Date: 8/11/23 Regulatory Consultant A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM Cc: Senior Director of Community Based Services|5927+++05/09/2023+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Klingberg Family Centers, Inc. - Phoenix House TIME OF VISIT (FROM - TO): 10:45am-1:15pm DATE: 5-9-23 AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: Asst. Program Supervisors (2) List of Areas / Topics covered during visit: This was a scheduled quarterly Licensing visit to obtain an update on the program, tour the physical plant and conduct a case record review. Meeting held with two Assistant Program Supervisors. Topics discussed included: • Census: 3 females. Licensed bed capacity = 4 • Significant events: 1 • Two admissions during the past quarter • Updates on the three residents • Children's Rights statute re: telephone use • Improvements to house interior: interior paintings, additional décor, new rugs, sensory area in the lower level • Menu planning and approval • Recreation activities • Life skills trainings: current focus includes boundaries, grocery shopping, home cleaning procedures • Planned outdoor gardening • Condition of wooden fence in rear yard; brush removal Staffing Update: • Program Director position is currently vacant • New Clinician assumed job duties in April • One full time third shift, one full-time and one part-time direct care worker vacancies for the awake shifts Physical Plant: Staff facilitated a tour of the physical plant. All areas appeared very clean and well organized. Milieu: Client were attending school off-site during the visit. Life Skills Coordinator observed in the dining room. Case Records: One case record was reviewed after the site visit. No regulatory deficiencies were noted Corrective Actions implemented as a result of previous visit: Not applicable Please submit a service development plan to address the above referenced areas of non-compliance within 30 days of receipt of this report. The service development plan must be submitted to the attention of the undersigned at the address listed above. - No service development plan is required for this Licensing visit. Kathleen Forsythe, LCSW Date: 5-11-23 Regulatory Consultant A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM. Cc: Sr. Director of Community-Based Programs|5871+++02/16/2023+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Klingberg - Phoenix House TIME OF VISIT (FROM - TO): 11:45am-1:15pm DATE: 2-16-23 AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: Clinical Director Program Supervisor Youth Development Specialist (2) List of Areas / Topics covered during visit: This was an unannounced quarterly Licensing visit to obtain an update on the program and tour the physical plant. Meeting held with Clinical Director. Topics discussed included: • Census: 1 female. • Referrals: 2. Anticipated admissions scheduled for March • Staffing vacancies: 1 third shift position, covered by perdiem staff. New Therapist hired today and will start next month. • Possible conversion of Phoenix House to a STAR home • Building plans for a bedroom on lower level • Conversion to Quality Residential Treatment program (QRTP) occurred in December 2022 • Recent purchase of three new beds • Aftercare services • Discharge planning for current resident • Surveillance cameras • Program vehicle monitoring • Planned improvements to house interior (relocating washer/dryer, painting bedrooms and bathrooms) • Neighbor relationships • Grocery shopping • Life skills trainings • Meeting the needs of a diverse female client population Physical Plant: The Supervisor facilitated a tour of the physical plant. All areas appeared organized and clean, with the exception of the bathroom shower in master bedroom. Milieu: Direct care staff observed cleaning common areas. Resident was attending school off-site. Corrective Actions implemented as a result of previous visit: Not applicable Areas of regulatory non-compliance identified during this visit: None. Kathleen Forsythe, LCSW Date: 2-17-23 Regulatory Consultant A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM Cc: Clinical Director Director of Community Based Programs|5824+++11/21/2022+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Klingberg Family Centers, Inc. - PHOENIX House Group Home TIME OF VISIT (FROM - TO): 1:00p-2:00p DATE: 11-21-22 AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: HR Benefits Coordinator List of Areas / Topics covered during visit: This was a scheduled Licensing visit to the HR office on the Klingberg campus in New Britain to conduct a semiannual personnel file review of staff hired in the previous six months for the Phoenix House group home. • Two personnel files were reviewed. Corrective Actions implemented as a result of previous visit: N/A Areas of regulatory non-compliance identified during this visit: 17a-131 CPR Training & 46a-154 Restraint Training • One personnel file of a Youth Development Specialist hired in July 2022 did not contain evidence of CPR certification and restraint training. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Kathleen Forsythe, LCSW Date: 11-23-22 Regulatory Consultant A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM Cc: Clinical Director HR Assistant|5808+++11/10/2022+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Klingberg Family Centers - PHOENIX House Group Home TIME OF VISIT (FROM - TO): 10:50am-2:00pm DATE: 11-10-22 AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: Clinical Director Therapist Program Supervisors (2) Client List of Areas / Topics covered during visit: This was a scheduled quarterly Licensing visit to obtain an update on the program and to tour the physical plant. Meeting held with program management staff, who provided an update on the program since the previous Licensing visit in August 2022: • Current census = 2 females. One client was discharged after she went AWOL. Discussed the involved client's history, family involvement, need for PRTF level of care, etc. Staff reported that two referrals for admission are currently under consideration. • Semiannual PNMI review conducted by DCF last week • Staffing vacancies: Program therapist who is a master's level Clinician will need to be replaced by a licensed clinician, per PNMI standards. Three full-time and one part-time direct care worker positions are open. • Police involvement in two incidents last quarter • Investigation • Recreation and leisure • Meals, menu, food shopping, food prep • Life skills training for clients; prepping older client to discharge next spring • Neighbor relations • Limited availability of parking for staff on the property; three cars parked on the street • QRTP designation: The group home is now a qualified residential treatment program, as designated by DCF, to comply with the Families First Act. Licensed bed capacity will reduce to four beds; six months of aftercare services will be provided. • Only one vehicle is assigned to the program Physical plant: Management facilitated a tour of the physical plant. All areas appeared clean and organized. Program installed video cameras this fall. Discussed bed frames, mattresses, bedroom furniture, enhancing privacy on bedroom windows, bathroom privacy, condition of backyard fence. Garbage cans stored in front of house. Planned renovation to create a single bedroom is on hold until early 2023. Milieu observation: Three direct care staff on duty. One client in the house. Client spoke briefly about the certification program she attends at a local technical institute. Corrective Actions implemented as a result of previous visit: N/A Areas of regulatory non-compliance identified during this visit: None Kathleen Forsythe, LCSW Date: 11-10-22 Regulatory Consultant A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM Cc: Dir. Of Community Based Programs Clinical Director|5757+++08/10/2022+++Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: _ Klingberg - PHOENIX HOUSE GROUP HOME ¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬ TIME OF VISIT (FROM - TO): 10:30am-12:45pm DATE: 8-10-22 AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: Senior Director of Community Based Programs Clinical Director Therapist Program Supervisor Client List of Areas / Topics covered during visit: This was a scheduled quarterly visit to introduce the newly assigned Regulatory Consultant, obtain an update on the program, and to tour the physical plant. Topics discussed: • Census (3) • Client cases • Neighbor relations • Physical plant security • New QRTP contract requirements • Life skills education for clients • Summer activities, summer school • Education/vocational plans for new school year • Menus, food storage • Staffing vacancies (1) • DMST training and future staff trainings • Agency vehicle • Physical plant inspection • Milieu observation • BBQ grill placement • Future renovation plan Corrective Actions implemented as a result of previous visit: None. Areas of regulatory non-compliance identified during this visit: None. Kathleen Forsythe, LCSW Date: 8-12-22 Regulatory Consultant A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM. Cc: Clinical Director Senior Director of Community Based Programs|5694+++04/26/2022+++ Steve Girelli, President 4/27/2022 Klingberg Family Centers 370 Linwood Street New Britain, CT 06052 Re: Licensing Inspection for Phoenix House Regulatory Consultants: Tom Cuchara and Penny Woodward Dear Dr. Girelli, On 4/26/22 & 4/27/22, a biennial re-licensing inspection was conducted at Phoenix House GH. This inspection was conducted to determine the compliance of this agency with the Regulations for Operation of Child-Caring Agencies and Facilities 17a-145-48 to 17a-145-98. Below are listed the areas of regulatory non-compliance which were identified during the re-licensing inspection. Please review the areas identified and submit a service development plan to address each area. The plan must be submitted within 30 days of receipt of this letter and should identify: 1. the steps to be taken to correct the non-compliance; and 2. the date the correction(s) will be completed. Also included in the report are recommendations. Recommendations are meant to highlight areas that are not currently areas of non-compliance, but may become non-compliant if actions are not taken. Recommendations are also made in order to enhance program functioning. Recommendations do not require the submission of a service development plan. The areas of non-compliance identified are as follows: Section 17a-145-64. Personnel policies and procedures. Evidence: Two personnel files were reviewed. CPR: One file did not have evidence of CPR certification. Section 17a-145-86. Instructions in safety procedures. Evidence: 2020: 1st quarter First shift fire drill missing. 2nd quarter Second & third shift fire drills missing. 3rd quarter First shift fire drill missing. 2021: 4th quarter Second & third shift fired drills missing. No time or shift is documented on the form. 2022: 1st quarter 1st, 2nd and 3rd fire drills were recorded on the fire drill form used, but there is no documentation of the time and shift of when the drills took place. Once licensing has reviewed and accepted the service development plan and has determined that your agency is in compliance with the regulations a decision on the issuance of a regular twenty-four month license for the program will be made. Until DCF makes this decision the current license will remain in effect. Please be advised that failure to submit an acceptable service development plan within the specified time frame may lead to licensing action up to and including revocation. Please forward a copy of your service development plan to your assigned DCF Program Development and Oversight Coordinator (PDOC) if applicable. Should you have any questions or comments regarding the contents of this report please do not hesitate to call me at (860) 550-6310 or 203-675-6975. Sincerely, _____Thomas S. Cuchara__________________________________ Thomas S. Cuchara, Regulatory Consultant Copy: Executive Director Licensing File|

5722+++03/25/2022+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: NAFI / Tress Road Home TIME OF VISIT (FROM - TO): ____First shift__________________ DATE: _3/25/22___________ AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: Program Director Direct Care Clinician List of Areas / Topics covered during visit: There were two youth in the program and they both were at school. Home was down one third shift staff. The position is for Wednesday through Saturday. Corrective Actions implemented as a result of previous visit: No actions were required. Areas of regulatory non-compliance identified during this visit: Section 17a-145-73. Sleeping accommodations (a) Sleeping accommodations for each child shall have adequate area, spacing and equipment in accordance with the child's age and needs. Bedrooms shall contain a window unless there is a 24-hour ventilation system approved by the state or local health department. Heating facilities shall be sufficient to maintain a room temperature consistent with existing department of health services' guidelines. Separate sleeping quarters shall be provided for children of the opposite sex six years of age or over. The facility shall provide each such child with a single bed with adequate linens and covers suitable for the temperature, and a locker, dresser or other storage space for the child's private use conveniently located in or near the child's sleeping room. Bedroom one needed a curtain rehung to afford the youth privacy. Bedroom #4 needed cleaning along with its closet. The patched spots on the wall were slated to be painted by maintenance. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. _Keith Bryan________ ____3/31/22_ Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

5716+++03/25/2022+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: _NAFI / Corbin House_________________________________________ TIME OF VISIT (FROM - TO): ____First shift__________________ DATE: _3/25/22___________ AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: Program Director List of Areas / Topics covered during visit: Program was at capacity with 4 youth. The program was down two full time staff. One second shift position was available on Wednesday through Saturday and a third shift position was available Thursday through Saturday. The program currently doesn’t have a nurse, but the agency nurse was covering the home until the position was filled. Corrective Actions implemented as a result of previous visit: No action was required. Areas of regulatory non-compliance identified during this visit: Section 17a-145-76. Kitchens, equipment, food-handling All kitchens shall be clean, well-lighted, properly ventilated and screened, and provided with essential and proper equipment for the preparation and serving of food. Storage, refrigeration and freezer facilities shall be adequate for the number of persons to be served. All perishable foods shall be refrigerated at a temperature at or below 45° Fahrenheit. Freezers and frozen food compartments shall be maintained at minus 10° to 0° Fahrenheit. Cooking utensils, dishes and tableware shall be in good condition and proper cleaning facilities for this equipment shall be provided. dishes shall be stored in a clean, dry place protected from flies, dust or other contamination. Food preparation and serving areas shall comply with Section 19-13-B42 of the public health code. Proper food handling techniques and sanitation to minimize the possibility of the spread of food-borne diseases shall be maintained. The cooking grate was missing from the top of the stove. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. _Keith Bryan_____________ ___3/25/22___ Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

5995+++08/17/2023+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Noank Community Support Services (Gray Farm House) TIME OF VISIT (FROM - TO): 12:00pm- 1:00pm DATE: 8-17-23 AGENCY PERSONNEL WHO PARTICIPATED: Job Title Gray Farm House Shelter Director Noank Community Support Services Administrator List of Areas / Topics covered during visit: • Discussed current census (3) and the licensed bed capacity is 4. Two TGH residents and 1 shelter resident. • Discussed current staffing levels and hiring. Three vacant positions for direct care staff. One vacancy for a clinician. There are currently 6 med-cert trained staff. Program is contracted to convert to a shelter from a TGH. Discussed staff from TGH transitioning to become shelter staff. • Observed resident in milieu. No concerns observed. Discussed the two TGH resident's plan for discharge. • Clinical programming for residents discussed. Currently there is a clinician covering from another program. • Discussed change in supervisory coverage. Supervisors now cover during the week and weekend with overlap on Wednesday. • Inspection of the Gray Farm House physical plant. No health or safety concerns noted. Corrective Actions implemented as a result of previous visit: • Not applicable Areas of regulatory non-compliance identified during this visit: • Not applicable James Funaro Regulatory Consultant Date: 8-30-23 A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM Cc: Program Director Executive Director|5948+++05/11/2023+++DCF-3034 1/2013 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: NOANK/ Gray Farm Group Home TIME OF VISIT: (FROM–TO): 12:00pm to 1:30pm DATE: 5/11/23 AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title N/A Acting Program Director Areas / Topics covered during visit: The Department of Children and Families conducted a scheduled quarterly inspection visit at the Gray Farm Group Home Program on May 11, 2023. Topics covered during the quarterly visit included a report on staffing changes, client census, staff training, physical plant inspection, milieu services and medication administration system. Physical plant: A walkthrough of the physical plant was conducted with the acting program director and citations were identified. Corrections implemented as a result of previous visit: N/A Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning) N/A Areas of regulatory non-compliance identified during this visit: Section 17a-145-63. Chief administrative officer: Upon review of staffing information, it was found that the program's staffing level continues not to meet regulatory requirements. Section 17a-145-63. Chief administrative officer: Upon review of program information, peer conflicts, disruptive behaviors by residents and ongoing issues with AWOLs has caused the milieu to become unstable on a regular basis. Section 17a-145-71. Living room lounge: Upon inspection of the facility, the living room walls contained multiple repair patches and they need to be addressed. Section 17a-145-73. Sleeping accommodations: Upon inspection of the facility, the hallway wall (next to bedrooms) contained a hole and it needs to be addressed. Section 17a-145-74. Lavatory facilities: Upon inspection of the facility, bathroom 1's backsplash wall was unpainted and it needs to be addressed. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Penny Woodward, LCSW_ June10, 2023 Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5883+++01/24/2023+++ DCF-3034 1/2013 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: NOANK/ Gray Farm Group Home TIME OF VISIT: (FROM–TO): 10:30am to 12:00pm DATE: 1/24/23 AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title N/A Acting Program Director Areas / Topics covered during visit: The Department of Children and Families conducted a scheduled quarterly inspection visit at the Gray Farm Group Home Program on January 24, 2023. Topics covered during the quarterly visit included a report on administrative changes, client census, program staffing and training, physical plant inspection, milieu services and medication administration system. Physical plant: A walkthrough of the physical plant was conducted with the acting program director and citations were identified and discussed with the program representative. Corrections implemented as a result of previous visit: N/A Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning) N/A Areas of regulatory non-compliance identified during this visit: Section 17a-145-63. Chief administrative officer: Upon review of staffing information, it was found that the program's staffing coverage did not meet regulatory requirements. Upon review of training information, it was determined that not all staff had been fully trained in Risking Connections. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Penny Woodward, LCSW_ March 1, 2023 Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5828+++10/21/2022+++ DCF-3034 1/2013 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: NOANK/ Gray Farm Group Home TIME OF VISIT: (FROM–TO): 12:30pm to 2:00pm DATE: 10/21/22 AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title N/A Program Director Areas / Topics covered during visit: The Department of Children and Families conducted a scheduled quarterly inspection visit at the Gray Farm Group Home Program on October 21, 2022. Topics covered during the quarterly visit included program staffing and training, physical plant inspection, milieu services and medication administration system. Physical plant: A walkthrough of the physical plant with the program director was conducted; deficiencies were identified and discussed with the director. Corrections implemented as a result of previous visit: N/A Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning) N/A Areas of regulatory non-compliance identified during this visit: Section 17a-145-63: Chief administrative officer. Upon reviewing of staffing information, it was found that the program's staffing coverage did not to meet regulatory requirements. Section 17a-145-63: Chief administrative officer. Upon review of training information, it was found that all staff had not been trained in Risking Connections and Restorative Approach. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Penny Woodward, LCSW November 21, 2022 Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5762+++07/07/2022+++ DCF-3034 1/2013 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: NOANK/ Gray Farm Group Home TIME OF VISIT: (FROM–TO): 12:30pm to 1:30pm DATE: 7/7/22 AGENCY PERSONNEL WHO PARTICIPATED: Name Job Tie N/A Program Director Areas / Topics covered during visit: The Department of Children and Families conducted a scheduled quarterly inspection visit at the Gray Farm Program on July 7, 2022. Topics covered during the quarterly visit included program staffing and training, physical plant inspection, milieu services and medication administration system. Physical plant: A walkthrough of the physical plant with the program director was conducted with the group home director. Please see citations that are listed below in the area of regulatory non-compliance section. Corrections implemented as a result of previous visit: N/A Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning) N/A Areas of regulatory non-compliance identified during this visit: Section 17a-145-63: Chief administrative Officer. Upon review of training information, it was found that all staff had not been trained in TCI, Risking Connections and Restorative Approach. Section 17a-145-63: Chief administrative Officer. Upon review of staffing information, it was found that the staffing levels at the group home was not meeting regulatory requirements. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Penny Woodward, LCSW JULY 7, 2022 Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5745+++05/03/2022+++ DCF-3034 1/2013 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: NOANK/ Gray Farm Group Home TIME OF VISIT: (FROM–TO): Morning to Afternoon DATE: 5/3/22 AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title N/A Program Director Areas / Topics covered during visit: The Department of Children and Families conducted a scheduled quarterly inspection visit at the Gray Farm Program on May 3, 2022. Topics covered during the quarterly visit included program staffing and training, physical plant inspection, milieu services and medication administration system. Physical plant: A walkthrough of the physical plant with the program director was conducted; deficiencies were identified and discussed with the director. Corrections implemented as a result of previous visit: N/A Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning) N/A Areas of regulatory non-compliance identified during this visit: Section 17a-145-63: Chief administrative Officer. Upon review of training information it was found that all staff had not been trained in TCI, Risking Connections and Restorative Approach. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Penny Woodward, LCSW_ May 3 , 2022 Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

6001+++08/30/2023+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: ____St. Vincent's__________________________________ TIME OF VISIT (FROM - TO): ____Morning______________________ DATE: ___8-30-23_ ________ AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: JN - Regional Director of Community Living AT - Nurse Manager AK - Habilitation Specialist SJ - Operations Manager KK & MD - DCF Nursing List of Areas / Topics covered during visit: • Census - 8 Approx. half the residents are over 21 and awaiting discharge to an adult facility. There is a lack of (DDS) adult facilities that offer 24 hour nursing care at the level needed by residents. The lack of facilities impacts the discharge and admissions process by stalling movement. • Staffing appears to be stable with only per diem nursing positions open. • Discussed the feasibility of re-opening the Trumbull GH and what that would look like and what DCF is looking for with regard to long term residential and emergency beds. Trumbull is a 6 bedroom home. The possibility of designating 2 of the beds as respite/emergency beds was discussed. The issue of a lack of resources, the impact on discharges and the likely result of residents not moving quickly to another facility was discussed. • Physical plant tour. New molding has been installed throughout the unit and the painting of bedrooms is being pursued. • Review of record by KK. No issues noted. • Discussed the scheduling of the relicensing visit next quarter. Corrective Actions implemented as a result of previous visit: ____________________________________________________________________________________________________________________________________________________________________________________________ Areas of regulatory non-compliance identified during this visit: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Terri Bohara 9-14-23 ______________________________ _________________ Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5939+++05/23/2023+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: _____St. Vincent's __________________________________________ TIME OF VISIT (FROM - TO): ____Morning______________________ DATE: ___5-23-23_______________ AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: Nurse Supervisor Clinical Manager Case Manager Regional Director of Community Living List of Areas / Topics covered during visit: • Census - 8. The discharge of another resident did not occur. • Recent admission of a 10 year old from the Hospital of Special Care. • Reviewed one personnel record. No issues. • Fire Drills for 2022-2023 reviewed. No issues. • Physical plant tour. The program is transitioning to the Sleep Safe beds after one was obtained for a resident. Feedback from staff has been positive. • Some of the bedrooms are in need of painting due to normal wear and tear. The replacement of baseboards, door panels and molding is also being pursued. • A Mother's Day brunch was hosted at the school. Staff report that the event was a success. • Anna Cherian, DCF Consulting Nurse, reviewed the chart of the resident who was recently admitted. No issues. Corrective Actions implemented as a result of previous visit: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Areas of regulatory non-compliance identified during this visit: • No regulatory citations. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Terri Bohara 6-5-23 ______________________________ _________________ Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5920+++02/14/2023+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: ______St. Vincents ______________________________________________ TIME OF VISIT (FROM - TO): __________________________ DATE: ____2-14-23______________ AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: JN - Regional Dir. AT - Nurse Manager MS - Care Manager AC - DCF nurse consultant List of Areas / Topics covered during visit: • Report on residents provided. One resident was hospitalized at the time of the visit. Two residents are due to be discharged if a facility can be identified for them. A client has been identified for admission. • Open positions - Direct Care Counselor (per diem); Speech Pathologist (per diem); RN (part-time); Nurse Educator (24 Hr.); RN (per diem). • A resident's bed has been replaced (per parent's request) and staff have been trained on its use. The transition to the bed has gone well with no major incidents reported. • Several residents have outside visitors/resources. The involvement of outside agencies/individuals was curtailed during the pandemic. It has not yet returned to pre-pandemic levels. • Physical plant tour. All bedrooms and bathrooms were clean. Each bedroom is decorated specifically to the likes of the individual resident. Rooms house medical equipment specific to the needs of the resident. Storage space in the unit is extremely limited with few options available either in the building or in outside buildings. • AC cited no nursing concerns. Corrective Actions implemented as a result of previous visit: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Areas of regulatory non-compliance identified during this visit: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. N/A Terri Bohara 2-28-23 ______________________________ _________________ Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5797+++10/26/2022+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: ______St. Vincent's _______________________________ TIME OF VISIT (FROM - TO): __________________________ DATE: ____10-26-22______________ AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: JN - Senior Dir. Of Community Living SJ - Clinical Program Manager/Operations YC - Clinical Nurse Lead MD - LCSW Case Manager AC - DCF Nurse Consultant List of Areas / Topics covered during visit: • Census - 8 • Current Staff Openings - Nurse Manager; 24 hr. Nurse Educator; Per-diem positions. The Clinical Nurse Lead will be leaving the program. • Physical plant tour - Bedrooms, Bathrooms and common areas were clean and free from clutter. Bedroom doors were decorated for Halloween as part of a contest. The rest of the unit was also decorated for Halloween. Residents will be dressed for the holiday on Monday. • A new bed has been found for SB. The bed ("Sleep safe") allows for visibility via side windows and quick access by staff. Staff made a site visit so that they could see the bed first- hand. The manufacturer is modifying the bed to lower the height to lessen the strain on staff when they have to access the child. No delivery date was provided. Once the bed is delivered all staff will have to be trained in the use of the bed before it can be used. Non-recording cameras have been installed in the bedroom with parent's consent. • Review of SB's case record by AC. Recommended that written reports be provided to the medical providers (visits) to assist in the assessment process. Corrective Actions implemented as a result of previous visit: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Areas of regulatory non-compliance identified during this visit: • There were no citations identified during this visit. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Terri Bohara 10-28-22 ______________________________ _________________ Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5767+++08/17/2022+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: _____St. Vincent's _______________________________ TIME OF VISIT (FROM - TO): __________________________ DATE: __8-17-22________________ AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: SJ - Clinical Program Manager YC - Clinical Nurse Lead JN - Senior Director of Community Living MD - LCSW Case Manager AK - Habilitation Specialist AC - DCF Nurse Consultant List of Areas / Topics covered during visit: • This was the first visit to the program. Program was previously overseen by a former Regulatory Consultant. • Census - 8. (3 girls/5 boys) • There are currently 3 staff positions open (Educator; per diem RN; Nurse Manager). • One youth has aged out of the program and his removal has been requested. DDS is reportedly attempting to secure a placement in close proximity to mother. • Review of bed purchased for a resident. The "Hannah bed" has a bar which lies across the two doors and padding covering all the internal walls. A camera has been installed above the bed. The bed has not been utilized by the resident as the program was working on procedures related to the use of the bed. Currently the resident is using a SOMA bed with additional padding. • Parents have requested that bed checks be suspended in order to allow their daughter to sleep. It was stated that parents cannot request changes to policies put in place to assure the safety of all residents. Bed checks should continue for all residents at the frequency identified in the policy. • Physical plant tour. All of the bedrooms were clean and decorated to reflect the personality of the resident. • Bathrooms were clean. Adaptive equipment is present to assist staff in bathing residents. • A meeting was held on 8-24-22 at DCF Central office to discuss the use of the Hannah bed. It was determined that the bed should not be utilized due to concerns about the restricted access to the child and the limited visibility. Corrective Actions implemented as a result of previous visit: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Areas of regulatory non-compliance identified during this visit: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Terri Bohara 8-29-22 ______________________________ _________________ Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5704+++05/26/2022+++DCF-3034 1/2013 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: ST. VINCENT’S SPECIAL NEEDS SERVICES Trumbull 975 Oronoque Lane. Stratford, CT DCF license CCF-GH 59 DATE: May 26, 2022 AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title Clinical Program Manager Areas / Topics covered during visit: This was an announced virtual visit to determine compliance with Regulations for Operation of Child Caring Facilities Sections 17a-145-48 through 17a-145-98, as well as the DCF Guidelines for the administration of medication by certified staff. The program census is 8. One referral was received by the program and is being reviewed. In the last three months, there were no hospitalizations. The atmosphere was reported to be stable and no major disruptions have occurred in the last quarter. A review of the program’s fire drills was conducted, no regulatory violations were identified. Staffing updates: No significant changes were reported by the agency that would affect the program's licensing status. Corrections implemented as a result of previous visit: N/A. Recommendations: Areas of regulatory non-compliance identified during this visit: N/A On behalf of the Department, I would like to thank you and your staff, for the courtesy and cooperation that was extended to us during our visits. If I may be of further assistance, please call me at (860) 550-6500. Sincerely, Maria L Tapia ____________________________________ Maria L. Tapia, MSW-L.C.S.W, APRN-PMHNP Regulatory Consultant Office of Legal Affairs Department of Children and Families 505 Hudson St. Hartford, Ct 06106 860-550-6500 fax: 860-550-6665 maria.arcos@ct.gov A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

5979+++08/15/2023+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Transitional Living Center (TLC) Foundation, Inc. - Diyeso-Lewis Group Home TIME OF VISIT (FROM - TO): 9:00am-11:30am DATE: 8-15-23 AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: • Program Director List of Areas / Topics covered during visit: This was a scheduled quarterly Licensing visit to obtain an update on the program, conduct a semi-annual personnel file review, review fire drill reports, and to tour the physical plant. Activities included: 1. Meeting held with Program Director. Topics discussed included: • Census = 3 (two males, one female). LBC=8. • Staff vacancies: House Parent position continues to remain vacant; no direct care staff vacancies. • Client incidents in the past quarter: 0 • Board of Directors subcommittee re: hiring a house parent • Status update on current clients: schools attending in Manchester, employment, extra-curricular activities • Summer activities • Life skills training • Family Day barbeque • Grant submitted for girls' bathroom renovation • Grant secured to replace all windows in the fall • Yard maintenance; Overgrown vegetation at second floor emergency fire exit stairs • Security cameras • Clients were attending off-site summer programming during Licensing visit. 2. Personnel file review: Three personnel files were reviewed. See Areas of Regulatory Non-compliance below. 3. Fire drill record review: Fire drill evacuation reports for the past year were reviewed. See Areas of Regulatory Non-compliance below. 4. Physical plant inspection: All areas found to be clean and organized. New light in basement stairwell. Corrective Actions implemented as a result of previous visit: Not applicable. Areas of regulatory non-compliance identified during this visit: 17a-145-64 Personnel policies and procedures. • Evidence of a physical exam completed prior to start date was not found in the three files reviewed. • Evidence of TB testing results was not found in one file (JR). • Evidence of a child protective services background check completed through the Department of Children and Families prior to start date was not found in two files (EH, DC). 17a-145-86 Instructions in safety procedures. Supervision. Documentation of fire drill reports were missing as follows: • 2022: 3rd shift 3rd quarter; 1st shift 4th quarter • 2023: 1st shift 1st quarter; 1st & 3rd shifts, 2nd quarter 46a-154. Internal monitoring, training and development of policies and procedures required and subject to state agency inspection. • Evidence of restraint training certification was not found in one file (DC). Please submit a service development plan to address the above referenced areas of non-compliance within 30 days of receipt of this report. The service development plan must be submitted to the attention of the undersigned at the address listed above. Kathleen Forsythe, LCSW Date: 8-15-23 Regulatory Consultant A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM Cc: Governing Board Chairperson -MMR File|5935+++05/18/2023+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Transitional Living Center (TLC) Foundation, Inc. - Diyeso-Lewis Group Home TIME OF VISIT (FROM - TO): afternoon DATE: 5-18-23 AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: • Program Director List of Areas / Topics covered during visit: This was a scheduled quarterly Licensing visit to obtain an update on the program and to tour the physical plant. Activities included: Meeting held with Program Director. Topics discussed included: • Census = 2 (one male, one female) • One admission and one discharge in the past quarter; one pending admission scheduled for next week • Staff vacancies: House Parent position continues to remain vacant; no direct care vacancies • Status update on current clients • Board of Directors membership has increased to 20 members; Board meeting is scheduled for tonight • Program funding from Town of Manchester • Youth Services Bureau • Client incidents in the past quarter: 1. Agency vehicle in accident last week (other driver at fault), no client or staff injuries; routine medical follow up sought; awaiting follow-up with an insurance company for rental car and vehicle repair • Significant event report form • Female client employed part time; recent attendance at Prom • Recreation and vocational activities planned for the summer; Title 1 funding for tutor & rec activities • Securing citizenship for one client Milieu Observation: One direct care staff member on duty; Clients returned from school & departed for a med appointment and work; house pet crated during visit Physical plant inspection: All areas found to be clean and organized. One vacant bedroom in the boys' wing was locked and not observed. Corrective Actions implemented as a result of previous visit: Not applicable. Areas of regulatory non-compliance identified during this visit: None. Please submit a service development plan to address the above referenced areas of non-compliance within 30 days of receipt of this report. The service development plan must be submitted to the attention of the undersigned at the address listed above. - No service development plan is required as a result of the Licensing visit. Kathleen Forsythe, LCSW Date: 5-22-23 Regulatory Consultant A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM Cc: Governing Board Chairperson -MMR File|5855+++02/01/2023+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Transitional Living Center (TLC) Foundation, Inc. - Diyeso-Lewis Group Home TIME OF VISIT (FROM - TO): afternoon DATE: 2-1-23 AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: • Residential Worker • Perdiem Residential Worker • Clients (2) • Education Tutor List of Areas / Topics covered during visit: This was an unannounced quarterly Licensing visit to obtain an update on the program and to tour the physical plant. Activities included: • Milieu observation - homework/tutor session; dinner prep • Staff interviews with Residential Workers • Interview with two female clients • Interview with Education Tutor • Tour of physical plant interior Discussion with Staff: • One admission/discharge for the past quarter in January • Intake procedures • Client incidents in the past quarter - none • Food procurement (shopping, local church donations); Food storage in kitchen, House Parent bedroom and two freezers in basement; Labeling/dating food in storage areas • House pets • Staff vacancies: house parent position continues to remain vacant • Training activities for new staff (CPR/first aid, PMT, Medication Administration certification, policies, etc.) • Resident chore list • COVID illness in one client last month • New perdiem worker shadowing seasoned employee on this date; perdiem started as student intern in summer 2022 • Video cameras • Addressing numerous unused items from storage areas, closets, basements, etc. • House vehicle maintenance • Schedule and duties of Education Tutor from Manchester public school system Discussions with Clients: • Holiday activities • House pets • School • Post-high school plans • Cooking • Quality of Relationships with peers and staff • Living skills • Total satisfaction with living in the group home Physical Plant Tour facilitated by Residential Worker. Areas appeared clean and organized. Observations: • Girls bathroom on second floor: contains deteriorated caulking in shower, peeling paint on walls • Storage of cleaning chemicals • Three twin mattresses stored in House Parent bedroom • One of two boys' bedrooms locked and inaccessible for tour - room is assigned for staff use • Insufficient lighting on one basement staircase • Worn appearance of some furniture • Scuff marks on walls, doors Corrective Actions implemented as a result of previous visit: Not applicable. Areas of regulatory non-compliance identified during this visit: None. Kathleen Forsythe, LCSW Regulatory Consultant Date: 2-2-23 A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM Cc: Governing Board Chairperson -MMR File|5807+++11/08/2022+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Transitional Living Center (TLC) Group Home TIME OF VISIT (FROM - TO): 3:00pm-4:45pm DATE: 11-8-22 AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: • Residential Child Care Worker • Clients (2) List of Areas / Topics covered during visit: This was a re-scheduled Licensing visit (postponed from October at the provider's request) to obtain an update on the program and to tour the physical plant. Meeting held with the direct care staff member on duty. Topics discussed included: • Census: Current census is two female clients. Staff member reported that since the Licensing visit in the summer, one additional client was admitted, and was discharged within days. Clients residing at TLC group home attend Manchester public schools. • Rec and leisure activities • Client employment: Both clients worked as junior counselors for two weeks at a 4-H overnight camp this summer, in addition to employment at a mall and a daycare center. • Life Skills training • Incidents from the last quarter: Staff reported on one incident of AWOL during which the police were contacted. Client was located by program staff and returned to the house in less than an hour. • Staffing: The staff member reported that the House Parent position remains vacant, and a staff member is assigned to cover all shifts at the house, including sleeping in the House Parent bedroom on the overnight shift. Staff reported an intern from UCONN started placement with TLC in September. A tutor from Manchester Publics Schools provides tutoring an academic support two afternoons each week. • Care of house pets (dog and a lizard). Interviews held with the two female residents. Topics discussed: length of stay thus far, daily routine, earning points, school, prepping for college application process, family contact, food prep, vocational interests, caring for house pets, staff support, chores, satisfaction with placement. Physical Plant tour: All areas of the house interior and exterior appeared clean and organized. House interior in need of touch-up painting in numerous areas. Corrective Actions implemented as a result of previous visit: A service development plan to address regulatory deficiencies noting during the relicensing inspection in July 2022 was accepted by the Department and a renewed license was issued effective 9-1-22. Areas of regulatory non-compliance identified during this visit: None. Kathleen Forsythe, LCSW Date: 11-9-22 Regulatory Consultant A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM Cc: Board of Directors Chairperson|5736+++07/06/2022+++July 11, 2022 Ms. Liama B. Holmes, LCSW Executive Director, Diyeso-Lewis group home TLC Foundation, Inc. PO Box 2334 Manchester, CT 06045-233 Dear Ms. Holmes, Re: TLC Foundation, Inc. Diyeso-Lewis House License #: CCF/GH 105 Regulatory Consultants: Kathleen Forsythe & Tom Cuchara On July 6-7, 2022, a biennial re-licensing inspection was conducted for the TLC Foundation Diyeso-Lewis House group home, located at 17 North Street, Manchester, CT. This inspection was conducted to determine the compliance of this program with the Regulations of the Connecticut Department of Children and Families Operation of Child-Caring Agencies and Facilities Regulations 17a-145-48 through 17a-145-124. Additionally, an onsite review was conducted by DCF Nurse Consultant Anna Cherian, RN, MSN, FNP-BC on 7-6-22 to determine the program’s compliance with the DCF Medication Administration Guidelines and the DCF Nursing Standards. A copy of the nursing review site visit summary report will be forwarded upon completion. Listed below and on the attached service development plan template are the areas of DCF regulatory non-compliance which were identified during the re-licensing inspection. Please review the areas identified and complete a service development plan (SDP) to address each area of noncompliance. The completed service development plan and applicable supporting documentation must be submitted to the assigned Regulatory Consultant within 30 days of receipt of this emailed report. The areas of regulatory noncompliance are as follows: Rights of Children and Youth Under the Supervision of the Commissioner of Children and Families. 17a-16-8 Use of the Telephone. • Written policy related to client use of a telephone does not include all provisions in the statute regarding a child's use of a telephone. 17-16-9 Use or Receipt of Mail. • Written policy related to children's mail was not provided for review. 814e - Physical Restraint, Medication & Seclusion of Persons Receiving Care, Education or Supervision in an Institution or Facility: 46a-154 Internal Monitoring, Training and Development of Policies and Procedures Required and Subject to State Agency Inspection. • Written policy on seclusion was not provided for review. • Written policy on restraint does not include all elements listed in the statutes. 17a-145-61 Written Policies and Procedures. • Policy on discipline does not address how the program will discipline residents. • Policies on feeding, staffing pattern, and client supervision were not found. • Documentation of an annual review of policies by the Executive Director for the licensed period was not provided for review. 17a-145-63 Chief Administrative Officer. • A review of personnel records for an educational tutor and a social work intern do not contain the results of a protective services history background check conducted through the Department of Children and Families. 17a-145-64 Personnel Policies and Procedures. • Personnel policies and operating procedures regarding facility employment and personnel practices were not provided for review. 17a-145-73 Sleeping Accommodations. a) A dresser in a bedroom designated for male residents is missing a dresser drawer. 17a-145-75 Health and Medical Treatment. Administration of First Aid. Prescription Medication. Administration of Medicine or Treatment. Written Records. Storage of Drugs, Medicines, and Instruments. Sick Room, Telephone. a) A written plan specifying the arrangements for the provision of elective medical care was not provided. b) Written policies for the administration of first aid, care of residents with minor illnesses, injuries or special conditions, and, the administration or use by residents of patent medicines were not provided. b) Evidence of a physician's quarterly review of medical policies for the licensed period was not provided for review. d) Written policy specifying the criteria used for designating staff to administer medication, along with a written plan for training the staff, was not provided for review. 17a-145-86 Instructions in Safety Procedures. • A review of fire drill records for the licensed period reflects that documentation or quarterly fire drills with residents is missing as follows: o 2020: 1st quarter, first shift o 2021: 1st quarter, third shift; 2nd quarter third shift o 2022: 2nd quarter, first shift 17a-145-93 Medical, Dental and Nursing Care. Based on a review of the case records by the DCF Nurse Consultant, it was determined that the facility failed to maintain preventive and remedial medical, dental, and annual eye exams as follows: • CT: no annual eye exam. • AK: no dental exam and eye exam • ND: no annual physical exam ************************************************************************************************************************ Once the Licensing Unit has reviewed and accepted the service development plan and has determined that your agency is in compliance with the regulations, a decision on the issuance of a regular twenty-four month license for the program will be made. Until DCF makes this decision the current license will remain in effect. Should you have any questions or comments regarding the contents of this report please do not hesitate to contact me at (860) 937-7551. Sincerely, Kathleen Forsythe _________________________ Kathleen Forsythe, LCSW Regulatory Consultant Cc: M. Michael - Rogers, Board Chairperson|5706+++06/02/2022+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: TLC Foundation, Inc. / Diyeso-Lewis House Group Home TIME OF VISIT (FROM - TO): 3:00pm-4:30pm DATE: 6-2-22 AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: Executive Director Direct Care Staff Regulatory Consultant List of Areas / Topics covered during visit: This was a scheduled visit to meet with the Executive Director to obtain an update on the program, tour the physical plant, and discuss the upcoming biannual relicensing inspection. Areas of discussion included: • Relicensing inspection scheduled for July 2022; application materials and due dates • Behavioral data since the last licensing visit • Current census: 3 females • Referrals; discharge plans • Summer plans for residents • Staff coverage; vacant house parent position • Group home precautions to mitigate COVID-19 infections • Bed bug problem in town of Manchester and precautions exercised by the group home • Nursing and Executive Director coverage • House parent model • Observation of education tutor with two residents • Physical plant tour • Menu planning • House pets • BBQ grill location • Condition of outdoor deck • Deck garden Corrective Actions implemented as a result of previous visit: Not applicable Areas of regulatory non-compliance identified during this visit: None. Kathleen Forsythe, LCSW Date: 6-3-22 Regulatory Consultant A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM Cc: Board of Directors President|5687+++03/31/2022+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Transitional Living Foundation, Inc./Dyeso-Lewis House TIME OF VISIT (FROM - TO): DATE: 4-1-22 AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title Executive Director DCF Regulatory Consultant List of Areas / Topics covered during visit: Verified LBC. Noted that all residents were present and were meeting with the tutor. Inspected all common areas of the home. Introduced the executive director to the new regulatory consultant for this program. Corrective Actions implemented as a result of previous visit: Not applicable. Areas of regulatory non-compliance identified during this visit: None. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. A plan of correction does not need to be filed. Regulatory Consultant Date James Richard Moore, LMSW 4-4-22 A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

5949+++06/05/2023+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: __Wellmore / Valiant House TIME OF VISIT (FROM - TO): ____9:15am to 11am____________________ DATE: 6/5/2023 AGENCY PERSONNEL WHO PARTICIPATED: Job Title Team Leader List of Areas / Topics covered during visit: • Census is 4. • Physical plant inspection of the Group Home. • Discussed the programing and resident's treatment and compliance. • One resident was home due to having broken his leg playing basketball. He states he likes living at Valiant House and likes the staff. During the visit, a physical therapist arrived to provide PT. He was cooperative. All other youth were in school. • Discussed staffing of shifts. Program has vacancies but manages to fill with current staff. In process of interviewing. Corrective Actions implemented as a result of previous visit: Section 17a-145-76. Kitchen. Completed. Evidence: The threshold between the kitchen and dining room is covered in red tap to prevent to a tripping hazard. The threshold should be replaced. Physical Plant. Completed. • At the time of inspection, the door frame leading to outside main entrance is missing due to damage by a resident. Program states a door and frame is on back order. Until the door frame order comes in the program should cover up the exposed wood, etc. Areas of regulatory non-compliance identified during this visit: No SDP. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Thomas S. Cuchara Regulatory Consultant Date 6/22/23 A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5932+++03/07/2023+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: __Wellmore / Valiant House TIME OF VISIT (FROM - TO): ____10am_to 12pm_____________________ DATE: 3/7/2023 AGENCY PERSONNEL WHO PARTICIPATED: Job Title Team Leader Supervisor List of Areas / Topics covered during visit: • Census is 4. • Physical plant inspection of the Group Home. See below. • Discussed the programing and resident's treatment and compliance. • One resident was home due to having broken his leg playing basketball. He states he likes living at Valiant House and likes the staff. During the visit, a physical therapist arrived to provide PT. He was cooperative. All other youth were in school. • Discussed staffing of shifts. Program has vacancies but manages to fill with current staff. In process of interviewing. • Fire drills reviewed and found to be in compliance. Corrective Actions implemented as a result of previous visit: Areas of regulatory non-compliance identified during this visit: Section 17a-145-76. Kitchen. Evidence: The threshold between the kitchen and dining room is covered in red tap to prevent to a tripping hazard. The threshold should be replaced. Physical Plant. • At the time of inspection, the door frame leading to outside main entrance is missing due to damage by a resident. Program states a door and frame is on back order. Until the door frame order comes in the program should cover up the exposed wood, etc. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Thomas S. Cuchara Regulatory Consultant Date 3/8/2023 A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5813+++09/15/2022+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: __Wellmore / Valiant House TIME OF VISIT (FROM - TO): ____9am______________________ DATE: __9/15/2022____ AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title DB Team Leader List of Areas / Topics covered during visit: • Census is 3 and LBC 5. • Physical plant inspection of the Group Home. • Discussed the programing and resident's treatment and compliance. • Reviewed meal plans and menu. • Discussed staffing of shifts. Corrective Actions implemented as a result of previous visit: Section 17a-145-73. Sleeping accommodations. Evidence: Room 5- the corner of the metal door frame is separated and needs to be tightened. Completed. Areas of regulatory non-compliance identified during this visit: No SDP required. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Thomas S. Cuchara 11/10/2022 Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

5982+++08/16/2023+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Wheeler Clinic / Farm Hill Group Home TIME OF VISIT (FROM - TO): 12:00 pm to 1:15 DATE: August 16, 2023 AGENCY PERSONNEL WHO PARTICIPATED: Job Title Farm Hill Group Supervisor Wheeler Director List of Areas / Topics covered during visit: • Discussion of Farm Hill's current census (1) and the licensed bed capacity is 4. • Discussion of the Farm Hill residents in the program and the status of the group home's milieu. • Discussion of Farm Hill's current staffing levels and hiring activities, and their ability to fill any vacant shifts. • Observation of the resident in their daily programming. Observations of staff and resident interaction. • Inspection of the Farm Hill group home's physical plant to assess the cleanliness of the group home, as well as to ensure there are no health or safety concerns. Corrective Actions implemented as a result of previous visit: • Not applicable Areas of regulatory non-compliance identified during this visit: • None at the time of this quarterly visit. Patrick Hughes 8/17/23 Regulatory Consultant|5965+++06/14/2023+++July 10, 2023 Sabrina Trocchi, PhD, MPA President and Chief Executive Officer Wheeler Clinic, Inc 91 Northwest Drive Plainville, CT 06062 RE: CCF # 36 Farm Hill Group Home Dear Ms. Trocchi, We conducted a relicensing visit of your agency's program on June 14th and June 16th 2023. This inspection determined your agency's program is in compliance with the Regulations for the Operation of Child Caring Agencies and Facilities; Sections 17a-145-48 through 17a-145-98, as well as DCF Guidelines for the Administration of Medication by Certified Staff. The Department has determined that your agency has met the requirements for a regular license. This license is effective as of August 1, 2023, and is valid for twenty-four months. We thank you and your staff for your cooperative participation in the review process. Sincerely, Patrick Hughes Patrick Hughes Regulatory Consultant Department of Children and Families 505 Hudson Street Hartford, CT 06106 (p) 860-550-6552 (f) 860-550-6665 patrick.hughes@ct.gov|5910+++03/29/2023+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Wheeler Clinic / Farm Hill Group Home TIME OF VISIT (FROM - TO): 1:00 pm to 2:30 DATE: March 29. 2023 AGENCY PERSONNEL WHO PARTICIPATED: Job Title Farm Hill Group Home Director List of Areas / Topics covered during visit: • Discussion of Farm Hill's current census (2) and the licensed bed capacity is 4. • Discussion of the Farm Hill residents in the program and the status of the group home's milieu. • Discussion of Farm Hill's current staffing levels and hiring activities. • Observation of the residents participating in their daily programming. • Inspection of the Farm Hill group home's physical plant to assess the cleanliness of the group home, as well as to ensure there are no health or safety concerns. Corrective Actions implemented as a result of previous visit: • Not applicable Areas of regulatory non-compliance identified during this visit: • None at the time of this quarterly visit. Patrick Hughes 4/12/23 Regulatory Consultant|5870+++11/14/2022+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Wheeler Farm Hill Group Home TIME OF VISIT (FROM - TO): 1:30 pm DATE: November 14, 2022 AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title KB Wheeler Associate Director List of Areas / Topics covered during visit: • Current census is 3 and the licensed bed capacity is 4. o Once resident has a upcoming pre-placement interview at Phoenix House. • Discussion of the residents in the program and the program's milieu. o The Farm Hill group home's milieu has settled somewhat since last quarter. There have been some incidents of AWOLs with one resident who at times will visit with some friends from school. • Discussion of Farm Hill's current staffing levels and hiring activities. o Farm Hill currently has 3 full-time and 2 part-time vacancies; however Farm Hill is able to fill any openings with extra staff from the other Wheelergroup home and with Wheeler per-diem staff. • Physical plant inspection of the facility o All areas of the group home were observed, and the group home was found to be nicely decorated, clean and orderly. There were no health or safety concerns observed at the time of this visit. • Observation of the residents participating in their daily programming. o One Farm Hill resident was home and having free time in her room being supervised by a Farm Hill staff. • Interviews with residents. o This regulatory consultant spoke very briefly with the resident who was home. The resident did say hello to this writer however she did not wish to talk with this writer any further. Corrective Actions implemented as a result of previous visit: • Not applicable Areas of regulatory non-compliance identified during this visit: • None at the time of this quarterly visit. Patrick Hughes 11/14/22|5806+++09/22/2022+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Wheeler Farm Hill Group Home TIME OF VISIT (FROM - TO): 1:30 pm DATE: September 22, 2022 AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title KB Wheeler Associate Director List of Areas / Topics covered during visit: • Current census is 3 and the licensed bed capacity is 4. o Since the last quarterly visit (5/25/22) there have been 2 new admissions to the Farm Hill group home. • Discussion of the residents in the program and the program's milieu. o The Farm Hill group home has been having a difficult time with their milieu since the most recent resident's admission in late August. There have been several incidents of AWOLs with the new resident trying to have the other residents AWOL with her. Several significant event reports have been filed over the last few weeks. • Discussion of Farm Hill's current staffing levels and hiring activities. o Farm Hill currently has some full-time vacancies; however Farm Hill is able to fill any openings in the schedule with Wheeler per-diem staff. • Physical plant inspection of the facility o All areas of the group home were observed, and the group home was found to be nicely decorated, clean and orderly. There were no health or safety concerns observed at the time of this visit. • Observation of the residents participating in their daily programming. o One Farm Hill resident was home and having free time in her room being supervised by a Farm Hill staff. This resident had recently gone AWOL. • Interviews with residents. o This regulatory consultant spoke very briefly with the resident who was home. The resident did say hello to this writer however she did not wish to talk with this writer any further. Corrective Actions implemented as a result of previous visit: • Not applicable Areas of regulatory non-compliance identified during this visit: • None at the time of this quarterly visit. Patrick Hughes 11/9/22|5733+++05/25/2022+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Wheeler Farm Hill Group Home TIME OF VISIT (FROM - TO): 1:00 pm DATE: May 25, 2022 AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title KB Wheeler Associate Director List of Areas / Topics covered during visit: • Current census is 1 and the licensed bed capacity is 5. o There is 1 current referral for the Farm Hill group home. • Discussion of the residents in the program and the program's milieu. O The 1 current resident is doing well in all aspects of the program. • Discussion of Farm Hill's current staffing levels and hiring activities. O Farm Hill is doing well with staffing and have absorbed some staff from other Wheeler programs that have recently closed. • Physical plant inspection of the facility o All areas of the group home were observed, and the group home was found to be nicely decorated, clean and orderly. There were no health or safety concerns observed at the time of this visit. • Observation of the residents participating in their daily programming. O The one Farm Hill resident was home and having free time and working on her artwork. The resident appeared comfortable in her surrounding and interactions between the resident and the staff were friendly and professional • Interviews with residents. O This writer was meeting the Farm Hill resident for the first time and she appeared shy and not very talkative but did not report any concerns for her safety or well-being. Corrective Actions implemented as a result of previous visit: • Not applicable Areas of regulatory non-compliance identified during this visit: • None at the time of this quarterly visit. Patrick Hughes 5/31/2022 Regulatory Consultant Date|5659+++02/16/2022+++DCF-3034 1/2013 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Wheeler Clinic Farm Hill Group Home 91 NORTHWEST DR. Plainville, CT 06062 DCF license CCF-GH 37 TIME OF VISIT (FROM - TO): afternoon. DATE: February 16, 2022 AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title Associate Director Areas / Topics covered during visit: This was an unannounced visit to determine compliance with Regulations for Operation of Child Caring Facilities Sections 17a-145-48 through 17a-145-98, as well as the DCF Guidelines for the administration of medication by certified staff. The program census was reportedly one. In the last three months, there were 0 AWOL with 0 hospitalizations. The atmosphere was reported to be stable and no major disruptions had occurred in the last quarter. Staffing updates: No significant changes were reported by the agency that would affect the program's licensing status. A review of the programs physical plant was conducted. No regulatory deficiencies were identified. Corrections implemented as a result of previous visit: N/A Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning) N/A. Areas of regulatory non-compliance identified during this visit: N/A. Maria L Tapia_______ __3/21/2022_______ Regulatory Consultant Date Maria L. Arcos, MSW-L.C.S.W, APRN-PMHNP Regulatory Consultant Office of Legal Affairs Department of Children and Families 505 Hudson St. Hartford, Ct 06106 860-550-6500 fax: 860-550-6665 maria.arcos@ct.gov Cc: file A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

5983+++08/16/2023+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Wheeler Clinic / Light House Group Home TIME OF VISIT (FROM - TO): 1:30 pm to 2:30 pm DATE: August 16, 2023 AGENCY PERSONNEL WHO PARTICIPATED: Job Title Light House Program Manager Wheeler Director List of Areas / Topics covered during visit: • Discussion of the current census (2) and the licensed bed capacity of Light House is 4. • Discussion of the Light House group home residents in the program and the program's milieu. • Discussion of Light House's current staffing levels, hiring activities, and their ability to fill any vacant shifts. • Observations of the one resident present and observations of the interactions between the resident and the Light House staff. • Conversation / interview with one Light House resident about his experiences at the Light House group home. • Inspection of the Light House group home's physical plant to assess the cleanliness of the group home, as well as to ensure there are no health or safety concerns. Corrective Actions implemented as a result of previous visit: • Not applicable to this quarterly visit. Areas of regulatory non-compliance identified during this visit: • Nothing identified during this quarterly visit. Patrick Hughes 8/17/23 Regulatory Consultant Date|5951+++06/14/2023+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Wheeler Clinic / Light House Group Home TIME OF VISIT (FROM - TO): 1:45 pm to 3:00 pm DATE: June 14, 2023 AGENCY PERSONNEL WHO PARTICIPATED: Job Title Light House Supervisor List of Areas / Topics covered during visit: • Discussion of the current census (2) and the licensed bed capacity of Light House is 4. • Discussion of the Light House group home residents in the program and the program's milieu. • Discussion of Light House's current staffing levels and hiring activities. • Observations of the one resident present and observations of the interactions between the resident and the Light House staff. • Discussion with the one resident present about his experiences at the Light House group home. • Inspection of the Light House group home's physical plant to assess the cleanliness of the group home, as well as to ensure there are no health or safety concerns. Corrective Actions implemented as a result of previous visit: • Not applicable to this quarterly visit. Areas of regulatory non-compliance identified during this visit: • Nothing identified during this quarterly visit. Patrick Hughes 6/20/23 Regulatory Consultant Date|5911+++03/29/2023+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Wheeler Clinic / Light House Group Home TIME OF VISIT (FROM - TO): 2:30 pm to 4:00 pm DATE: March 29, 2023 AGENCY PERSONNEL WHO PARTICIPATED: Job Title Light House Program Director List of Areas / Topics covered during visit: • Discussion of the current census (2) and the licensed bed capacity of Light House is 4. • Discussion of the Light House group home residents in the program and the program's milieu. • Discussion of Light House's current staffing levels and hiring activities. • Observations of the residents present and the interactions between the residents and the Light House staff. • Interviews / Discussions with residents about their experiences at Light House group home. • Inspection of the Light House group home's physical plant to assess the cleanliness of the group home, as well as to ensure there are no health or safety concerns. Corrective Actions implemented as a result of previous visit: • Not applicable to this quarterly visit. Areas of regulatory non-compliance identified during this visit: • Nothing identified during this quarterly visit. Patrick Hughes 4/12/2023 Regulatory Consultant Date|5861+++12/21/2022+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Wheeler Clinic / Light House Group Home TIME OF VISIT (FROM - TO): 3:30 pm DATE: December 21, 2022 AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title Chelsea M Light House Program Director List of Areas / Topics covered during visit: • Current census is 2 and the licensed bed capacity is 4. o There has been one recent discharge from the Light House Group Home this quarter. o There has been one recent admission to the Light House Group Home this quarter. • Discussion of the residents in the program and the program's milieu. o The two current residents are doing very well in the program and are receptive to treatment. The two residents get along well with each other. The two residents know each other from a previous placement. o Both residents were home at the time of this quarterly visit. Resident R reported he is doing well at Light House and is treated well by the staff. He did not report any concerns for his safety or well-being. Resident L reported he is doing well at Light House and just started his new school. Resident L reported he likes being at Light House and did not report any concerns for his safety or well-being. • Discussion of Light House's current staffing levels and hiring activities. o Currently Light House can maintain the required staffing ratios. o The Light House clinician position is currently vacant and at this time the Program Director is filling-in as the clinician. • Physical plant inspection of the facility o All areas of the group home were observed, and the group home was found to be nicely decorated, clean and orderly. There were no health or safety concerns observed at the time of this visit. • Corrective Actions implemented as a result of previous visit: o Not applicable to this quarterly visit. • Areas of regulatory non-compliance identified during this visit: o Nothing identified during this quarterly visit. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Patrick Hughes 2/7/2022 Regulatory Consultant Date|5800+++09/22/2022+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Wheeler Clinic / Light House Group Home TIME OF VISIT (FROM - TO): 3:00 pm DATE: September 22, 2022 AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title KB Wheeler Associate Director List of Areas / Topics covered during visit: • Current census is 2 and the licensed bed capacity is 4. o One recent discharge to a DMHAS independent living program. o There is one current referral for the Light House Group Home. • Discussion of the residents in the program and the program's milieu. o The two current residents are doing very well in the program and are receptive to treatment. The two residents get along well with each other. Resident R was home at the time of the visit and was cooking in the kitchen under the supervision of a staff member. o Resident R reported he is doing well at Light House and is treated well by the staff. He did not report any concerns for his safety or well-being. • Discussion of Light House's current staffing levels and hiring activities. o Light House had 2 full time staff begin in June, and a part-time staff begin in August. o Given the large pool of Wheeler per-diem staff; Light House is able to fill any shift openings when they arise. • Physical plant inspection of the facility o All areas of the group home were observed, and the group home was found to be nicely decorated, clean and orderly. There were no health or safety concerns observed at the time of this visit. • Corrective Actions implemented as a result of previous visit: o Not applicable to this quarterly visit. • Areas of regulatory non-compliance identified during this visit: o Nothing identified during this quarterly visit. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Patrick Hughes 10/27/2022 Regulatory Consultant Date|5732+++05/25/2022+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Wheeler Lighthouse Group Home TIME OF VISIT (FROM - TO): 2:30 pm DATE: May 25, 2022 AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title KB Wheeler Associate Director List of Areas / Topics covered during visit: • Current census is 3 and the licensed bed capacity is 5. o There are no referrals currently for the Lighthouse group home. • Discussion of the residents in the program and the program's milieu. o Two of the current residents are doing very well in the program with one resident starting the process of transitioning back to his home. The third resident has court involvement and is currently in detention after incidents at his school and for going AWOL. No residents were at the group home during this visit. • Discussion of Lighthouse's current staffing levels and hiring activities. o Lighthouse is doing well with staffing and have absorbed some staff from other Wheeler programs that have recently closed. Lighthouse also has 2 full-time staff starting in June, and 1 part-time staff starting in August. • Physical plant inspection of the facility o All areas of the group home were observed, and the group home was found to be nicely decorated, clean and orderly. There were no health or safety concerns observed at the time of this visit. Corrective Actions implemented as a result of previous visit: • Not applicable Areas of regulatory non-compliance identified during this visit: • None at the time of this quarterly visit. Patrick Hughes 6/3/2022 Regulatory Consultant Date|5691+++03/29/2022+++April 14, 2022 Sabrina Trocchi, PhD, MPA Chief Operating Officer Wheeler Clinic, Inc 91 Northwest Drive Plainville, CT 06062 Re: License CCF GH# 130 Dear Mrs. Trocchi, On March 29 and 30, 2022 a re-licensing inspection was conducted at the Child Caring Facility, LIGHT program. This inspection was conducted to determine compliance with Regulations for Operation of Child Caring Facilities 17a-145-48 through 17a-145-98 as well as the DCF Guidelines for the administration of medication by certified staff. The re-licensing inspection is based on review of documentation and other materials presented, inspection of the site and information provided by agency personnel to the inspectors. It is the Department’s expectation that the program will maintain full compliance with Child Care regulations as well as with DCF Guidelines. The Department has determined that the program is in full compliance with all applicable regulatory provisions. The Department has made a decision to issue a regular twenty-four-month license from the original renewal date of April 1, 2022. On behalf of the Department, I would like to thank you and your staff, for the courtesy and cooperation that was extended to us during our visits. If I may be of further assistance, please call me at (860) 550-6500. Any comments, concerns, or questions you have regarding these findings should be addressed to this Department. Your response will become part of the permanent record of your organization. Sincerely, Maria L Tapia Regulatory Consultant Maria L. Arcos, MSW-L.C.S.W, APRN-PMHNP Regulatory Consultant Office of Legal Affairs Department of Children and Families 505 Hudson St. Hartford, Ct 06106 860-550-6500 fax: 860-550-6665 maria.arcos@ct.gov|

5984+++08/03/2023+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: ______Helen's House _______________________________ TIME OF VISIT (FROM - TO): __Morning/Afternoon_______________DATE: _______8-3-23___________ AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title AT PD ES Program Clinician List of Areas / Topics covered during visit: • Current census is 2 (includes an emergency short-term placement). The resident who was placed short-term may be placed permanently. • Some staff from Bradley House have accepted positions at Helen's House. There are currently 6 med cert staff. There were none on duty at the time of the visit. • Discussed residents and incident that occurred on 7-29-23. The PD indicated that there are approx. 4 program staff that rotate on-call responsibilities. • The agency is submitting a request for financial assistance to make numerous repairs in the home including replacing the windows, floors in the kitchen, a bedroom and nurse's office and the front porch area. • New furniture has been purchased for the enclosed porch area and the upstairs living room. • Tour of physical plant. One bedroom had a broken window (one of the window pane frames was broken and the pane was on the floor). The PD had it temporarily repaired the following day. The second occupied bedroom had dents in the wall (resident indicated he had hit the wall). There was also a slight odor in this bedroom. The flooring in one bedroom is slanted. The stairs on the outside entryway are starting to splinter/pieces breaking off and are in need of replacement. Corrective Actions implemented as a result of previous visit: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Areas of regulatory non-compliance identified during the visit: Section 17a-145-63 Chief administration officer. • The wooden stairs on the side entryway are starting to splinter/pieces breaking off. Section 17a-145-68. Heating, ventilation, lighting. • There was a broken window in one of the bedrooms. It was temporarily repaired the following day. Section 17a-145-73. Sleeping accommodations. • There were holes in the wall in one of the occupied bedrooms. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Terri Bohara 8-15-23 ______________________________ _________________ Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5943+++05/10/2023+++May 12, 2023 Youth Continuum, Inc. 41 Marne St. Hamden, CT 06514 Attn: Mr. Michael Moynihan, Executive Director Re: Licensing Inspection for Helen's House Inspectors: Terri Bohara Dear Mr. Moynihan, In May 2023 a biennial re-licensing inspection was conducted at Helen's House. This inspection was conducted to determine the compliance of this facility with the Regulations for Operation of Child-Caring Agencies and Facilities 17a-145-48 through 17a-145-98, as well as the DCF Guidelines for the Administration of Medication by Certified Staff. Below are listed the areas of regulatory non-compliance which were identified during the re-licensing inspection. Please review the areas identified and submit a service development plan to address each area. The plan must be submitted within 30 days of receipt of this letter and should identify: 1. the steps to be taken to correct the non-compliance; and 2. the date the correction(s) will be completed. The areas of non-compliance are listed below. Also included in the report are recommendations. Recommendations are meant to highlight areas that are not currently areas of non-compliance, but may become non-compliant if actions are not taken. Recommendations do not require the submission of a service development plan. Section 17a-145- 64. Personnel policies and procedures. • Three personnel files were reviewed. • Two files did not have documentation of receipt of the personnel policies. • Two files did not have documentation of CPR training. • Two files did not have documentation of restraint training. Section 17a-145-68. Heating, ventilation, lighting. • A wooden window frame in the porch area had splintered in one section. • Windows throughout the house are in various conditions. A recent health inspection indicated that all of the windows should be inspected for peeling paint, etc. and repaired. Please respond to the following issues identified in the Nursing Review. MEDICAL CMCU approval is necessary for psychotropic medications prescribed to children for whom DCF is the legal guardian. 1.Based on the review of the medical records the facility failed to get CMCU approval and AIMS tests for two clients. DCF Responsibilities in Administration of the Medication Training Program: DCF Regulation 17a-6(g)-15 (a - g) Submit a DCF-2272 Monthly Medication Administration Program Supervision and Review to DCF Risk Management. Violations 1. Based on the review of the DCF Data system the facility failed to provide DCF-2272 from July 2021 to August 2022. Annual Observation of Medication Administration Skills Once a year the facility nurse must observe medication certified staff performing the DCF medication administration procedure. This must be documented using the DCF-2275 DCF Medication Administration Program Procedure Checklist and placed in the employees file. 2. Based on the review of the training records the facility failed to provide Annual Observation of Medication Administration Skills for ten staff members. Mandatory Training for All Staff • Annual Emergency Medication Administration - Epi-pens and Asthma Rescue Medication. • This training must be provided at least annually and whenever necessary to maintain a safe environment for children 3. Based on the review of the training records the facility failed to provide annual epipen/inhaler training in 2023. DCF Reg: 17a-6(g) -16 (c): "Day programs and residential facilities shall provide continuing education on administration of medication to trained person staff members." Facility nurses and/or appropriate personnel must offer continuing education opportunities for DCF medication certified staff. The facility nurse must document on a quarterly basis all continued education opportunities offered in the past 3 months. See Forms section for suggested form to document quarterly offerings. 4. Based on the review of the training records the facility failed in providing quarterly training in 2021 & in 2022 some attended, some employees are missing the quarterly training. Some no documentations of attending the training. Once licensing has reviewed and accepted the Service Development Plan and has determined that your agency is in compliance with the regulations a decision on the issuance of a regular twenty-four month license for the program will be made. Until DCF makes this decision the current license will remain in effect. Should you have any questions or comments regarding the contents of this report please do not hesitate to call me at (860) 550-6395. Sincerely, Terri Bohara _______________________________________ Terri Bohara Regulatory Consultant Department of Children and Families 505 Hudson St. Hartford, CT 06106 Phone: 860-550-6395 Fax: 860-860-550-6665 Theresa. Bohara@ct.gov Copy: file|5877+++02/02/2023+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: ______Helen's House ________________________________ TIME OF VISIT (FROM - TO): __________________________ DATE: ____2-2-23______________ AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: AB - Program Director ES - Program Clinician MD - Bradley PD List of Areas / Topics covered during visit: • Census - 2 (Helen's); 0 - Bradley • Several staff positions remain vacant. Currently in Helen's there is 1 supervisor position, 2 full time positions and 4 part-time positions open. Bradley currently has 2 supervisor positions, 2 full time positions and 4 part time positions open. Some open shifts are being filled with staff from third party agencies (All Point and Delta T). Staff from these agencies are trained in PMT. Staff employed by Youth Continuum are trained in TCI. There are currently two staff from Youth Continuum who are certified to train. • TCI trainings will occur in February (Feb. 7,9,13,15) for the full course. A re-certification class will be held in March. • One resident is slated to move to independent living in the next couple of months. • The other youth is 14 and has some difficulties with hygiene which the program and his school are targeting. He has no family supports that can offer a long term viable resource. • Physical plant tour. Some of the walls in enclosed porch area have been painted. The program hopes to "whitewash" the surfaces with (barn) boards on them. The downstairs areas were clean and free from clutter. • There was a slight odor in the small bedroom where one resident resides. • The bedroom of the second resident had a stronger odor (in the closet). The resident has some significant hygiene issues (behavioral in nature). • One bedroom was newly painted. It was suggested that a dresser in another room be painted. • Review of MAR's. Controlled medications counted during the exchange of keys. The medication room keys were initially locked up. Staff reported that he is in and out of the program so he will lock up the keys when he is going off site. A reminder was given that keys should be in his possession when he is in the house. There were no youth at the home during the visit. There were several meds being kept for a youth who was discharged in July 2022. He is not DCF involved. His parent was reportedly made aware of the medication but never came to the house to pick them up. It was suggested that the medication be destroyed given the amount of time that has elapsed. • New security cameras provide good picture resolution. Blind spots remain outside the house (back area). • The paint on the stairway and landing on the entryway on side of the house has peeled away in several areas. This has been addressed in the past however this entryway is heavily utilized. Corrective Actions implemented as a result of previous visit: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Areas of regulatory non-compliance identified during this visit: Section 17a-145-63 Chief administrative officer. • Paint on the side entryway (stairs and landing) has peeled away in several areas. Section 17a-145-73. Sleeping accommodations. • The two occupied bedrooms both had foul odors. The closet in one room seemed to contain soiled clothing placed there by the resident. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Terri Bohara 2-24-23 ______________________________ _________________ Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5838+++12/14/2022+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: ________Helen's House _______________________________________ TIME OF VISIT (FROM - TO): __________________________ DATE: ______12-14-22____________ AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: AB - PD (Helen's) MD - PD (Bradley) DF - CCW ES - Clinician (Helen's) AT - Clinician (Bradley) List of Areas / Topics covered during visit: • Census - 2 (Helen's); 0 (Bradley) • Programs have merged due to staffing difficulties. There are multiple staff openings between the two programs. Helen's House has no permanent second shift staff. Shifts are being covered by staff from both homes as well as staff from a third-party agency. Between the two programs there are in excess of 10 ten vacant positions. Helen's House has 7 open positions while Bradley has one supervisor and 6 child care worker positions that are currently unfilled. One former employee left due to being mandated to cover shifts on weekends. The previous program nurse left and the position is being covered by a former program nurse. • The two youth in the program are reportedly doing well. One recently obtained a state ID and established a bank account. AWOL's have ceased with the discharge of 3 former residents. • Holiday plans have not been formalized however the PD indicated that a meal will be prepared based on what resident's request. • The downstairs areas were clean and decorated for the holidays. • There was not working ceiling ventilation in either bathroom. • The occupied bedrooms were fairly clean. Doors were kept open to allow heat to circulate into the rooms. • The program is planning to order new living room furniture for the program. Corrective Actions implemented as a result of previous visit: • One staff has obtained their CPR certification, and another is scheduled. Another staff is currently on hold. • The office door has been replaced. Areas of regulatory non-compliance identified during this visit: Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Terri Bohara 12-19-22 ______________________________ _________________ Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5768+++08/11/2022+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: ____Helen's House __________________________________ TIME OF VISIT (FROM - TO): __________________________ DATE: ____8-11-22______________ AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: AB - Program Director List of Areas / Topics covered during visit: • Census - 2 • There are 4 positions open (Five1 supervisor & 3 full time positions on 2nd shift). Staff are picking up extra hours. Third party staff have also been brought in to cover positions. • The agency recently lost two TCI trainers however replacements have been trained to teach the classes. • There will be a TCI training class at the end of August followed by re-certifications. • A review of 5 staff personnel files was done on 8-1-22. Of the 5 reviewed, two employees are no longer there. • Three staff did not have CPR certifications. Two did not have TCI certifications. • Baseboards in an empty bedroom were in need of cleaning. • There were holes in the door leading to the staff office. • A former resident was discharged to the hospital and is not returning. • A former resident left for a SWEPT program despite not really completing the program. Corrective Actions implemented as a result of previous visit: • The electrical outlet has been fixed in the bedroom. • The toilet in the downstairs bathroom has been replaced. • Shelves have been replaced in the kitchen. • An updated list of med admin certified staff has been posted in the nurses office. Areas of regulatory non-compliance identified during this visit: Section 17a-145-64 Personnel policies and procedures. • Three staff did not have CPR certifications. • Two staff did not have TCI certifications. Section 17a-145-71 Living room, lounge. • There were holes in the door leading to the staff office. Section 17a-145-73 Sleeping accommodations. • Baseboards in one bedroom were in need of cleaning. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Terri Bohara 8-29-22 ______________________________ _________________ Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5726+++06/13/2022+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: ________Helen's House _______________________________ TIME OF VISIT (FROM - TO): ___Late morning____________DATE: ___6-13-22_______________ AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: AB - PD TW - nurse AW - Sr. CCW List of Areas / Topics covered during visit: • Census - 5. Currently capped at 5 due to changes related to changes in residential care (QRTP). • The third shift supervisor resigned. There are currently 3 vacant 2nd shift positions and one vacant 3rd shift position. A new nurse has been hired. She will be overseen by the nurse from Clifford Beers. • One resident (1) is currently AWOL. He turns 18 in a couple weeks. Another resident (2) had not been in the home for 2 days. After the visit he returned to the home to collect his belongings as he reported he was signing himself out of DCF care. One resident (3) recently attended his prom and is reportedly doing well in school. One resident (4) is struggling in the program. He is 16 and attends the Aces school program. One resident (5) (recently admitted) was charged after throwing rocks at a responding police car. It was thought he may have don this to fit in. • A new screen door was installed on the side door. The bedroom off of the living room was recently painted. Plants and tables have been added to the upstairs living room. The electrical outlet (box) was loose and needs to be secured. The vinyl covering on the arm of one of the chairs was peeling. • A review of one MAR found that the prescriptions for two topical medications were missing. These were secured by the program by the end of the day. The medication administration certification list of staff was outdated. The PD indicated that she would update the list. Corrective Actions implemented as a result of previous visit: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Areas of regulatory non-compliance identified during this visit: Section 17a-145-73 Sleeping accommodations. • The electrical box in one electrical outlet was lose and needs to be secured in one bedroom. Section 17a-145-75. Health and medical treatment. Administration of first aid. Prescription medication. Administration of medicine or treatment. Written records. Storage of drugs, medicines and instrument. Sick room, telephone. • A review of an MAR found that there were no prescriptions on file for two topical medications. These were secured the same day by the program from the pharmacy. _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Terri Bohara 6-24-22 ______________________________ _________________ Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5660+++03/16/2022+++DCF-3034 1/2013 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: ___Helen's House_ ________________________ TIME OF VISIT (FROM - TO): _________________________ DATE: _3-16-22____ AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title AB Program Director Areas / Topics covered during visit: • Census -3 One bed is placed "on hold" and another resident is currently at "respite". • Three staff openings including the program nurse position are open. A candidate for the nursing position has been identified. Staff have been identified for some of the other positions. The PD was recently promoted to her position. • Physical plant tour. Some areas are in need of painting. Rust present on the baseboard in the upstairs bathroom. The PD said she will be pursuing various physical plant upgrades once she is acclimated to the position. • Review of case record. No issues. • Review of fire drills. No issues. Corrections implemented as a result of previous visit/Follow up to Previous citations: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning) ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Areas of regulatory non-compliance identified during this visit: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Please submit a service development plan to address the above referenced areas of non-compliance within 30 days of receipt of this report. The service development plan must be submitted to the attention of the undersigned at the address listed above. Terri Bohara 3-21-2022 ______________________________ _________________ Terri Bohara, Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

5992+++08/31/2023+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: The American School for the Deaf, Inc. - CORE Residential Education Program TIME OF VISIT (FROM - TO): 10:00am-12:15pm DATE: 8-31-23 AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: Independent Interpreter Senior Administrative Assistant Overnight Dean of Students Associate Director of Student Life Head of Security List of Areas / Topics covered during visit: This was a scheduled quarterly Licensing visit to obtain an update on the Core residential education program and tour the physical plant of the CORE program dorms. Brief meeting held with Senior Administrative Assistant • Discussed the elements of the relicensing inspection for Core program scheduled for October 2023. A meeting was held with an Associate Director of Student Life (KF) with an interpreter present. Topics discussed included: • Core residents returned to campus this week from summer break. School year started 8-28-23. • Census = 15 (6 females, 9 males). Census will increase by 3-4 residents when admission paperwork is completed. • Core staffing vacancies = 0 • Division of duties among three Associate Directors of Student Life • Selected Core residents (6-8) to participate in the International Study Club with out-of-country trips. Trip to Costa Rica planned for April 2024. • Fall athletics: Male soccer team and female volleyball team. Games scheduled against other schools for the deaf in RI, NY and MA. • Camp Isla Bella: New Camp Director. Summer camp completed. • Homecoming scheduled for weekend of 9-30-23; dozens of alumni expected to attend; homecoming dance, social events. • New Director of Student health Center expected to start early September. Current Director is retiring - will remain as a consultant for remainder of 2023. • ASD completed initial survey for accreditation by the Council on Accreditation earlier this summer. • Trauma Informed Care model ('Risking Connections') to be implemented at ASD. Train-the trainer scheduled for this fall with 8 instructors selected. All ASD staff to be trained in the model this fall. • Applying for Quality Residential Treatment Program (QRTP) status with DCF. Physical plant inspection facilitated by the Overnight Dean of Students. Butterworth and Cogswell Core dorms were toured. All areas appeared very clean and organized. Corrective Actions implemented as a result of previous visit: Not applicable Areas of regulatory non-compliance identified during this visit: None. Please submit a service development plan to address the above referenced areas of non-compliance within 30 days of receipt of this report. The service development plan must be submitted to the attention of the undersigned at the address listed above. - No service development plan is required following the Licensing visit. Kathleen Forsythe, LCSW Date: 8-31-23 Regulatory Consultant A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM Cc: File Asst. Executive Director, Assoc. Director of Student Life (KF) Director of Operations|5936+++05/24/2023+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: The American School for the Deaf, Inc. - CORE Residential Education Program TIME OF VISIT (FROM - TO): 10:00am-12:15pm DATE: 5-24-23 AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: Independent Interpreter Human Resources Director Associate Director of Student Life Human Resources Manager Human Resources Associate List of Areas / Topics covered during visit: This was a scheduled quarterly Licensing visit to obtain an update on the Core residential education program and tour the physical plant of the CORE program dorms. A meeting was held with an Associate Director of Student Life with an interpreter present. Topics discussed included: • Census = 19 (12 males, 7 females) • Core program staffing vacancies = 0 • Incident data from the past quarter • Graduation scheduled for June 12th • End of year activities for Core residents (Prom, BBQ, Senior trip, etc. • Supervision protocol & med administration during upcoming senior class trip to New Jersey • Core students move home for summer vacation in June • Opening Cottage E in the fall for older female students • Search policy & contraband • New HR Director • Revised three week Orientation program for new hires: required trainings, ASL immersion, shadowing • New hires train for three weeks prior to assuming job duties • ASD to host a one week summer basketball camp in collaboration with Gallaudet University • Male Core resident representing ASD while wrestling on a team in Avon; recently featured on ESPN Physical plant inspection conducted for Butterworth and Cogswell Core dorms. All areas appeared very clean and organized. • New laundry hampers in use • New hygiene totes in girls' dorm • New water cooler in Cogswell • Posted laundry and shower schedules • Radiator covers in Cogswell dorm Introductory meeting held with new HR Director who assumed the position last month. Topics discussed: • New pilot 3-week Orientation program to launch in June • Twenty-eight (28) applicants offered positions • Staff incentives to involve current employees in training opportunities • DCF semi-annual personnel file review schedule • Deaf/HOH employee joined HR Dept. last summer Corrective Actions implemented as a result of previous visit: Not applicable Areas of regulatory non-compliance identified during this visit: None. Please submit a service development plan to address the above referenced areas of non-compliance within 30 days of receipt of this report. The service development plan must be submitted to the attention of the undersigned at the address listed above. - No service development plan is required following the Licensing visit. Kathleen Forsythe, LCSW Date: 5-24-23 Regulatory Consultant A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM. Cc: File, Asst. Executive Director, Assoc. Director of Student Life|5878+++02/23/2023+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: The American School for the Deaf, Inc. - CORE Residential Education Program TIME OF VISIT (FROM - TO): 11:00am-1:15pm DATE: 2-23-23 AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: • Independent Interpreters (2) • Interpreter Student Intern • Associate Director of Student Life • Assistant Director of Operations • Security Manager • Maintenance Staff Member List of Areas / Topics covered during visit: This was a scheduled quarterly Licensing visit to obtain an update on the Core residential education program and tour the physical plant of the CORE program dorms. Associate Director of Student Life facilitated tours of the Cogswell and Butterworth dormitories with interpreters and Assistant Director of Operations present. Topics discussed included: • Census = 20 (14 males, 6 females) • Male students in Core program relocated from Butterworth to Cogswell dorm this week to provide more space. • Female students in Core program reside in Butterworth dorm. • Core program students go home on weekends; One male student remains on campus on the weekends and resides in Holt dorm. • Fall sports • Bedroom and lounge furniture • Flooring • Water temperatures • New delayed crash bars on exit doors with alarms in Cogswell • Accommodations for a deaf/blind student in Cogswell • Internet access safety measures • Bedroom temperatures; individual thermostats • Bathroom supervision protocol • Proposed new dorms for Paces program • AED signage and location map at Butterworth dorm entrance Corrective Actions implemented as a result of previous visit: Not applicable Areas of regulatory non-compliance identified during this visit: None. Please submit a service development plan to address the above referenced areas of non-compliance within 30 days of receipt of this report. The service development plan must be submitted to the attention of the undersigned at the address listed above. - No service development plan is required following the Licensing visit. Kathleen Forsythe, LCSW Date: 2-24-23 Regulatory Consultant A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM Cc: File Director of Finance & Operations Asst. Executive Director Assoc. Director of Student Life|5842+++12/22/2022+++ Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: The American School for the Deaf, Inc. - CORE Residential Education Program TIME OF VISIT (FROM - TO): morning DATE: 12-22-22 AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: • Independent Interpreters (2) • Associate Director of Student Life (KF) • Employment Specialist • HR Manager List of Areas / Topics covered during visit: This was a scheduled quarterly Licensing visit to obtain an update on the Core program, observe the dorm physical plant, and to conduct a semiannual personnel file review. A meeting was held with an Associate Director of Student Life with interpreters present. Topics discussed included: • Core program residents are on home visit for Christmas break • Census = 18 (10 males, 8 females) • Two female residents are transitioning into the Core program from the Paces program • Homecoming celebration held on campus for the first time since pandemic started; alumni in attendance, vendor booths, etc. • On campus rec activities: soccer and volleyball team practices, cooking projects, Halloween, Winter party • Off campus rec activities, weekly trips into the community, safety/supervision procedures for crossing streets in West Hartford • UCONN Dental School students to provide a workshop on campus in January re: good oral health • Core residents' participation in Fall and Winter sports teams; Volleyball team traveled to OHIO to compete in a tournament; ASD hosted a multi-school 'Tip-Off Tournament' for basketball and both ASD male and female teams won the Sportsmanship award • Core program staff vacancies: 2 full time direct care positions • New Associate Director position filled, completing the team of three; discussed division of responsibilities • Core progress reports with individualized goals/objectives • Over age waiver for a Core program resident • Tour of the Butterworth dorm: All areas appeared extremely clean, organized, and decorated for the holiday season. Minor adjustments made to dorm at start of school year to accommodate a new deaf blind resident, based on recommendations from the Bureau of Education and Services for the Blind (BESB) consult in September 2022. Workshop held with Core male residents on how to interact with deaf blind student. Observed new 'suggestion' box. Discussed 'resident grievance' process. A semiannual personnel file review was conducted in HR. Five files were reviewed. Personnel files are well organized. No regulatory deficiencies were noted. Corrective Actions implemented as a result of previous visit: Not applicable Areas of regulatory non-compliance identified during this visit: None. Kathleen Forsythe, LCSW Date: 12-27-22 ______________________________ Regulatory Consultant A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM Cc: File Director of Finance & Operations Asst. Executive Director Assoc. Director of Student Life|5787+++09/28/2022+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: The American School for the Deaf, Inc. - CORE Program TIME OF VISIT (FROM - TO): 1:00pm-2:00pm DATE: 9-28-22 AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: • Independent Interpreters (2) • Associate Director of Student Life List of Areas / Topics covered during visit: This was a scheduled quarterly Licensing visit to obtain an update on the Core program and to tour the dorm. This visit was conducted virtually due to COVID concerns. • Core program residents returned to campus earlier this month from summer break for new school year. • Census = 16 (10 males, 6 females) • Fall sports teams (soccer and volleyball) • Core program staff vacancies: 1 full time direct care • Interviews in process for the Director of Student Life position • ASD online Academy • Off-campus recreation activities for Core residents • Camp Isla Bella: ASD's summer camp had a successful season after being closed for two years due to the pandemic. Nine (9) Core residents attended a two-week session this year. • Dorm bathroom supervision protocol • One Core resident employed on campus • Tour of the Butterworth dorm: All areas appeared very clean and organized. Seasonally decorated. New bean bag chairs in living rooms at students' request Corrective Actions implemented as a result of previous visit: Not applicable Areas of regulatory non-compliance identified during this visit: None. Kathleen Forsythe, LCSW Date: 9-29-22 ______________________________ Regulatory Consultant A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM Cc: File Director of Finance & Operations Asst. Executive Director Assoc. Director of Student Life|5714+++06/20/2022+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: The American School for the Deaf, Inc. - CORE Program TIME OF VISIT (FROM - TO): 11:00am-1:45pm DATE: 6-20-22 AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: Director of Student Life Interim Assistant Director of Student Life HR Manager List of Areas / Topics covered during visit: This was a scheduled visit to obtain an update on the program. • Core program residents home for the summer; three residents graduated • One Core resident interning in ASD IT Dept. for the summer • Core dorm (Butterworth) closed for the summer • Butterworth dorm security • End-of-year student activities (Prom, Graduation, etc.) • Director of Student Life resignation effective 7/2022 & interim Residential Dept. management plan • ASD hosting Gallaudet basketball camp • Semiannual personnel file review scheduled - no new hires in CORE residential program • Three graduates living on campus in independent living housing • Core resident personal cell phone protocol • Agency vehicles • Planned vocational training opportunities Corrective Actions implemented as a result of previous visit: Not applicable Areas of regulatory non-compliance identified during this visit: None. Kathleen Forsythe, LCSW Date: 6-20-22 ______________________________ Regulatory Consultant A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM Cc: File Director of Student Life|5666+++03/24/2022+++Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: The American School for the Deaf, Inc. - CORE Program TIME OF VISIT (FROM - TO): 10:30am-2:00pm DATE: 3-24-22 AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: Director of Student Life Assistant Director of Student Life Clinical/Education/Residential Liaison Independent Interpreters (2) Senior Administrative Assistant Director of Finance & Operations List of Areas / Topics covered during visit: Announced visit. • Renovation of Butterworth dorm • Renovation of Cottage D for independent living residents • Relocation of Residential Dept. Management offices to Butterworth dorm effective April 2022 • Census for Core program (18) • Student activities during the quarter • Student Lounge scheduled for upgrade during summer 2022 • New living room furniture installed in dorms • Clinical counseling weekly group therapy for Core female residents • Weekly interdisciplinary team meeting • Student cell phone use/agency telephone procedures • End of year Senior Class activities: Prom, Senior Trip, Senior BBQ, Graduation ceremony • Residential Staffing • Camp Isla Bella: open to Core students with new funding • Camp Isla Bella Director • Physical Plant tour: Cook Lodge, Cottage D, Butterworth Dorm, Cogswell Dorm Corrective Actions implemented as a result of previous visit: • New furniture purchase • Cottage D renovation Areas of regulatory non-compliance identified during this visit: None. Kathleen Forsythe, LCSW 3-25-22 DCF Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM Cc: Director of Student Life Director of Finance & Operations|

6002+++09/06/2023+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: ______Devereux Glenholme________________________________ TIME OF VISIT (FROM - TO): ____Morning______________________ DATE: ____9-6-23 ________ AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: JM - Operations Manager JM - Director of Ops and Finance CS - People Operation Manager MF -Dean of Student Services SH - Director of Milieu Treatment DT - Program Supervisor List of Areas / Topics covered during visit: • Joint visit with DCF Regulatory Consultant, AP. • Census - 40 with new admissions occurring throughout the week. ORR - 18. This is one of the largest groups they've had since opening. • First day of school. Students just returned to the campus. • The agency has established contacts with educational consultants in India and China. International admissions were halted during COVID. • The PD of the ORR program has resigned. They are looking to fill several vacancies (PD; PSA; 2 teachers;2 - 2nd shift; 1-2 overnight positions; CNA). The H1B visa program is currently on hold. There is one more employee who is coming in via the process. No more are expected after that. • The program has almost completed the updated swipe card reader installation. Perimeter fencing is being installed along the far side of the campus. A fire escape was recently repaired. Paving will be done in conjunction with the expansion of one of the parking lots. Laurelholme and Glenholme (G-2) are closed. • The program continues to get staff in compliance with CPR and SPA trainings. They now have 4 staff qualified to train in CPR. • Tour of the Whiteholm and Gardens apartments. Both apartments have decreased supervision with a supervisor checking in throughout the night. Parents must sign off on this arrangement. Both apartment units were a bit cluttered as students had just returned to the campus. Cleaning schedules and expectations were posted in one unit. In the Garden apartment the faucet in the bathroom shower appeared to have a minor leak. The couch was in need of replacement as it was torn/worn in places. • Tour of ORR program. Planned interviews could not occur due to permissions not being obtained from assigned attorneys (federal requirements). There was water in the basement (where items/clothing are stored) that reportedly occurs during rain storms. Residents are not allowed there however it was suggested that corrective measures take place since items are kept there. The unit was clean and residents were observed in the kitchen interacting with staff. Corrective Actions implemented as a result of previous visit: • Training of staff in CPR and SPA is ongoing. Areas of regulatory non-compliance identified during this visit: Section 17a-145-71 Living room, lounge. • The couch in the Garden apt. was worn/torn and in need of replacement. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Terri Bohara 9-14-23 ______________________________ _________________ Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5956+++05/17/2023+++June 1, 2023 Devereux Glenholme, Inc. 81 Sabbaday Ln. Washington, CT 06793-1318 Attn: Dan Bailey, Executive Director Re: Licensing Inspection for Devereux Glenholme RE Inspectors: Terri Bohara , Kathy Forsyth, Keith Bryan and Pat Hughes. Dear Mr. Bailey, In May 2023 a biennial re-licensing inspection was conducted at Devereux Glenholme residential educational facility. This inspection was conducted to determine the compliance of this facility with the Regulations for Operation of Child-Caring Agencies and Facilities 17a-145-48 through 17a-145-98, as well as the DCF Guidelines for the Administration of Medication by Certified Staff. Below are listed the areas of regulatory non-compliance which were identified during the re-licensing inspection. Please review the areas identified and submit a service development plan to address each area. The plan must be submitted within 30 days of receipt of this letter and should identify: 1. the steps to be taken to correct the non-compliance; and 2. the date the correction(s) will be completed. The areas of non-compliance are listed below. Also included in the report are recommendations. Recommendations are meant to highlight areas that are not currently areas of non-compliance, but may become non-compliant if actions are not taken. Recommendations do not require the submission of a plan of correction. Section 17a-145-61 Written policies and procedures. • A policy attestation indicating a review and approval of policies for the year 2022 was not provided. Section 17a-145-64 Personnel policies and procedures. • On 5-17-23 34 personnel files were reviewed. • One file had no documentation of a physical. • The date of the exam was not noted in one file. • One file had noted a physical 5 months prior to hire. • Two files did not contain the results of the TB test. • Two files had expired CPR certification. • Twenty files did not contain evidence of CPR certification. • Four files contained documentation of incomplete restraint training. • Nine files had no evidence of restraint training. Section 17a-145-75. Health and medical treatment. Administration of first aid. Prescription medication. Administration of medicine or treatment. Written records. Storage of drugs, medicines, and instruments. Sick room, telephone. Section 17a-145-86. Instructions in safety procedures. Supervision. • There were multiple fire drills not documented for all 3 shifts and for all four quarters for the year 2022. • There was no documentation of a first quarter/second shift drill for 2023. • Building opening and closing dates were not clearly documented making it difficult to determine if a drill was missed or a building was closed. *Based on nursing review conducted on 5-17-23. ORR program Responsibilities in Administration of the Medication Training Program: DCF Regulation 17a-6(g)-15 (a - g) Annual Observation of Medication Administration Skills Once a year the facility nurse must observe medication certified staff performing the DCF medication administration procedure. This must be documented using the DCF-2275 DCF Medication Administration Program Procedure Checklist and placed in the employees file. Violation 1 Based on the review of the records the facility failed to do Annual Observation of Medication Administration Skills Once a year for two staff members. Staff Members: M. G & L.M. Storage of Internal and External (Topical) Medications Internal medications must be kept separate from External medications: • Internal medications are kept on a different shelf or in a different cabinet or drawer than the external medications. OR • External medication are placed in plastic bins or baskets that are used for external medications only. • Storage areas for external medications must be labeled, "For External Medications Only". Violation 2 Based on the inspection of the medication cabinet the facility failed separate external & Internal medications. ………………………………………………………………………………………………………………… RE Program DCF Responsibilities in Administration of the Medication Training Program: DCF Regulation 17a-6(g)-15 (a - g) Submit a DCF-2272 Monthly Medication Administration Program Supervision and Review to DCF Risk Management. Violation 1 Based on the review of the DCF Data system the facility failed to submit Monthly Medication Administration Program to the DCF Risk Management from 06/01/2021 to 03/01/2023. DCF Reg: 17a-6(g) -16 (c): "Day programs and residential facilities shall provide continuing education on administration of medication to trained person staff members." Facility nurses and/or appropriate personnel must offer continuing education opportunities for DCF medication certified staff. The facility nurse must document on a quarterly basis all continued education opportunities offered in the past 3 months. Violation 2 Based on the review of the training records the facility failed in providing quarterly training in April & July 2022 Once licensing has reviewed and accepted the Service Development Plan and has determined that your agency is in compliance with the regulations a decision on the issuance of a regular twenty DCF -four month license for the program will be made. Until DCF makes this decision the current license will remain in effect. Should you have any questions or comments regarding the contents of this report please do not hesitate to call me at (860) 550-6395. Sincerely, Terri Bohara _______________________________________ Terri Bohara Regulatory Consultant Department of Children and Families 505 Hudson St. Hartford, CT 06106 Phone: 860-550-6395 Fax: 860-860-550-6665|5881+++02/15/2023+++6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: _____Devereux Glenholme_________________ TIME OF VISIT (FROM - TO): __________________________ DATE: _____2-15-23_____________ AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: DB JM JM LK RE List of Areas / Topics covered during visit: • Census - 55/9 - ORR • The program is pursuing an accreditation (Praesidium Accreditation) which requires additional background checks. • Staff vacancies - ORR program - 1 clinician and 3 direct care (1 each shift); RE - 2 overnight vacancies; 2 - 3pm-11pm direct care • Four potential staff are ready to come to the program from Jamaica on an H1Visa • Physical plant upgrades include a new sidewalk in front of the main administrative building. A new brick walkway has been installed as well. The installation of new cameras continues. The cameras will be integrated with a new key card system. The cameras will retain video for 30 days with an option to "bookmark" segments that can be saved. • New bedroom furniture, carpeting and laminate flooring has been installed in several of the homes. • In October 2022 a tree fell on local power lines causing a power outage to the school and local homes. When the power was turned back on a power surge destroyed several hard wire items on campus as well posed a potential for fire. Surge protectors saved some equipment. • Tour of Whiteholm. New bedroom furniture. Unit was clean and well maintained. • Tour of the Garden apartments. Semi-independent living for youth ages 16-18. Average length of stay is one year. The apartment houses 4 males (2 in each bedroom). Bathrooms were extremely dirty and in need of cleaning. The floors, sinks and shower stalls did not appear to have been regularly and thoroughly cleaned. Corrective Actions implemented as a result of previous visit: • Photos were submitted with the previous SDP showing that light fixtures had been cleaned and curtains have been hung up in the bedroom. Areas of regulatory non-compliance identified during this visit: Section 17a145-74 Lavatory facilities. Toilet articles and linens. • Bathrooms in the Garden apartment were extremely dirty and in need of cleaning. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Terri Bohara 3-9-23 ______________________________ _________________ Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5840+++11/30/2022+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: ____Devereux Glenholme _________________________________ TIME OF VISIT (FROM - TO): __________________________ DATE: ____11-30-22______________ AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: NN - Executive Director JM - Operations Manager JM - Dir. Of Finance & Operations LK - Clinical Director DB - Dean of Students List of Areas / Topics covered during visit: • Census - 54. The ORR program has 9. • Staffing - There are currently 2 overnight staff positions and 1 clinician position open. There is currently a vacant (bi-lingual) clinician and lead case manager position. • The installation of campus wide security cameras ( in and outside throughout the campus) continues. • Housing units are being upgraded with new bedroom furniture, new carpeting/flooring and painting being done. • The agency continues to pursue the installation of a new EHR - "My Avatar". It has not yet been installed at the Connecticut site. In addition, each Devereux site (in various states) will be registered as its own corporation. • Tour of Holleyhouse. Upgrades including new furniture and painting have been done on the unit. One bedroom did not have a window covering in the bedroom. There were bugs in several of the light covers. Mold was found in one shower unit. • Had lunch with 2 students. They both indicated that they have found staff helpful and had no complaints about the school. One resident said he had no window covering (verified/staff said they would correct) and he recommended additional lighting on one of the campus paths. Students have access to phones for calls in the dorm as well as video calls with clinicians. Corrective Actions implemented as a result of previous visit: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Areas of regulatory non-compliance identified during this visit: Section 17a-145-68 Heating, Ventilation, lighting. • Light fixture coverings in the Holleyhouse unit were in need of cleaning (dead bugs). Section 17a-145-73. Sleeping accommodations. • One bedroom had no window covering. Please submit a service development plan to address the above referenced areas of non-compliance within 30 days of receipt of this report. The service development plan must be submitted to the attention of the undersigned at the address listed above. Terri Bohara 12-19-22 ______________________________ _________________ Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5763+++08/10/2022+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: _______Devereux Glenholme RE ___________________ TIME OF VISIT (FROM - TO): __________________________ DATE: ____8-10-22______________ AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: JM TT EL List of Areas / Topics covered during visit: • Census - 68 (total) 51 - Glenholme RE; 7 - ORR • There are currently 132 staff employed at Glenholme. (full & pt staff) • Two buildings (Van Holme & Glenholme) are closed at the moment. • The current summer schedule is academics until noon followed by recreational activities for the afternoon. There are 2 recreational "blocks" offered. Students are allowed to select the activities they want to participate in and are encouraged to make selections. • The ORR program is currently utilizing two cottages. Pueblo for girls and Birchwood for boys. There is a certified teacher along with classroom educational assistants. • Tour of both ORR cottages. Common areas and rooms were clean. Carpeted areas throughout the campus are slowly being replaced with a plank flooring. Both houses were stocked with food. In addition to food from the kitchen staff reported that they will often cook foods that the children may be more familiar with and likely to enjoy. • The Office of Refugee Resettlement visits approx. monthly to inspect the program compliance. They also review for compliance with PREA standards. The average length of stay remains between 10-12 days. • Review of Biopsychosocial and treatment plan from case file. Corrective Actions implemented as a result of previous visit: • The decking on Laurelholme has been replaced. • Two entry doors in Laurelholme have been replaced. Areas of regulatory non-compliance identified during this visit: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Terri Bohara 8-16-22 ______________________________ _________________ Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5710+++05/25/2022+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: ____Devereux RE _______________________________________ TIME OF VISIT (FROM - TO): _____Mid Morning ( Approx. 11am)______DATE: ___5-25-22 AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: NN JM DB LK JM TT List of Areas / Topics covered during visit: • Current census - 69. The ORR has a census of 4 but with approx. 10 pending admissions. Some staff positions have been filled since the last visit. The medical dept. currently has 5 staff (2- RN's; 2 LPN's & a CNA). There are 6 staff openings in the RE program and 3 openings in the ORR program. • A new Program Administrator has been hired to work 1pm-9pm. He will provide additional support to supervisors and staff. • SPA (restraint training) is currently on hold due to Covid. • There has been a slight increase in Covid cases on campus. At the time of the visit 8 students and some staff had tested positive for Covid but were out of quarantine. The majority of the students were home for the holiday and only 14 were on campus. • The school prom has been moved to on-grounds and other activities are being re-structured to limit in-person contact. • It is anticipated that approx. 23 students will leave in June due to graduation or leaving the program. • Review of MAR's. The effect of a prn is documented in a general communication log. It was suggested that this documentation be captured in the individual students record. • There were no counter signatures for staff initials on the cardex. • A tour of Laurelholme (boys 14-17). New flooring has been installed. Expectations of the residents were posted throughout the house. Two knobs were missing from the kitchen cabinets. • There were holes in the wall in one bedroom. • There is gap between the kitchen floor (threshold) and the entry door. Corrective Actions implemented as a result of previous visit: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Areas of regulatory non-compliance identified during this visit: Section 17a-145-73. Sleeping accommodations. • One bedroom had several holes in the wall. Section 17a-145-75. Health and medical treatment. Administration of first aid. Prescription medication. Administration of medicine or treatment. Written records. Storage of drugs, medicines and instruments. Sick room, telephone. • There were no staff counter signatures on the cardex's or in the MARs. Section 17a-145-76 Kitchens, equipment, food-handling. • There is a gap between the kitchen floor (threshold) and the door. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Terri Bohara 6-10-22 ______________________________ _________________ Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5681+++03/30/2022+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: _____Devereux Glenholme ___ TIME OF VISIT (FROM - TO): __________DATE: __3-30-22________________ AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title NN PD JM LK JM DB MC List of Areas / Topics covered during visit: • Census 70 - 15 in the ORR program. The census in the ORR program has gone up to 20. • There are approx. 8 staff openings. The school has hired a total of 7 foreign staff members who are slowing being on-boarded. Currently 3 are actively employed at the school with others scheduled to arrive. • A review of 22 personnel was done. • Three files had no evidence of TB tests. One file had no date of a test. • One file had no documentation of a physical. • Ten files were missing documentation of CPR certification. • Three files had no documentation of restraint training while 11 files contained evidence of incomplete training. • New flooring (laminate planking) is being installed throughout the campus. Some of the flooring has already been installed in some of the cottages. Painting has been done in some of the cottages and new furniture has been ordered. Additional security cameras are slated to be installed throughout the campus. A new key card system that is linked to the camera system will also be installed. Pueblo and Birchwood (ORR) have cameras as required by the federal government. Additional fencing around the perimeter will also be installed. • Tour of Carriage House, Holley House and Whiteholm apartment. • Food in refrigerator in Holley house was uncovered and undated. • Additional nursing staff has been hired including a Director of Nursing. • Sixteen students will be graduating in June. Corrective Actions implemented as a result of previous visit: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Areas of regulatory non-compliance identified during this visit: Section 17a-145-64. Personnel policies and procedures. • A review of 22 personnel files was conducted. • Three files had no evidence of a TB test. One file had no date of the TB test. • One file had no documentation of a physical. • Ten files did not have evidence of CPR certification. • Three files had no documentation of restraint training while 11 files contained evidence of partial training. Section 17a-145-76 Kitchens, equipment, food-handling. • Food in the refrigerator of one cottages was uncovered and undated. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Terri Bohara 4-8-22 ______________________________ _________________ Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

5718+++03/29/2022+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Grove School TIME OF VISIT (FROM - TO): ____First shift__________________ DATE: _3/29/22___________ AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: Campus security List of Areas / Topics covered during visit: Unannounced quarterly visit all students, teachers, administrators and staff were home for spring break Corrective Actions implemented as a result of previous visit: Section 17a-145-73. Sleeping accommodations: All areas were responded to satisfactorily. Areas of regulatory non-compliance identified during this visit: Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. _Keith Bryan___________ ___3/29/22____ Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

5987+++08/16/2023+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: _______WCS - Therapeutic Boarding ___________________ TIME OF VISIT (FROM - TO): _____Afternoon_____________________ DATE: ____8-16-23 ____ AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title JE MH Program clinician - SP List of Areas / Topics covered during visit: • Census is 9 however several residents were home on school break. • Tour of bedrooms. There were several bedrooms that were in disarray with clothing and other items on the floor. Staff reported that the residents had left for school vacation leaving their rooms in this condition. When questioned regarding program expectations staff reported that rooms should be cleaned before leaving the unit. • A couple of the toilets were dirty and in need of cleaning. One of the shower stalls had mold and an unidentified substance on the shower floor. This was later addressed by a staff member. The grate in the bathroom floor was rusty. • Residents spent the summer participating in summer school, recreational activities, working on the farm and working at the summer camp in addition to other activities. Corrective Actions implemented as a result of previous visit: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Areas of regulatory non-compliance identified during this visit: Section 17a-145-73. Sleeping accommodations. • Several bedrooms were in disarray with clothing and other items on the floor. Section 17a-145-74 Lavatory facilities. Toilet articles and linens. • Toilets were dirty and in need of cleaning. • One shower stall had mold and a substance on the floor of the shower. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. __Terri Bohara ____________________________ __8-23-23_______________ Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

5976+++08/14/2023+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Adelbrook TIME OF VISIT (FROM - TO): 10:00 am DATE: August 14, 2023 AGENCY PERSONNEL WHO PARTICIPATED: Job Title Adelbrook Director of Residential Services Adelbrook Charge Supervisor List of Areas / Topics covered during visit: • The current census for Adelbrook is 34 and the licensed bed capacity it 35. • Discussion of Adelbrook's current staffing levels, vacant positions, and hiring activities. • Discussion with Adelbrook staff regarding the status of Adelbrook's milieu, the clinical programming, and summer activities for the residents. • Observations of the Adelbrook residents in the milieu, and observations of the interactions between Adelbrook staff and the Adelbrook residents. • Brief interviews / discussions with the Adelbrook residents. • Inspection of the Adelbrook physical plant to assess the cleanliness of the facility, as well as to ensure there are no health or safety concerns. • Received an update on the renovations in progress across the Adelbrook program. Corrective Actions implemented as a result of previous visit: • Not applicable Areas of regulatory non-compliance identified during this visit: • None observed at the time of this quarterly visit. Patrick Hughes _8/15/2023 Regulatory Consultant Date|5968+++06/26/2023+++Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Adelbrook TIME OF VISIT (FROM - TO): 10:00 am DATE: June 26, 2023 AGENCY PERSONNEL WHO PARTICIPATED: Job Title Adelbrook Director of Residential Services Adelbrook Charge Supervisor List of Areas / Topics covered during visit: • The current census for Adelbrook is 35 and the licensed bed capacity it 35. • Discussion of Adelbrook's current staffing levels, vacant positions, and hiring activities. • Discussion with Adelbrook staff regarding the status of Adelbrook's milieu, the clinical programming, and summer activities for the residents. • Observations of the Adelbrook residents and observations of the interactions between Adelbrook staff and the Adelbrook residents. • Inspection of the Adelbrook physical plant to assess the cleanliness of the facility, as well as to ensure there are no health or safety concerns. Discussion of the current bedroom renovations being completed. Corrective Actions implemented as a result of previous visit: • Not applicable Areas of regulatory non-compliance identified during this visit: • None observed at the time of this quarterly visit. Patrick Hughes 6/26/2023 Regulatory Consultant Date|5889+++03/15/2023+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Adelbrook TIME OF VISIT (FROM - TO): 10:00 am DATE: March 15, 2023 AGENCY PERSONNEL WHO PARTICIPATED: Job Title Adelbrook Director of Residential Services Adelbrook Charge Supervisor List of Areas / Topics covered during visit: • The current census for Adelbrook is 34 and the licensed bed capacity it 35. There is a scheduled admission this coming Monday. There are several residents on discharge delays waiting for their next placement to finalized. • Staffing at Adelbrook has gotten better during this quarter. All first shift direct care positions are filled, there are only 3 overnight direct care vacancies, and the most direct care vacancies continue to be on 2nd shift. The vacant Recreation Therapist position has been filled. Adelbrook is able to maintain the required staffing ratios for all 3 shifts. • The residents are doing well at Adelbrook this quarter. There are no longer any covid restrictions in place, so the residents are in the community often. Adelbrook is now using Floreo; a virtual reality autism education App. Floreo has many lesson plans for children with autism including social skills, and coping skills. Many of the residents are involved with special Olympics. All Adelbrook residents will soon be participating in the Miracle League Baseball program. The newly installed splash pad is operational and ready to use when the weather permits. • Adelbrook has started renovating the residents' bedrooms. The renovations include painting, new floors, closets, and windows. During this quarterly visit a physical plant inspection was completed; all areas of the Adelbrook campus and the extension homes were inspected, with no health or safety concerns observed. Corrective Actions implemented as a result of previous visit: • Not applicable Areas of regulatory non-compliance identified during this visit: • Not at the time of this quarterly visit. Patrick Hughes 3/17/23 Regulatory Consultant Date|5865+++12/21/2022+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Adelbrook TIME OF VISIT (FROM - TO): 9:00 am DATE: December 21, 2022 AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title ENW-B Adelbrook Director of Residential Services JS Adelbrook Charge Supervisor List of Areas / Topics covered during visit: • The current census for Adelbrook is 33 and the licensed bed capacity it 35. There are 2 referrals pending for the 2 current vacancies. There is also an upcoming discharge. Adelbrook has received more out of state referrals lately. Adelbrook currently has residents placed by DCF, DDS, and local school districts. • The residents are doing well at Adelbrook this quarter. There have been more activities on and off grounds, and the Winter Ball is happening soon. More parents have been visiting on grounds this quarter. The outdoor pool has been replaced with a splash pad that will be ready for the spring. The residents have winter vacation next week. • Adelbrook is in a better position with their staffing this quarter as there have been 11 new hires. Adelbrook is able to maintain the proper staffing ratios for all 3 shifts. • During this quarterly visit this regulatory consultant walked through the school building. At the time of this visit the school building was calm and quiet and the residents were observed engaged in their school programming. A few residents were moving through the school building with school staff. The residents were observed and appeared well-cared for and comfortable in their surrounds. • During this quarterly visit a physical plant inspection was completed; all areas of the Adelbrook campus and the extension homes were visited with no health or safety concerns observed. Corrective Actions implemented as a result of previous visit: • Not applicable Areas of regulatory non-compliance identified during this visit: • Not at the time of this quarterly visit. Patrick Hughes 2/10/23 Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5793+++08/30/2022+++September 30, 2022 Alyssa Goduti, President and CEO Adelbrook 60 Hicksville Road Cromwell, CT 06416 RE: CCF# 3 Adelbrook RT Dear Ms. Goduti, On August 30th through August 31st, 2022, a biennial licensing inspection was conducted at your facility. This inspection was conducted to determine the compliance of this facility with the Regulations for Operation of Child-Caring Agencies and Facilities 17a-145-48 through 17a-145-98, as well as the DCF Guidelines for the Administration of Medication by Certified Staff. Below are the areas of regulatory non-compliance which were identified during the re-licensing inspection. Please review the areas of non-compliance identified on the enclosed Service Development Plan and submit your responses on the enclosed Service Development Plan to address each area. The plan must be submitted within 30 days of receipt of this letter and should identify: 1. the steps to be taken to correct the non-compliance; and 2. the date the correction(s) will be completed. The areas of non-compliance are listed on the attached DCF Licensing Service Development Plan. Once the Licensing Unit has reviewed and accepted the Service Development Plan and has determined that your agency is in compliance with the regulations, a decision on the issuance of a regular twenty-four month license for the program will be made. Until DCF makes this decision, the current license will remain in effect. Sincerely, ¬¬¬¬¬Patrick Hughes Patrick Hughes DCF Regulatory Consultant DCF LICENSING UNIT INSPECTION REPORT Date of Licensing Visit: August 30th & 31st, 2022 Date Licensing Report Received by Facility: October 4, 2022 License Type: CCF License No. #: CCF- 3 Date Service Development Plan Submitted to Licensing Unit: Corporate Name: Adelbrook Corporate Address: 60 Hicksville Road, Cromwell, CT Program Name: Adelbrook Residential Facility Program Address: 60 Hicksville Road, Cromwell, CT Person Submitting Plan (Name and Title): Person Approving Plan (Name and Title): Date: Statute/ Licensing Regulation # Non-Compliance Citation Plan of Correction/Service Development Plan A System to Prevent Re-Occurrence Completion Date Title Responsible to Monitor Plan 17a-145-86. Instructions in safety procedures. Supervision 17a-6(g)-15 (a - g) Medication Management of Youth in Care DCF Regulation) 17a -6(g) - 16 (c) (Health Care Standards and Practice for Children and Youth in Care). For the year 2021 there is no evidence that 3rd shift fire drills were conducted. For the year 2022 there is a 3rd shift fire drill missing for the 1st quarter, and a 2nd shift and 3rd shift fire drill missing for the 2nd quarter. During the review of medication orders, three cases did not have signed orders. During the inspection the external and internal medications were stored together. Based on the review of the training records the facility failed to provide quarterly training for all medication certified staff. A review of the training records found the facility failed to provide an annual skill check for 3 medication certified staff and provided the annual skill check late for three other staff members. October 19, 2022 Alyssa Goduti / President & CEO Adelbrook 60 Hicksville Road Cromwell, CT 06416 RE: CCF/RT- 3 Adelbrook Residential Treatment Center Dear Ms. Goduti, On August 30th & 31st, 2022 a re-licensing inspection was conducted at your facility. This inspection was conducted to determine the compliance of this facility with the Regulation for Operation of Child-Caring Agencies and Facilities 17a-145-48 through 17a-145-98, as well as the DCF Guidelines for the Administration of Medication by Certified Staff. We have received your agency's service development plan. The plan submitted by your agency addresses the areas of non-compliance identified in the inspection report. The Department accepts the service development plan and has determined that your agency has met the requirements for a regular license. This license is effective as of October 30, 2022 and is valid for twenty-four months. Sincerely, Patrick Hughes Patrick Hughes Regulatory Consultant Department of Children and Families 505 Hudson Street Hartford, CT 06106 (w) 860-550-6552 / (c) 860-716-2199|5698+++05/16/2022+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Adelbrook TIME OF VISIT (FROM - TO): 10:30 am DATE: May 16, 2022 AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title ENW-B Adelbrook Director of Residential Services JS Adelbrook Charge Supervisor List of Areas / Topics covered during visit: • The current census for Adelbrook is 37 and the licensed bed capacity it 35. Adelbrook has a DCF licensing waiver for the 2 additional residents. There are several residents scheduled to discharge in the next few weeks. Adelbrook currently has residents placed by DCF, DDS, and local school districts. • Discussed the progress of the Adelbrook residents and the status of the Adelbrook milieu. • Discussed Adelbrook employment vacancies and hiring updates. Hiring has increased over this past quarter. A new Nursing Director has been hired. • Discussed the lessening of covid-19 restrictions; residents are slowly returning to off-grounds activities. • Physical plant inspection of the facility; all areas of the Adelbrook campus and the extension homes were visited with no health or safety concerns observed. • Observation of the residents in the milieu; residents were observed and appeared well-cared for and comfortable in their surrounds. Corrective Actions implemented as a result of previous visit: • Not applicable Areas of regulatory non-compliance identified during this visit: • Not at the time of this quarterly visit. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Patrick Hughes 5/18/22 Regulatory Consultant Date|5670+++03/14/2022+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Adelbrook TIME OF VISIT (FROM - TO): 10:00 am DATE: March 14, 2022 AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title ENWB Adelbrook Director of Residential Services JS Adelbrook Charge Supervisor List of Areas / Topics covered during visit: • The current census for Adelbrook is 35 and the licensed bed capacity it 35. Adelbrook currently has residents placed by DCF, DDS, and local school districts. • Discussed the progress of the Adelbrook residents and the status of the Adelbrook milieu. • Discussed Adelbrook employment vacancies and hiring updates. The vacant positions are slowly being filled. • Discussed the lessening of covid-19 restrictions and activities scheduled for the residents. • Physical plant inspection of the facility; all areas of the Adelbrook campus and the extension homes were visited with no health or safety concerns observed. • Observation of the residents in the milieu; residents were observed and appeared well-cared for and comfortable in their surrounds. Corrective Actions implemented as a result of previous visit: • Not applicable Areas of regulatory non-compliance identified during this visit: • Not at the time of this quarterly visit. Patrick Hughes 3/29/22 Regulatory Consultant Date|

5964+++07/21/2023+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: The American School for the Deaf, Inc. - PACES Program TIME OF VISIT (FROM - TO): 11:00am-1:00pm DATE: 7-21-23 AGENCY PERSONNEL WHO PARTICIPATED: Job Title: Assoc. Director, Residential Services Operations Director Independent Interpreters (2) Weekend Deans (3) List of Areas / Topics covered during visit: This was a scheduled quarterly Licensing visit to obtain an update on the Paces program and to tour residential living units. A meeting was held with an Associate Director of Residential Services (KF) with independent interpreters present. The following topics were discussed: • Census: Thirty-six residents in the Paces program (26 males, 13 females). • Staffing vacancies: Uncertain of exact number, as ASD just completed a very large orientation group. Fourteen interviews scheduled next week. • Summer school. • Recreation: o Camp Isla Bella: Paces residents enjoyed 3-night stay earlier this month; new Camp Isla Bella Director hired o Off campus recreation activities (swimming, baseball game, Lake Compounce on Tuesdays & Thursdays) o ASD hosting a deaf rap performer in August • Graduation: Ceremony held last month, one Paces program graduate. • Cottages: One of the cottages was opened in June for two 18-year old residents to focus on independent living skills training. • Overnight supervision. • Council on Accreditation (COA) successful survey. • New dorm construction to begin in the coming months; the plan to re-purpose the Vocational Center. • Video cameras; monitoring. • Quarterly incident data Physical plant: Staff facilitated a tour of the Butterworth, Holt, & Clerc dormitories, and Cottage D. o All areas appeared generally clean and organized. o Window blinds contained minor damage in numerous bedrooms. Corrective Actions implemented as a result of previous visit: A service development plan from a July Licensing visit to review personnel files is pending. Areas of regulatory non-compliance identified during this visit: None. Please submit a service development plan to address the above referenced areas of non-compliance within 30 days of receipt of this report. The service development plan must be submitted to the attention of the undersigned at the address listed above. - No service development plan is required following this visit. Kathleen Forsythe, LCSW Date: 7-24-23 Regulatory Consultant A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM Cc: Asst. Executive Director Assoc. Director, Residential Services|5953+++06/22/2023+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: The American School for the Deaf, Inc. - PACES Program TIME OF VISIT (FROM - TO): 9:30am - 3:15pm DATE: 6-22-23 AGENCY PERSONNEL WHO PARTICIPATED: Job Title Training & Onboarding Coordinator Talent Manager Human Resources Manager Assistant Executive Director Chief Financial Officer List of Areas / Topics covered during visit: This was a scheduled Licensing visit to conduct a semiannual personnel file review for the PACES program. 1. Personnel file review: A semiannual personnel file review was conducted for employees hired since December 2022. See Areas of Regulatory Non-compliance below. 2. Meetings were held with the Assistant Executive Director and the Chief Financial Officer. Topics discussed included: - COA Survey: First accreditation survey by the Council on Accreditation (COA) held earlier in June. - Opportunities for improvement identified by surveyors (staff evaluation process, treatment plan, recreation, performance quality improvement, etc.). - Strengths reported by surveyors (Board of Directors, communication with staff and students, medication administration, case records, facilities & grounds, décor, emergency response, finances, staff longevity, HR reorganization, transportation, management of technology, etc.). Final report due in a month. • Proposed Construction of two new dorms: Planning & Zoning approval secured, meeting with neighbors, description of pod-style living in the two dorms • Policy manual reorganization • Revamped 3-week onboarding program for new hires • DCF Deaf and Hard of Hearing Committee; ASD membership • Increase in deaf and hard of hearing staff members in numerous departments (IT, HR, Business Office, Operations, Finance, contracted food service company, etc.) • Trauma-Informed Care - 'Risking Connections' selected as the trauma-informed care model for ASD - Thirty (30) staff trained thus far -Risking Connections 'train-the-trainer' planned this summer for 8 instructors Corrective Actions implemented as a result of previous visit: N/A Areas of regulatory non-compliance identified during this visit: Thirty-one (31) personnel files were reviewed. The following deficiencies were noted: 17a-145-64 Personnel Policies and Procedures. • Physical Exam results documentation was not found in one file (AW). • TB testing results documentation was not found in one file (AW). Please submit a service development plan to address the above referenced areas of non-compliance within 30 days of receipt of this report. The service development plan must be submitted to the attention of the undersigned at the address listed above. Kathleen Forsythe, LCSW Date: 6-26-23 Regulatory Consultant A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM. Cc: Asst. Executive Director Human Resources Manager|5908+++04/04/2023+++April 10, 2023 Mr. Jeffrey S. Bravin Executive Director The American School for the Deaf, Inc. 139 North Main Street West Hartford, CT 06107 Re: Relicensing inspection – PACES Program Regulatory Consultants: Kathleen Forsythe, Keith Bryan Dear Mr. Bravin, On April 4-6, 2023, a biennial re-licensing inspection was conducted for the PACES program at The American School for the Deaf, located at 139 North Main Street, West Hartford, CT. This inspection was conducted to determine the compliance of this program with the Regulations of the Connecticut Department of Children and Families Child Caring Regulations 17a-145-48 through 17a-145-124. Additionally, an onsite review was conducted by DCF Nurse Consultant Anna Cherian, RN, MSN, FNP-BC to determine the program’s compliance with the DCF Medication Administration Guidelines and the DCF Nursing Standards. A sample of client medical records was reviewed, and a ‘full standard’ rating of compliance was issued. Listed in this report are the areas of DCF regulatory non-compliance which were identified during the re-licensing inspection. Please review the areas identified and complete a service development plan (SDP) to address each area of noncompliance. The completed service development plan must be submitted to the assigned Regulatory Consultant within 30 days of receipt of this emailed report. The areas of regulatory noncompliance are as follows: 17a-145-64 Personnel Policies and Procedures. Eight (8) personnel files were reviewed. The following deficiencies were noted: • The personnel file of an intern did not contain documentation of TB test results and a physical exam performed immediately prior to hire. 17a-145-73 Sleeping Accommodations. • One bedroom (second floor Holt dorm) was in an unkempt condition and contained a foul odor. 17a-145-86 Instructions in Safety Procedures. Supervision. Fire drill records for the twenty-four months prior to the relicensing inspection were reviewed. • The following fire drill evacuation deficiencies were noted: Clerc Dorm 2021: 1st shift, 2nd quarter - no residents participated 2022: 3rd shift, 3rd quarter - missing Holt Dorm 2021: 1st shift, 2nd quarter - no residents participated 2022: 3rd shift, 3rd quarter - missing Cogswell Dorm 2022: 3rd shift, 3rd quarter - missing Cottages 2021: 1st shift, 2nd quarter - no residents participated 2022: 2nd shift, 2nd & 4th quarters - missing 3rd shift for 1st, 2nd, 3rd, & 4th quarters - missing 2023: 1st, 2nd, 3rd shift - missing for 1st quarter Cook Lodge: 2021: 1st shift, 2nd quarter- no residents participated 2022: 3rd shift, 3rd quarter - missing 17a-145-96 Discharge of a Child. • The discharge summary reports were not found in two records reviewed (AW, ES). • Evidence was not found in two closed records (LG, AW) indicating that the clients were discharged to the legal guardian, nor was written documentation found from the legal guardian authorizing discharge to another party. 17a-145-98 Case Records. Reports. Confidentiality. Eleven (11) open case records were reviewed. The following deficiencies were noted: • The plan for discharge and disposition is missing on treatment plans in five case records (BA, GC, JLu, JLe, JS). ******************************************************************************** Once the Licensing Unit has reviewed and accepted the completed service development plan and has determined that your agency is in compliance with the regulations, a decision on the issuance of a regular twenty-four month license for the program will be made. Until DCF makes this decision, the current license will remain in effect. Should you have any questions or comments regarding the contents of this report please do not hesitate to contact me at (860) 937-7551. Sincerely, Kathleen Forsythe, LCSW DCF Regulatory Consultant Licensing Unit Dept. of Children and Families 505 Hudson street Hartford, CT 06106 Kathy.forsythe@ct.gov Copy: File Asst. Executive Director Assoc. Dir. of Student Life|5893+++03/16/2023+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: The American School for the Deaf, Inc. - PACES Program TIME OF VISIT (FROM - TO): 11:00am-3:30pm DATE: 3-16-23 AGENCY PERSONNEL WHO PARTICIPATED: Job Title Executive Director Associate Director of Student Life Independent Interpreters (2) Interpreter Intern Assistant Director of Operations Human Resources Manager General Manager, Brock Food Services List of Areas / Topics covered during visit: This was a scheduled quarterly Licensing visit to the Paces program to obtain a program update and to tour the physical plant. A meeting was held with the Executive Director and the Associate Director of Student Life. Topics discussed included: • Census = LBC of 40 beds; Current census = 31 (14 females & 18 males) • Staff vacancies: 13 in Residential program; • Paces program DCF relicensing inspection scheduled for April; • Investigations update; • Self-injurious behavior (SIB); SIB training for staff; • Health Center: Nursing Director planned retirement in June; seeking two perdiem nurses; occasional use of nursing temp agency; • Planned construction of two new dormitories for Paces; anticipated construction dates August 2023 to September 2024; pod design in each dorm; proposed increase in LBC to 50 beds • Paces staff/client supervision ratios; • Bridge program for graduates; access to campus buildings; • CORE program LBC; • Vacant cottages available for Departmental needs for deaf and hard of hearing children. Meeting with General Manager of Brock Food Services. Topics discussed: • food prep/serving allergy protocol; • beverage dispensing; • menus; • planned upgrades to serving line; • Registered Dietician involvement and coordination with Health Center re: resident dietary issues; • milieu observation at lunch time. Associate Director of Student Life facilitated tour of physical plant with Assistant Director of Operations: • First floor Clerc dorm; • Tiger Den physical plant safety; • Clerc dorm kitchen; food storage. Brief meeting with the Human Resources Manager: • Personnel file review conducted in the Human Resources Department. Brief meeting with Associate Director of Student Life: • Reviewed quarterly client behavior data • Provided fire drill evacuation reports for the past two years Corrective Actions implemented as a result of previous visit: Not applicable. Areas of regulatory non-compliance identified during this visit: Not applicable. Please submit a service development plan to address the above referenced areas of non-compliance within 30 days of receipt of this report. The service development plan must be submitted to the attention of the undersigned at the address listed above. - No service development plan was required as a result of this Licensing visit. Kathleen Forsythe, LCSW Date: 3-20-23 Regulatory Consultant A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM. Cc: Assistant Executive Director Assoc. Director of Student Life|5841+++12/22/2022+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: The American School for the Deaf, Inc. - PACES Program TIME OF VISIT (FROM - TO): morning/afternoon DATE: 12-22-22 AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: • Employment Specialist • HR Manager List of Areas / Topics covered during visit: This was a scheduled visit to the Human Resources Office to conduct a semiannual personnel file review. Eighteen (18) personnel files of staff associated with the PACES program were reviewed. Personnel files are well organized. No regulatory deficiencies were observed. Corrective Actions implemented as a result of previous visit: N/A Areas of regulatory non-compliance identified during this visit: None Kathleen Forsythe, LCSW Date: 12-22-22 Regulatory Consultant A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM CC: Asst. Executive Director, Director|5823+++11/22/2022+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: The American School for the Deaf, Inc. - PACES Program TIME OF VISIT (FROM - TO): 10:30am - 2:00pm DATE: 11-22-22 AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: Associate Director of Student Life Independent Interpreters (2) Asst. Executive Director Director of Finance & Operations Clinical Social Work Coordinator Assistant Director of Operations Direct Care Worker - Holt dorm List of Areas / Topics covered during visit: This was a scheduled quarterly DCF Licensing visit to obtain an update on the program and tour the residential living units for the Paces program. Meeting held with the Clinical Social Work Coordinator and an Associate Director of Student Life, with two interpreters present. Topics discussed: • Census = 29. New admission from Wisconsin; recent planned discharges • Staff vacancies: 5 direct care staff on 2nd shift, 2 staff vacancies on weekends • New structure of Residential Department management team, which includes three Associate Directors and three Dean of Students; elimination of Director of Student Life position; new Resident Support Behavior Technician position • Student incident data for the quarter • Student rec/leisure activities for the quarter • Monthly inter-departmental meetings resumed with Clinical, Residential, Nursing, Psychiatrist, Autism services • Clinical services in the Paces program; therapeutic support groups weekdays 12:30p-3p, weekend equine therapy for one resident, clinical intern to start in January 2023 • Life skills assessment in progress for PACES residents • Child Trafficking training • Transportation vehicles, three new leased vans, large bus • Video camera footage review process • Gift cards given to families for Thanksgiving Meeting held with Assistant Executive Director, Director of Finance and Operations and Associate Director of Student Life, with interpreters present. Topics discussed: • Proposed construction of two new dorms and two sports courts for the PACES program; funding secured; target date to break ground is June 2023 with completion targeted for June 2024. • Draft schematic of proposed dorms reviewed. Pod concept design with single and double bedrooms, kitchenette, laundry facilities, lounges, single person bathrooms; window type, overhead sprinklers, heating/cooling; town zoning, fire marshal, health inspection approvals • Proposed underground electrical project; funding secured • COA accreditation preparation resumed after delay; proposed COA survey to occur June 2023 • Animal assisted therapy (two dogs) occurring in the school building two mornings per week • QRTP (Quality Residential Treatment Program) preparation for Department approval • Risking Connections trauma focused training to begin January 2023, 18-month roll out schedule; Train-the-Trainer sessions Physical plant tour of PACES residential living units (Clerc, Holt and Cogswell dorms) with interpreters, Associate Director of Student Life and Assistant Director of Operations. All areas appeared clean and organized. Contracted cleaning staff observed in two dorms. Areas discussed: • Enhancing bedroom window privacy • Adjusting treatment plan for student refusing to attend school • Brief interview with direct care worker re: student supervision • Thanksgiving celebration plans, home visits • Providing additional storage cabinets in identified bedrooms Corrective Actions implemented as a result of previous visit: N/A Areas of regulatory non-compliance identified during this visit: None Kathleen Forsythe, LCSW Date: 11-23-22 Regulatory Consultant A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM CC: Asst. Executive Director, Associate Director of Student Life, Director of Finance & Operations|5770+++08/26/2022+++Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: The American School for the Deaf - PACES Program TIME OF VISIT (FROM - TO): 9:30am-1:00pm DATE: 8-26-22 AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: Executive Director ASD Interpreter Asst. Executive Director Associate Director of Student Life Interim Associate Director of Student Life Director of Finance & Operations Asst. Director of Operations Resident Independent Interpreter List of Areas / Topics covered during visit: This was a scheduled quarterly DCF Licensing visit to obtain an update on the program and tour the residential living units. • Meetings held with Executive Director and Interim Associate Directors of Student Life • Restructuring of Residential Management positions for weekends • Weekly Student Life meeting • Staff vacancies, hiring incentives, pay scale • Physical plant tour of Cook Lodge, Cogswell dorm, Clerc dorm & Holt dorm • Creation of post-graduate living center • Milieu observations; client interview • Camp Isla Bella summer camp • Summer recreation activities • Completion of new parking area at Cogswell dorm • Completion of IT/HR/Business office renovation • Installation of new AC unit at Cogswell building • New resident computer room in Cogswell dorm • Anticipated installation of door alarm at Cogswell dorm • Mattresses • Fall sports program • Incident data for the quarter Corrective Actions implemented as a result of previous visit: N/A Areas of regulatory non-compliance identified during this visit: None Kathleen Forsythe, LCSW Date: 8-29-22 Regulatory Consultant A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM CC: Asst. Executive Director, Interim Director of Student Life|5724+++06/23/2022+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: The American School for the Deaf, Inc. - PACES program TIME OF VISIT (FROM - TO) afternoon DATE: 6-23-22 AGENCY PERSONNEL WHO PARTICIPATED: Job Title HR Manager List of Areas / Topics covered during visit: • Scheduled remote semiannual personnel file review • Ten personnel files reviewed for compliance with DCF Licensing regulations Corrective Actions implemented as a result of previous visit: N/A Areas of regulatory non-compliance identified during this visit: None. Kathleen Forsythe, LCSW Date: 6-23-22 ______________________________ Regulatory Consultant A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM Cc: File Asst. Executive Director Supervisor of IT, Campus Security & Infrastructure|5709+++05/31/2022+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: The American School for the Deaf, Inc. - PACES Program TIME OF VISIT (FROM - TO): 11:30am-3:00pm DATE: 5-31-22 AGENCY PERSONNEL WHO PARTICIPATED: Job Title Director of Student Life Interim Assistant Director of Student Life Education/Residential/Clinical (ERC) Liaison Supervisor of IT, Campus Security & Infrastructure Independent Interpreter (HC) List of Areas / Topics covered during visit: This was a scheduled quarterly Licensing visit to obtain an update on the program and tour the Paces residential units. A meeting was held with some members of the administration who provided an update on the PACES program. An independent interpreter was present for the meeting. List of Areas / Topics covered during visit: • Review of February-April 2022 student behavioral data • Performance Improvement • Direct care staff vacancies • Current group counseling for girls; planned topics for summer & fall • Student personal cell phone use • Staff cell phone use • New DCF physical plant checklist • ECR Coordinator recently served as the Assistant Women's Basketball Coach for the Deaf Olympics, held in Brazil, at which Team USA won a gold medal • ASD's Camp Isla Bella scheduled to open this summer with two sessions; Paces students to visit in July; ECR Coordinator to serve at Camp Director for five weeks • End of school year activities: recreation, awards, Prom, Graduation • Recent acquisition of CEASD (Conference of Educational Administrators of Schools and Programs for the Deaf) Accreditation for three years • Suicide Prevention Physical Plant Audit Report by an outside consultant completed in Spring 2022 • Construction in Cogswell building; planned move of several departments (IT, Human Resources, Plant Operations, Administrative offices) into the renovated space scheduled for late summer 2022 • ASD hosting events in summer 2022: U.S women's tryouts for the Deaf Olympics; Gallaudet basketball camp • Age waivers for two female clients • Streamlining transportation A tour of Paces living units (Holt, Clerc and Cogswell dorms, Cook Lodge) was facilitated by the Interim Assistant Director of Residential Life. The Supervisor of IT, Campus Security & Infrastructure joined for a portion of the tour and reported on the following: • Campus tree trimming currently underway • Renovation of Cogswell lower level by an outside contractor • Plans for the construction of two new dorms on campus, schedule to begin in summer 2023 • Driveway repair near Cogswell building • Interior dorm painting schedule • New lounge furniture purchased for dorms • Planned expansion of classrooms in Vocational building and new STEM Center Corrective Actions implemented as a result of previous visit: N/A Areas of regulatory non-compliance identified during this visit: None. Kathleen Forsythe 6-1-22 ______________________________ _________________ Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM Cc: Director of Student Life|

6006+++08/29/2023+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Boys and Girls Village / Safe Haven Residential TIME OF VISIT (FROM - TO): 1:30pm to 2pm DATE: 8/29/23 AGENCY PERSONNEL WHO PARTICIPATED: Job Title VP of Administrative Operations List of Areas / Topics covered during visit: • LBC 12. Census is 10. • At the time youth were in school except for one. • Spoke with one resident. He likes it at the program, but prefers to live elsewhere. • Discussed the programing and resident behaviors. • Physical plant inspection completed. No concern. Corrective Actions implemented as a result of previous visit: No SDP Areas of regulatory non-compliance identified during this visit: NONE. No SDP required. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Thomas S. Cuchara 9/21/23 Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5914+++04/13/2023+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Boys and Girls Village / Safe Haven Residential TIME OF VISIT (FROM - TO): 10:30am-12pm DATE: 4/13/23 AGENCY PERSONNEL WHO PARTICIPATED: Job Title VP of Administrative Operations List of Areas / Topics covered during visit: • LBC 12. Census is 11. • At the time of the visit the youth were eating lunch. • Discussed the programing and resident behaviors. • Physical plant inspection completed. No concern. • Reviewed two client charts. No concern. Corrective Actions implemented as a result of previous visit: Sec. 17a-16. Client Rights- Room Searches. Completed. At the time of the inspection staff were observed searching a client's bedroom. Staff state the program completes daily room searches while clients are attending school during the week. Residents are not present or asked to be present while the room search is conducted. This is a citation. There is no evidence a resident was present when a room search is completed by staff. Residents should be present during the room search, unless there is an emergency situation that requires immediate search of the resident's bedroom. Medication Administration: Completed. Security of Medication Keys. The identified medication certified staff member gave the medication keys (noncontrolled and controlled keys) to another medication certified staff who subsequently left the building and later returned handing the keys back. This key exchange was observed by Licensing. No controlled medication count was completed. This writer did complete a controlled medication count and all pills are accounted for. Staff also report the medication keys are stored in the staff office. The program will be cited for the following reasons: • Security of controlled medication keys is lack. A key exchange was completed, but no documentation occurred. Staff left the building and returned. • Staff did not complete a controlled medication count at the time of the initial key exchange or document a key exchange was done and document the count was completed when the key was returned. • Non-controlled and controlled medication keys are stored in the staff office. The keys should be stored in the nurse's station, which has a lock box for both sets of keys. • The sheet used to document key exchanges calendar dates are predated. The document has room for only signatures of staff handing the key off to the oncoming shift. The document does not have sufficient space to accommodate multiple key exchanges for each shift. Areas of regulatory non-compliance identified during this visit: NONE. N/A Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Thomas S. Cuchara 4/14/23 Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5875+++02/09/2023+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Boys and Girls Village / Safe Haven Residential TIME OF VISIT (FROM - TO): __12:30pm _______ DATE: 2/9/23 AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title TK Clinical Coordinator DL Milieu Supervisor KH Mental Health Worker List of Areas / Topics covered during visit: • Census is 12. One resident is in the hospital due to psychiatric concerns. • At the time of the visit the youth were in school. • Discussed the programing and resident behaviors. See below. • Physical plant inspection completed. No concerns. • Completed review of medication room. See below. Corrective Actions implemented as a result of previous visit: No corrective action required from last visit. Areas of regulatory non-compliance identified during this visit: NONE. Sec. 17a-16. Client Rights- Room Searches. At the time of the inspection staff were observed searching a client's bedroom. Staff state the program completes daily room searches while clients are attending school during the week. Residents are not present or asked to be present while the room search is conducted. This is a citation. There is no evidence a resident was present when a room search is completed by staff. Residents should be present during the room search, unless there is an emergency situation that requires immediate search of the resident's bedroom. Medication Administration: Security of Medication Keys. The identified medication certified staff member gave the medication keys (noncontrolled and controlled keys) to another medication certified staff who subsequently left the building and later returned handing the keys back. This key exchange was observed by Licensing. No controlled medication count was completed. This writer did complete a controlled medication count and all pills are accounted for. Staff also report the medication keys are stored in the staff office. The program will be cited for the following reasons: • Security of controlled medication keys is lack. A key exchange was completed, but no documentation occurred. Staff left the building and returned. • Staff did not complete a controlled medication count at the time of the initial key exchange or document a key exchange was done and document the count was completed when the key was returned. • Non-controlled and controlled medication keys are stored in the staff office. The keys should be stored in the nurse's station, which has a lock box for both sets of keys. • The sheet used to document key exchanges calendar dates are predated. The document has room for only signatures of staff handing the key off to the oncoming shift. The document does not have sufficient space to accommodate multiple key exchanges for each shift. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Thomas S. Cuchara 2/14/23 Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

5980+++07/25/2023+++DCF-3034 1/2013 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: JRI/ Susan Wayne Residential Center TIME OF VISIT (FROM - TO): 11:00am to 1:00pm DATE: July 25, 2023 AGENCY PERSONNEL WHO PARTICIPATED: Job Title Program Director Areas / Topics covered during visit: The residential program census was thirty-three (19 males,13 females and 1 overcapacity approval) at the time of the quarterly visit and the licensed bed capacity has been temporarily extended to thirty-four. The program reported that there is a nurse and six residential workers' vacancies. A walkthrough of the physical plant was conducted with the residential director and several deficiencies were identified. Corrections implemented as a result of previous visit: N/A Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning) N/A Areas of regulatory non-compliance identified during this visit: Section 17a-145-73: Sleeping accommodations. Upon inspection of the Pine Unit, bedroom 18 contained a wall with repair patches and it needs to be addressed. Bedroom 19 contained a wall with a small repair patch (near the electrical outlet) and it needs to be addressed. Section 17a-145-77: Dining areas and supervision. Upon inspection of the cafeteria, several of the dining room tables were in disrepair and they need to be addressed. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Penny Woodward, LCSW August 14, 2023 Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5954+++05/16/2023+++DCF-3034 1/2013 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: JRI/ Susan Wayne Residential Center TIME OF VISIT (FROM - TO): 11:30am to 1:00pm DATE: May 16, 2023 AGENCY PERSONNEL WHO PARTICIPATED: Job Title Program Director Areas / Topics covered during visit: The residential program census was thirty-three (17 males and 16 females) at the time of the quarterly visit and the licensed bed capacity remains at thirty-three. The program reported that there is a nurse and four residential workers' vacancies. A walkthrough of the physical plant was conducted with the residential director and no deficiencies were identified. Corrections implemented as a result of previous visit: N/A Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning) N/A Areas of regulatory non-compliance identified during this visit: N/A Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Penny Woodward, LCSW __June 16, 2023___ Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5916+++03/14/2023+++DCF-3034 1/2013 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: JRI/ Susan Wayne Residential Center TIME OF VISIT (FROM - TO): 11:00am to 1:30pm DATE: March 14, 2023 AGENCY PERSONNEL WHO PARTICIPATED: Job Title Program Director Areas / Topics covered during visit: The census was thirty-three at the time of the quarterly visit and the residential program licensed bed capacity is thirty-three. The program reported that there is a nurse and three residential workers' vacancies. A walkthrough of the physical plant was conducted with the program director and minor deficiencies were identified that will need to be addressed before the next quarterly visit. Corrections implemented as a result of previous visit: N/A Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning) N/A Areas of regulatory non-compliance identified during this visit: N/A Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Penny Woodward, LCSW April 10, 2023 Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5895+++10/03/2022+++October 31, 2022 Re: Bi-annual licensing inspection of JRI Susan Wayne Center in Thompson, CT. Regulatory Consultants: Penny Woodward, Tom Cuchara and Keith Bryan. On October 3rd through October 7tha biennial re-licensing inspection was conducted at the Susan Wayne Center to determine compliance with Regulations for Operation of Child Caring Agencies and Facilities Sections 17a-145-48 through 17a-145-98, as well as the DCF Guidelines for the Administration of Medication by certified staff. DCF has determined that the program is in compliance with all applicable regulatory provisions except those itemized below: Please review areas identified and submit a plan of correction to address each area. The service development plan must be submitted within 30 days of receipt of this letter and should identify: 1. The steps to be taken to correct the non-compliance. 2. The date the correction(s) will be completed. The areas of non-compliance identified are as follows: Section 17a-145-61: Written policies and procedures. Evidence: Upon review of the telephone policy, the restricted list and suspension of telephone privilege sections contained confusing language that could be misinterpreted by staff and the information needs to be amended or removed. The repair policy contained vague language and the information needs to be amended or removed. The seclusion policy contained incorrect information and the statement needs to be amended. The supervision policy contained information that was a regulatory violation and it should be removed. The safety assessment plan contained vague information that could be misinterpreted by staff and it needs to be amended or removed. The resident handbook contained vague information under the student belongings section and it needs to be amended or removed. Section 17a-145-63: Chief administrative officer. Evidence: Upon review of seclusion practices, it was found that the use of the procedure was not always consistent with program policies and on multiple occasions the use of seclusions did not always ensure the safety or emotional well-being of residents. Section 17a-145-64: Personnel policies. Evidence: Upon review of the program manual, the personnel section did not contain information that required new employees to have TB and physical health exams prior to hire. Section 17a-145-71: Dining areas. Evidence: Upon inspection of the dining hall, several of the walls contained chipping paint and scuffmarks and they need to be addressed. Section 17a-145-73: Sleeping accommodations. Evidence: Upon inspection of the residential facility, the Cedar Unit contained a bedroom that had a dresser with scuffmarks and it needs to be addressed. The Pine Unit contained a bedroom that had a window with chipping glazed material and it needs to be addressed. Section 17a-145-74: Lavatory facilities. Evidence: Upon inspection of the residential facility, one of the bathrooms in the Cedar Unit contained a tub that was in disrepair and it needs to be addressed. The Pine Unit contained a bathroom that had a window with chipping glazed material and it needs to be addressed. Section 17a-145-98: Case records. Evidence: Upon review of case files, one record did not contain a signed placement agreement form as required by regulations. Section 46a-153: Physical restraint. Evidence: Upon review of seclusion documentation, it was confirmed that the program was allowing staff to use seclusion as a form of discipline to control and address residents' behavioral issues. This practice is a statute violation. Once licensing has reviewed and accepted the service development plan and has determined that your agency is in compliance with the regulations a decision on the issuance of a regular twenty-four-month license for the program will be made. Until DCF makes this decision the current license will remain in effect. Please be advised that failure to submit an acceptable service development plan within the specified time frame may lead to a licensing action up to and including revocation. Should you have any questions or comments regarding the contents of this report please do not hesitate to call me at (959) 255-0615. Sincerely, Penny Woodward, LCSW DCF Regulatory Consultant Copy: File|5781+++08/11/2022+++ DCF-3034 1/2013 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: JRI / Susan Wayne Residential Center TIME OF VISIT: (FROM–TO): 11:30 a.m. to 1:00 p.m. DATE: 8/11/22 AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title N/A Program Director Areas / Topics covered during visit: The Department of Children and Families conducted a scheduled quarterly inspection visit at the Susan Wayne Center on August 11, 2022. Topics covered during the quarterly visit included program staffing, physical plant inspection, milieu services and the fall biannual inspection visit. Physical plant: A walkthrough of the physical plant with the residential director was conducted to confirm that the facility was in compliance with regulatory standards. Corrections implemented as a result of previous visit: N/A Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning) N/A Areas of regulatory non-compliance identified during this visit: N/A Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Penny Woodward, LCSW September 12, 2022 Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5739+++04/29/2022+++ DCF-3034 1/2013 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: JRI / Susan Wayne Residential Center TIME OF VISIT: (FROM–TO): Morning to Afternoon DATE: 4/29/22 AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title N/A Program Director Areas / Topics covered during visit: The Department of Children and Families conducted a scheduled quarterly inspection visit at the Susan Wayne Center on April 29, 2022. Topics covered during the quarterly visit included program staffing, physical plant inspection, milieu services and medication administration system. Physical plant: A walkthrough of the physical plant with the program director was conducted; deficiencies were identified and discussed with the director. Corrections implemented as a result of previous visit: N/A Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning) N/A Areas of regulatory non-compliance identified during this visit: N/A Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Penny Woodward, LCSW April 29, 2022 Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5778+++02/10/2022+++ DCF-3034 1/2013 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annuall licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: JRI Susan Wayne Center TIME OF VISIT: (FROMTO): Morning to Afternoon DATE: 2/10/22 AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title N/A Program Director Areas / Topics covered during visit: The Department of Children and Families conducted a scheduled quarterly inspection visit at the Susan Wayne Center on February 10, 2022. Topics covered during the quarterly visit included program census, staffing, personnel review, physical plant inspection and medication administration system. Physical plant: A walkthrough of the physical plant with the program director was conducted. Lounge areas, bathrooms, the Cedar floor, Pine floor, Elm floor, Sunflower floor, Fox floor, sensory rooms and breakrooms were inspected. Minor deficiencies were identified during the walkthrough and they were discussed with the residential director. No physical plant issues were reported to the Department at the time of the quarterly inspection visit. Corrections implemented as a result of previous visit: N/A Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning) N/A Areas of regulatory non-compliance identified during this visit: N/A Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Penny Woodward, LCSW February 28, 2022 Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

5938+++05/24/2023+++505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Newport Academy / Double Hill campus TIME OF VISIT: 10:30 am DATE: May 24, 2023 AGENCY PERSONNEL WHO PARTICIPATED: Newport Academy Compliance Specialist. Areas / Topics covered during visit: • Discussion of the current census, which is 51, and the LBC is 54. • Discussion of Newport Academy Double Hill's current staffing levels, vacant positions, and hiring activities. • Discussion with Newport Academy Double Hill's staff regarding the status of Double Hill's milieu, the clinical programming, incidents and activities for the residents. • Inspection of the Double Hill's physical plant to assess the cleanliness of the home, as well as to ensure there are no health or safety concerns. Corrections implemented as a result of previous visit: Not applicable. Areas of regulatory non-compliance identified during this visit: Not applicable. Patrick Hughes 5/30/2023 Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5887+++03/08/2023+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Newport Academy / Double Hill campus TIME OF VISIT: 11:00 am DATE: March 8, 2023 AGENCY PERSONNEL WHO PARTICIPATED: Newport Academy Compliance Specialist. Areas / Topics covered during visit: Census The current census is 49 and the bed capacity for Newport Double Hill is 53. Currently one resident is hospitalized and is expected to return soon. Newport Double Hill will be applying to increase their Licensed Bed Capacity (LBC) to 54. Staffing / Hiring Newport Double Hill's staffing is reported to be stable, with a recent hiring of 12 direct care staff. Newport Double Hill has all their clinical positions filled. Program / Milieu Overall, the girls are doing well at Newport Academy. There have been very few significant event reports this quarter at Newport Double Hill. Newport Double Hill has restarted family visitation on campus and increased off-grounds activities. This regulatory consultant toured the campus during this quarterly visit. The atmosphere on the campus was calm and quiet. The girls were moving around the campus from classrooms to the cafeteria. This regulatory consultant passed several groups of students who were quick to say hello to this writer. All residents observed appeared to be in good spirits and comfortable in their surroundings. All interactions observed between staff and residents were friendly and professional. Physical Plant During this quarterly visit this regulatory consultant completed a physical plant inspection. All areas observed were clean and nicely decorated with no health or safety concerns noted. Corrections implemented as a result of previous visit: Not applicable. Areas of regulatory non-compliance identified during this visit: Not applicable. Patrick Hughes 3/14/2023 Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5866+++12/21/2022+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Newport Academy / Double Hill campus TIME OF VISIT: 1:00 pm DATE: December 21, 2022 AGENCY PERSONNEL WHO PARTICIPATED: HB Newport Academy Compliance Specialist. Areas / Topics covered during visit: Census The current census is 50 and the bed capacity for Newport Double Hill is 53. Newport Academy's licensed age range has recently changed to include 13-year-olds. Staffing / Hiring Newport Double Hill has sufficient staff to maintain staffing ratios across all 3 shifts. Newport Double Hill has direct care vacancies (Care Coordinators) on all 3 shifts, but are fully staffed at the Residential Program Director, Clinician, and Residential Supervisor positions. Newport Double Hill continues to hire for their open positions. Program / Milieu Overall, the girls are doing well at Newport Academy. There haven't been any significant incidents this quarter at Newport Double Hill. Newport Academy has seen an uptick in covid 19 cases, but the residents have been quarantined and there hasn't been any further spread. During this quarterly visit this regulatory consultant toured the Newport Double Hill campus. The atmosphere on the campus was calm and quiet. The girls appeared engaged with their school programming but did greet this regulatory consultant. All interactions observed between staff and residents were friendly and professional. Physical Plant During this quarterly visit this regulatory consultant completed a physical plant inspection. All areas observed were clean and nicely decorated with no health or safety concerns noted. Corrections implemented as a result of previous visit: None at this time. Areas of regulatory non-compliance identified during this visit: None at this time Patrick Hughes 2/10/23 Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5827+++09/22/2022+++ Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Newport Academy / Double Hill campus TIME OF VISIT: 10:30 DATE: September 22, 2022 AGENCY PERSONNEL WHO PARTICIPATED: HB Newport Academy Compliance Specialist. Areas / Topics covered during visit: Census The current census is 47 and the bed capacity for Newport Double Hill is 53. One of the residents is currently hospitalized. Recently the age of clients being referred to Newport Double has been trending younger than previously. Staffing / Hiring Newport Double Hill has 18 vacancies campus wide. There is some hiring currently in process for some of these positions. Newport Academy has sufficient staff to maintain staffing ratios across all shifts. Program / Milieu Newport Double Hill has opened their own horse barn to provide Equine Therapy to all residents. Prior to acquiring the horse barn, Newport Double Hill was using a community provider for Equine Therapy. Overall, the girls are doing well at Newport Academy. There haven't been any significant incidents this quarter at Newport Double Hill. During this quarterly visit this regulatory consultant toured the Newport Double Hill campus. The atmosphere on the campus was calm and quiet. The girls appeared engaged with their school programming but did greet this regulatory consultant. All interactions observed between staff and residents were friendly and professional. Physical Plant During this quarterly visit this regulatory consultant completed a physical plant inspection. All areas observed were clean and nicely decorated with no health or safety concerns noted. Corrections implemented as a result of previous visit: None at this time. Areas of regulatory non-compliance identified during this visit: None at this time Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Patrick Hughes 9/22/2022 Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5697+++05/09/2022+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Newport Academy Double Hill campus TIME OF VISIT (FROM - TO): 1:00 pm DATE: May 9, 2022 AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title HB Compliance Specialist List of Areas / Topics covered during visit: • Current census is 53 and the licensed bed capacity is 53. • Discussion of the residents in the program and the program's milieu. • Discussion of Newport's staffing and hiring, and changes to the supervisory structure. • New Executive Director CB has started at Double Hill. • Physical plant inspection of the facility; no health or safety concerns observed. • Observation of the residents participating in their daily programming. • Interviews with residents; (no concerns for their safety or well-being reported). • Review of personnel files for newly hired staff. Corrective Actions implemented as a result of previous visit: • Not applicable Areas of regulatory non-compliance identified during this visit: • None at the time of this quarterly visit. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Patrick Hughes 5/18/2022 Regulatory Consultant|5662+++03/10/2022+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Newport Academy Double Hill campus TIME OF VISIT (FROM - TO): 10:30 DATE: March 10, 2022 AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title HB Compliance Specialist RB Compliance Specialist List of Areas / Topics covered during visit: • Current census is 52 and the licensed bed capacity is 53. • Discussion of the residents in the program and the program's milieu. • Discussions of Newport's staffing and hiring. • Physical plant inspection of the facility; no health or safety concerns observed. • Observation of the residents participating in their daily programming. • Conversations with a few residents; no concerns for their safety or well-being reported. Corrective Actions implemented as a result of previous visit: • Not applicable Areas of regulatory non-compliance identified during this visit: • None at the time of this quarterly visit. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Patrick Hughes 3/21/2022 Regulatory Consultant Date|

5720+++03/30/2022+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Newport Academy / Todd Hill TIME OF VISIT (FROM - TO): First shift / Second shift_____ DATE: _3/30/22_ AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: Quality Assurance Manager Executive Director List of Areas / Topics covered during visit: Youth in the program, the physical plant, and staffing. There were total of 49 youth residing at the facility. The executive director, campus director along with 3 supervisors were on duty. There were a total of 7 therapist on duty. There were a total of 18 staff on duty one of which was a floating staff that helps out in areas of need. The program expects a potential intake later today and the floating staff will cover the living area of the new intake. Corrective Actions implemented as a result of previous visit: None Areas of regulatory non-compliance identified during this visit: Section 17a-145-73. Sleeping accommodations (a) Sleeping accommodations for each child shall have adequate area, spacing and equipment in accordance with the child's age and needs. Bedrooms shall contain a window unless there is a 24-hour ventilation system approved by the state or local health department. Heating facilities shall be sufficient to maintain a room temperature consistent with existing department of health services' guidelines. Separate sleeping quarters shall be provided for children of the opposite sex six years of age or over. The facility shall provide each such child with a single bed with adequate linens and covers suitable for the temperature, and a locker, dresser or other storage space for the child's private use conveniently located in or near the child's sleeping room. One poster with marijuana as part of the content was removed from the wall. One bedroom needed items removed from the floor. Section 17a-145-76. Kitchens, equipment, food-handling All kitchens shall be clean, well lighted, properly ventilated and screened, and provided with essential and proper equipment for the preparation and serving of food. Storage, refrigeration and freezer facilities shall be adequate for the number of persons to be served. All perishable foods shall be refrigerated at a temperature at or below 45° Fahrenheit. Freezers and frozen food compartments shall be maintained at minus 10° to 0° Fahrenheit. Cooking utensils, dishes and tableware shall be in good condition and proper cleaning facilities for this equipment shall be provided. dishes shall be stored in a clean, dry place protected from flies, dust or other contamination. Food preparation and serving areas shall comply with Section 19-13-B42 of the public health code. Proper food handling techniques and sanitation to minimize the possibility of the spread of food-borne diseases shall be maintained. One dorm's refrigerator needed cleaning. Two dorms' refrigerators were missing a thermometer. One dorms refrigerator thermometer was not functioning. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. _Keith Bryan______________ ____3/30/22_____________ Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

 

5721+++03/31/2022+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: The Learning Clinic TIME OF VISIT (FROM - TO): First shift _____ DATE: _3/31/22_ AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: Executive Director Executive Secretary Maintenance List of Areas / Topics covered during visit: Youth in the program, the physical plant, and staffing. There were total of 2 youth residing at the facility in Briggs cottage. Both youth were at work with one staff on duty. The executive director, new school administrator and administrative assistant were on duty. Corrective Actions implemented as a result of previous visit: None Areas of regulatory non-compliance identified during this visit: Section 17a-145-73. Sleeping accommodations (a) Sleeping accommodations for each child shall have adequate area, spacing and equipment in accordance with the child's age and needs. Bedrooms shall contain a window unless there is a 24-hour ventilation system approved by the state or local health department. Heating facilities shall be sufficient to maintain a room temperature consistent with existing department of health services' guidelines. Separate sleeping quarters shall be provided for children of the opposite sex six years of age or over. The facility shall provide each such child with a single bed with adequate linens and covers suitable for the temperature, and a locker, dresser or other storage space for the child's private use conveniently located in or near the child's sleeping room. The bedroom in apartment A needed cleaning. The ceiling tiles in the hallway near the bedroom needed replacing due to water damage from a previous leak in the roof. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. _Keith Bryan____________ ___3/31/22___ Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

5723+++03/30/2022+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Wellspring TIME OF VISIT (FROM - TO): First shift / Second shift_____ DATE: _3/30/22_ AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: Quality Assurance Manager Executive Director Program Director - Shiloah House List of Areas / Topics covered during visit: Youth in the program, the physical plant, and staffing. There were total of 9 youth in Beauvais House and 6 youth in Shiloah House. There were 5 staff on duty, 2 therapist, a program director and a nurse. The provider was creating 3 twenty hour positions to have an extra staff on duty at night. The provider was creating a 32 hour therapist position, whose duties would be split between conducting therapy with youth in the house and animal therapy in the barn. Corrective Actions implemented as a result of previous visit: None Areas of regulatory non-compliance identified during this visit: None Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. _Keith Bryan__________ ____3/30/22___ Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

 

 

5970+++07/07/2023+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Boys and Girls Village / Kraft House TIME OF VISIT (FROM - TO): __9am to 12pm__________ DATE: 7/7/23 AGENCY PERSONNEL WHO PARTICIPATED: Job Title VP of Administrative Operations List of Areas / Topics covered during visit: • Census is 8. LBC 8. • Kraft House is on a 2nd Provisional License (60 days). The License expires 7/22/23. • All youth were at school at the time of the visit. One youth, 11 years old is on census and a waiver was approved. • Physical plant inspection was conducted and in compliance. See below. • Discussed the programing, resident safety, etc. • Discussed staffing of shifts. The Director of Nursing recently resigned, but the program was able to hire another Director of Nursing that will begin duties 7/10/23. • Reviewed fire drills and found to be incompliance • One case record reviewed. Corrective Actions implemented as a result of previous visit: n/a Areas of regulatory non-compliance identified during this visit: Physical Plant: At the time of the visit, the exit door 'safety' glass was found broken. One youth escalated in the milieu hallway and broke the window on two exit doors. Maintenance was able to use durable plexiglass to cover the affected area until a replace window is purchased. Although this is a temporary repair, please identify in the Service Development Plan an approximate date the exits doors will be restored to their original condition. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Thomas S. Cuchara __8/1/23_______ Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5925+++04/28/2023+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Boys and Girls Village / Kraft House TIME OF VISIT (FROM - TO): __9am to 12pm__________ DATE: 4/28/23 AGENCY PERSONNEL WHO PARTICIPATED: Job Title VP of Administrative Operations List of Areas / Topics covered during visit: • Census is 4. LBC 4. • This the first visit to the Kraft House since receiving the 1st Provisional License (60 days). The License expires 5/23/23. • At the time of the visit there was one youth in the program and the other youth in school. • Physical plant inspection was conducted and in compliance. • Discussed the programing, resident safety, etc. • Discussed staffing of shifts. • Reviewed medication. • One case record reviewed. Corrective Actions implemented as a result of previous visit: n/a Areas of regulatory non-compliance identified during this visit: N/A Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Thomas S. Cuchara __5/4/23_______ Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

5960+++07/12/2023+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: The Children's Center of Hamden, Inc. - START (PRTF) Program TIME OF VISIT (FROM - TO): 9:30am- 1:00pm DATE: 7-12-23 AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: VP, Residential Services Lifeguard Nurse (2) Direct Care Worker/ Brewster Cottage Direct Care Worker / Heaton Cottage Direct Care Worker / Marcy Cottage Male clients List of Areas / Topics covered during visit: This was a scheduled quarterly visit to the START program, a psychiatric residential treatment facility (PRTF), to obtain a program update and tour the physical plant. A meeting was held with the VP of Residential Services who reported on the following: • Census: 21 residents (8 females, 13 males). Female admission scheduled for today. • Food Services: Cafeteria schedule is lunch only Monday-Friday, other meal deliveries to cottage, take-out dinner on Sundays. • Summer school. • Summer worker program with Horticulturist. • Recreation activities on campus. • Anticipated video camera upgrade on campus. • Staff vacancies; three direct care workers; one part time nurse. • Fencing. • Clinical Department: Clinician positions are full; VP of Clinical Services on leave, covered by a licensed clinician administrator. • Incident data for the quarter not available. • Recent 190th birthday celebration for CCOH. • DSS authorization for full capacity of 28 beds. Physical Plant: The Vice President of Residential Services facilitated a tour of the Brewster, Marcy and Heaton cottages. • All interior areas appeared clean and organized. • Overgrown vegetation observed at Marcy and Heaton cottages. • Stockade fence in rear yard of Marcy has been repainted. • Client interviews with male residents in two cottages. • Milieu observation. • Drinking water available. • Discussion on window coverings. Swimming pool: A tour was conducted of the facility outdoor pool. Topics discussed with Lifeguard on duty included: • Several direct care staff present in pool area when clients are in the pool. • Swim testing procedures for clients. • Pool rescue equipment. • Pool water-testing logs. • Cell phone and walkie-talkie for communication. • Security of pool house. • Three Lifeguards cover pool schedule. Milieu Observation: • Medication administration in Brewster. • Lunch in male cottages. • Outdoor recreation activity. • Swimming pool. Corrective Actions implemented as a result of previous visit: N/A Areas of regulatory non-compliance identified during this visit: None. Please submit a service development plan to address the above referenced areas of non-compliance within 30 days of receipt of this report. The service development plan must be submitted to the attention of the undersigned at the address listed above. - A service development plan is not required following this Licensing visit. Kathleen Forsythe, LCSW Date: 7-17-23 Regulatory Consultant A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM Cc: VP, Residential Services|5950+++06/21/2023+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: The Children's Center of Hamden, Inc. - START (PRTF) Program TIME OF VISIT (FROM - TO): 10:30am - 2:00pm DATE: 6-21-23 AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: Human Resource Hiring & Training Manager VP of Human Resources Chief Development Officer List of Areas / Topics covered during visit: This was a scheduled visit to the START program, a psychiatric residential treatment facility (PRTF), to conduct a semi-annual personnel file review for regulatory compliance. A meeting was held with the Human Resource Hiring & Training Manager and the VP of Human Resources. Topics discussed included: • Professional license verification • Annual CPR refresher training • Physical exam documentation Eight personnel files were reviewed. No regulatory deficiencies were noted. Corrective Actions implemented as a result of previous visit: N/A Areas of regulatory non-compliance identified during this visit: None. Please submit a service development plan to address the above referenced areas of non-compliance within 30 days of receipt of this report. The service development plan must be submitted to the attention of the undersigned at the address listed above. - A service development plan is not required following this Licensing visit. Kathleen Forsythe, LCSW Date: 6-22-23 Regulatory Consultant A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM Cc: VP, Residential Services VP, Human Resources|5923+++04/27/2023+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: The Children's Center of Hamden, Inc. - START (PRTF) Program TIME OF VISIT (FROM - TO): 10:00am - 1:50pm DATE: 4-27-23 AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: VP of Residential Services Chief Executive Officer Client (male) VP of Human Resources Director of Human Resources List of Areas / Topics covered during visit: This was a scheduled visit to the START program, a psychiatric residential treatment facility (PRTF), to tour the physical plant and obtain a program update. A meeting was held with the Vice President of Residential Services and VP President of Human Resources. Topics discussed included: • Census = 24 (9 females, 15 males) • Staff Vacancies (4 direct care workers, 2 nursing positions); all clinician positions are filled • Nursing coverage for the PRTF • Length of stay in the PRTF for some residents • New Director of Human Resources • New Principal in the education program • Recent successful Joint Commission triennial survey • Staff appreciation activities • Increased communication with staff and administration; Quarterly 'All Staff' meetings; Monthly staff/CEO lunches • On-site psychiatrist activities • Review of incident data report for the quarter Meeting held with VP of Residential Services and CEO. Topics discussed included: • Investigations • Proposed subacute program at CCOH; possible renovations for ADA compliance • Emergency physical intervention reduction initiative • Proposed upgrade to campus fencing; proposed gate at main entrance • Emergency physical intervention data reflects an increase due to DPH new category ('restriction of movement') VP of Residential Services facilitated a tour of the three PRTF cottages. • All areas appeared very clean and well organized. Case record Review - One client record reviewed for regulatory compliance and PRTF Standards compliance. Corrective Actions implemented as a result of previous visit: N/A Areas of regulatory non-compliance identified during this visit: None. Please submit a service development plan to address the above referenced areas of non-compliance within 30 days of receipt of this report. The service development plan must be submitted to the attention of the undersigned at the address listed above. - A service development plan is not required following this Licensing visit. Kathleen Forsythe, LCSW Date: 5-2-23 Regulatory Consultant A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM Cc: VP, Residential Services|5844+++01/05/2023+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: The Children's Center of Hamden, Inc. (CCOH) - START/PRTF Program TIME OF VISIT (FROM - TO): 10:00am-12:30pm DATE: 1-5-23 AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: Chief Development Officer Vice President, Residential Services Vice President, Clinical Services Director of Residential Services Food Services Workers Client List of Areas / Topics covered during visit: At the request of CCOH, a scheduled meeting was held onsite with three agency administrators to tour physical plant space for a proposed new co-ed eight bed program. The Chief Development Officer reported that CCOH was contacted by DCF to consider opening the sub-acute portion of an urgent care center. It was reported that an agreement has been made between Yale New Haven Hospital and CCOH to serve children in need of short term residential care when discharging from the hospital Emergency Department. The space is located in Wakeman Hall on the first floor and contains numerous rooms to be used for bedrooms, a kitchen, offices, and two lounges. Two full bathrooms are housed in the space, one of which is ADA compliant. Clinical services and staffing ratios were discussed. Renovation plans were discussed (addition of fire sprinklers, nursing office, kitchen, adding a ramp at a rear exit, ligature-risk assessment, consultation with the fire marshal regarding emergency exits, etc.). Discussion held on bedroom size requirements listed in the child caring facility regulations. It was reported that CCOH is still considering DCF's request and may move forward with submitting a proposal to the Department. An unscheduled visit was conducted at the START/PRTF program with the Vice President of Residential Services and the Director of Residential Services. Topics discussed included: • Current census in the START program is at 16 (9 females, 7 males) • Female client in the program for more than one year • Provider meeting scheduled for this date to discuss a male client currently hospitalized • Average length of stay for clients in the PRTF • Supervisory coverage seven days per week • Recent holiday activities • Meals for the PRTF program continue to be served in the cottages instead of the Cafeteria, with the exception of lunch on school days • Storage of dry goods in cottage kitchens • New game room scheduled to open • Client incidents • Recent COVID cases among clients and staff; mask requirement for cottage staff has remained in place since start of pandemic • Staffing vacancies (3 direct care workers, two nurses, 3 clinicians) • CEO monthly lunch meetings with staff • Unannounced visits from DPH • Physical plant tour of Brewster and Marcy cottages. All appears appeared very clean and organized. Heaton cottage was not observed due to a client on quarantine status due to testing positive for COVID. The Cafeteria was observed during the lunch period: • Lunch served this day consisted of pesto chicken pasta, minestrone soup, garden salad, milk (including chocolate and lactose-free) and choice of three fresh fruits. • Four kitchen workers were on duty along with a paid client worker in the dish room. • The client was interviewed, and no complaints were reported. • Observed lunch being served to day school students and the PRTF residents. Numerous school staff and supervisors were observed eating lunch with students throughout the Cafeteria. • When asked, a food services worker reported that there was one staff opening in the Kitchen. Corrective Actions implemented as a result of previous visit: • A service development plan submitted by The Children's Center of Hamden following a November 2022 Licensing visit that addressed regulatory citations in relation to staff training documentation for CPR and restraint. The plan was accepted by the Department. Areas of regulatory non-compliance identified during this visit: None. Kathleen Forsythe, LCSW Date: 1-6-22 Regulatory Consultant A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM Cc: VP, Residential Services Chief Development Officer|5826+++11/17/2022+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: The Children's Center of Hamden, Inc. (TCCOH) - START/PRTF Program TIME OF VISIT (FROM - TO): 9:30am - 1:30pm DATE: 11-17-22 AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: Director of Human Resources Human Resources Coordinator Training & Hiring Manager VP of Support Services Culinary Arts Teacher Education Director Client List of Areas / Topics covered during visit: This was a scheduled Licensing visit to conduct a semiannual personnel file review, as well as to review training records for staff affiliated with the psychiatric residential treatment facility (PRTF) for standards compliance. Personnel file review: • Two personnel files of recently hired staff were reviewed. See 'Areas of Regulatory Non-Compliance' below. PRTF staff training records review: • Employee restraint and CPR training documentation for 2022 for the PRTF program was reviewed. • Agency switched restraint training programs in the Fall of 2022 from CPI (Crisis Prevention Institute) to CCG (Crisis Consulting Group). • Ten employees attended a CCG 'train the trainer' session on 8-31-22. • Training documentation for 66 employees in the PRTF (psychiatric residential treatment facility) program was reviewed. PRTF standards require semiannual restraint refresher training and annual CPR training. See 'Areas of Regulatory Non-Compliance' below. Staff Appreciation Event: • Luncheon held during visit for employee appreciation. • Observation of agency's new wood-fired pizza oven trailer in operation. • Interview with client learning vocation skills. • Interviews with Culinary Arts Teacher and Director of Education. Corrective Actions implemented as a result of previous visit: • A service development plan submitted by The Children's Center of Hamden following an October 2022 Licensing visit that addressed regulatory citations in relation to cottage kitchens was accepted by the Department. Areas of regulatory non-compliance identified during this visit: 1. The results of a criminal history background check and the results of a child protective services background check for one employee are dated after the employee's hire date rather than prior to hire. 2. Documentation of semiannual restraint training was not found for six employees as required by §483.3 76(f). Staff must demonstrate their competencies as specified in paragraph (a) of this section on a semiannual basis and their competencies as specified in paragraph (b) of this section on an annual basis", listed under 483.376 Education and Training in Appendix N- State Operations Manual for Psychiatric Residential Treatment Facilities (PRTF) Interpretive Guidance from the Center for Medicare & Medicaid Services. 3. No evidence was found in files reviewed that any PRTF staff have been trained annually in CPR as required by §483.376(b) 4. No evidence was found that one perdiem nurse has been trained in CPR. 5. Evidence was found that 42 staff members affiliated with the PRTF have participated in online CPR training only and are not certified in CPR. No evidence was found that these staff completed the hands-on skills demonstration of CPR as required by §483.376(d) "Staff training must include training exercises in which staff members successfully demonstrate in practice the techniques they have learned for managing emergency safety situations." Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Kathleen Forsythe, LCSW Date: 11-22-22 Regulatory Consultant A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM Cc: VP, Residential Services VP, Support Services HR Director|5790+++10/06/2022+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: The Children's Center of Hamden, inc. - START Program TIME OF VISIT (FROM - TO): 12:30pm-2:15pm DATE: 10-6-22 AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: • Vice President of Residential Services • Director of Residential services • Brewster Cottage Program Manager • Marcy Cottage Program Manager • PRTF program Psychiatrist • Vice President of Clinical Services • Medical APRN Areas / Topics covered during visit: This was an unannounced Licensing visit to tour the PRTF cottages and obtain an update on the PRTF program. Topics discussed: • Admissions re-opened for the PRTF program earlier this week after follow-up visit from DPH and accepted corrective action plan • Current census = 11 (7 males, 4 females) after two females discharged this week • Anticipated admission scheduled for 10-11-22 • Physical plant tour of Brewster, Heaton, and Marcy cottages, as well as Clinic. Cottages contained seasonal décor. Areas in some boys' bedrooms in need of touch-up painting. • Scheduled summer/fall events (Fall Carnival, Family Day, acrobat show, football camp, musician classes, cottage bake-off, cottage decoration contest, haircare/barber classes, talent show, etc.) • Recreation activities no longer held in the community since Summer 2022 • Emergency Safety Manager office/Onsite supervisor office moved to the Clinic • Meal delivery continues to the cottages; lunch only served in dining hall on school days for PRTF clients; ensuring food safety for meals delivered to cottages • Numerous dry goods not stored in sealed containers in Marcy cottage, and Brewster/Heaton rear kitchen • Condition of cottage bathroom shower curtains; deteriorated condition of bathroom stalls in boys' cottages • Additional storage needed in some bedrooms • New TV purchased for Heaton cottage • New 'welcome room' in Marcy cottage for new admissions • CCOH purchased a pizza truck for weekly pizza day; offers vocational opportunities for some students • Weekly outdoor co-ed rec activities on campus • Weekly movie nights in Cafeteria • Renovations to Marcy bathroom to reduce ligature risk areas • Deteriorated fence in Marcy cottage backyard • Brief meeting with PRTF Leadership team • New PRTF Psychiatrist began duties in August 2022 • Part-time Psychiatric APRN hired in October for EDT & OPCC programs Corrective Actions implemented as a result of previous visit: N/A Areas of regulatory non-compliance identified during this visit: 17a-145-76 Kitchen, Equipment, Food-Handling • A refrigerator/freezer in Heaton cottage does not contain thermometers to ensure proper temperatures are maintained. • Disposable dishes were not stored in a manner to prevent contamination in Brewster cottage. • Perishable food from the breakfast meal was observed on a dining table in Brewster cottage, which does not contain a refrigerator. • Numerous dry goods in the Marcy, Brewster and Heaton cottages are not stored in a manner to prevent contamination. Please submit a service development plan to address the above referenced areas of non-compliance within 30 days of receipt of this report. The service development plan must be submitted to the attention of the undersigned at the address listed above. Kathleen Forsythe, LCSW Date: 10-7-22 Regulatory Consultant A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM Cc: VP of Residential Services|5753+++07/21/2022+++Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: The Children's Center of Hamden, Inc. - START Program TIME OF VISIT (FROM - TO): 10:00am - 2:15pm DATE: 7-21-22 AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: Chief Development and Engagement Officer Vice President of Residential Services HR Director Lifeguard WJ Several clients List of Areas / Topics covered during visit: This was a scheduled visit to conduct a semi-annual personnel file review and to tour the PRTF cottages. • Twenty-one (21) personnel files were reviewed of PRTF staff hired since January 2022. • Physical plant tour of the Marcy, Brewster, and Heaton cottages: areas appeared clean and organized • Milieu observation in three cottages • Client interviews • Physical plant tour of the campus swimming pool and interview with Lifeguard on duty re: client swim testing, pool water testing, safety equipment, certifications, staff supervision locations in pool area, availability of drinking water and phone, security of pump house, etc. • Meeting with Chief Development and Engagement Officer. Topics discuss: o Beacon Healthcare providing consultation resources for the PRTF program effective this month o New psychiatrist to start full time in August 2022 o VP of Clinical Services filled by existing employee o All PRTF Clinician positions are filled; VP of Clinical Services covering the Clinical Director position o Program Manager assignments/locations in three PRTF cottages o Random weekly audits of orientation checklists and supervision notes for skills assessments of new employees o Monthly 'Direct Care Worker 101' trainings o Revised competency assessments for probationary employees o Waiting on the 2567 report from DPH from Spring 2022 recertification process o Off campus trip client supervision ratios (1:3); licensed clinicians make determination for client eligibility for off campus rec trips o Group sessions held in cottages with clients by nursing staff to discuss neurological protocol for head injuries o Use of two temp agency RN's o Clinicians providing education for residential managers Corrective Actions implemented as a result of previous visit: N/A Areas of regulatory non-compliance identified during this visit: None. Kathleen Forsythe, LCSW DATE: 7-25-22 Regulatory Consultant A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM Cc: VP of Residential Services Chief Development and Engagement Officer|5708+++06/06/2022+++Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: The Children's Center of Hamden, Inc. - START/PRTF program TIME OF VISIT (FROM - TO): 1:30pm-4:00pm DATE: 6-6-22 AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: Chief Executive Officer Chief Operations Officer Vice President of Residential Services Director of Residential Services Vice President of Clinical Services Quality Assurance/Compliance Coordinator Lead Environmental Safety Manager/Lifeguard DCF Regulatory Consultant List of Areas / Topics covered during visit: This was an unannounced visit to tour the physical plant of the PRTF cottages and swimming pool area, and, to meet the new CEO. • Meeting with new CEO & COO • Recent IJ report • Consolidation of cottages • Census: 19 residents • Admissions status • Cottage physical plant tour with Residential & Clinical Management, and QA • Milieu observation in three PRTF cottages; conversations with residents • Food Services discussion with VP of Residential Services • Physical Plant tour of campus swimming pool o Pool shed o Lifeguard and CPR certifications o Town of Hamden pool inspection certificate o Safety signage o Lifesaving equipment o Cell phone and two-way radio o Swim test logs o Pool water testing logs o Drinking water availability in pool area Corrective Actions implemented as a result of previous visit: Not applicable Areas of regulatory non-compliance identified during this visit: None. Kathleen Forsythe, LCSW Date: 6-9-22 _______________________ Regulatory Consultant A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM Cc: COO VP, Residential Services|5701+++05/18/2022+++Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: The Children's Center of Hamden Inc. - START/PRTF Program TIME OF VISIT (FROM - TO): 1:25pm - 3:40pm DATE: 5-18-22 AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: Vice President of Clinical Services Residential Director Direct Care Workers - 5 Clients - 10 (8 males, 2 females) Nurse, LPN Vice President of Residential Services Interim CEO Supervisor/Trainer Compliance/Quality Assurance Coordinator List of Areas / Topics covered during visit: This was an unannounced visit to observe the milieu and interview clients. • COVID testing and safety protocols • Emergency exit testing • Meal service • Milieu observation • Update on DPH activities • Physical plant tour of living units (Kids Cottage, Care, Brewster, Heaton cottages) Corrective Actions implemented as a result of previous visit: N/A Areas of regulatory non-compliance identified during this visit: None. Kathleen Forsythe, LCSW 5-19-22 ______________________________ _________________ Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM Cc: VP, Residential Services Interim CEO|5695+++05/13/2022+++ Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: The Children's Center of Hamden, Inc. - START (PRTF) Program TIME OF VISIT (FROM - TO): 1:00pm - 5:30pm DATE: 5-13-22 AGENCY PERSONNEL WHO PARTICIPATED: Job Title: CFO/ Interim CEO team Executive Office Manager Senior Director of Clinical Services Female clients (4) Male client (1) Areas / Topics covered during visit: This was an unannounced Licensing visit to interview DCF-involved clients. • Staff training activities this week • DPH corrective action plan • Revised EPR policy and form • Revised Incident policy and form • Incident tracking by Executive Office Manager • COVID testing, protocols, etc. • Client interviews Corrections implemented as a result of previous visit: N/A Areas of regulatory non-compliance identified during this visit: None. Kathleen Forsythe, LCSW 5-16-22 ______________________________ _________________ Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM cc: VP, Residential Services Interim CEO|5655+++03/15/2022+++Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: The Children's Center of Hamden, Inc. - PRTF/START program TIME OF VISIT (FROM - TO): 11:30am-1:30pm DATE: 3-15-22 AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: Vice President, Residential Services Vice President, Clinical Services Clinic Director/APRN Nursing Supervisor Director of Compliance, Safety & Quality Improvement Chief Development Officer Interim CEO Director of Human Resources List of Areas / Topics covered during visit: • Unannounced visit • Tour of physical plant (Brewster, Heaton & Marcy cottages) • Carpeting in client bedrooms slated for replacement • Tour of Clinic • Residential management restructuring of personnel, promotions, etc. • Census • Staff vacancies, use of perdiem clinicians from other CCOH programs • Search activities for open CEO position • Staff appreciation activities • Current emergency physical intervention program • Moving Program Managers, Campus Supervisor, & Brewster/Heaton case manager offices into cottages • Expansion of Dining Hall hours in April • Psychiatrist search activities • Temporary division of CEO duties among three administrators • Reported full compliance with Dept. of Public Health Corrective Actions implemented as a result of previous visit: None. Areas of regulatory non-compliance identified during this visit: None. Katheen Forsythe 3-15-22 ______________________________ _________________ Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM Cc: VP, Residential Services|

5937+++05/31/2023+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: The Village for Families and Children / Eagle House TIME OF VISIT (FROM - TO): 10:00 am to 11:30 am DATE: May 31, 2023 AGENCY PERSONNEL WHO PARTICIPATED: Eagle House Senior Program Director List of Areas / Topics covered during visit: • Discussion of the current census; there are 21 residents, and the LBC is 28. • Discussion of Eagle House's current staffing levels, vacant positions, and hiring activities. • Discussion of Eagle House's milieu, the clinical programming, and activities for the residents. • Discussion of recent incidents and behavior trends. • Inspection of the Eagle House physical plant to assess the cleanliness of the buildings, as well as to ensure there are no health or safety concerns. Corrective Actions implemented as a result of previous visit: Not applicable Areas of regulatory non-compliance identified during this visit: None at the time of this quarterly visit. Patrick Hughes 5/31/23 Regulatory Consultant Date|5907+++03/28/2023+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: The Village for Families and Children / Eagle House TIME OF VISIT (FROM - TO): 10:00 am to 11:30 am DATE: March 28, 2023 AGENCY PERSONNEL WHO PARTICIPATED: Eagle House Senior Program Director List of Areas / Topics covered during visit: • Discussion of the current census; there are 20 residents, and the LBC is 28. • Discussion of Eagle House's current staffing levels, vacant positions, and hiring activities. • Discussion of Eagle House's milieu, the clinical programming, and activities for the residents. • Observations of the Eagle House residents and observations of the interactions between Eagle House staff and the Eagle House residents. • Inspection of the Eagle House physical plant to assess the cleanliness of the home, as well as to ensure there are no health or safety concerns. Corrective Actions implemented as a result of previous visit: Not applicable Areas of regulatory non-compliance identified during this visit: None at the time of this quarterly visit. Patrick Hughes Regulatory Consultant Date 3/28/23|5894+++12/19/2022+++505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: The Village for Families and Children / Eagle House TIME OF VISIT (FROM - TO): 10:00 am DATE: December 19, 2022 AGENCY PERSONNEL WHO PARTICIPATED: Eagle House Program Director List of Areas / Topics covered during visit: Census The current census for Eagle House is 20 and the licensed bed capacity is 28. One resident is currently hospitalized but is expected to return soon. Eagle House has seen a slowdown in referrals as of late. Discussion of the residents' progress in the program and the program's milieu. The residents are doing well at Eagle House with incidents and physical holds having decreased over the last few months. Most of the Eagle residents will visit home on Christmas either for the day or overnight. There are several residents that are on discharge delay due to adoption disruptions, unstable housing for some families. During the quarterly visit this regulatory consultant had planned to walk through the school building to observe the school day in progress. As this regulatory consultant approached the entrance there was a student in crisis at the entrance. The student was being supported by staff and the staff were attempting to deescalate the situation. As a result of the situation at the entrance this regulatory consultant opted to forego the school walk through until the next quarterly visit. Discussion of current staffing levels and hiring of vacant positions. Eagle House has created a clinical case manager position who will be responsible for insurance approvals, authorizations, and commercial insurance approvals. There is a large group of Eagle House new hires that will start on January 9th. There are still vacant direct care positions, mostly for 1st shift and weekend positions. The Village is offering bonuses for weekend shift positions. Eagle House can fill any vacant shifts with the use of per-diem staff, supervisors, and overtime for current workers. Physical plant inspection of the facility. All areas of the program were clean and organized with no health or safety concerns observed. Corrective Actions implemented as a result of previous visit: Not applicable Areas of regulatory non-compliance identified during this visit: None at the time of this quarterly visit. Patrick Hughes 2/23/2023 Regulatory Consultant Date|5799+++09/15/2022+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: The Village for Families and Children / Eagle House TIME OF VISIT (FROM - TO): 2:00 pm DATE: September 15, 2022 AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title JT Eagle House Program Director List of Areas / Topics covered during visit: The current census for Eagle House is 21 and the licensed bed capacity is 28. There have been several recent discharges at Eagle House. There has been a slow down in referrals as of late, and there has been a shift in referrals with an increase of the number of referrals for 11- and 12-year-olds. Discussion of the residents' progress in the program and the program's milieu. The residents are doing well at Eagle House with incidents and physical holds having decreased over the last few months. The Eagle House residents are assigned into groups of 6 for treatment and activities. There are volunteers working on beautification projects at Eagle House painting murals and making the environment more child friendly. Discussion of current staffing levels and hiring of vacant positions. Eagle House has hired a Milieu Operations Director, who is responsible for overseeing and supervising the Eagle House supervisors. There is also a Milieu Administrator to be filled. This position will be responsible for equipment, environmental safety, payroll and documentation, and safety checks. There are some current vacancies for full time and part time staff. Eagle House can fill any vacant shifts with per-diem staff. Physical plant inspection of the facility. All areas of the program were clean and organized with no health or safety concerns observed. New items have been added to the residents' game room. Construction of permanent fencing around the campus will begin in spring of 2023. Corrective Actions implemented as a result of previous visit: Not applicable Areas of regulatory non-compliance identified during this visit: None at the time of this quarterly visit. Patrick Hughes 10/28/2022 Regulatory Consultant Date|5772+++08/24/2022+++August 24, 2022 Gallo A. Rodriquez, Executive Director Village for Families and Children 1680 Albany Avenue Hartford, CT 06105 RE: CCF/RT-44 Eagle House Dear Mr. Rodriguez, On August 23, 2022 we received your agency's service development plan. The plan submitted by you addresses the areas of non-compliance identified in the inspection report. This inspection included the Regulations for Operation of Child-Caring Agencies and Facilities 17a-145-48 through 17a-145-98, the Psychiatric Residential Treatment Facilities Guidelines and the DCF Guidelines for the Administration of Medication by Certified Staff. The Department accepts the plan of correction and has determined that your agency has met the requirements for a regular license. This license is effective as of August 1, 2022 and is valid for twenty-four months. We thank you and your staff for your cooperative participation in the review process. Sincerely, Patrick Hughes Patrick Hughes Department of Children and Families 505 Hudson Street Hartford, CT 06106 (p) 860-550-6552 (f) 860-550-6665 patrick.hughes@ct.gov|5771+++06/22/2022+++July 22, 2022 Gallo A. Rodriquez, Executive Director Village for Families and Children 1680 Albany Avenue Hartford, CT 06105 RE: CCF/RT-44 Eagle House Dear Mr. Rodriguez, On June 22nd and June 23rd, 2022, a biennial licensing inspection was conducted at your facility. This inspection was conducted to determine the compliance of this facility with the Regulations for Operation of Child-Caring Agencies and Facilities 17a-145-48 through 17a-145-98, the Psychiatric Residential Treatment Facilities Guidelines, and the DCF Guidelines for the Administration of Medication by Certified Staff. Please review the areas of non-compliance identified on the enclosed Service Development Plans (part 1 and part 2) and submit your responses on the enclosed Service Development Plans to address each area. The plan must be submitted within 30 days of receipt of this letter and should identify: 1. the steps to be taken to correct the non-compliance; and 2. the date the correction(s) will be completed. The areas of non-compliance are listed on the attached DCF Licensing Service Development Plan. Once the Licensing Unit has reviewed and accepted the Service Development Plan and has determined that your agency is in compliance with the regulations, a decision on the issuance of a regular twenty-four-month license for the program will be made. Until DCF makes this decision, the current license will remain in effect. Sincerely, Patrick Hughes Patrick Hughes DCF Licensing Unit 860-550-6552 860-716-2199 (cell) patrick.hughes@ct.gov DCF LICENSING UNIT INSPECTION REPORT Date of Licensing Visit: June 22nd & 23rd , 2022 Date Licensing Report Received by Facility: 7/25/22 License Type: CCF License No. #: CCF # 44 Date Service Development Plan Submitted to Licensing Unit: Corporate Name: Village for Families and Children Corporate Address: 1680 Albany Avenue, Hartford, CT Program Name: Eagle House Program Address: 1680 Albany Avenue, Hartford, CT Person Submitting Plan (Name and Title): Person Approving Plan (Name and Title): Date: Regulations for the Operation of Child-Caring Agencies and Facilities Statute/ Licensing Regulation # Non-Compliance Citation Plan of Correction/Service Development Plan A System to Prevent Re-Occurrence Completion Date Title Responsible to Monitor Plan 17a-145-73 Sleeping Accommodations Brainard Building. Bedroom # 5's Window Frame is bent which prevents the window from completely closing. Brainard Building. The Bedroom Hallway Flooring is peeling, has divots and has a missing piece of planking. A plan with a time frame to repair the flooring needs to be developed. Brainard Building The bedroom Hallway Exit Door has a crack in the window. DCF LICENSING UNIT INSPECTION REPORT Date of Licensing Visit: June 22 & 23, 2022 Date Licensing Report Received by Facility: 7/25/22 License Type: CCF License No. #: CCF #44 Date Service Development Plan Submitted to Licensing Unit: 8.23.2022 Corporate Name: Village for Families and Children Corporate Address: 1680 Albany Avenue, Hartford, CT Program Name: Eagle House Program Address: 1680 Albany Avenue, Hartford, CT Person Submitting Plan (Name and Title): Jennifer Timreck, LCSW, Senior Program Director Person Approving Plan (Name and Title): Hector Glenn, MSW Chief Operating Officer Date: 8.23.2022 Psychiatric Residential Treatment Facilities Guidelines Statute/ Licensing Regulation # Non-Compliance Citation Plan of Correction/Service Development Plan A System to Prevent Re-Occurrence Completion Date Title Responsible to Monitor Plan 42 CFR 483.358 Orders for the Use of Restraint or Seclusion 42 CFR 483.370 Post-Intervention Debriefings 42 CFR 483.360 Consultation with Treatment Team Physician # 13 Two case records reviewed had an order for physical restraint that was not signed by the ordering physician. # 15 One case record reviewed had an order for physical restraint that was not signed in a timely manner by the ordering physician. One case record contained a physical restraint in which the staff debriefing occurred more than 24 hours after the restraint. One case record contained one physical restraint where the consultation between the ordering licensed practitioner and the treatment team physician did not occur. This was a technical issue in the Carelogic system. The hold orders were being routed to the medical provider Andrea Cronin, APRN however the system was routing the hold order automatically to another person for both of these cases. The issue was reported to IT/Carelogic on 6/21/22 and has been rectified. Policy will be updated with the following: Hold orders will be signed by the MD as soon as possible, preferably within 24 hours, but no later than 3 days. Staff retraining on policy and procedure for staff debriefing in July- August 2022 staff meeting. Medical Director will re-educate medical providers on required documentation for consultation. The issue was reported to IT/Carelogic on 6/21/22 and has been rectified. Periodic sample reviews of hold orders. Policy review and reminders at staff meeting. Weekly reports of missing staff debrief forms are pulled directly from the electronic health record and reviewed by supervisors. Medical Director will develop a checklist for ordering practitioners to use when ordering holds. Completed 6/21/2022 8/24/22 8/24/22 8/31/22 Jennifer Timreck, LCSW Laine Taylor, D.O., M.B.A Jennifer Timreck, LCSW Laine Taylor, D.O., M.B.A|5669+++03/22/2022+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: The Village for Families and Children; Eagle House TIME OF VISIT (FROM - TO): 9:00 am DATE: March 22, 2022 AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title JT Eagle House Program Director List of Areas / Topics covered during visit: • The current census for Eagle House is 21 and the licensed bed capacity is 28. There is a scheduled admission for today. • Discussion of the residents' progress in the program and the program's milieu. Incidents and physical holds have decreased over the last few months. • Discussion of current staffing levels and hiring for vacant positions. All the clinical vacancies have been filled, there are some vacant direct care positions and a supervisor position has been filled. At times Eagle House has needed to use some per-diem staff from outside agencies. Eagle House has a new initiative to increase the collaboration between the Eagle House disciplines (residential, nursing, clinical). • Physical plant inspection of the facility; no health or safety concerns observed. Construction of permanent fencing around the campus will begin soon. • Observation of the residents participating in their daily programming. Residents were in school during this quarterly visit. The school building was quiet and calm, and residents were engaged in their schoolwork. Corrective Actions implemented as a result of previous visit: • Not applicable Areas of regulatory non-compliance identified during this visit: • None at the time of this quarterly visit. Patrick Hughes 3/28/2022 Regulatory Consultant Date|

 

 

 

 

5963+++07/18/2023+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY/PROGRAM: CT Clinical Services d/b/a Turnbridge Residential Treatment Program -Woodside Circle, Woodbury, CT TIME OF VISIT (FROM - TO): 9:30am-12:00pm DATE: 7-18-23 AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: • Operations Director • Clinical Director • Chef • Clients List of Areas / Topics covered during visit: This was a scheduled quarterly Licensing visit to tour the physical plant and obtain a program update. A meeting was held with the Clinical Director and Director of Operations. Topics discussed included: • Census: 11 males. Program is full. • Staffing vacancies: 0. One full time vacancy anticipated. • Family visitation schedule on Tuesday and Thursdays. • Client incidents during the quarter (calls for EMS). • Recreation: On campus activities, swimming pool, ROPES course. • New building on campus scheduled to open next week. Contains education rooms, gym, and offices. • Full time contracted house cleaner; additional part time cleaner to be hired in near future. • Review of Lifeguard certifications for six (6) Lifeguards on Turnbridge staff. • Client search and drug testing procedures. • Laundry procedures. • Client intake procedures and physical exams; waitlist, average length of stay • Staff/Client ratio during visit: 1:3 • One agency vehicle available shared with another program on campus. Physical Plant: Staff facilitated a tour of the physical plant. • All areas appeared generally clean and organized. Home is beautifully decorated. • Minor damage to couch, coffee table, dining chair and several window blinds observed. • Review of safety equipment at outdoor swimming pool. • Fire safety protocol discussed for outdoor fireplace. Milieu Observation: Group therapy; break time; lunch time; new admission tour by peer and staff. Client Interviews: One client was interviewed. No concerns reported. Client feels program is helpful. Semiannual Personnel File Review: A personnel file review was conducted prior to the visit. See Areas of Regulatory Non-compliance below. Corrective Actions implemented as a result of previous visit: N/A Areas of regulatory non-compliance identified during this visit: 17a-145-22 Personnel Policies and Procedures. Five personnel files were reviewed for the home at Woodside Circle. The following deficiencies were noted: • Documentation of a physical exam and TB testing results were not completed immediately prior to hire in four files (TR, SM, JS, AS). • One file (SM) does not contain evidence of a criminal history background check conducted through the CT State Police. Additionally, two files (TJ, JR) contain evidence that the criminal history background check through the CT State Police was conducted more than four months after hire. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Kathleen Forsythe, LCSW Date: 7-19-23 Regulatory Consultant A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM Cc: Clinical Director Operations Director|5913+++04/13/2023+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY/PROGRAM: CT Clinical Services d/b/a Turnbridge Residential Treatment Program -Woodside Circle, Woodbury, CT TIME OF VISIT (FROM - TO): 10:30a-1:00pm DATE: 4-13-23 AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: Clinical Director Director of Operations Clients (2) Director of Culinary Services List of Areas / Topics covered during visit: This was a scheduled quarterly Licensing visit to obtain an update on the program and to tour the physical plant. ? A meeting was held with the Director of Operations and the Clinical Director. Topics discussed included: • Census = 11 males - Program is full. • No nursing or direct care staff vacancies; additional Educational Coordinator recently hired • Behavior management systems; reward system • Lifeguards, pool safety equipment, client swim tests • New gymnasium/school building on campus - construction to be completed next month • EMS visits in the past quarter • Case record review conducted remotely on 4-12-23 • Swimming pool company onsite during visit to inspect the pool and prepare for seasonal opening • Improvements to the physical plant • ROPES course, recreation activities ? Meeting held with Culinary Services Director. Topics discussed: weekly menu cycle and approval, food allergy accommodations, food purchase and storage, soliciting client input on menus. ? Milieu Observation: Lunch prep, lunch and interviews with two clients - Positive feedback from residents interviewed re: staff, clinical services, food, recreation. ? Physical Plant tour: Graffiti observed on closet door in a client bedroom; recent repairs to walls in some bedrooms. Corrective Actions implemented as a result of previous visit: N/A Areas of regulatory non-compliance identified during this visit: None. Please submit a service development plan to address the above referenced areas of non-compliance within 30 days of receipt of this report. The service development plan must be submitted to the attention of the undersigned at the address listed above.- A Service Development Plan is not required for this Licensing visit. Kathleen Forsythe, LCSW Date: 4-14-23 Regulatory Consultant A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM. Cc: File|5847+++01/18/2023+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY/PROGRAM: CT Clinical Services d/b/a Turnbridge Residential Treatment Program -Woodside Circle, Woodbury, CT TIME OF VISIT (FROM - TO): 11:45a-2:00p DATE: 1-18-23 AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: Clinical Director Director of Operations Clients (3) APRN List of Areas / Topics covered during visit: This was an unannounced quarterly Licensing visit to obtain an update on the program and to tour the physical plant. ? A meeting was held with the Director of Operations and the Clinical Director. Topics discussed included: • Census = 11 • Average length of stay • Discharge and admission scheduled this date • Client incidents for the past quarter • No staff vacancies • Staff/client supervision ratios • Clinical team • Weather-related power outage in December; Generator activated • Education programming for residents • Family visits • Holiday activities; On-campus recreation/leisure activities • New gymnasium/school building under construction • APRN serving as program Nursing Director • One agency vehicle shared with another program on campus • Menu planning • Laundry schedule • Search policy • Headcount policy ? Milieu Observation: lunch, free time, basketball game ? Physical Plant tour of first and second floors; numerous beds unmade; graffiti observed on dining tables and door in a client bedroom. ? Client interviews: Positive feedback from residents interviewed on all aspects of the program. Corrective Actions implemented as a result of previous visit: • A service development plan was submitted to DCF by Turnbridge Woodside Circle program following a December 2022 Licensing review that addressed regulatory citations in relation to personnel files. The plan was accepted by the Department. Areas of regulatory non-compliance identified during this visit: None. Kathleen Forsythe, LCSW Date: 1-19-23 Regulatory Consultant A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM Cc: Executive Vice President File|5837+++12/12/2022+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY/PROGRAM: CT Clinical Services d/b/a Turnbridge Residential Treatment Program -Woodside Circle, Woodbury, CT TIME OF VISIT (FROM - TO): morning DATE: 12-12-22 AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: Executive Vice President List of Areas / Topics covered during visit: This was a scheduled semiannual personnel file review of staff hired since July 2022. The review was conducted remotely. Four personnel files were reviewed. Corrective Actions implemented as a result of previous visit: N/A Areas of regulatory non-compliance identified during this visit: 17a-145-64 Personnel Policies and Procedures. • One personnel file (CH) did not contain evidence of the employee receiving a physical exam immediately prior to assuming assigned duties. • One personnel file (JM) contained evidence of a physical exam obtained 7.5 months prior to hire rather than immediately prior to assuming assigned duties. Please submit a service development to address the above referenced areas of non-compliance within 30 days of receipt of this report. The service development plan must be submitted to the attention of the undersigned at the address listed above. Kathleen Forsythe, LCSW Date: 12-14-22 Regulatory Consultant A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM Cc: Executive Vice President File|5802+++10/26/2022+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: CT Clinical Services d/b/a Turnbridge - Woodside Circle, Woodbury RTC Program TIME OF VISIT (FROM - TO): 10:30am-1:00pm DATE: 10-26-22 AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: • Clinical Director • Director of Operations • Clients List of Areas / Topics covered during visit: This was a scheduled quarterly Licensing visit to tour the physical plant, obtain an update on the program since the relicensing inspection conducted in July 2022, and to follow up on a complaint forwarded to DCF from DPH. Discussion included: • Census = 11 males. The program is full. • Staffing: Discussed staff to client ratios, staffing schedule, staffing vacancies (none), client supervision procedures including bed checks, staff stations on the overnight shift, camera monitoring, 24-hour nursing coverage. Clinical staff include four therapists, a Clinical Director, and a discharge planner. • Program: Discussed the client daily schedule/routine. Discussed with program management client incidents since the last Licensing visit which included eight incidents of elopement, five incidents of police involvement, and seven incidents of seeking medical care in the community. • Discussed complaint filed with DPH from a former resident's family, which was forwarded to the DCF Licensing unit on 10-25-22. • Reviewed recreation schedules for August 2022 through October 2022. Staff reported recreation activities are all conducted on campus. In addition to physical daily recreation/leisure activities with an emphasis on team building (i.e., lawn games, kickball, whiffle ball, flag football, basketball, soccer, hiking, ROPES course, circuit training, swimming, etc.), special events held on site this summer included a video game truck, laser tag company, dunk tank, scavenger hunt, and outdoor movie screening. • Reviewed group therapy schedule. Staff reported that group therapy is held minimally four times per week and includes CBT, DBT, ACT, etc. Family therapy and individual therapy sessions are held weekly. • Reviewed program intake paperwork packet. • Case record review of former resident involved in complaint to DPH will be conducted by DCF Licensing. • Discussed with program management staff client use of telephone, search procedures, and client grievance procedures. • Client interviews were conducted. • Food Services: Food storage was discussed. The current 6-week menu cycle was reviewed. Discussion on menu approval process. Client interviews included discussion of food served. • Physical plant tour: All areas of the Woodside Circle home appeared clean, organized, attractive and decorated for the season. All bedrooms contain televisions. The outdoor heated swimming pool was observed covered for the winter and staff reported that the pool closed for the season the day before this visit. Discussed enhancing infection control procedures in shared bathrooms by storing personal objects outside of shower stalls. Breakaway closet rods are scheduled for installation. Discussed enhancing client privacy in a bedroom that contains two private bathrooms, one of which is utilized by clients from another bedroom. Small repairs to walls in some areas need painting. Personnel and equipment from a construction company were observed on the campus and staff reported that Turnbridge is building a fitness center with office space. • Milieu observation included lunch, fitness, academic time, basketball, and hiking. Corrective Actions implemented as a result of previous visit: A service development plan to address regulatory deficiencies noting during the relicensing inspection was accepted by the Department and a renewed license was issued in August 2022. Areas of regulatory non-compliance identified during this visit: No regulatory deficiencies were noted during this visit. Kathleen Forsythe, LCSW Date: 10-31-22 Regulatory Consultant A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM Cc: Executive Vice President Clinical Director Director of Operations|5773+++07/19/2022+++July 25, 2022 Dr. Christopher Cutter, PhD. Executive Director -Turnbridge Adolescent Programs CT Clinical Services, Inc. 189 Orange Street New Haven, CT 06510 Re: Turnbridge Woodside Circle, Woodbury Boys group home License #: CCF/GH #169 Regulatory Consultants: Kathleen Forsythe & Terri Bohara Dear Dr. Cutter, On July 19-20, 2022, a biennial re-licensing inspection was conducted for the Turnbridge boys group home, located at 15 Woodside Circle, Woodbury, CT. This inspection was conducted to determine the compliance of this program with the Regulations of the Connecticut Department of Children and Families Operation of Child-Caring Agencies and Facilities Regulations 17a-145-48 through 17a-145-124. Additionally, an onsite review was conducted by DCF Nurse Consultant Anna Cherian, RN, MSN, FNP-BC on 6-28-22 to determine the program’s compliance with the DCF Medication Administration Guidelines and the DCF Nursing Standards. A copy of the nursing review site visit summary report is included with this report. Listed below are the areas of DCF regulatory non-compliance which were identified during the re-licensing inspection. Please review the areas identified and complete a service development plan (SDP) to address each area of noncompliance. The completed service development plan and applicable supporting documentation must be submitted to the assigned Regulatory Consultant within 30 days of receipt of this emailed report. The areas of regulatory noncompliance are as follows: 17a-145-64 Personnel Policies and Procedures. A review of documentation in ten (10) personnel files identified the following deficiencies: • Nine files did not contain evidence that the employee received a physical examination immediately prior to assuming duties (TrG, TeG, NG, AH, CK, DL, FM, SS, SA,). • One file contained evidence of a physical examination that was obtained eleven months after the hire date rather than immediately prior to hire (KM). • One file contained evidence of TB testing results that were obtained eleven months after the hire date rather than immediately prior to hire (KM). • Evidence of current CPR training was missing in two files (NG, CK). 17a-145-66 Health, Sanitation, Fire Safety, and Zoning Approval. Evidence of a local health inspection report for the license renewal was not provided with application materials. 17a-145-67 Water Supply. Sewage and Garbage Facilities. Evidence of a current well water inspection report indicating the water is safe was not found in relicensing application materials. 17a-145-75 Health and Medical Treatment. Administration of First Aid. Prescription Medication. Administration of Medicine or Treatment. Written Records. Storage of Drugs, medicines, and Instruments. Sick Room, Telephone. 17a-6(g)-15(a-g) DCF Medication Administration. d) Based on a DCF nursing review, it was determined that: • the facility failed to provide quarterly training to all medication certified staff • the facility failed to provide annual skills checks for two medication certified staff members (JB, SA). f) Medication cabinets were found to contain internal and external medications stored together rather than separately. 17a-145-86 Instructions in Safety Procedures. Supervision. Based on a review of fire drill evacuation records for the Woodside Circle group home for the licensed period, it was found that the facility did not have documentation of fire drills as follows: • 2020: 2nd shift, 3rd and 4th quarters 3rd shift, 3rd quarter • 2021: 2nd shift: 1st, 2nd & 4th quarters 3rd shift: 2nd & 4th quarters • 2022: 2nd shift: 2nd quarter 3rd shift: 1st & 2nd quarters 17a-145-93 Medical, Dental, Nursing Care. Based on a DCF nursing review, it was determined that one client record (EJ) did not contain evidence of an immunization record, as well as the results of a dental hygiene exam. 814e - Physical Restraint, Medication & Seclusion of Persons Receiving Care, Education or Supervision in an Institution or Facility: 46a-154 Internal Monitoring, Training and Development of Policies and Procedures Required and Subject to State Agency Inspection. • Written policy on seclusion was not provided for review. • Written policy addressing restraint does not include all elements listed in the statute. ********************************************************************************************* Once the Licensing Unit has reviewed and accepted the service development plan and has determined that your agency is in compliance with the regulations, a decision on the issuance of a regular twenty-four month license for the program will be made. Until DCF makes this decision, the current license will remain in effect. Should you have any questions or comments regarding the contents of this report please do not hesitate to contact me at (860) 937-7551. Sincerely, Kathleen Forsythe _________________________ Kathleen Forsythe, LCSW Regulatory Consultant Cc: Executive Vice President|

5962+++07/18/2023+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY/PROGRAM: CT Clinical Services d/b/a Turnbridge Residential Treatment Program -Washington Rd., Woodbury, CT TIME OF VISIT (FROM - TO): 12:00pm-1:00pm DATE: 7-18-23 AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: • Operations Director • Clinical Director • Chef • Clients List of Areas / Topics covered during visit: This was a scheduled quarterly Licensing visit to tour the physical plant and obtain a program update. A meeting was held with the Clinical Director and Director of Operations. Topics discussed included: • Census: 7 males. Program is full. • Staffing vacancies: 0. • Family visitation schedule on Tuesday and Thursdays. • Client incidents during the quarter. • Recreation: On campus activities, swimming pool, ROPES course. • New building on campus scheduled to open next week. Contains education rooms, gym, and offices. • Review of Lifeguard certifications for six (6) Lifeguards on Turnbridge staff. • Client search and drug testing procedures. • Laundry procedures. • Client intake procedures and physical exams; waitlist, average length of stay • Staff/Client ratio during visit: 1:3 • One agency vehicle available shared with another program on campus. • Storage of linens in basement. • Client haircut procedures. Physical Plant: Staff facilitated a tour of the physical plant. • All areas appeared generally clean and organized. Home is beautifully decorated. • Address bird droppings on front porch and damage to couch. • Fire safety protocol discussed for outdoor firepit. • Food storage. Milieu Observation: Clients from Washington Road home attend day programming at Turnbridge program at Woodside Circle on campus. Observation included group therapy; break time; lunch time; new admission tour by peer and staff. Client Interviews: Two clients were interviewed. Clients report program is helpful. Semiannual Personnel File Review: A personnel file review was conducted prior to the visit. See Areas of Regulatory Non-compliance below. Corrective Actions implemented as a result of previous visit: N/A Areas of Regulatory Non-compliance identified during this visit: • Five personnel files were reviewed for the home at Washington Road. The following deficiencies were noted: 17a-151. Investigation. Issuance of license or provisional license. Revocation, suspension or limitation of license. Appeal. - Evidence was not found in three personnel files (PM, KM, TD) of a completed check of the child abuse and neglect registry in any state in which such person or individual resided in the preceding five years. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Kathleen Forsythe, LCSW Date: 7-19-23 Regulatory Consultant A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM Cc: Clinical Director Operations Director|5912+++04/13/2023+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY/PROGRAM: CT Clinical Services d/b/a Turnbridge Residential Treatment Program -Washington Rd., Woodbury, CT TIME OF VISIT (FROM - TO): 1:00pm-2:30pm DATE: 4-13-23 AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: Clinical Director Director of Operations Client (1) Director of Culinary Services List of Areas / Topics covered during visit: This was a scheduled quarterly Licensing visit to obtain an update on the program and to tour the physical plant. ? A meeting was held with the Director of Operations and the Clinical Director. Topics discussed included: • Census = 7 males - Program is full. • No nursing or direct care staff vacancies; additional Educational Coordinator recently hired • Behavior management systems; reward system • Lifeguards, pool safety equipment, client swim tests • New gymnasium/school building on campus - construction to be completed next month • Case record review conducted remotely on 4-12-23 • Swimming pool company observed onsite during visit to inspect the pool at Woodside Circle house on campus to prepare for seasonal opening • ROPES course, recreation activities ? Meeting held with Culinary Services Director. Topics discussed: weekly menu cycle and approval, food allergy accommodations, food purchase and storage, soliciting client input on menus. ? Milieu Observation: Lunch prep, lunch and interview with one client - Positive feedback from resident re: physical plant, staff, clinical services, food, recreation. ? Physical Plant tour: Graffiti and stains observed on walls in one client bedroom; recent repair on bedroom door frame, bird droppings at two exterior porch lights, loose board on porch. Corrective Actions implemented as a result of previous visit: N/A Areas of regulatory non-compliance identified during this visit: None. Please submit a service development plan to address the above referenced areas of non-compliance within 30 days of receipt of this report. The service development plan must be submitted to the attention of the undersigned at the address listed above.- A Service Development Plan is not required for this Licensing visit. Kathleen Forsythe, LCSW Date: 4-14-23 Regulatory Consultant A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM. Cc: File|5846+++01/18/2023+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: CT Clinical Services d/b/a Turnbridge - Residential Treatment Program - Washington Rd., Woodbury, CT TIME OF VISIT (FROM - TO): 11:45am-2:00pm DATE: 1-18-23 AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: Clinical Director Director of Operations Client (1) List of Areas / Topics covered during visit: List of Areas / Topics covered during visit: This was an unannounced quarterly Licensing visit to obtain an update on the program and to tour the physical plant. A meeting was held with the Director of Operations and the Clinical Director. Topics discussed included: • Census = 7 • Average length of stay • Client incidents for the past quarter • No staff vacancies • Staff/client supervision ratios • Clinical team • Education programming for residents • Family visits • Holiday activities; On-campus recreation/leisure activities • New gymnasium/school building under construction on campus • APRN serving as program Nursing Director • One agency vehicle shared with another program on campus • Menu planning • Search policy • Headcount policy Milieu Observation: lunch, free time, basketball game with residents in Woodside and Washington programs Physical Plant tour of first and second floors; First floor lighting discussed. Client interviews: Positive feedback from resident interviewed on all aspects of the program. Corrective Actions implemented as a result of previous visit: • A service development plan was submitted to DCF by Turnbridge Washington Road program following a December 2022 Licensing review that addressed regulatory citations in relation to personnel files. The plan was accepted by the Department. Areas of regulatory non-compliance identified during this visit: None. Kathleen Forsythe, LCSW Date: 1-19-23 Regulatory Consultant A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM Cc: Executive Vice President File|5836+++12/12/2022+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: CT Clinical Services d/b/a Turnbridge - Residential Treatment Program - Washington Rd., Woodbury, CT TIME OF VISIT (FROM - TO): afternoon DATE: 12-12-22 AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: Executive Vice President List of Areas / Topics covered during visit: This was a scheduled semiannual personnel file review of staff hired since July 2022. The review was conducted remotely. Four personnel files were reviewed. Corrective Actions implemented as a result of previous visit: N/A Areas of regulatory non-compliance identified during this visit: 17a-145-64 Personnel Policies and Procedures. • One personnel file (EF) did not contain evidence of the employee receiving a physical exam immediately prior to assuming duties. 17a-145-63 Chief Administrative Officer. • One personnel file (HP) contained evidence that the results of a criminal history background check conducted through the CT State Police is dated after the employee's start date. Please submit a service development plan to address the above referenced areas of non-compliance within 30 days of receipt of this report. The service development plan be submitted to the attention of the undersigned at the address listed above. Kathleen Forsythe, LCSW Date: 12-14-22 Regulatory Consultant A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM Cc: Executive Vice President File|5801+++10/26/2022+++ Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: CT Clinical Services d/b/a Turnbridge - Woodbury Washington Rd. Program TIME OF VISIT (FROM - TO): 1:00p-3:30p DATE: 10-26-22 AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: Director of Operations Clinical Director Clients List of Areas / Topics covered during visit: This was a scheduled quarterly Licensing visit to tour the physical plant, as well as obtain an update on the program since the relicensing inspection conducted in July 2022. Discussion included: • Census = 7 males. The program is full. • Staffing: Staff to client ratios, staffing schedule, staffing vacancies (none), staff supervision procedures including bed checks, staff stations on the overnight shift, camera monitoring, nursing coverage. • Program: The program changed the gender served from females to males on 8-1-22 and an amended license was issued on that date. Discussed the resident daily schedule/routine, which involves attending meals, academics, group therapy and recreation activities with male residents in the other program on the Turnbridge Woodbury campus. Discussed client incidents with program management staff since the last Licensing visit which included two incidents of EMS/police involvement resulting in evaluation at a hospital. Recreation schedules for August through October were reviewed. Client interviews were conducted. • Food Services: Food storage was discussed. A 6-week menu cycle was reviewed. Discussion on menu approval process. Client interviews included discussion of food served. Discussed cleaning procedures for the refrigerator/freezer, as well as an unused refrigerator stored in the basement. • Physical plant tour: All areas of the Washington Road home appeared clean, organized, attractive and decorated for the season. Discussed enhancing infection control procedures in shared bathrooms. Discussion on outdoor fire pit. Breakaway closet rods are scheduled for installation. Discussion on possible installation of handrail at outdoor stone steps. Discussion on dining table seating and basement storage. Livingroom rug and coffee table have been replaced since last Licensing visit. Corrective Actions implemented as a result of previous visit: A service development plan to address regulatory deficiencies noting during the relicensing inspection was accepted by the Department and a renewed license was issued in August 2022. Areas of regulatory non-compliance identified during this visit: No regulatory deficiencies were noted during this visit. Kathleen Forsythe, LCSW Date: 10-28-22 Regulatory Consultant A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM Cc: Executive Vice President Clinical Director Director of Operations|5774+++07/19/2022+++July 25, 2022 Dr. Christopher Cutter, PhD. Executive Director -Turnbridge Adolescent Programs CT Clinical Services, Inc. 189 Orange Street New Haven, CT 06510 Re: Turnbridge Washington Rd, Woodbury Girls group home License #: CCF/GH #170 Regulatory Consultants: Kathleen Forsythe & Terri Bohara Dear Dr. Cutter, On July 19-20, 2022, a biennial re-licensing inspection was conducted for the Turnbridge girls group home, located at 760 Washington Rd., Woodbury, CT. This inspection was conducted to determine the compliance of this program with the Regulations of the Connecticut Department of Children and Families Operation of Child-Caring Agencies and Facilities Regulations 17a-145-48 through 17a-145-124. Additionally, an onsite review was conducted by DCF Nurse Consultant Anna Cherian, RN, MSN, FNP-BC on 6-28-22 to determine the program’s compliance with the DCF Medication Administration Guidelines and the DCF Nursing Standards. A copy of the nursing review site visit summary report is included with this report. Listed below are the areas of DCF regulatory non-compliance which were identified during the re-licensing inspection. Please review the areas identified and complete a service development plan (SDP) to address each area of noncompliance. The completed service development plan and applicable supporting documentation must be submitted to the assigned Regulatory Consultant within 30 days of receipt of this emailed report. The areas of regulatory noncompliance are as follows: 17a-145-64 Personnel Policies and Procedures. A review of personnel files identified the following deficiencies: • Five (5) files did not contain evidence that employee received a physical examination immediately prior to assuming duties (TC, JD, JF, CF, TF). • Evidence of current CPR training was missing in one file (TF). 17a-145-66 Health, Sanitation, Fire Safety, and Zoning Approval. Evidence of a local health inspection report for the license renewal was not provided with relicensing application materials. 17a-145-67 Water Supply. Sewage and Garbage Facilities. Evidence of a current well water inspection report indicating the water is safe was not provided with relicensing application materials. 17a-145-75 Health and Medical Treatment. Administration of First Aid. Prescription Medication. Administration of Medicine or Treatment. Written Records. Storage of Drugs, medicines, and Instruments. Sick Room, Telephone. 17a-6(g)-15(a-g) DCF Medication Administration. D) Based on a DCF nursing review, it was determined that: o the facility failed to provide quarterly training to all medication certified staff. O the facility failed to provide annual skills checks for two medication certified staff members (JB, SA). F) Medication cabinets were found to contain internal and external medications stored together rather than separately. 17a-145-86 Instructions in Safety Procedures. Supervision. Based on a review of fire drill evacuation records for the Washington Road group home for the licensed period, it was found that the facility did not have documentation of fire drills as follows: • 2020: 1st shift: 3rd & 4th quarters 2nd shift: 4th quarter 3rd shift: 3rd & 4th quarters • 2021: 1st shift: 1st, 2nd, 3rd, & 4th quarters 3rd shift: 1st, 2nd, & 3rd quarters • 2022: 1st shift: 1st & 2nd quarters 3rd shift: 2nd quarter 814e - Physical Restraint, Medication & Seclusion of Persons Receiving Care, Education or Supervision in an Institution or Facility: 46a-154 Internal Monitoring, Training and Development of Policies and Procedures Required and Subject to State Agency Inspection. • Written policy on seclusion was not provided for review. • Written policy addressing restraint does not include all elements listed in the statute. ****************************************************************************** Once the Licensing Unit has reviewed and accepted the service development plan and has determined that your agency is in compliance with the regulations, a decision on the issuance of a regular twenty-four month license for the program will be made. Until DCF makes this decision the current license will remain in effect. Should you have any questions or comments regarding the contents of this report please do not hesitate to contact me at (860) 937-7551. Sincerely, Kathleen Forsythe _________________________ Kathleen Forsythe, LCSW Regulatory Consultant Cc: Executive Vice President|

6008+++09/19/2023+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: __Stonegate - Rushford____________________________________ TIME OF VISIT (FROM - TO): ____Afternoon_______________ DATE: ____ 9-19-23________ AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: BA - PD List of Areas / Topics covered during visit: • Census - 6 • Clinical - 1 clinical position open; 2 FT residential assistants. The program nurse position is currently filled with a nurse from a third party agency. • New living room furniture has been ordered and shipped however there is no arrival date as yet. Some ripped pieces of furniture have been removed however several pieces remain. • Repairs to walls and surfaces were noted in some bedrooms. There were some places in bedrooms where small amounts of graffiti were noted. • Recreational activities are conducted 2-3 a week and on weekends. On weekends direct care staff oversee recreational activities. • Went inside the gym (a shared space with residents from a separate program). The padding near the ceiling was ripped in multiple places reportedly from being hit by basketballs. While the basketball court appeared clean and in good condition, the surrounding floor and walls were extremely dirty and in need of cleaning. The upkeep of the gym is the responsibility of the property owners. • Review of fire drills for 2023. There is no documentation of a 3rd shift drill for the second quarter. Corrective Actions implemented as a result of previous visit: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Areas of regulatory non-compliance identified during this visit: Section 17a-145-72 Living room, lounge. • Several pieces of ripped furniture remain in the living room area. New furniture has been ordered and shipped to the program. Section 17a-145-86 Instructions in safety procedures. Supervision • There was no documentation of a third shift drill for the second quarter of 2023.|5946+++06/14/2023+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: _____Rushford - Stonegate _________________________ TIME OF VISIT (FROM - TO): _____Afternoon_________________DATE: ____6-14-23______________ AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: Program Director List of Areas / Topics covered during visit: • Census is currently 4. Visit occurred on the last day of school. • Staffing - The program is currently down a total of 5 staff. They are utilizing a nurse through a temp agency. In addition, they are down a clinician, a lead RTA and 3 RTA's. Shifts are being filled by existing staff. Bonuses are being offered to staff to work shift openings during the week. There are currently 5 per diems assigned to the program. Some are former employees who have stayed on in this capacity. Per diems are required to work at least 1 shift (2nd) every 6 weeks. There is also a new facilities manager. • Requests to replace damaged and worn furnishings have been made and are currently working their way through the Capital Funding process. The PD indicated they may not actually be able to replace torn couches until October. • Tour of physical plant. The couches in the living room/TV area are heavily ripped. The majority of the cushions had significant tears. The dining room tables and chairs are significant worn (original furniture). A request to purchase new tables has been submitted. • There was ample food on hand. Staff do the ordering for breakfast food and snacks. Meals are sent over from a main kitchen that provides meals for several Rushford programs. • A tour of bedrooms found that there was various levels of wear and tear throughout the bedrooms on walls and surfaces. The majority of the bedrooms are in need of painting. Some painting has occurred since the last visit. There were two bedrooms that had missing pieces of molding. Foam "egg crates" remained in some of the rooms. The PD indicated that these should have been removed. • There was one shower stall (#4) that had discoloration/dirt on the edge where the two flooring surfaces met. One shower stall (#2) was in need of re-grouting. • The program is expecting a visit as part of an audit by DMHAS and ABH (in relation to the Substance Abuse Disorder waiver). • The PD indicated that Yale New Haven Hospital recently began offering in-patient services to adolescents detoxing from opioids and benzodiazepines. He indicated that this in an important resource for their program and the community. He indicated that they maintain a significant amount of Narcan on hand due to recent information received that some overdoes are not responding to (the typical) 1-2 does of Narcan. Corrective Actions implemented as a result of previous visit: • Bathroom vents were cleaned. Areas of regulatory non-compliance identified during this visit: Section 17a-145-71 Living room, lounge. • The couches in the living room/TV area are excessively ripped and in need of replacement. Cushions were torn down the middle in some cases. This was cited on the previous licensing report. Section 17a-145-73. Sleeping accommodations. • Walls and surfaces throughout the bedrooms were in need of painting. Section 17a-145-74. Lavatory facilities. Toilet articles and linens. • One section of flooring near a shower stall was discolored/dirty. • One shower stall was in need of re-grouting. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Terri Bohara 6-15-23 ______________________________ _________________ Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5874+++02/01/2023+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: _____Rushford at Stonegate _________________________ TIME OF VISIT (FROM - TO): __________________________ DATE: ______2-1-23____________ AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title BA Program Manager List of Areas / Topics covered during visit: • Current census is 7. • There are currently 3 full time residential assistant positions open. The program nurse position remains open with coverage being provided by a nurse from another program. The nurse currently covering is not an DCF Endorsed instructor and is unable to perform certain functions. One case manager is leaving 2-10-23. There is currently one vacant clinician position. Coverage will be provided by clinicians from other programs providing rotating coverage. • Admissions now include a standardized assessment (ASAM) which is conducted periodically throughout a residents stay in the program. A suicide risk assessment is also conducted. Staff are to be trained in Motivational interviewing. • There is now a recreational director on staff. Cooking groups are held regularly. • Physical plant tour. Couches in the downstairs recreational area/living room are in need of replacement. Cushions are covered in duct tape in several areas. There were several tears of varying sizes on just about every cushion. • Tables in the dining room area are showing signs of wear and tear. Surfaces are fairly worn. • While a few bedrooms have been painted in spots the painting was done without plugging holes. Graffiti was still found in several rooms. Closet areas are being poorly utilized and are often used to store/pile clothes. • Vents in the bathrooms were in need of cleaning. • Several lights in the bathrooms and one in the hallway contained dead bugs. • One shower stall was in need of regrouting. • A check of medications found externals and internals separated and no expired medications. • No trainings have been provided by the nurse. • No "pass and pours" observations have occurred as the nurse currently covering the program is not an endorsed instructor. • A list of staff who are Med Certified was posted. • There is a worn leather chair in the lobby hallway. Corrective Actions implemented as a result of previous visit: • Chairs in the main floor lobby area have been replaced. • Medications have been separated and expired medications have been removed. Areas of regulatory non-compliance identified during this visit: Section 17a-145 -71. Living room, lounge. • Couches in the downstairs living room are ripped in multiple places and are in need of replacement. Section 17a-145-73. Sleeping accommodations. • Walls in several bedrooms are in need of painting. Graffiti still exists in several rooms. Section 17a-145 -74. Lavatory facilities. Toilet articles and linens. • Bathroom ceiling vents and lights were in need of cleaning. • One shower stall is in need of regrouting. DCF Reg: 17a-6(g) -16 (c): "Day programs and residential facilities shall provide continuing education on administration of medication to trained person staff members." Facility nurses and/or appropriate personnel must offer continuing education opportunities for DCF medication certified staff. The facility nurse must document on a quarterly basis all continued education opportunities offered in the past 3 months. • No continuing education has been provided to staff. This was cited on the licensing report from the previous quarter. Annual Observation of Medication Administration Skills Once a year the facility nurse must observe medication certified staff performing the DCF medication administration procedure. This must be documented using the DCF-2275 DCF Medication Administration Program Procedure Checklist and placed in the employees file. • No "pass and pours" observations of trained staff have been conducted. The nurse currently overseeing the medication administration is not a DCF endorsed instructor. This was noted on the 2022 licensing report. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Terri Bohara 2-23-23 ______________________________ _________________ Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5863+++10/20/2022+++October 28, 2022 Mr. James O'Dea - VP Behavioral Health Rushford Center Inc. 883 Paddock Ave. Meriden, CT 06450 Re: Licensing Inspection for Rushford at Stonegate Inspectors: Terri Bohara Dear Mr. O'Dea, In October 2022 a biennial re-licensing inspection was conducted at Rushford at Stonegate. This inspection was conducted to determine the compliance of this facility with the Regulations for Operation of Child-Caring Agencies and Facilities 17a-145-48 through 17a-145-98, as well as the DCF Guidelines for the Administration of Medication by Certified Staff. Below are listed the areas of regulatory non-compliance which were identified during the re-licensing inspection. Please review the areas identified and submit a service development plan to address each area. The plan must be submitted within 30 days of receipt of this letter and should identify: 1. the steps to be taken to correct the non-compliance; and 2. the date the correction(s) will be completed. The areas of non-compliance are listed below. Also included in the report are recommendations. Recommendations are meant to highlight areas that are not currently areas of non-compliance, but may become non-compliant if actions are not taken. Recommendations do not require the submission of a service development plan. Section 17a-145-61. Written policies and procedures. • Evidence of a policy review and approval was not provided for the last two years. This is a repeat citation. Section 17a-145-64 Personnel Policies and Procedures • Three personnel files were reviewed. • The state police background checks were all done several weeks after the date of hire. • The DCF background checks were all done several weeks after the date of hire. Section 17a-145-71. Living room, lounge. • The arm of the chair in the downstairs sitting area was frayed. Section 17a-145-73. Sleeping Accommodations. • Multiple bedrooms had areas on the walls that had been patched and were in need of painting. • Several surfaces in the bedrooms had graffiti on them. Section 17a-145-86. Instructions in safety procedures. Supervision. • There was no documentation of a fire drill for third shift/third quarter in 2022. • There was no documentation of a fire drill for third shift/third quarter in 2021. Section 17a-145-93. Medical, dental and nursing care. • Based on the review of the clinical records the facility failed to provide medical, dental and nursing care for four clients. Case records were missing annual physical exams, immunizations, nursing assessment, dates of last dental and eye exam and nursing care plan. Administration of the Medication Training Program (Nursing Report) DCF Regulation17a-6(g)-15 (a-g) Check monthly that all prescriptions/orders are current, correctly transcribed on the medication record and match the pharmacy labels. • Based on the review of the physician orders the facility failed in getting MD orders for one client in 90 days. DCF Responsibilities in Administration of the Medication Training Program: DCF Regulation 17a-6(g)-15 (a - g) Check monthly that all prescriptions/orders are current, correctly transcribed on the medication record and match the pharmacy labels. Including but not limited to the following: Orders are not over 90 days Violation 1 Based on the review of the physician orders the facilty failed in getting MD orders for one client in 90 days. Evidence Client: Carey Darren, DOB:04/25/2009, DOA: 07/05/2022 Medication orders were signed by the physcian on 07/05/2022, and it expires on 10/03/2022. The medication review orders are not signed on 10/03/2022 by the physician. DCF Reg: 17a-6(g) -16 (c): "Day programs and residential facilities shall provide continuing education on administration of medication to trained person staff members." Facility nurses and/or appropriate personnel must offer continuing education opportunities for DCF medication certified staff. The facility nurse must document on a quarterly basis all continued education opportunities offered in the past 3 months. See Forms section for suggested form to document quarterly offerings. Violation 2 Based on the review of the training records the facility failed in providing quarterly training. Evidence Missing trainings on 0/5/2021. 08/2021, December 2021, June 2022, & September 2022. Storage of Internal and External (Topical) Medications Internal medications must be kept separate from External medications: • Internal medications are kept on a different shelf or in a different cabinet or drawer than the external medications. OR • External medications are placed in plastic bins or baskets that are used for external medications only. • Storage areas for external medications must be labeled, "For External Medications Only". Violation 3 Based on the review of the medication cabinet the facility failed to separate external and internal medications. Stock Medication Process for routinely checking the expiration date (at least monthly) Violation 4 Based on the inspection of the medication cabinet the facility failed to check the over the counter medications expiration date. During inspection found two expired medications. Evidence Benadryl expiration date: 10/21/2021 Robitussin liquid expired on 09/2021 Annual Observation of Medication Administration Skills Once a year the facility nurse must observe medication certified staff performing the DCF medication administration procedure. This must be documented using the DCF-2275 DCF Medication Administration Program Procedure Checklist and placed in the employees file. Violation 5 Based on the review of the training records the facility failed to provide Annual Observation of Medication Administration Skills for four staff members Evidence: Staff members L.C.- - Annual Observation of Medication Administration Skills-misisng in 01/2022 A.F - Annual Observation of Medication Administration Skills-misisng in 04/2022 S. L- Annual Observation of Medication Administration Skills-misisng in 04/2022 C. L. - Annual Observation of Medication Administration Skills-misisng in 07/2022 DCF Medication Administration Regulation Submit a DCF-2272 Monthly Medication Administration Program Supervision and Review to DCF Risk Management. Violation 6 Based on the review of the DCF Data system the facility failed to provide DCF-2272 from March 2022 to August 2022. Quarterly Review of Policies and Procedures Quarterly, the supervising registered nurse or licensed medical person will document a review of the facility’s medication policies and a review of the continuing education offered related to medication administration. Violation 7 Based on the review of the records the facility failed to review of the facility’s medication policies. Recommendations: Section 17a-145-63 Chief administrative. • The basement area is utilized for the storage of tools, supplies, decorations and recreational equipment as well as housing the laundry area and classrooms. The area is extremely cluttered. It is recommended that an outside storage unit be purchased so that some of these items can be relocated out of the hallway. Once licensing has reviewed and accepted the service development plan and has determined that your agency is in compliance with the regulations a decision on the issuance of a regular twenty-four month license for the program will be made. Until DCF makes this decision the current license will remain in effect. Should you have any questions or comments regarding the contents of this report please do not hesitate to call me at (959) 255-0614. Sincerely, ___Terri Bohara 10-28-22____________________________________ Terri Bohara, Regulatory Consultant Copy: file|5798+++10/19/2022+++October 28, 2022 Mr. James O'Dea - VP Behavioral Health Rushford Center Inc. 883 Paddock Ave. Meriden, CT 06450 Re: Licensing Inspection for Rushford at Stonegate Inspectors: Terri Bohara Dear Mr. O'Dea, In October 2022 a biennial re-licensing inspection was conducted at Rushford at Stonegate. This inspection was conducted to determine the compliance of this facility with the Regulations for Operation of Child-Caring Agencies and Facilities 17a-145-48 through 17a-145-98, as well as the DCF Guidelines for the Administration of Medication by Certified Staff. Below are listed the areas of regulatory non-compliance which were identified during the re-licensing inspection. Please review the areas identified and submit a service development plan to address each area. The plan must be submitted within 30 days of receipt of this letter and should identify: 1. the steps to be taken to correct the non-compliance; and 2. the date the correction(s) will be completed. The areas of non-compliance are listed below. Also included in the report are recommendations. Recommendations are meant to highlight areas that are not currently areas of non-compliance, but may become non-compliant if actions are not taken. Recommendations do not require the submission of a service development plan. Section 17a-145-61. Written policies and procedures. • Evidence of a policy review and approval was not provided for the last two years. This is a repeat citation. Section 17a-145-64 Personnel Policies and Procedures • Three personnel files were reviewed. • The state police background checks were all done several weeks after the date of hire. • The DCF background checks were all done several weeks after the date of hire. Section 17a-145-71. Living room, lounge. • The arm of the chair in the downstairs sitting area was frayed. Section 17a-145-73. Sleeping Accommodations. • Multiple bedrooms had areas on the walls that had been patched and were in need of painting. • Several surfaces in the bedrooms had graffiti on them. Section 17a-145-86. Instructions in safety procedures. Supervision. • There was no documentation of a fire drill for third shift/third quarter in 2022. • There was no documentation of a fire drill for third shift/third quarter in 2021. Section 17a-145-93. Medical, dental and nursing care. • Based on the review of the clinical records the facility failed to provide medical, dental and nursing care for four clients. Case records were missing annual physical exams, immunizations, nursing assessment, dates of last dental and eye exam and nursing care plan. Administration of the Medication Training Program (Nursing Report) DCF Regulation17a-6(g)-15 (a-g) Check monthly that all prescriptions/orders are current, correctly transcribed on the medication record and match the pharmacy labels. • Based on the review of the physician orders the facility failed in getting MD orders for one client in 90 days. DCF Responsibilities in Administration of the Medication Training Program: DCF Regulation 17a-6(g)-15 (a - g) Check monthly that all prescriptions/orders are current, correctly transcribed on the medication record and match the pharmacy labels. Including but not limited to the following: Orders are not over 90 days Violation 1 Based on the review of the physician orders the facilty failed in getting MD orders for one client in 90 days. Evidence Client: Carey Darren, DOB:04/25/2009, DOA: 07/05/2022 Medication orders were signed by the physcian on 07/05/2022, and it expires on 10/03/2022. The medication review orders are not signed on 10/03/2022 by the physician. DCF Reg: 17a-6(g) -16 (c): "Day programs and residential facilities shall provide continuing education on administration of medication to trained person staff members." Facility nurses and/or appropriate personnel must offer continuing education opportunities for DCF medication certified staff. The facility nurse must document on a quarterly basis all continued education opportunities offered in the past 3 months. See Forms section for suggested form to document quarterly offerings. Violation 2 Based on the review of the training records the facility failed in providing quarterly training. Evidence Missing traingings on 0/5/2021. 08/2021, December 2021, June 2022, & September 2022. Storage of Internal and External (Topical) Medications Internal medications must be kept separate from External medications: • Internal medications are kept on a different shelf or in a different cabinet or drawer than the external medications. OR • External medications are placed in plastic bins or baskets that are used for external medications only. • Storage areas for external medications must be labeled, "For External Medications Only". Violation 3 Based on the review of the medication cabinet the facility failed to separate external and internal medications. Stock Medication Process for routinely checking the expiration date (at least monthly) Violation 4 Based on the inspection of the medication cabinet the facility failed to check the over the counter medications expiration date. Durin inspection found two expired medications. Evidence Benadryl expiration date: 10/21/2021 Robitussin liquid expired on 09/2021 Annual Observation of Medication Administration Skills Once a year the facility nurse must observe medication certified staff performing the DCF medication administration procedure. This must be documented using the DCF-2275 DCF Medication Administration Program Procedure Checklist and placed in the employees file. Violation 5 Based on the review of the training records the facility failed to provide Annual Observation of Medication Administration Skills for four staff members Evidence: Staff members L.C.- - Annual Observation of Medication Administration Skills-misisng in 01/2022 A.F - Annual Observation of Medication Administration Skills-misisng in 04/2022 S. L- Annual Observation of Medication Administration Skills-misisng in 04/2022 C. L. - Annual Observation of Medication Administration Skills-misisng in 07/2022 DCF Medication Administration Regulation Submit a DCF-2272 Monthly Medication Administration Program Supervision and Review to DCF Risk Management. Violation 6 Based on the review of the DCF Data system the facility failed to provide DCF-2272 from March 2022 to August 2022. Quarterly Review of Policies and Procedures Quarterly, the supervising registered nurse or licensed medical person will document a review of the facility’s medication policies and a review of the continuing education offered related to medication administration. Violation 7 Based on the review of the records the facility failed to review of the facility’s medication policies. Recommendations: Section 17a-145-63 Chief administrative. • The basement area is utilized for the storage of tools, supplies, decorations and recreational equipment as well as housing the laundry area and classrooms. The area is extremely cluttered. It is recommended that an outside storage unit be purchased so that some of these items can be relocated out of the hallway. Once licensing has reviewed and accepted the service development plan and has determined that your agency is in compliance with the regulations a decision on the issuance of a regular twenty-four month license for the program will be made. Until DCF makes this decision the current license will remain in effect. Should you have any questions or comments regarding the contents of this report please do not hesitate to call me at (959) 255-0614. Sincerely, ___Terri Bohara 10-28-22____________________________________ Terri Bohara, Regulatory Consultant Copy: file|5780+++08/22/2022+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: ____Rushford - Stonegate ________________________________________ TIME OF VISIT (FROM - TO): __________________________ DATE: ___8-22-22_______________ AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: BA - Program Director List of Areas / Topics covered during visit: • The census is currently 7. The program is currently capped at 8 due to staffing shortages. LBC is 12. • There are currently 2 full time positions open. The nursing position remains open and medication administration is being covered by a nurse from another program. The recreational therapist position will likely be filled by an internal candidate. An RTA will be starting in approximately a week. • A review of 3 personnel files was conducted on 7-28-22. Two staff did not have CPR and restraint training. • As a result of the recent changes in the program (SUD waiver) the school affiliated with the Rushford Academy program has closed and all clients will receive tutoring. • The program is currently not meeting the stipulated clinical hours required in the new program design. The new program requirements are 20 hours per client. The program plans to utilize Fellows affiliated with Hartford Healthcare for the additional hours. • The program is also required to accept new admissions 16 hours per day. • Tour of the facility. There were numerous rips in the cushions of the couches in the living room area. The area rug was worn in spots. • Bedroom #1 had graffiti on the walls and bedframes. The room needed painting. • Bedroom #2 had dirt on the baseboards. • Bedroom #11 had a bent electrical outlet cover. • Bedroom #9 had a pen stuck in the wall and graffiti on the door. • There were several areas throughout the building that were in need of painting. • There was a band aide on the wall in one bathroom and a small opening (chipped sheetrock) by one of the electrical outlets. • In the parking lot of the program there were 13 propane tanks and approx. 8 gas cans and other assorted items) left by the other program that shares the campus. The PD stated that these were removed after the licensing visit. • New flooring is scheduled to be installed in the dining room, kitchen, living room and hallway areas. Corrective Actions implemented as a result of previous visit: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Areas of regulatory non-compliance identified during this visit: Section 17a-145-64 Personnel policies and procedures. • Three files were reviewed on 7-28-22. • Two files did not have documentation of CPR certification. • Two files did not have documentation of restraint training. Section 17a-145-71 Living room, lounge. • There were numerous rips in the couch cushions. • The area rug was worn in spots. Section 17a-145-73 Sleeping accommodations. • Several bedrooms had graffiti on the walls and other surfaces. • One room had dirt on the baseboards. • The electrical outlet cover in one room was in need of replacement. Section 17a- 145-74. Lavatory facilities. Toilet articles and linens. • There was a band aid stuck to the wall in one shower stall. • The area around an electrical outlet in one bathroom had a small opening (chipped sheetrock). Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Terri Bohara 8-30-22 ______________________________ _________________ Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5749+++06/21/2022+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: _____Rushford - Stonegate ___________________ TIME OF VISIT (FROM - TO): __________________________ DATE: _____6-21-22_____________ AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: JS - VP Operations List of Areas / Topics covered during visit: • Current census is 5. • The program is still seeking a nurse (24 hrs.) to fill the vacant position. Coverage is being provided by a nurse from another program. The recreational therapist position is currently open but pending. A staff resigned the previous week but there is a new employee starting on 7-20-22. That will leave them 64 hours shy of being fully staffed. • The program will be changing its programming and funding structure. Their LBC will be changing to 12. Residents will have the option to stay up to approx. 3 months. • Physical plant tour. Several bedrooms had graffiti on surfaces throughout the rooms. Several rooms had broken slats in the blinds. One (empty) bed room had several dead bugs on the floor. • Common areas and bathrooms were clean. • Kitchen area was clean and there was ample food was on hand. A new oven is in the budget. Corrective Actions implemented as a result of previous visit: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Areas of regulatory non-compliance identified during this visit: Section 17a-145-73. Sleeping accommodations. • Blinds in some rooms had broken slats. • There was graffiti on walls and surfaces(to varying degrees). Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Terri Bohara 7-15-22 ______________________________ _________________ Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5671+++03/23/2022+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. ( 3- Academy NAME OF FACILITY / PROGRAM: ______Rushford - Stonegate ________________________ TIME OF VISIT (FROM - TO): __________________________ DATE: ___3-23-22______________ AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title BA PD List of Areas / Topics covered during visit: • Census - 7 (3- Academy /4 - Stonegate) • Staffing - One Residential Treatment Assistant (32 hrs.) and the recreational therapist position (32 hr.) remain open. The program nurse position (24 hr.) is also vacant. Total open positions - 3 • Kitchen was stocked with ample food. The microwave above the stove is broken (missing plate/plastic facing) and the PD indicated he has asked for its removal. • Tour of program bedrooms. Bedroom #6 had a loose piece of wood with staples exposed inside the closet. The PD said he would put in a request for immediate repair. All of the bedrooms are in need of painting. Some had graffiti on the walls/windowsills. • Bathroom ventilation is insufficient. The PD closed down one bathroom due to the presence of mold. The PD indicated he would be requesting the replacement of all of the exhaust fans in the bathrooms. The shower curtain in one shower was stained/discolored. • Chairs in the program lobby were worn in spots. The PD is pursuing replacements. Corrective Actions implemented as a result of previous visit: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Areas of regulatory non-compliance identified during this visit: Section 17a-145-73 Sleeping accommodations. • One of the bedrooms had a piece of loose wood in the bedroom closet exposing wood staples. • Bedrooms needed painting. Graffiti and carvings present in some of the rooms. Section 17a-145-74. Lavatory facilities. Toilet articles and linens. • Improper ventilation has led to mold in one of the bathrooms. • The shower curtain in one bathroom was discolored/stained. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Terri Bohara 3-25-22 ______________________________ _________________ Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

6005+++09/18/2023+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Boys and Girls Village / STAR TIME OF VISIT (FROM - TO): __9:10am 10:30am__________ DATE: 9/18/23 AGENCY PERSONNEL WHO PARTICIPATED: Job Title Program Director List of Areas / Topics covered during visit: • Census is 6. LBC 6. • At the time of the visit all youth were in school. • Physical plant inspection was conducted. See below. • Discussed the programing, resident safety. • Followed up on significant event reports. • Discussed staffing of shifts. Corrective Actions implemented as a result of previous visit: • N/A Areas of regulatory non-compliance identified during this visit: Section 17a-145-73. Sleeping accommodations. Evidence of water damage in ceiling tile found in bedroom #2. Section 17a-145-74. Lavatory facilities. Shower on second floor has mold in the soap holder. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Thomas S. Cuchara ___9/22/23_______ Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5924+++04/27/2023+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Boys and Girls Village / STAR TIME OF VISIT (FROM - TO): __10am__________ DATE: 4/27/23 AGENCY PERSONNEL WHO PARTICIPATED: Job Title Program Director Milieu Staff List of Areas / Topics covered during visit: • Census is 4. LBC 6. • At the time of the visit one youth in the program, but is a new admission. • Physical plant inspection was conducted and in compliance. • Discussed the programing, resident safety, juggling room challenges. • Discussed staffing of shifts. • Fire drills reviewed for the 1st quarter for 2023. No concern. Corrective Actions implemented as a result of previous visit: Medication Administration: Completed. • The sheet used to document key exchanges calendar dates are predated. The document has room for only signatures of staff handing the key off to the oncoming shift. The document does not have sufficient space to accommodate multiple key exchanges for each shift. Areas of regulatory non-compliance identified during this visit: N/A Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Thomas S. Cuchara ___5/4/23_______ Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5804+++10/25/2022+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Boys and Girls Village / STAR TIME OF VISIT (FROM - TO): __10am _______________________ DATE: ___10/25/22____ AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title OT Program Director DV Vice President of Residential Services DB Program Coordinator LP Clinical Coordinator WS Youth Mentor List of Areas / Topics covered during visit: The STAR program is currently under a 2nd Provisional license. The license expires 10/28/22. The LBC is 4 with age range 14 to 18. The STAR accepts Boys. • At the time of the visit the census is 2 who were in school at the start of the visit. One youth returned from school. He stated he likes it here and is treated well. • Physical plant has no concerns • Discussed the programing, supervision of residents, resident safety, etc. • Medication room was reviewed, and citation listed below. Corrective Actions implemented as a result of previous visit: No corrective action required from last visit. Areas of regulatory non-compliance identified during this visit: Medication Guidelines: The non-controlled mediation key was found in the cabinet lock where non-controlled medication is stored. Consequently, the key was not in possession of the staff member assigned to administer medication, per Medication Guidelines training. The mediation room is accessible to all medication certified staff or others with access via the key fob. In addition, there is no evidence whereby staff document a key exchange for each shift. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Thomas S. Cuchara ___10/28/2022_______ Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5758+++07/22/2022+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Boys and Girls Village / STAR TIME OF VISIT (FROM - TO): __10am_______________________ DATE: ___7/22/22____ AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title OT Program Director LP Clinical Coordinator BK Family Support Worker DJ Program Coordinator List of Areas / Topics covered during visit: This is a STAR program is under its 1st Provisional license. The license will expire 8/28/2022. The LBC is 4 with age range 14 to 18. The STAR accepts Boys. • At the time of the visit there was no youth in the program. • Physical plant inspection was completed and in compliance. • Discussed the programing, resident safety (rooms and fire drills), food storage, etc. • Discussed staffing of shifts. Staff noted that they are in the process of hiring two staff. Vacant positions are filled by per diem BGV staff. Corrective Actions implemented as a result of previous visit: Areas of regulatory non-compliance identified during this visit: NONE. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Thomas S. Cuchara ___7/22/2022_______ Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

5929+++05/10/2023+++aDCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: _Bridge Family Center / Hastings House TIME OF VISIT (FROM - TO): __11am to 1pm______ DATE: 5/10/23 AGENCY PERSONNEL WHO PARTICIPATED: Job Title Program Director List of Areas / Topics covered during visit: Census is 6. LBC 6. 6 males. Physical plant inspection of the STAR. No concerns. Discussed program issues and concerns. Discussed staffing of shifts. Medication: Controlled medication reviewed. N/A Corrective Actions implemented as a result of previous visit: N/A Areas of regulatory non-compliance identified during this visit: N/A Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. N/A Thomas S. Cuchara ___5/15/23_______ Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5900+++03/30/2023+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: _Bridge Family Center / Hastings House TIME OF VISIT (FROM - TO): __11am to 12:15pm__________ DATE: 3/30/23 AGENCY PERSONNEL WHO PARTICIPATED: Job Title Program Director Program Coordinator List of Areas / Topics covered during visit: Census is 3. LBC 6. 6 males. Physical plant inspection of the Group Home. No concerns. Discussed program issues and concerns. Discussed staffing of shifts. Medication: Controlled medication reviewed. N/A Corrective Actions implemented as a result of previous visit: N/A Areas of regulatory non-compliance identified during this visit: N/A Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. N/A Thomas S. Cuchara ___3/31/23_______ Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5857+++12/21/2022+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: _Bridge Family Center / Hastings House TIME OF VISIT (FROM - TO): ___2pm_______________________ DATE: ___12/21/2022____ AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title SH Program Director List of Areas / Topics covered during visit: • Census is 5 and LBC 6. 6 males. One youth is in detention. • Physical plant inspection of the Group Home. • Residents were at school. • Discussed staffing of shifts. • One case record reviewed and found in compliance. Corrective Actions implemented as a result of previous visit: 17a-145-73. Sleeping accommodations. Completed. At the time of the visit Rooms 4 & 6 found the wood trim around the bedroom door is broken. A work order was put in for repair. Licensing will follow up on next visit. Areas of regulatory non-compliance identified during this visit: No SDP needed. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Thomas S. Cuchara ___2/3/23_______ Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5812+++09/28/2022+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: _Bridge Family Center / Hastings House TIME OF VISIT (FROM - TO): ___9am_______________________ DATE: ___9/28/22____ AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title SH Program Director List of Areas / Topics covered during visit: • Census is 3 and LBC 6. 6 males. • Physical plant inspection of the Group Home. Program Director reports a new dining room table and chairs were purchased. New patio furniture for the deck and new dressers for bedrooms ordered. • Discussed the programing and resident's treatment and compliance. • Residents were at school. • Discussed staffing of shifts. Interim Clinical Coordinator used until a fulltime clinician is hired. APRN hired to provide supervision for Medication Administration Program. • One case record reviewed and found in compliance. Corrective Actions implemented as a result of previous visit: NO SDP from last visit. Areas of regulatory non-compliance identified during this visit: 17a-145-73. Sleeping accommodations. At the time of the visit Rooms 4 & 6 found the wood trim around the bedroom door is broken. A work order was put for repair. Licensing will follow up on next visit. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Thomas S. Cuchara ___11/10/2022_______ Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5750+++06/07/2022+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: _Bridge Family Center / Hastings House TIME OF VISIT (FROM - TO): ___1pm_______________________ DATE: ___6/7/22____ AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title SH Program Director MW Clinical Coordinator List of Areas / Topics covered during visit: • Census is 6 and LBC 6. 6 males. • Physical plant inspection of the Group Home. No concerns. • Discussed the programing and resident's treatment and compliance. Program Director relayed there has been awols due to oppositional defiant behaviors. The program works with each resident individually to address their issues. One resident who has struggled with ADL skills made significant changes for which he is very proud. • Residents were at school. • Discussed staffing of shifts. Clinical Coordinator announced their resignation, but will continue on parttime until a replacement is found. The RN covering Hastings, Winifred and Harwinton resigned. The program will use the RN from Freymann House until a replacement is found. Corrective Actions implemented as a result of previous visit: Section 17a-145-73. Sleeping accommodations. Completed. One bedroom had evidence of broken blinds that covered his window. A work order has been submitted. Areas of regulatory non-compliance identified during this visit: No SDP required. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Thomas S. Cuchara ___7/8/2022_______ Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5673+++03/22/2022+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: _Bridge Family Center / Hastings House TIME OF VISIT (FROM - TO): ___1pm_______________________ DATE: ___3/22/22____ AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title SH Program Director List of Areas / Topics covered during visit: • Census is 4 and LBC 6. 4 males. • Physical plant inspection of the Group Home. See below. • Discussed the programing and resident's treatment and compliance. • Residents were at school. • Discussed staffing of shifts. Corrective Actions implemented as a result of previous visit: No SDP from last visit. Areas of regulatory non-compliance identified during this visit: Section 17a-145-73. Sleeping accommodations. One bedroom had evidence of broken blinds that covered his window. A work order has been submitted. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Thomas S. Cuchara ___3/29/2022_______ Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

6007+++06/12/2023+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: _Bridge Family Center / Freymann House TIME OF VISIT (FROM - TO): ___11:15am to 1pm_____________________ DATE: ___6/12/23 AGENCY PERSONNEL WHO PARTICIPATED: Job Title Program Manager List of Areas / Topics covered during visit: . • Current Census= 7. LBC 6 DCF and 3 Community beds. Total Bed Capacity 9. o One youth is using one of the Community beds. • Physical plant inspection of the Group Home. No concern. • Discussed the programing challenges and resident's treatment and compliance. • Discussed staffing of shifts. 2nd shift has no FTE vacancies, but is looking to fill shifts using parttime and per diem staff. • Discussed the length of stay for youth. Corrective Actions implemented as a result of previous visit: n/a Areas of regulatory non-compliance identified during this visit: n/a Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Thomas S. Cuchara ___8/4/23_______ Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5901+++03/29/2023+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: _Bridge Family Center / Freymann House TIME OF VISIT (FROM - TO): ___9:45 to 12pm_____________________ DATE: ___3/29/23 AGENCY PERSONNEL WHO PARTICIPATED: Job Title Program Manager Director of Residential Services Youth Worker List of Areas / Topics covered during visit: . • Current Census= 6. LBC 9- 6 DCF and 3 Community beds. • Physical plant inspection of the Group Home. No concern. • Discussed the programing challenges and resident's treatment and compliance. • Discussed staffing of shifts. Vacancy one full time youth worker on 1st and 2nd shifts • Reviewed controlled medication. No concern. Corrective Actions implemented as a result of previous visit: n/a Areas of regulatory non-compliance identified during this visit: n/a Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Thomas S. Cuchara ___4/4/23_______ Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5810+++09/01/2022+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: _Bridge Family Center / Freymann House TIME OF VISIT (FROM - TO): ___9:20am_______________________ DATE: ___9/1/2022 AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title CD Program Manager KP Clinical Director of Residential Services List of Areas / Topics covered during visit: . • Census. One resident is in school and the other in hospital. • Physical plant inspection of the Group Home. See below. • Discussed the programing challenges and resident's treatment and compliance. • Discussed staffing of shifts. • One case record reviewed and in compliance. Corrective Actions implemented as a result of previous visit: Areas of regulatory non-compliance identified during this visit: Section 17a-145-73. At the time of the licensing visit one of the bedrooms cloths and numerous items on the floor. The room was cluttered. Prior to the end of the visit the room was cleaned and organized. No further action required. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Thomas S. Cuchara ___11/7/2022_______ Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5680+++04/01/2022+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: The Bridge Family Center/Freymann House TIME OF VISIT (FROM - TO): 12:45 -- 1:15 DATE: 4-1-22 AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title CD Program Director List of Areas / Topics covered during visit: Verified LBC. Noted which residents were home and not in school. Inspected the entire home. Reviewed job vacancies. Corrective Actions implemented as a result of previous visit: Not applicable. Areas of regulatory non-compliance identified during this visit: None. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. A plan of correction does not need to be filed. Regulatory Consultant Date James Richard Moore, LMSW 4-1-22 A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

5917+++04/19/2023+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Bridge Family Center / Winifred STAR TIME OF VISIT (FROM - TO): 11am-1pm DATE: 4/19/23 AGENCY PERSONNEL WHO PARTICIPATED: Job Title Program Director Clinical Coordinator List of Areas / Topics covered during visit: • LBC 6. Census is 5. • At the time of the visit one youth home. Youth stated he likes the staff. • Discussed the programing and resident behaviors. • Physical plant inspection completed. Corrective Actions implemented as a result of previous visit: Section 17a-145-73. Sleeping accommodations. Completed. Evidence: • At the time of the licensing visit, the bedroom door to Room C was found broken. A work order was submitted prior to the licensing visit. Section 17a-145-74. Lavatory facility. Completed. Evidence: • The second-floor bathroom sink was found to be broken at the time of the licensing visit. A work order was submitted prior to the licensing visit. Section 17a-145-84. Office space. Confidential files. Completed. Evidence: • Closed records were found to be on the floor in the Program Director's office. There is no evidence of a locked room or file cabinet dedicated to storage of closed files. Section 17a-145-86. Instructions in safety procedures. Completed. Evidence: • Fire drill missing for the 4th quarter 2022. • Fire Marshal report: Basement area needs exit signs for occupants. Completed. Section 17a-145-84. Office space. Confidential files. Completed. Evidence: • Closed records were found to be on the floor in the Program Director's office. There is no evidence of a locked room or file cabinet dedicated to storage of closed files. Section 17a-145-86. Instructions in safety procedures. Completed. Evidence: • Fire drill missing for the 4th quarter 2022. • Fire Marshal report: Basement area needs exit signs for occupants. Areas of regulatory non-compliance identified during this visit: NONE. Section 17a-145-73. Sleeping accommodations. Evidence: At the time of the visit, a mirror was found to have inappropriate graffiti/statements written on the frame. It was immediately removed by the Program Director. No SDP. Section 17a-145-76. Kitchen, equipment, food-handling. Evidence: • At the time of the visit the cabinet door to the center island was missing. A work order had been submitted prior to the licensing visit. Repeat from last relicense inspection. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Thomas S. Cuchara 4/19/23 Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5809+++09/28/2022+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: _Bridge Family Center / Winifred TIME OF VISIT (FROM - TO): ___12:30pm__________________ DATE: ___9/28/22____ AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title AB Youth Worker HB Youth Worker List of Areas / Topics covered during visit: • Census is 3. LBC 6. • Physical plant inspection of the Group Home. See below. • Discussed the programing challenges and resident's treatment and compliance. • Reviewed 1 open client file. Found to be in compliance. Corrective Actions implemented as a result of previous visit: No SDM from last visit Areas of regulatory non-compliance identified during this visit: No SDM required. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Thomas S. Cuchara 11/10/2022 Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5675+++03/23/2022+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: _Bridge Family Center / Winifred TIME OF VISIT (FROM - TO): ___9:30am__________________ DATE: ___3/23/22____ AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title NB Clinical Coordinator List of Areas / Topics covered during visit: • Census is 0 and LBC 6. • Physical plant inspection of the Group Home. See below. • Discussed the programing challenges and resident's treatment and compliance. • Discussed on-going training with staff when census is low. • Discussed staffing of shifts. • Reviewed Fire Drills. • Reviewed 2 discharge files. Corrective Actions implemented as a result of previous visit: No SDM from last visit Areas of regulatory non-compliance identified during this visit: No SDM required. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Thomas S. Cuchara 4/6/2022 Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

6004+++09/26/2023+++Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: The Bridge Family Center - Harwinton House STAR program TIME OF VISIT (FROM - TO): 12:30pm-4:00pm DATE: 9-26-23 AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: • Director of Residential Services • Program Director • Facilities Manager • Youth Worker (2) List of Areas / Topics covered during visit: This was a scheduled Licensing visit for this newly assigned Regulatory Consultant to meet with the Director of Residential Services and the new Harwinton Program Director. Topics discussed included: • Census=0. One resident was officially discharged on this date due to extended AWOL status. Admissions remain closed. • Biennial relicensing inspection to be held in January 2024; due dates for application materials. • Corrective action plan (CAP) updates. • Bridge Family Centers hands-off practice; restraint training for staff. • Client cell phone practices. • Age waiver process. • Schedule of Director of Residential Services at Harwinton House. • Direct care worker schedules and replacement coverage practice. • Staff responsibilities list for each shift in development. • Employee supervision practices; support from Management. • Client supervision: Recent change to client headcount practice (every 15 minutes); recording, staff assignment each shift, staff stations for overnight client supervision. • Staff training activities since summer 2023 listed in CAP. • Several staff scheduled to complete DCF Medication Administration training in October. • Maintenance staff schedule and process for maintenance requests; one Facilities Manager covers five group homes. • Life Skills curriculum in use. • Resident Handbook in development; Target date for completion is late November 2023. • Restraint/seclusion reporting requirements to the Department. • Updating client bulletin board information. • Updating menu. • Food storage. Tour of the physical plant facilitated by the Program Director and Facilities Manager. Items discussed included: • Discontinued use of space heaters after recent Fire Marshal consultation. • Professional cleaning company scheduled for 9-29-23. • Improving appearance of aging bathtub, bathroom sinks and shower. • New bathroom and one bedroom door installed. • Bedrooms have been painted and new area rugs in place. • Closed client case record storage in basement. • New basement upright freezer installed; basement refrigerator exterior has been reconditioned. • New sump pump installed in basement; large area of wet floor observed; dehumidifier and large fan in operation; monitoring humidity levels. • Bedroom furniture layout. • New master key for client bedrooms. • Master key for exterior doors will be completed in late September. • Heating units scheduled for replacements in some rooms in early October; monitoring room temperatures. • Recent meeting with a security company to install window alarms in October. • Bedroom closet rod replacement scheduled. • Basement cleaned and unused items scheduled for removal next week. • New bedroom dresser to be assembled. • Providing areas in client bedrooms for displaying personal effects. • Repair needed for freezer drawer in kitchen. Corrective Actions implemented as a result of previous visit: An active corrective action plan (CAP) is in place with the Department. • Staff training activities. • Staffing. • Physical plant improvements. Areas of regulatory non-compliance identified during this visit: None. Please submit a service development plan to address the above referenced areas of non-compliance within 30 days of receipt of this report. The service development plan must be submitted to the attention of the undersigned at the address listed above. - A service development plan is not required following this Licensing visit. Program is currently on a corrective action plan with the Department. Kathleen Forsythe, LCSW ______________________________ Date: 9-27-23 Regulatory Consultant A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM Cc: Director of Residential Services Program Director|5978+++08/03/2023+++ DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: _Bridge Family Center / Harwinton House TIME OF VISIT (FROM - TO): 9:45am to 11:50am DATE: ___8/3/2023____ AGENCY PERSONNEL WHO PARTICIPATED: Job Title Youth Worker (2) List of Areas / Topics covered during visit: Current Census 1. LBC 6. Physical plant inspection conducted. Discussed the programing and resident's treatment and compliance. One resident was home watching a movie. States she likes it here yet wants to return home. Corrective Actions implemented as a result of previous visit: Section 17a-145-86. Instructions in safety procedures. Supervision. This was addressed. Areas of regulatory non-compliance identified during this visit: Section 17a-145-73. Sleeping accommodations. Items were identified in the bedrooms that need to be addressed. Section 17a-145-74. Lavatory facilities. Items were identified in the kitchen that need to be addressed. Section 17a-145-76. Kitchens, equipment, food-handling. Items were identified in the kitchen that need to be addressed. Physical Plant: Items were identified in the kitchen that need to be addressed. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Thomas S. Cuchara __8/4/23_____ Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5999+++07/27/2023+++DCF Corrective Action Plan – The Bridge – Harwinton STAR Site Corporate Name: The Bridge Family Center Program Name: Harwinton STAR Date: 7/27/23 The plan of correction should include specific goals, objectives, and steps that effectively reflect the issues described above. Please submit this plan to the undersigned by the close of business on September 27, 2023. We hope to continue an ongoing dialogue with you as you work on the plan of correction. If you have any questions, please feel free to contact Kathleen Dituccio at kathleen.diticco@ct.gov Area Needing Attention The Bridge Plan of Correction Completion Date Title/Person Responsible to Monitor Plan 1. Section 17a-145-62. Chief administrative officer (Each facility shall provide the staff and complementary services to enhance the physical and emotional well-being and ensure the safety of the children.) a) Submit a plan to ensure that all staff are trained in ESI practices, including temporary staff. b) Submit a plan to provide consistent therapeutic services to residents. c) Submit a plan to provide consistent life skills groups to residents. d) Submit a plan to document all contact with family members. e) Submit a plan to ensure that new and/or unexperienced staff are not working a shift without an experienced staff member present. f) Submit a plan to ensure that there is a consistent activities schedule for the residents. 2. Supervision: Section 17a-145-60. Written policies and procedures a) Submit a plan to provide adequate and consistent supervision of all residents. b) Submit a plan to ensure that all residents receive immediate medical treatment when needed. c) Submit a plan to keep residents safe when there are physical disputes among residents. d) Submit a detailed protocol to handle major incidents (during & after) at the program (thefts, assaults, etc.) e) Submit a plan to ensure that all staff working at the program feel safe and confident to do their job. 3. Section 17a-145-86. Instructions in Safety Procedures. Supervision. a) Submit a plan to ensure that nothing is hung by residents on the sprinkler system. b) Submit a plan to ensure that residents do not have any contraband or paraphernalia (lighter, marijuana) c) Submit a plan/policy to ensure that staff cell phones and program keys are always safe and secure. i. Physical Plant Submit a plan to ensure that the following is rectified: ii. Replace/fix missing bureau drawer and window screen in the first-floor bedroom iii. Paint over graffiti and repair the door frame in the first-floor bedroom. iv. Clean basement and ensure all chemicals are stored properly. v. Ensure that all beds have clean sheets and bedding. vi. Ensure that bathrooms are always kept clean and tidy. vii. Repair microwave. viii. All food is stored properly and refrigerated when applicable. ix. Install curtains/blinds in second-floor bedroom x. Remove splashed paint from walls, lighting, and window blinds.|5941+++05/25/2023+++ DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: _Bridge Family Center / Harwinton House TIME OF VISIT (FROM - TO): 9:45am to 11am DATE: ___5/25/2023____ AGENCY PERSONNEL WHO PARTICIPATED: Job Title Program Director Youth Worker (1) List of Areas / Topics covered during visit: Current Census 6. LBC 6. Physical plant inspection: See below. Discussed the programing and resident's treatment and compliance. Discussed staffing of shifts and medication administration. Corrective Actions implemented as a result of previous visit: No SDP from last visit. Areas of regulatory non-compliance identified during this visit: Section 17a-145-86. Instructions in safety procedures. Supervision. The double bedroom on second floor found evidence youth are hanging LED lights, a picture and coat hanger on the sprinklers and sprinkler guards. When conducting daily room checks all staff must check to ensure the fire suppression system is not compromised in any manner. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Thomas S. Cuchara ___5/25/23_____ Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5899+++03/29/2023+++ DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: _Bridge Family Center / Harwinton House TIME OF VISIT (FROM - TO): 12:45pm to 1:45pm DATE: ___3/29/2023____ AGENCY PERSONNEL WHO PARTICIPATED: Job Title Program Director Youth Worker (1) List of Areas / Topics covered during visit: Current Census 6. LBC 6. Physical plant inspection: No concerns. Discussed the programing and resident's treatment and compliance. Discussed staffing of shifts and medication administration. Controlled medication count completed with Med Certified staff and found correct. Corrective Actions implemented as a result of previous visit: Section 17a-145-73. Sleeping accommodations. Completed. Room 1-damage found to the door and frame. Room was found to have clothes and items all over floor and bed. Room 3- Several holes in walls. A work order was put in place. Areas of regulatory non-compliance identified during this visit: N/A Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. N/A Thomas S. Cuchara ___3/31/23_____ Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5856+++01/17/2023+++ DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: _Bridge Family Center / Harwinton House TIME OF VISIT (FROM - TO): __11am_______________________ DATE: ___1/17/2023____ AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title CR Program Director TC Clinical Coordinator KG Youth Worker GJ Youth Worker List of Areas / Topics covered during visit: • LBC 6. Census is 6. Five youth are in program with one in the hospital. • Physical plant inspection of the Group Home. See below. • Discussed the programing and resident's treatment and compliance. • 4 Residents are at school, and one is Hospitalized inpatient. • 1 resident was home meeting with clinician. • Discussed staffing of shifts and medication administration. • Controlled medication count completed with Med Certified staff and found correct. Corrective Actions implemented as a result of previous visit: NO SDP from previous visit. Areas of regulatory non-compliance identified during this visit: Section 17a-145-73. Sleeping accommodations. Room 1-damage found to the door and frame. Room was found to have clothes and items all over floor and bed. Room 3- Several holes in walls. A work order was put in place. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Thomas S. Cuchara ___1/25/23_____ Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5811+++09/26/2022+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: _Bridge Family Center / Harwinton House TIME OF VISIT (FROM - TO): __1pm_______________________ DATE: ___9/26/22____ AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title CR Program Director TC Clinical Coordinator List of Areas / Topics covered during visit: • Census is 4 and LBC 6. • Physical plant inspection of the Group Home. See below. • Discussed the programing and resident's treatment and compliance. • 3 Residents were at school and one inpatient. • Discussed staffing of shifts. APRN hired to oversee medication administration program. Corrective Actions implemented as a result of previous visit: Section 17a-145-73. Sleeping accommodations. Room 4: At the time of the licensing inspection, room 4 had acrylic paint splattered inside and outside the bathroom. Maintenance is in the process of cleaning and painting. Completed. Areas of regulatory non-compliance identified during this visit: NO SDP required. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Thomas S. Cuchara ___11/10/2022_______ Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

5719+++03/29/2022+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Kids In Crisis TIME OF VISIT (FROM - TO): ____First shift__________________ DATE: _3/29/22___________ AGENCY PERSONNEL WHO PARTICIPATED: Job Titles: Executive Director Assistant Executive Director Supervisor Clinician Three direct care staff List of Areas / Topics covered during visit: Three youth were residing in the home and they were at the home during the site visit on spring vacation. The program is down 4 staffing positions, there was a third shift Thursday through Sunday, first shift Wednesday through Saturday and a second shift Wednesday through Saturday staff positions available. There was also a first shift Monday through Friday position available for a social worker. Corrective Actions implemented as a result of previous visit: No actions were required. Areas of regulatory non-compliance identified during this visit: None Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. _Keith Bryan____________ ____3/29/22__ Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

 

5993+++08/17/2023+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Noank Community Support Services (Church Hill House) TIME OF VISIT (FROM - TO): 10:45am- 12:00pm DATE: 8-17-23 AGENCY PERSONNEL WHO PARTICIPATED: Job Title Program Director List of Areas / Topics covered during visit: • Discussed current census (3) and the licensed bed capacity is 4. • Discussed current staffing levels. Currently two contracted staff will become full time Noank staff members. • No residents in milieu at the time of the visit. Overall milieu discussed and staff has been implementing Circle Forward with the residents daily. • Clinical programming for residents discussed. Clinician running individual and group sessions with the residents. • Discussed change in supervisory coverage. Supervisors now cover during the week and weekend with overlap on Wednesday. • Upcoming relicensing inspection discussed. • Inspection of the Church Hill House physical plant was completed with the program director. Corrective Actions implemented as a result of previous visit: • Not applicable Areas of regulatory non-compliance identified during this visit: Section 17a-145-74: Lavatory facilities: There appeared to be mold forming on the second floor bathroom ceiling. Section 17a-145-73. Sleeping accommodations: Screen missing from second floor bedroom window. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. James Funaro Regulatory Consultant Date: 8-30-23 A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM Cc: Program Director|5947+++05/11/2023+++DCF-3034 1/2013 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: NOANK/ Church Hill Program TIME OF VISIT: (FROM–TO): 10:30 am to 11:45am DATE: 5/11/23 AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title N/A Program Director Areas / Topics covered during visit: The Department of Children and Families conducted a scheduled quarterly inspection visit at the Church Hill Program on May 11, 2023. Topics covered during the quarterly visit included current census, program staffing and training, physical plant inspection, milieu issues and medication administration system. Physical plant: A walkthrough of the physical plant was conducted with the program director and areas of improvements were addressed with the program. Corrections implemented as a result of previous visit: N/A Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning) N/A Areas of regulatory non-compliance identified during this visit: Section 17a-145-63: Chief administrative officer. Upon review of program information, ongoing and pervasive behavioral issues of residents at the facility has caused the milieu to become unstable on a regular basis. Section 17a-145-73: Sleeping accommodations: Upon inspection of the facility, bedroom four's walls contained dirt and scuff marks and they need to be addressed. Section 17a-145-74: Lavatory facilities. Upon inspection of the first-floor bathroom, a wall tile was missing and it needs to be addressed. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Penny Woodward, LCSW_ June 10, 2023 Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5884+++01/24/2023+++DCF-3034 1/2013 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: NOANK/ Church Hill Program TIME OF VISIT: (FROM–TO): 12:00 pm to 1:30pm DATE: 1/24/23 AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title N/A Program Director Areas / Topics covered during visit: The Department of Children and Families conducted a scheduled quarterly inspection visit at the Church Hill Program on January 24, 2023. Topics covered during the quarterly visit included current census, program staffing and training, physical plant inspection, milieu services and medication administration system. Physical plant: A walkthrough of the physical plant with the program director was conducted; a citation was identified and discussed with the director. Corrections implemented as a result of previous visit: N/A Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning) N/A Areas of regulatory non-compliance identified during this visit: Section 17a-145-63: Chief administrative officer. Upon reviewing of staffing information, it was confirmed that the program's staffing level remains low and does not meet regulatory standards. Section 17a-145-63: Chief administrative officer. Upon review of training information, it was found that not all staff had been fully trained in Risking Connections. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Penny Woodward, LCSW March 1, 2023 Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5829+++10/21/2022+++DCF-3034 1/2013 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: NOANK/ Church Hill Program TIME OF VISIT: (FROM–TO): 10:45am to 12:30pm DATE: 10/21/22 AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title N/A Program Director Areas / Topics covered during visit: The Department of Children and Families conducted a scheduled quarterly inspection visit at the Church Hill Program on October 21, 2022. Topics covered during the quarterly visit included program staffing and training, physical plant inspection, milieu services and medication administration system. Physical plant: A walkthrough of the physical plant with the program director was conducted; deficiencies were identified and discussed with the director. Corrections implemented as a result of previous visit: N/A Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning) N/A Areas of regulatory non-compliance identified during this visit: Section 17a-145-63: Chief administrative officer. Upon reviewing of staffing information, it was confirmed that the program's staffing level for each shift continue not to meet regulatory requirements. Section 17a-145-63: Chief administrative officer. Upon review of training information, it was found that all staff had not been trained in TCI, Risking Connections and Restorative Approach. Section 17a-145-74: Lavatory facilities. Upon inspection of the facility, the second-floor bathroom was in disrepair and it needs to be addressed. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Penny Woodward, LCSW November 21, 2022 Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5755+++07/07/2022+++ DCF-3034 1/2013 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: NOANK/ Church Hill Program TIME OF VISIT: (FROM–TO): 11:30am to 12:30pm DATE: 7/7/22 AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title N/A Program Director N/A Director Areas / Topics covered during visit: The Department of Children and Families attended a meeting and conducted a physical plant inspection at the Church Hill Program on July 7, 2022. Topics covered during the meeting included administrative changes at the shelter, program staffing and training, the client population, milieu services and medication administration system. Physical plant: During the quarterly visit a walkthrough of the physical plant was conducted with the shelter's program director. Please see citations that are listed below in the area of regulatory non-compliance section. Corrections implemented as a result of previous visit: N/A Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning) N/A Areas of regulatory non-compliance identified during this visit: Section 17a-145-63: Chief administrative Officer. Upon review of training information, it was found that all staff had not been trained in TCI, Risking Connections and Restorative Approach. Section 17a-145-63: Chief administrative Officer. Upon review of staffing information, it was found that the staffing levels at the shelter was not meeting regulatory requirements. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Penny Woodward, LCSW August 2, 2022 Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5746+++05/03/2022+++ DCF-3034 1/2013 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: NOANK/ Church Hill Program TIME OF VISIT: (FROM–TO): Morning to Afternoon DATE: 5/3/22 AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title N/A Program Director Areas / Topics covered during visit: The Department of Children and Families conducted a scheduled quarterly inspection visit at the Church Hill Program on May 3, 2022. Topics covered during the quarterly visit included program staffing and training, physical plant inspection, milieu services and medication administration system. Physical plant: A walkthrough of the physical plant with the program director was conducted; deficiencies were identified and discussed with the director. Corrections implemented as a result of previous visit: N/A Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning) N/A Areas of regulatory non-compliance identified during this visit: Section 17a-145-63: Chief administrative Officer. Upon review of training information, it was found that all staff had not been trained in TCI, Risking Connections and Restorative Approach. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Penny Woodward, LCSW_ May 3 , 2022 Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|5649+++03/01/2022+++ DCF-3034 1/2013 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: NOANK/Church Hill Program TIME OF VISIT: (FROM–TO): Morning to Afternoon DATE: 3/1/22 AGENCY PERSONNEL WHO PARTICIPATED: Name Job Title Program Director Areas / Topics covered during visit: The Department of Children and Families conducted a scheduled quarterly inspection visit at the Church Hill Program on March 1, 2022. Topics covered during the quarterly visit included program census, staffing and training, physical plant inspection and medication administration system. Physical plant: A walkthrough of the physical plant with the program director was conducted; deficiencies were identified and reported to the director. Corrections implemented as a result of previous visit: N/A Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning) N/A Areas of regulatory non-compliance identified during this visit: Section 46a-153: Physical restraint. Upon review of staff training, only one employee has been certified in TCI since the last inspection visit that was held in December of 2021. The program continues not to have enough TCI trained staff working at the facility. 17a-145-63: Chief administrative officer. Upon review of staff training, it was confirmed that no staff members have been trained in Risking Connection or Restorative Approach since the last inspection visit. It is an agency requirement that all staff be trained in the treatment models. Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above. Penny Woodward, LCSW March 7 , 2022 Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

5994+++08/28/2023+++DCF-3034 6/2021 (Revised) Department of Children and Families 505 Hudson Street Hartford, CT 06106 Field Visit Reporting Form This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken. NAME OF FACILITY / PROGRAM: Noank Community Support Services (Clift House Shelter) TIME OF VISIT (FROM - TO): 10:45am- 12:00pm DATE: 8-28-23 AGENCY PERSONNEL WHO PARTICIPATED: Job Title Clift House Shelter Director List of Areas / Topics covered during visit: • Discussed current census (6) and the licensed bed capacity is 12. • Discussed current staffing levels and hiring. Two vacant positions for a floater and 2nd shift direct care staff. • During the last quarter there were 28 admissions and 24 discharges. • Observed residents participating in on site educational programming. No concerns reported or observed with the current milieu. • Clinical programming for residents discussed. • Inspection of the Clift House physical plant both inside and the outside grounds. The physical plant was clean and well maintained with no health or safety concerns noted. Corrective Actions implemented as a result of previous visit: • Not applicable Areas of regulatory non-compliance identified during this visit: • Not applicable Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the