secure.dss.ca.gov/ccld/TransparencyAPI/api/FacilityReports Department of SOCIAL SERVICES Community Care Licensing FACILITY EVALUATION REPORT Facility Number: 602300007 Report Date: 08/03/2016 Date Signed 10/11/2016 11:00:14 AM STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY FACILITY EVALUATION REPORT CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, 744 P STREET, MS 8-3-54 SACRAMENTO, CA 95814 FACILITY NAME: NORMATIVE SERVICES, INC. FACILITY NUMBER: 602300007 ADMINISTRATOR: GARY FLOHR FACILITY TYPE: 731 ADDRESS: TELEPHONE: CITY: STATE: ZIP CODE: CAPACITY: 132 CENSUS: 61 DATE: 08/03/2016 TYPE OF VISIT: Case Management - Other UNANNOUNCED TIME BEGAN: 09:48 AM MET WITH: Gary Flohr, Executive Director; Jeff Johnson, Deputy Director; Kristen Averett, Admissions Director TIME COMPLETED: 04:30 PM NARRATIVE 1/11 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 On August 3, 2016, the undersigned analyst with the Out of State Certification Unit (OOSCU) conducted an annual inspection of the facility referenced for the purpose of re-certification pursuant to California Family Code section 7911.1(c) et., al. Normative Services Incorporated (NSI,) established in Wyoming in April of 1990, is a private, nonprofit agency offering residential care, treatment and educational services for up to a 132 male and female youth ages 12- 17 who present with behavioral and/or mental health challenges. NSI has been certified by the California Department of Social Services, Community Care Licensing Division (CDSS-CCLD) as an out-of-state group home provider since February 15, 2000. The youth in placement are assigned to one of seven homes spread over the campus. At the time of visit, five of the homes were operating. Of the two that were not, one was vacant due to remodeling; the other was not being utilized due to low census. While there have not been any significant programming changes since the facility's last visit by the CDSS, there have been a few organizational/administrative staffing changes: Gary Flohr continues to be the executive director. Jeff Johnson, deputy director (new position) Kristen Averett, admissions director Alisa Brantz, quality assurance Ethan Manning, group living director SUPERVISOR'S NAME: MaryJo Tobola TELEPHONE: (916) 2634723 LICENSING EVALUATOR NAME: Carol Lancaster TELEPHONE: (916) 8385751 LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2016 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2016 This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC809 (FAS) - (06/04) Page: 1 of 7 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY FACILITY EVALUATION REPORT (Cont) CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, 744 P STREET, MS 8-3-54 SACRAMENTO, CA 95814 2/11 FACILITY NAME: NORMATIVE SERVICES, INC. FACILITY NUMBER: 602300007 VISIT DATE: 08/03/2016 NARRATIVE 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 At the time of visit, nine clients placed by California social services or probation agencies were in the facility's care. Placing California agencies included: Riverside, Santa Clara, San Luis Obispo and San Bernardino County Social Services; and Santa Cruz and San Francisco County Probation. Additionally, the facility had four clients from California who were private (parental) placements (i.e., mental health/educational or post-adoption.) Other clients in placement were from Wyoming and Montana. WYOMING LICENSING INFORMATION: NSI is licensed in the state of Wyoming by the Wyoming Department of Family Services. Each of the seven houses on campus is licensed individually. Current licenses were issued April 15, 2016 and are good for two years (through April 15, 2018.) Big Goose (Girls; Capacity 20) Willow Brook (Girls; Capacity 20) Riverside (Boys; Capacity 20) Mountain View (Boys; Capacity 20) Hillside (Boys; Capacity 20) Eagle Ridge (Boys; Capacity 20) Resource Center (Boys; Capacity 12) Prior to WY licenses being re-issued, WY Licensing conducted a visit on February 24, 2016. Overall, the review was good although there were a few physical plant deficiencies and one deficiency related to a policy and procedure non-compliance issue. The report on the evaluation reflected the following positive information: The organization has uniform and systematic policy and procedures to combat suicide ideation, gestures and self-harm. Good communication between staff concerning youth in care. Thorough intake assessments and policies and procedures. Psychiatric evaluations completed usually prior to student's arrival of shortly after. Facility safety plans and crisis prevention and intervention (SAFE method) policies and procedures are being presented and signed by student, authorized representative and therapist at (or prior to) intake. Clear policy and procedures concerning have clear conditions in which law enforcement will be called. SUPERVISOR'S NAME: MaryJo Tobola TELEPHONE: (916) 2634723 LICENSING EVALUATOR NAME: Carol Lancaster TELEPHONE: (916) 8385751 LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2016 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. 3/11 FACILITY REPRESENTATIVE SIGNATURE: LIC809 (FAS) - (06/04) DATE: 08/22/2016 Page: 2 of 7 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY FACILITY EVALUATION REPORT (Cont) FACILITY NAME: NORMATIVE SERVICES, INC. CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, 744 P STREET, MS 8-3-54 SACRAMENTO, CA 95814 FACILITY NUMBER: 602300007 VISIT DATE: 08/03/2016 NARRATIVE 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Staff files complete and organized; good documentation related to staff orientation, training, certifications relative to required and pertinent areas. Youth files in exceptional form - - all needed documentation such as intake information, authorized representative (or parent) contact information, medical, educational records, signed notification of rights and grievances procedures as well as awareness of the rules being present and timelines met. Critical incident reporting in full compliance. Adequate policy and procedure for distribution of money and handling of student's accounts. Facility vehicles in proper operating condition with proper maintenance logs, current insurance cards, first aid kits and fire extinguishers present. Medication distribution rules being followed systematically; evidence of medication safekeeping (i.e., properly locked and maintained.) Facility's outdoor area clean, mainicured lawn and overall excellent maintenance providing a beautiful and peaceful campus. Other than the noted corrections needed (above), indoor spaces are clean and represent a pleasant, friendly environment. Current fire and health inspections - - all corrective action necessary completed timely. Unfortunately, numerous Licensing investigations began to occur after the first part of 2016 and continued to occur up through the time of the undersigned's visit. These investigations were largely prompted from serious incident reports submitted by the facility to WY Licensing (i.e., self-reported) As a result of the reports and investigations, the facility was cited numerous times and required to submit plans of correction. Below is a summary of events and investigations: On or about January 16, 2016, NSI self-reported that a direct care staff was alleged to have purchased and given tobacco products (contraband) to residents. NSI immediately placed the staff on administrative leave and his employment was terminated. Investigation by WY Licensing revealed the organization followed all required policy and procedure in place to act accordingly to individual staff poor choices. WY Licensing required no further action or plan of correction on the part of the facility. 4/11 SUPERVISOR'S NAME: MaryJo Tobola TELEPHONE: (916) 2634723 LICENSING EVALUATOR NAME: Carol Lancaster TELEPHONE: (916) 8385751 LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2016 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: LIC809 (FAS) - (06/04) DATE: 08/22/2016 Page: 3 of 7 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY FACILITY EVALUATION REPORT (Cont) FACILITY NAME: NORMATIVE SERVICES, INC. CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, 744 P STREET, MS 8-3-54 SACRAMENTO, CA 95814 FACILITY NUMBER: 602300007 VISIT DATE: 08/03/2016 NARRATIVE 5/11 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 OTHER ACCREDITATIONS / CERTIFICATIONS: NSI is certified by the Wyoming Department of Health, Behavioral Health Division for service delivery of Residential Substance Abuse Services. This certification is valid through February 28, 2016. NSI is accredited by the Joint Commission for behavioral health care. The facility was last surveyed February 9, 2013, and the accreditation is customarily valid for up to 36 months. SCOPE OF VISIT: Entrance interview/meeting with Gary Flohr, Executive Director; Jeff Johnson, Deputy Director; Kristen Averett, Admissions Director Collection of updated facility forms, policies and procedures and critical incidents and investigations occurring over the last year. Staff interviews and buildings and grounds tour with Ethan Manning, new Group Living Director and Kristen Averett, Admissions Director (who was also acting as Quality Assurance Director, in Alisa Brantz' absence.) Sample of staff records reviewed. Sample of client records reviewed. FINDINGS: The facility presented well: Clean, safe, sanitary and in good repair. Records reviewed were also in good shape. What is concerning however is the number and nature of the many different investigations that have occurred since approximately March 2016. While what prompted the investigations was also reported to the CDSS in incident reports, it was WY Licensing that handled the investigations - - a good portion of which did not involve CA foster children, thereby making it more difficult for the CDSS to investigate. While on campus for this visit, WY Licensing and CPS authorities were also on grounds which presented the undersigned with an opportunity to speak directly to them. While the facility has been afforded the opportunity to respond to the numerous citations related to the investigations, acceptance and agreement to the plans of correction presented by the facility to WY Licensing are still pending in part. SUPERVISOR'S NAME: MaryJo Tobola TELEPHONE: (916) 2634723 LICENSING EVALUATOR NAME: Carol Lancaster TELEPHONE: (916) 8385751 LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2016 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: LIC809 (FAS) - (06/04) DATE: 08/22/2016 Page: 6 of 7 6/11 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY FACILITY EVALUATION REPORT (Cont) FACILITY NAME: NORMATIVE SERVICES, INC. CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, 744 P STREET, MS 8-3-54 SACRAMENTO, CA 95814 FACILITY NUMBER: 602300007 VISIT DATE: 08/03/2016 NARRATIVE 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 On or about June 10, 2016, a facility staff prevented a resident from contacting his/her caseworker. Lastly, on June 10, 2016, Wyoming Licensing rendered two additional findings in a report based on the multitude of incidents and investigations that had occurred in a relatively short period of time : 1. The facility was accepting youth into their program requiring a higher level of care than the facility is equipped to care for; thus, being unable to maintain a safe facility for youth. 2. The organization uses physical restraints as punishment, for the convenience of staff and as a program substitution. FIRE CLEARANCE The facility's most recent fire inspection was conducted by the WY State Fire Marshall's Office on February 8, 2016. The report issued in connection with this inspection cited five violations that were sufficiently corrected prior to the issuance of that agency's final report. HEALTH INSPECTIONS (FOOD SERVICE; WATER): Meals for youth at NSI are prepared in a commercial type kitchen on the NSI campus and are served cafeteria style in an adjoining dining hall. Menus and serving portions are developed utilizing federal guidelines. The kitchen operation and its staff are licensed and under the oversight of the Wyoming Department of Agriculture. The facility's food license is good through June 30, 2016. The facility's well water was last collected and tested by Wyoming Department of Environmental Quality on June 30, 2015 and found to meet recognized EPA standards. SCHOOL ACCREDITATION: Clients at NSI attend an on-grounds school. The school is accredited by the Wyoming Board of Education (last awarded June 5, 2015) and the North Central Association Commission on Accreditation (valid until June 30, 2019). NSI's school is also certified for Special Education by the California Department of Education. SUPERVISOR'S NAME: MaryJo Tobola TELEPHONE: (916) 2634723 LICENSING EVALUATOR NAME: Carol Lancaster TELEPHONE: (916) 8385751 LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2016 7/11 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: LIC809 (FAS) - (06/04) DATE: 08/22/2016 Page: 5 of 7 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY FACILITY EVALUATION REPORT (Cont) FACILITY NAME: NORMATIVE SERVICES, INC. CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, 744 P STREET, MS 8-3-54 SACRAMENTO, CA 95814 FACILITY NUMBER: 602300007 VISIT DATE: 08/03/2016 NARRATIVE 8/11 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 On or about March 8, 2016, two students went AWOL from the facility and were missing for about 30 minutes before noticed to be gone. NSI subsequently submitted an updated policy as a plan of correction related to maintaining a control log tracking student movements. On or about April 4, 2016, a staff member improperly restrained a resident resulting in the resident suffering a fractured arm. While the restraint may have been warranted, the single person technique the staff used was not safe and approved of. On or about April 12, 2016, a resident ingested some illicit drugs that he had brought into the facility previously. As a plan of correction, the facility has updated their intake, return to campus and search policy and staff have been retrained in same. On or about May 4, 2016, a similar situation occurred. Benedryl pills were ingested by one or more clients after a client was successful in bringing them in undetected through the intake process. The 60 pills were later determined to have been concealed in a sock which was among the client's properly. All clothes brought in by or for clients are now being searched and laundered prior to their return to the client. On or about May 7, 2016, a direct care staff member lost his temper during a difficult physical intervention and punched and kicked the resident involved. When the staff realized what he had done, he immediately fled the grounds. Law enforcement was summoned, his employment immediately terminated and felony child abuse charges are pending. During the same physical intervention, another staff pinned the resident's arm to the floor using his knees (thereby using an unapproved restraint technique.) He was reprimanded and required to reattend SAFE training. In the investigation related to the staff who punched and kicked the resident as described above, WY Licensing discovered that he was not background cleared after the facility was informed via letter that he "may not meet employment eligibility." In this case, it is the facility's responsibility to require the employee to obtain the necessary records which resulted in the given response, present them to his employer, and the employer (facility) is required to follow specific rules and standards should they continue to want to employ him. Because both the employee and facility did not, he should have never been permitted to work alone with clients and be counted in the staff-ratio ratio. SUPERVISOR'S NAME: MaryJo Tobola TELEPHONE: (916) 2634723 LICENSING EVALUATOR NAME: Carol Lancaster TELEPHONE: (916) 8385751 LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2016 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: LIC809 (FAS) - (06/04) DATE: 08/22/2016 Page: 4 of 7 9/11 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY FACILITY EVALUATION REPORT (Cont) FACILITY NAME: NORMATIVE SERVICES, INC. CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, 744 P STREET, MS 8-3-54 SACRAMENTO, CA 95814 FACILITY NUMBER: 602300007 VISIT DATE: 08/03/2016 NARRATIVE 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 In the meantime no restrictions on new placements have been imposed. The facility is still in the process of responding to findings and violations in the most recent WY Licensing report dated July 27, 2016. The facility has until August 27, 2016 to present a plan of correction which WY Licensing will consider. Since the situation between the facility and WY Licensing is still fluid, continued CDSS certification will be approved only so long as WY Licensing continues to allow new placements and does not seek revocation or other administrative action. If such does occur, CDSS certification may be reconsidered and/or revisited and subject to change. SUPERVISOR'S NAME: MaryJo Tobola TELEPHONE: (916) 2634723 LICENSING EVALUATOR NAME: Carol Lancaster TELEPHONE: (916) 8385751 LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2016 10/11 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: LIC809 (FAS) - (06/04) DATE: 08/22/2016 Page: 7 of 7 11/11