Form M-3A Form M-3A FFS Compliance and Safety Site Visit Report

Site Visit Form For Visit #125880 (Program Name) 12/10/2023
Visit Information

Site Visit Walkthrough

Child Interviews

Trends & Follow-up

Visit Information
ORR Region:

Program Name:

Program Name

Region Name
Level of Care:

ORR Representative Name:

Level of Care Selection

John Doe

Date of Visit

12/10/23

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Site Visit Form For Visit #125880 (Program Name) 12/10/2023
Site Visit Walkthrough

Visit Information

Child Interviews

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Trends & Follow-up

Notes

Site Visit Walkthrough
Site Visit Form For Visit #125880 (Program Name) 12/10/2023
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Did the program have a Facility Inspection Checklist for a Child Friendly Environment completed?
Yes
W

No

hat date was it completed?

Did the Checklist for a Child Friendly Environment meet all satisfactory markings (i.e., was it all marked yes)?
Yes

No

Note any deficiencies

:

Does the program have working video cameras and are they reviewed by the program?
Yes

No

A comment is required

:

Are all entry and exit alarms tested to ensure they work (including windows and doors)?
Yes

No

A comment is required

:

Do all entries and exits have safety measures? (e.g., perimeter barriers, perimeter lighting, alarms to note for

entry/exit without permission)? Note: FFS can ask to see these safety measures.
Yes

No

A comment is required

:

All required bulletin board postings to educate youth about sexual abuse, sexual harassment, and reporting
are posted in ALL required areas in language the child understands?
Yes

No

A comment is required

:

Are Garza Notices and Infographics posted?
Yes

No

A comment is required

:

Required pre-programmed phone is accessible to child, private, and correctly preprogrammed for child to

report sexual abuse, sexual harassment, and sexually inappropriate behavior? All three must be compliant to
indicate “Yes".
Yes

No

A comment is required

:

Overall appearance of the program is neat, organized, and clean that does not present any health or safety

concerns?
Yes

No

A comment is required

:

Is the program in compliance with all staffing ratio requirements?
Yes

No

A comment is required

:

Are there staffing concerns?
Yes

No

Please confirm you elevated this to the Project Officer for resolution or to address child capacity.

Observations(e.g., recent improvements, recent repairs,shade for kids outside, old/new furniture, etc.):

Concerns(focus on safety issues for child or staff - blind spot supervision, etc.)

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Site Visit Form For Visit #125880 (Program Name) 12/10/2023
Visit Information

Site Visit Walkthrough

Child Interviews

Trends & Follow-up

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Notes

Child Interviews
Child interviews are for the purposes of general information and general well-being and safety.

Guidance:

Child interviews can be conducted individually or with small group of children at one time in an informal
setting.

Children have a right to refuse an interview. If this occurs, please document the reason the child refused an
interview
This is not an investigation. This should not evolve into counseling
FFS and CFS are mandated reporters to CPS and law enforcement
Do not promise children anything. Do not discuss the child’s legal case
Redirect issues that move away from the intent of this site visit report and encourage them to speak with
their clinician/case

manager or attorney/legal services provider.

If you have any immediate safety concerns, please contact the FFS Supervisor.

If any child responds in the negative or "NO" then mark it as "No" but you can add any comments.
Add Child Interview

No children were interviewed on this visit.
Reason

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Site Visit Form For Visit #125880 (Program Name) 12/10/2023
Visit Information
Interview 1

Site Visit Walkthrough

Trends & Follow-up

Child Interviews

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Add Interview

Estimated age range of the child(ren).

Interpreter used?
Yes

No

Provide comment:

Does the child have the opportunity for daily Recreation(large and small muscle)?

Refer to Policy 3.3.8
Yes

No

Provide comment:

Does the child have access or a choice to participate in preferred Religious
Services?
Yes

No

Provide comment:

Does the child have Leisure Time?

Refer to Policy 3.3.8
Yes

No

Provide comment:

Does the child meet with his/her CM once per week?

Refer to Policy 2.3.2
Yes

No

Provide comment:

Does the child meet with his/her Clinician for one hour sessions per week?

Refer to Policy 3.3
Yes

No

Provide comment:

Does the child have a Clinical Group?

Refer to Policy 3.3
Yes

No

Provide comment:

Are there Community Meetings the child can participate in?

Refer to Policy 3.3
Yes

No

Provide comment:

Does the child get at least two calls per week with his/her parent and/or sponsor?

Refer to Policy 3.10, 3.3.7
Yes

No

Provide comment:

Are Sexual Abuse Hotline pre-programmed phones accessible to the child at any

time?

Refer to Policy 4.10.1, 4.10.6
Yes

No

Provide comment:

Is the child aware of the legal services provider and his/her access to the LSP?

Refer to Policy 3.3
Yes

No

Provide comment:

Does the child understand his/her family reunification case?

Refer to Policy 2.3.2
Yes

No

Provide comment:

Does the child attend school/education classes for at least 6 hours per day

Monday-Friday?

Refer to Policy 3.3.5
Yes

No

Provide comment:

Is the child aware of how to file a grievance?

Refer to Policy 4.10.1, 3.2.2
Yes

No

Provide comment:

Do you feel safe?
Yes

No

Provide comment:

Do you like living at this program?
Yes

No

Provide comment:

Who would you ask for help if you have a problem while living here at the

program?

Do you have anything else I have not asked you about that you want to tell me?

Do I need to follow up on any items that came up during the interview?
Yes

No

What items require follow-up?

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Site Visit Form For Visit #125880 (Program Name) 12/10/2023
Visit Information

Site Visit Walkthrough

Child Interviews

Trends & Follow-up

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Notes

Trends & Follow-up
Utilize the trends and follow up sections of the report for a record of your overall findings, reporting to your
supervisor, and to check on the program’s improvements from month to month, as well as have a record in the
event a corrective action is required for identified trends. This is the final section where you record your
findings for the visit, and what you left in place for the program to follow up on.

Guidance
Share this with your supervisor, PO, and CFS
Also, it is fine to give it to your program so that when you go back to the program, you have a record of what
has already been addressed and whether progress has been made
Please feel free to engage your supervisor along the way should you have questions or need support with
anything.

Remember that this visit and form is a tool for you to use to help the programs improve
Lastly, remember you are a mandated reporter to CPS and law enforcement. For any immediate safety
concerns or findings, contact your supervisor.

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Site Visit Form For Visit #125880 (Program Name) 12/10/2023
Visit Information

Site Visit Walkthrough

Child Interviews

Trends & Follow-up

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Trends & Follow-up
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Trends/Comments: Please provide a narrative discussion of your main findings and areas of potential concern.

Did you identify any potential issues to monitor or for additional follow up?
Yes

No

list any specific issues that need to be reviewed again during the next site visit?

Follow up: List any follow up conducted on any previous concerns (Corrective Actions, SA/SIRs, Emergency
SIRs, Notice of Concern from PRS provider, any outcomes, or issues from a previous site visit by the FFS, CFS,
or Monitoring Team)

Action Items: List any plans to address newly identified or remaining concerns. Please include who you have
notified if you are not the responsible party for follow up or the next site visit and the due date.

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Site Visit Form For Visit #125880 (Program Name) 12/10/2023
Visit Information

Site Visit Walkthrough

Child Interviews

Trends & Follow-up

Flags

Notes

Flags
Flags can be used to call out areas within the site that need to be followed up on. They can also be used to
denote something positive that you noticed during the visit.

Simply press the “Add Flag” button, choose the thumbs up (positive) or thumbs down (follow up) button,
choose a category and add any details for each flag.

Add as many flags you wish.
Add Flag

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Site Visit Form For Visit #125880 (Program Name) 12/10/2023
Visit Information

Child Interviews

Site Visit Walkthrough

Trends & Follow-up

Flags

Notes

Flags
Flags can be used to call out areas within the site that need to be followed up on. They can also be used to
denote something positive that you noticed during the visit.

Simply press the “Add Flag” button, choose the thumbs up (positive) or thumbs down (follow up) button,
choose a category and add any details for each flag.

Add as many flags you wish.
Add Flag

Flag category

The facility doors were fully locked and secured.

Child rights

Child safety

Compliance with ORR policies & procedures

Facility safety

Licensing standards

Staff performance

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Site Visit Form For Visit #125880 (Program Name) 12/10/2023
Visit Information

Child Interviews

Site Visit Walkthrough

Trends & Follow-up

Flags

Notes

Flags
Flags can be used to call out areas within the site that need to be followed up on. They can also be used to
denote something positive that you noticed during the visit.

Simply press the “Add Flag” button, choose the thumbs up (positive) or thumbs down (follow up) button,
choose a category and add any details for each flag.

Add as many flags you wish.
Add Flag

Child safety

The facility doors were fully locked and secured.

Child rights

The child’s exercise time has consistently ended 15 minutes early.

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Site Visit Form For Visit #125880 (Program Name) 12/10/2023
Visit Information

Site Visit Walkthrough

Child Interviews

Additional Notes
Any additional details about the visit can be captured here.

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Trends & Follow-up

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