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HomeMy WebLinkAboutApplication APPLICANT 1/24/2023'City of Springfield Development & Public Works 225 Fifth Street Springfield, OR 97477 Site Plan Review SPRINGFIELD Site Plan Review Pre -Submittal: ❑ Ma'or Site Plan Modification Pre -Submittal: ❑ Site Plan Review Submittal: Major Site Plan Modification Submittal: ❑ 9991111111will Q-34111 A plicant Name: Jennifer Oeker Phone: (541) 735-9421 Company: G Street Integrated Health Email:Jocker@gstih.org Address: 1435 G Street, Springfield, OR 97477 Applicant's Re ,:JohnSchmidt Phone.(541)68E-4540 Company: The Satre Group Email: John@satregroup.corr Address: 375 W 4th Avenue, Suite 201, Eugene, OR 97401 Property Owner: Wood Duck Properties, LLC Phone: company: Wood Duck Properties, LLC Email: Address: PO Box 10691, Eugene, OR 97440 ASSESSOR'S MAP NO: 17-03-36-21 TAX LOT NOS :04700, 04800, 05700, 05800 Property Address: 1600 H Street, Springfield, OR Size of Pro ert :1.7 Acres E] Square Feet El Proposed No. of Dwellingr acre. N/A Proposed Name of Project: Kaitlin's House De$Dri PtlOn of if you are filing in this form by hand, please attach your proposal description to this application. Pro osal• Develop a supervised Youth Detox Facility Existing Use: Medical Office Development New Impervious Surface Coverage (Including Bldg. Gross Floor Area :0 sf Si natures: Please sin and print your name and date in the appropriate box on the next page. Associated Applications: Si ns: Pre -Sub Case No.: Date: Reviewed by: Case No.: I Date: Reviewed by. Application Fee: Technical Fee: $ Posta a Fee: TOTAL FEES: $ PROJECT NUMBER: Revised 1/7/14 KL 1 of 11 Owner Signatures This application form Is used for both the required pre -submittal meeting and subsequent complete application submittal. Owner signatures are required at both stages in the application process. An application without the Owner's original signature will not be accepted. The undersigned acknowledges that the information In this application is correct and accurate for scheduling of the Pre- Submittal Meeting. If the applicant is not the owner, the owner hereby grants permission for the applicant to act In his/her behalf. I/we do hereby acknowledge that I/we are legally responsible for all statutory timelines, information, requests and requirements conveyed to my representative. 1- 5d-,-) ®ate: Signature ._._-. ._—. Print at I represent mrs appreatmn to be complete for submittal to the Qty. Conslsoent with the completeness beck performed on this application at the Pre -Submittal Fleeting, l afflrm the Information Identlfied by the city as rehouse, far processing the application Is Provided herein or the Information will not be provided If not otherwise .pained wlMln the submittal, and the cry may mill. prores..be the appreahon with the information as submitted This statement serves as written notkt pursuant to the requirements of ORS 227.170 pertaining to a complete applontlen. ®ate: Signature Pring Revised 10114 NL 2 of 11 Site Plan Review Application Process 1. Applicant Submits a Site Plan Review Application for Pre -Submittal • The application must conform to the Site Plan Review Submittal Requirements Checklist on pages 4-7 of this application packet. • A pre -submittal meeting to discuss completeness is mandatory, and pre -submittal meetings are conducted every Tuesday and Friday, from 10:00 am - noon. • Planning Division staff strives to conduct pre -submittal meetings within five to seven working days of receiving an application. 2. Applicant and the City Conduct the Pre -Submittal Meeting • The applicant, owner, and design team are strongly encouraged to attend the pre - submittal meeting. • The meeting is held with representatives from Public Works Engineering and Transportation, Community Services (Building), Fire Marshall's office, and the Planning Division and is scheduled for 30 to 60 minutes. • The Planner provides the applicant with a Pre -Submittal Checklist specifying the items required to make the application complete if it is not already complete, and the applicant has 180 days submit a complete application to the City. 3. Applicant Submits a Complete Application, City Staff Review the Application and Issue a Decision • A complete application must conform to the Site Plan Review Submittal Requirements Checklist on pages 4-7 of this application packet. • A Type II decision, made after public notice, but without a public hearing, unless appealed, is issued within 120 days of submittal of a complete application. • Mailed notice is provided to property owners and occupants within 300 feet of the property being reviewed and to any applicable neighborhood association. In addition, the applicant must post one sign, provided by the City, on the subject property. • There is a 14 -day public comment period, starting on the date notice is mailed. • Applications are distributed to the Development Review Committee, and their comments are incorporated into a decision that addresses all applicable approval criteria and/or development standards, as well as any written comments from those given notice. • Applications may be approved, approved with conditions, or denied. • At the applicant's request, the Planner can provide a copy of the draft land use decision prior to issuing the final land use decision. • The City mails the applicant and any party of standing a copy of the decision, which is effective on the day it is mailed. • The decision issued is the final decision of the City but may be appealed within 15 calendar days to the Planning Commission or Hearings Official. Revised 1/7/14 KL 3 of 11 Site Plan Review Submittal Requirements Checklist NOTE: • ALL of the following items MUST be submitted for BOTH Pre -Submittal and Submittal. • If you feel an item on the list below does not apply to your specific application, please state the reason why and attach the explanation to this form. Application Fee - refer to the Development Code Fee Schedule for the appropriate fee calculation formula. A copy of the fee schedule is available at the Development & Public Works Department. Any applicable application, technology, and postage fees are collected at the pre -submittal and submittal stages. Site Plan Review Application Form Narrative explaining the purpose of the proposed development, the existing use of the property, and any additional information that may have a bearing in determining the action to be taken. The narrative should also include the proposed number of employees and future expansion plans, if known. Density - if applicable, list the size of property (acres), maximum allowable density and the density proposed. [� Copy of the Deed Copy of the Site Plan Reduced to 8'/2"x 11", which will be mailed as part of the required neighboring property notification packet. State or Federal Permits Required - The applicant must demonstrate that an application has been submitted for any required federal or state permit and provide a copy of the application upon request. Completed Attached Scoping Sheet Four (4) Copies of the Following Plan Sets for Pre -Submittal OR Four (4) Copies of the Following Plan Sets for Submittal: All of the following plans must include the scale appropriate to the area involved and sufficient to show detail of the plan and related data, north arrow, and date of preparation. All plan sets must be folded to 81/2" by 11" and bound by rubber bands. Please Note: • These plans must provide enough information to enable the City to determine that the proposed development is feasible, but are not necessarily required to be detailed construction level documents. • The City's Engineering Design Standards Manual, while not land use criteria, may be used in whole or n part, by the City Engineer to determine the feasibility of a proposed plan. • Nothing herein should be interpreted as implying any requirement in contradiction of Oregon Statute or Oregon Administrative Regulation. Revised 1/7/14 KL 4 of 11 a. Site Assessment of Existing Conditions ❑✓ Prepared by an Oregon licensed Architect, Landscape Architect, Civil Engineer or Surveyor ❑✓ Vicinity Map ❑✓ The name, location and dimensions of all existing site features including buildings, curb cuts, trees and impervious surface areas, clearly indicating what is remaining and what is being removed. For existing structures to remain, also indicate present use, size, setbacks from property lines, and distance between buildings. N/A❑ The name, location, dimensions, direction of flow and top of bank of all watercourses and required riparian setback that are shown on the Water Quality Limited Watercourse Map on file in the Development & Public Works Department N/A ❑ The 100 -year floodplain and floodway boundaries on the site, as specified in the latest adopted FEMA Flood Insurance Rate Maps or FEMA approved Letter of Map Amendment or Letter of Map Revision ❑✓ The Time of Travel Zones, as specified in SDC 3.3-200 and delineated on the Wellhead Protection Areas Map on file in the Development & Public Works Department ❑✓ Physical features including, but not limited to trees 5" in diameter or greater when measured 4'/2 feet above the ground (stands of more than five (5) trees may be shown as a cluster with mix of trees species noted), riparian areas, wetlands and rock outcroppings b. Site Plan ❑✓ Prepared by an Oregon licensed Architect, Landscape Architect, Civil Engineer or Surveyor ❑✓ Proposed buildings: location, dimensions, size (gross floor area applicable to the parking requirement for the proposed use(s)), setbacks from property lines, and distance between buildings; measured setbacks shall be prepared by an Oregon licensed Surveyor when minimum setbacks are shown. 0 Location and height of existing or proposed fences, walls, outdoor equipment, storage, trash receptacles, and signs ❑✓ Location, dimensions, and number of typical, compact and ADA parking spaces; including aisles, wheel bumpers, directional signs, and striping. ADA routes from public rights-of-way whall be designated including at grade connections 0 Dimensions of the development area, as well as area and percentage of the site proposed for buildings, structures, parking and vehicular areas, sidewalks, patios, and other impervious surfaces N/A ❑ Observance of solar access requirements as specified in the applicable zoning district © On-site loading areas and vehicular and pedestrian circulation ❑✓ Access to streets, alleys, and properties to be served, including the location and dimensions of existing and proposed curb cuts and curb cuts proposed to be closed ❑✓ Location, type, and number of bicycle parking spaces ❑✓ Note location of existing and planned Lane Transit District facilities (within 1/1 mile) Revised 1/7/14 KL 5 of 11 ❑ Area and dimensions of all property to be conveyed, dedicated, or reserved for common open spaces, recreational areas, and other similar public and semi-public uses N/A E] Phased Development Plan — where applicable, the Site Plan application must include a phasing plan indicating any proposed phases for development, including the boundaries and sequencing of each phase. Phasing must progress in a defined sequence addressing street connectivity between the various phases and accommodating the logical extension of other required public improvements, including but to limited to, sanitary sewer, stormwater management, water and electricity. The applicant must clearly indicate which phases are proposed for approval under the current Site Plan application and which are deferred to future review procedures. c. Existing Improvement and Public Utilities Plan ❑✓ Prepared by an Oregon licensed Architect, Landscape Architect, Civil Engineer or Surveyor 0 Location and width of all existing easements V Location, widths (of paving and right-of-way), and names of all existing streets, alleys, dedications or other right-of-ways within or adjacent to the proposed development, including jurisdictional status other than City. Indicate connection points for roof drainage. ❑✓ Location and type of existing street lighting ❑✓ Location of existing and required traffic control devices, fire hydrants, power poles, transformers, neighborhood mailbox units, waterline backflow preventers and similar public facilities ❑✓ Location, width, and construction material of all existing and proposed sidewalks, sidewalk ramps, pedestrian access ways, and trails 0 Location and size of existing utilities on and adjacent to the site including sanitary sewer mains, stormwater management systems, water mains, power, gas, telephone, Utilities exist, no and cable TV. Indicate the proposed connection points. Detail must be proportionate connections proposed to the complexity of the proposed project. ❑✓ Show existing and proposed spot elevations or contours, and direction of drainage patterns. d. Proposed Grading, Paving, & Utilities Plan ❑✓ Prepared by an Oregon licensed Civil Engineer, except where noted below ❑✓ The approximate size and location of storm water management systems components ❑✓ Location, widths (of paving and right-of-way), and names of proposed streets, alleys, dedications or other rights -of -ways within or adjacent to the proposed development 0 Location and width of all proposed easements ❑ Location and type of proposed street lighting ❑ Information on existing slopes over 5% shall be prepared by an Oregon licensed surveyor and be drawn with one foot contour interval lines; land with a slope over 10 percent shall be shown with 5 foot contour interval lines Revlsed 1/7/14 KL 6 of 11 e. Landscape Plan Prepared by an Architect, Landscape Architect, or other Landscape Professional approved by the Director ❑✓ Location and dimensions of landscaping and open space areas to include calculation of landscape coverage 0 Where applicable, screening in accordance with SDC 4.4-110 0 Location of existing and proposed street trees f. Architectural Plans FO Where abutting residentially zoned properties, exterior elevations of all proposed structures over 140 square feet for the development site, including height, shall be shown g. On -Site Lighting Plan FVJ Location, orientation, and maximum height of exterior light fixtures, both free standing and attached Ft/1 Type and extent of shielding, including cut-off angles, and type of illumination, wattage, and luminous area Additional Materials That May be Deferred at the discretion of the applicant until Final Site Plan or Building Permit Submittal: FVJ List in chart form the proposed types of landscape materials (trees, shrubs, ground cover). Include in the chart genus, species, common name, quantity, size and spacing ❑✓ Where plants are proposed as part of the stormwater management system, a planting plan shall be provided. 0 Irrigation Plan showing of irrigation lines, required backflow preventers and above ground utilities. 0 Photometric test report for each light source. ❑✓ An applicant may submit conceptual floor plans in order to have staff address Resolution of potential nuisance conflicts Additional Materials That May be Required by the Director: IT IS THE APPLICANT'S RESPONSIBILITY TO DETERMINE IF ADDITIONAL STANDARDS/APPLICATIONS APPLY TO THE PROPOSED DEVELOPMENT. THE APPLICANT SHOULD CONSIDER UTILIZING PRE -DEVELOPMENT MEETINGS AS DISCUSSED IN SDC 5.1-120: F1 Copy of a Preliminary Title Report issued within the past 30 days documenting ownership and listing all encumbrances. N/A ❑ A developer may be required to prepare a Traffic Impact Study (TIS) to identify potential traffic impacts from proposed development and needed mitigation measures. Revised 1/7/14 KL 7 of 11 N/A ❑ Where a multi -family development is proposed, any additional materials to demonstrate compliance with SDC 3.2-240 N/A ❑ Riparian Area Protection Report for properties located within 150 feet of the top of bank of any Water Quality Limited Watercourses (WQLW) or within 100 feet of the top of bank of any direct tributaries of WQLW N/A ❑ A Geotechnical Report prepared by an engineer must be submitted concurrently if the Soils Survey indicates the proposed development area has unstable soils and/or a high water table, or if required by the City Engineer © Where the development area is within an overlay district, address the additional standards of the overlay district on plans and narratives N/A ❑ Where physical aspects of a proposed development, including but not limited to scale, odor noise, glare or vibration, will impact less intensive surrounding uses, the Director may request submittal of conceptual floor plans or other information necessary to determine compliance with applicable standards. N/A ❑ If five or more trees are proposed to be removed, a Tree Felling Permit as specified in SDC 5.19-100 N/A ❑ A wetland delineation approved by the Oregon Division of State Lands must be submitted concurrently where there is a wetland on the property NIA ❑ The applicant must demonstrate that an application has been submitted for any required federal or state permit and provide a copy of the application upon request N/A ❑ Where any grading, filling or excavating is proposed with the development, a Land and Drainage Alteration permit must be submitted prior to development N/A ❑ Where applicable, any Discretionary Use or Variance as specified in SDC 5.9-100 and 5.21-100 N/A ❑ An Annexation shall be submitted prior to submission of application, as specified In SDC 5.7-100, where a development is proposed outside of the city limits but within the City's urban service area and can be served by sanitary sewer Revms d 1/7/14 KL 8 of 11 January 23, 2023 KAITLIN'S HOUSE Site Plan Review Map 17-03-36-21, Lots 04700, 04800, 05700, and 05800 WRITTEN STATEMENT In accordancewith Site Plan Review requirements, thiswritten statement describes the proposed development and demonstrates that the proposal complies with the standards contained in SDC 5.17-100 through 5.17-125. LAND USE REQUEST A. Development Objective G Street Integrated Health was founded on the principle that everyone in the community deserves comprehensive, professional health care, delivered with respect and kindness, including to those most vulnerable. G Street Integrated Health is interested in opening a youth detox facility at the above referenced property. Included in the application and written statement is information about G Street and the proposed facility specifics. Subject Propedy RLID Maps 2022 B. Project Directory Owner Wood Duck Properties, LLC P.O. Box 10691 Eugene, OR 97440 Contact: Jennifer Oeker Email: Jockeraastih.ora Phone: (541) 735-9421 Planner (arid Applicant's Representative) Landscape Architect John Schmidt, ASLA John Schmidt, ASLA The Satre Group The Satre Group 375 West 4b Avenue, Suite 201 375 West 4b Avenue, Suite 201 Eugene, OR 97401 Eugene, OR 97401 Phone: (541) 686-4540 Phone: (541) 686-4540 Email: John(alsatrecrouo.com Email: iohn@satrecrouo.com THE SITE AND EXISTING CONDITIONS A. Development Site The development site is located on and accessed from the south side of I Street and north of H Street, in Springfield. The site is primarily large, single -story multi -unit office building with a large parking lot, adjacent to the McKenzie Medical Center. The site is made up of four (4) tax lots and is approximately .60 acres (26,136 square feet) in size. Abutting the site to the north and east is single-family residential, to the south is a large right-of-way (H Street) and then single-family residential, and to the west is the medical center. The project area is fully within the Springfield city limits. FW + w.o:r�PEMr..rrTT + PLANNERS + LANDSCAPE ARCHITECTS + ENVIRONMENTAL SPECIALISTS 375lNesl4th, Suite 201, Eugene, OR 9]401 Phone: 541.66fiA540 www. satregroup.com I I I Kaill'n's H.. Stile Plat Review Map 17-03-38-21 Lots 4700, 4800, 5700, 8 5800 B. Planning Context 1. Planning and Zoning. The Eugene -Springfield Metro Plan designates the Kaitlin House property as Nodal Development (ND) and the zoning is Low Density Residential (LDR). The site is within the Mohawk Special Development Plan Area, the Hospital Support Overlay District, and the Drinking Water Protection Overlay Zone (the site is within the 5- and 10 -year Time of Travel Zone Concentrations). Mel. Ran Ran 2010 Page 2 of 7 2. Transportation. a. TransPlan. The metro area adopted transportation plan, The Eugene -Springfield Transportation System Plan (TransPlan) shows that Mohawk Boulevard is a Minor Arterial and that there are no future projects in the vicinity of the subject property. Springfield 2035 Transportation The City of Springfield's Local Street Network diagram shows no proposed future streets within the area of the project. The plan is illustrative only and is not parcel specific. Future local streets, their locations, and projects can be adjusted at time of specific development proposals. Local 9lred NdWolk Map City of Spnngfidd August 2018 c. Public Transit. The nearest public transit service is an LTD bus stop a quarter mile west on Mohawk Boulevard. 3. Utilities. a. Stormwater and Wastewater. The Springfield Stormwater Facilities Master Plan shows the property as being serviced as built within the O Street Floodway Basin. There are no future stormwater projects planned within the area of the property. The Springfield Wastewater Master Plan shows two future projects, just north and south of the site. These projects are upgrades to the existing lines and the project as proposed will have no impacts on these lines. The Satre Group • 375 Wed Avenue, 3uie 201, Eugene, OR 97,401 • (541) 886-4540 • vrew.sisrec.up.. Milan's House Stile Plan Review Map 17-03-3&21 Lots 4700, 4800, 5700, & 5800 Ow t. Millreee J Stamwater Facilities Master Pla City of Springfield, October 2008 b. Wellhead Protection. The subject property is within the 5 -year and 10-yeartime of travel zone of the i nearby 16' and Q wellfield. Wellhead Protection Areas Map Excerpt City of Springfield and Springfield Utility Board January 2813 1? Page 3 of 7 Centra likI f Wastewater Master Plan City of Springfield 2008 c. Water & Electric. All infrastructure is in place and as such the water and electric infrastructure exist on and adjacent to the subject site. 4. Natural Resources. a. Springfield Natural Resources Study. The Springfield Natural Resource Study Report does not identify any resources on or near the site that would be impacted by the proposed project. b. Springfield Wetland Inventory / Water Quality Limited Watercourses (WQLVV). Neither the National Wetlands Inventory nor the Local Wetlands Inventory document the presence of jurisdictional wetlands on or adjacent to the subject property. Springfield's Water Quality Limited Watercourses inventory also documents that there are no WQLW features on or adjacent to the subject property. The Sal Group • 375 West 4 Avenue, Suite 201, Eugene, OR 97401 • (541) (58&4540 • w .salreereuo.can Kaillin's House Stile Plan Review Map 17-03-36-21 Lots 4700, 4800, 5700, & 5&00 Parks and Open Space. a. The Wllamalane Park and Recreation Comprehensive Plan has one proposed project (1.12) to the east of this project site. This would be the acquisition and redevelopment for a new neighborhood park in an underserved area. Excapl WMmalane Future Pmjeds Map Page 4 & 7 III. SITE REVIEWSTANDARDS This section is presented in the same order of applicable requirements found in Section 5.17.125, Site Plan Review Approval Standards the Springfield Development Code. Applicable sections ofthe Code are in bold italics, followed by proposed findings in normal text. The Director must approve, approve with conditions, or deny an application for Site Plan Review based upon the approval standards listed below. 5.17.125—Approval Standards (A) The Director must approve, approve with conditions, or deny a proposed Site Plan Review application based on the following standards: (1) The proposed land use is a permitted use or is allowed as a discretionary use in the land use district Response: The Metro Plan shows the property as Nodal Development (N D) and the Zoning as Low - Density Residential (LDR) for the site. The site is also within the Mohawk Special Development Plan and is designated as Low -Density Residential in the plan. The property is also within the Hospital Support Overlay District (Section 3.3.1100) and Group Care Homes are an allowed use. The zoning allows for a Residential Care Facility (6 or more people) as a permitted use if it is in conformance with cited code standards. The Site Plan Review is required due to the change in use, Section 5.17.110(A)(1)(c) which states that "Additions, expansions, and changes of use, regardless of size or intervening use, that: (iv) Are located within 50 feet of property in a residential land use district or residentially designated land (as measured from the property line of the subject property)."Therefore, the use is an allowed use, and the following criteria and code standards will be discussed below, followed by the findings for each section. (2) If a use is allowed as a discretionary use, in addition to meeting the standards below, a Discretionary Use application must be approved in conformance with the standards in SDC 5.9.100. Response: The proposed use is a supervised youth detm center within the Hospital Support Overlay District which is an allowed use per SDC 3.3.1120. The Satre Group • 375 West 4 Avenue, 3uie 201, Eugene, OR 97401 • (541) 68&4540 • �.serenmun.oan Kaillin's House Stile Men Review Map 17-03-36-21 We 4700, 4800, 5700, & 5800 Page 5 of 7 (3) The proposal complies with the standards of the land use district of the sub)ect property. The zone is LDR which equates to R-1 Single -Family Residential. In the R-1 Zone, Residential Care Facility — 6 or more people, is an allowed use if it currently meets the Residential Care Facility section 4.7.350. The project meets the section as shown below: Section 4.7.350 Residential Care Facility (A) These facilities must have a front yard setback of 15 feet and side and rear yard setbacks of 20 feet. The landscaped setbacks for parking lots and driveways may be reduced to 5 feet when the Director determines, through a Type 2 process, that adequate buffering has been provided. (B) A minimum of 25 percent of the lol/paroel shall be landscaped. (C) No parking is permitted within the front yard setback. Required parking must be screened from public view. (D) For structures on the Springfield Historic Inventory, any external modification must be in conformance with SDC 3.3.900. (E) The maximum density in the R-1 District is 24 bedrooms per net acre. Response: The property is already developed, and the use is changing from medical offices to a supervised youth detox care facility. The project meets the setbacks required above (see sheet L 2.0 and architectural plans) and the lot has 33% (8,728 square feet) of landscaping which exceeds the 25%(6,534 square feet) minimum landscaping required. There is no parking within the front yard setback, off of H Street, and all parking (located off I Street) is screened from all sides with landscaping. Any distressed or missing required landscaping screening is proposed to be replaced with this application (see sheet L4.0). The primary area for re -landscaping is the planting adjacent to existing parking along the street, adjacent to residential, and the property line along I Street. Additionally, the site is not on the Springfield Historic Inventory list and the maximum density does not apply to this use; therefore, this project meets or exceeds the standards listed above. (4) The proposal complies with any applicable approved masterplan, rnaster facilities plan, refinement plan, and/or special planned district Response: The project site is within the Hospital Support Overlay District, which provides an area in the immediate vicinity of the McKenzie- Willamette cKenzie- WIlamette Hospital with options for future hospital expansion and for hospital related support services. The plan has design standards (Section 3.3.1125) and those standards guide development within the overlay. The design standards state: (A) All yard, lot/parcel size, coverage, density, fencing, parking standards shall be subject to the same standards as professional offices in residential districts. (B) A minimum of 25 percent of the lot/parcel shall be of planted material. (C) Parking lots shall meet the planting standards applicable to commercial development. The Satre Group • 375 West 4 Avenue, 3uie 201, Eugene, OR 97401 • (541) 68&4540 • w .salreomuo.c Mflin's House Site K. Review Map 17-03-36-21 Lots 4700, 4800, 5700, & 5800 Page 6 or 7 As stated above in section 3 the project meets all setbacks, landscaping requirements, parking, and associated standards. Therefore, this criterion is met. (5) The proposal complies with the applicable sections of SDC 4.2, Infrastructure Standards -Transportation. Response: The project site is an existing, approved, and developed medical office complex. The infrastructure is readily available for the site. There are no new public streets or new driveways connecting to the public right-of-way, or public intersections, public sidewalks, or any new street trees proposed with this application. Vision clearance areas will be shown for the existing drive aisle to I Street. The existing parking lot lighting was constructed and is in operation currently and will be discussed below in section 8. Therefore, this criterion is met. (6) The proposal complies with the applicable sections of SDC 4.3, Infrastructure Standards -Utilities. Response: The project does not include any new facilities requiring additional services, water, or wastewater systems or modification to current service. The project stormwater has been designed and is operational. There are no identified or visible natural resources located on-site or adjacent to the development site area. Electrical service to the site is existing and operational. All existing utilities have been researched and shown on the plans. (7) The proposal complies with the applicable sections of SDC 4.4, Landscaping, Screening, and Fence Standards. Response: The project is an existing medical office building that will change the use to a supervised youth detox center. The parking lot, landscape areas, and screening are existing and are in excess of the requirements listed in Section 4.4. There are eight (8) street trees along 16a Street, two (2) street trees along I Street, and three (3) street trees along H street, which is no longer a through street to 16' Street. None of the street trees will be impacted and no new street trees are proposed. There are also five (5) trees within the property in the landscape areas. There is no fencing on-site and none is proposed. There are some distressed shrubs and screening landscaping areas along the eastern property line and within the street frontage along I Street. As part of the project these are proposed to be replaced and enhanced to the standards (see sheet L4.0). All existing mechanical equipment is proposed to be screened. The material will be a solid screen painted to match the existing building. The project is proposing a new trash enclosure (see sheet L3.0) for roll away trash receptacles. This enclosure will also be constructed and painted to match the existing building. Per the email received by the City Engineer Clayton McEachern on 1-18-23, the city will waive the sanitary connection within the trash enclosure since the use is not intensive and no underground site work is being proposed for this project. (8) The proposal complies with the applicable sections of SDC 4.5, Orr -Site Lighting Standards. Response: The three existing boxed lighting for the parking lot and all are shielded downward including the light adjacent to residential property. See sheet L4.0 for locations. (9) The proposal corrplies with the applicable sections of SDC 4.6, Motor Vehicle Parking, Loading, and Bicycle Parking Standards. Response: Per Section 4.6.115, Table 4.6.1, the existing parking spaces meet the dimension requirements for standard spaces, 9 x 18 feet, and have 24 feet of aisle width for backing up. The Satre Group • 375 West 4 Avenue, Suie 201, Eugene, OR 97401 • (541) 68&4540 • w satreomuo.can Mflin's House Site Man Review Map 17-03-36-21 Lots 4700, 4800, 5700, & 5800 Page 7 of 7 There are 31 spaces, of which 21 are standard size spaces, 2 are ADA spaces, 8 spaces are compact, and all spaces meet the dimensions for size and required 24 feet of backup area. Per 4.6.120, the existing parking area is paved, and has a permanent concrete curb system along its perimeter. All spaces will be clearly marked. One existing space is being remove to accommodate the trash enclosure. The number of parking spaces required is based upon the number of employees at the busiest time. The applicant has provided awritten description on how the facility will be operated. The busiest time would have approximately 7-10 employees on shift and there are four (4) bedrooms. This would require one space for the bedrooms and 10 spaces for the employees, requiring 11 dedicated spaces. There are 31 spaces within the parking lot, therefore exceeding the required parking. The project site has two (2) short term bicycle parking spaces adjacent to the entrance on I Street. The standard for bicycle parking is one (1) space per every five (5) employees. This would require two (2) spaces, and this is covered by the existing two spaces on-site. See plan sheet L2.0 for location information. (10) The proposal complies with the applicable sections of SDC 4.7, Specific Development Standards. Response: The standards at 4.7.350, for Residential Care Facilities, was discussed above in Section 3. To recap, the facility meets or exceeds the 15 -foot front yard setback, and the 20 - foot side and rear yard setbacks. The percentage of landscaping is proposed at 33 %or 8,728 square feet, which exceeds the minimum 25% required. There is no parking in the front yard setback and all parking is screened from public areas or proposed to refurbish the existing landscape areas. The east property line and street frontage on I Street will be replanted to replace any of the missing or dilapidated shrubs as part of the development. (11) The proposal complies with the applicable sections of SDC 4.8, Tenporary Use Standards. Response: None of the Temporary Use Standards apply to the project site, therefore this standard does not apply. IV. CONCLUSION The above information represents known applicable planning, zoning, and site development requirements for the contemplated project. It presents known physical conditions and contexts. It captures the project's primary objective. Based on the information and findings contained in this written statement, associated attachments, and plan set the proposed Kaitlin's House project meets the Site Plan Review criteria of approval contained in the Springfield Development Code. Therefore, the applicant requests that the City of Springfield approve the proposal. Both the applicant and the applicant's representative are available for questions. We look forward to working with staff to ensure this project meets the goals and objectives of the applicant and the city. If you have any questions about the above application, please do not hesitate to contact John Schmidt, at The Satre Group, 541-686-4540, or ohn0satrearoup.com. Sincerely, John Schmidt, ASLA The Satre Group The Satre Group • 375 West 4°' Avenue, Suie 201, Eugene, OR 97401 • (541) 68&4540 • w , satreorouo. com G Street Integrated Health Proposed Services Located at 1601 I Street, Springfield OR Dba Kaitlin's House September 6, 2022 City of Springfield Development and Public Works 225 Fifth St Springfield, OR 97477 RE: 1601 I St, Springfield, OR 97477 To Whom It May Concern, G Street Integrated Health is interested in opening a youth detox facility at the above referenced property. Included in this packet is information about G Street and the proposed facility specifics. I have included our Site Plan Pre -Submittal and a check for $449. Our Mission G Street Integrated Health was founded on the principle that everyone in our community deserves comprehensive, professional health care, delivered with respect and kindness, including to those most vulnerable. Our History G Street Integrated Health developed through a Trillium Community Health Plans grant, and opened on October 1, 2019, as a non-profit 501(c)3. We were soon hit with a global pandemic and when other ambulatory clinics were furloughing employees and closing their doors, we stayed open and experienced exponential growth. We started in 2019 with eight employees and within three years have grown to a staff of 57. Each member of our team shares in our mission and provides unsurpassed care to our patients, regardless of their economic status. We are a Five Star Patient Centered Medical Home as designated by the Oregon Health Authority. This is the highest honor bestowed upon clinics who undergo a rigorous auditing process to prove their commitment to patients, quality, and the health care experience. While Family Medicine is our core service, we also expanded our offerings as we identified gaps in service availability within our community. We have dual Certificates of Authority from the Oregon Health Authority for our co -located Behavioral Health Services and Addiction Services. Not only do we have a Board -Certified Addiction Medicine physician on Page 1 1 staff, we also are so fortunate to have two Psychiatrists on staff - truly unheard of in a Family Practice setting. As we continue to find voids in the medical offerings in our community, we add needed services. Most recently, we added a dental clinic, and in-house Pharmacist for consultation on patients with complex pharmacologic regimens. Our Proposal There currently is no medically supervised detox facility for youth in Oregon. The closest is in Spokane, WA. Most residential treatment centers for youth require that the patient be detoxed prior to placement in their facility. Currently, the youth of Lane County are detoxing at home or in the Emergency Department of one of our two local hospitals. Kaitlin's House is designed to serve 10 youth, all genders, ages 13-17, in need of medically supervised detoxification prior to placement in a residential treatment center. The youth are divided into two wings based on gender, are roomed with youth of similar age and substance use background. The program will provide a safe and secure environment for youth to detox, under medical supervision, for three to seven days. Youth will be welcomed in a home -like environment and receive their initial assessment including medical and dental care. We will provide stabilization services and lay the groundwork for successful treatment at a residential treatment center. Family participation and partnership is paramount in the child's quest for a drug and alcohol free life. We will contract with both the State of Oregon and all commercial insurance plans for services provided to youth. Admission Criteria Kaitlin's House will welcome youths of any gender between the ages of 13 and 17 years who are in need of short-term, secure, medically monitored drug and alcohol detox and stabilization. With a very specific screening process, Kaitlin's House will protect those in its care; therefore, the following conditions will exclude youth from detoxing at Kaitlin's House: • Non -treated sex offender • Current predatory sexual acting out • Severe Development Disabilities (mild impairment considered on a case-by-case basis) • Severe mental health diagnosis as primary presenting problem o Severe psychosis o Auditory or visual hallucinations o Extreme suicide risk Proeram Structure Kaitlin's House will be designated as a Detox for Youth facility. All staff will pass a background check and be cleared to work with children prior to start date. The building as well as its grounds will be monitored by 12 CCTV cameras that are backed up to the cloud. Visitors to Kaitlin's House are allowed during regularly scheduled visitation times only and are limited to immediate family members. Exterior doors are to remained locked and staff will have access badges to enter the facility. Youth are not allowed to leave while in Page 12 treatment unless removed from the program by a guardian, in which case they are no longer eligible for services moving forward. The staffing model will include: • Medical Director - Michelle Kaplan, MD (board certified family medicine and addiction medicine) • Director of Youth Services Kaitlin Richardson • Medical Staff Services o Sebastian Brunning, PA -C o Anna Hancock, PA -C o Amanda Aldrich, FNP o Six Registered Nurses to provide 24-hour coverage • Security - six security workers to provide 24-hour coverage • Behavioral Health Workers o Three Qualified Mental Health Associates (QMHA) will work with youth on skill - building o Two Certified Alcohol and Drug Counselors (CADC) will work with youth in one-hour individualized counseling sessions with family in attendance to help prepare for residential treatment. There is no foot traffic in this design. Youth have an intake, stay in the building three -seven days, and then are transported to a residential treatment center. The campus at 1601 I St is perfect and requires no modifications to the interior or exterior of the building. Staff Trainine All staff will have mandatory training to include: • Trauma Informed Care • Attachment Regulation Competency • Collaborative Problem Solving • Basic Mental Health • Oregon Intervention System or Crisis Prevention Intervention • Effectively Engaging with Parents • Child Brain Development • General training in child abuse prevention • HIPAA • Behavioral health/substance use disorder records laws • Office policies, procedures, and compliance Page 13 In Conclusion Kaitlin's House will be the only medically assisted youth detox center in the State of Oregon. The locality of 1601 I St, Springfield, OR, is ideal for this program, given its close proximity to G Street Integrated Health (its parent facility) and McKenzie—Willamette Hospital. We truly hope that we do not experience a medical crisis but are well supported and prepared if we do. It is my hope that the City of Springfield will support and endorse this program and its proposed location. This property was recently purchased and I have met with the new owners, who take possession later this month. They have indicated they will offer G Street Integrated Health a five-year lease, contingent on our ability to gain Springfield's Planning Division approval for our project. If you would like additional information, please let me know. With sincerest thanks, Jennifer Ocker Executive Director G Street Integrated Health dba Kaitlin's House 541-735-9421 desk jocker@gstih.org Page 14 )DHS I of HOregon Department ,man Services Attachment A Initial Licensing Required Documents Instructions: Do not submit your application unless all required documents listed below are included with your application. You are encouraged to submit documentation in an electronic format. Please note that additional documentation may be requested as needed. f/ a/ Applicant: By-laws, Amendments 413 -215 - Form 413-215-0081(3) (c) (see attached V 413-215-0081(4)(k) Completed Executive Background Check 413-215-0081(3) (f) This request was submitted to the Background Check Unit on your behalf on 413 -215 - Program Description 413-215-0081(3)(h) Proof of compliance with ORS 336.57 413-215-0081(3)(1) Residential ro rams onl - r� J'V Policies and procedures 413-215-0081(3)(j) (see Attachment C) Floor Plans 413-215-0081(3) (k) excludes Adoption, Foster Care A encies and non -base cam Outdoor Youth programs Proof of adequate fire, auto, and liability Insurance ata -215- 0081 3 1 $1 million each occurrence, $ 3 million aggreRate Emergency Procedures 413-215-0081(3)(m) (please refer to me Attachment C that is specific to the type of license to which you are V a 1 in Completed Fire Marshal Inspection 413-215-0081(3)(n) excludes Adoption, Foster Care Agencies and non -base camp Outdoor Youth P rams Completed Sanitarian Inspection 413-215-0081(3)(n) excludes Adoption, Foster Care Agencies and non -base camp Outdoor Youth Pro hams ✓ Suitability Questionnaire 413-215-0081(3) (o) or Program klLICENSING)CCLU Forms& TsmplateslNew Applicants - Forms (Rev. 1]0329) Y(wS APPLICATION FOR LICENSE PRIVATE CHILD CARING AGENCY epartment (Pursuant to ORS 418.240, 418.327) of Human Servicess (Thisform is notforfamiilyf./o/sstterparents) LICENSEE U.()f7Y G �/1� �CLWebsite--(�•ISiti • �l v !V !.-��%�9 (Corporation or Agene ams) /- ADMINISTRATIVE OFFICE ADDRESS �� 3�E & 5t j'k -174 77 (Street) (city) (Zip)p,p MAILING ADDRESS (if different) -� T�C� I� �d �`�"'"- //_ 4 777 (Street) (City) (Zip) tl '/7}y/`# '/ (-ter ,L COUNTY r—�"''t' `� Phone i✓�`'r� 73D' Fax # 6ti?-7y-7 ��ma�address PURPOSE: X Initial License 7 Re -license :1 Change (of facility orprogam) :1 Add a New Pmgmm PROGRAM TYPE (If more than one, skip below to 111): (A) Academic Boarding School (413-215-0301 through 0276) (B) Foster Care Agencies (413-215-0301 through 0396) C Ado lion A --gi - - ihr u 0481 (D) Residential Care (413-215-0501 through 0586) (E) Eherapeufie Boarding Schao (413-2 L5-0601 ough 0681) (F) Homeless, Runaway, and Transitional Living Shelters (413-215-0701 through 0761) (G) Day Treatment (413-215-0801 through 0856) (H) Outdoor Youth Programs (413-215-0901 through 103 1) np LIST EACH OF THE ABOVE PROGRAM COMPONENTS for which you are requesting licensure. Also provide details as requested below. (Use additional paper if needed) Program/Component/Name Address Type (Choose Letter above) pge Range Capacity Executive Director: (Print or type full name) 61 1/11 k 66(1, / Executive Director: Chairman of the Boa Received (Date Stamp) RETURN TO: Department of Human Services Children's Care Licensing Program 201 High Street NE; Suite 500 Salem, OR 97301 (503) 947-2331—phone (503)378 -2558 -fax _7 7 cQ D CD `G n 0 0 0 7 O 3 7 r l z 3 m is 'm 'o O w �1 W a N v � 3 m_ _7 7 cQ D CD `G n 0 0 0 7 O 3 7 [\}! \{\)}(\ LL (3(((\ }(��\ N � 0 w a e w M ? w P fU N �wi O ti' O N � rn n ° w m a � o ° '3 `°C m rn N m �J z o0 G Street Integrated Health DBA Kaitlin's House Personnel List with lob Titles October 2022 Jennifer Ocker Executive Director Michelle Kaplan, MD Medical Director Allen Jost Director of Operations Kaitlin Richards Director of Youth Services Richard Reaksecker Director of Technology Sebastian Brunning, PA -C Physician Assistant Amanda Aldrich, FNP Family Nurse Practitioner David Nowak, CADC II Drug and Alcohol Counselor Jodi Hecht, QMHA Case Manager Brenda Torres -Sanchez, MA Medical Assistant Jessica Harris, MA Medical Assistant To be determined Cook To be determined Security (3) — 24 hour coverage To be determined Nurse (3) —24 hour coverage m qi� �� � 0 ) w ( CD //. / � w/ G � 00 > »eƒ � \/\ � \ 9 \ m qi� �� � w ( CD / > � � \ } / to 3 0 » 0 0 0 0 0 0))( w 0 0 } / } } / / / / /CD m qi� �� n3 E 0 m 3 m 3 n 0 n m N s 0 'm m 3 w W m a 0 0 m 2. m N U O G O N 2 )DHS ° °s°n DepadmeM Verification of Suittability %y �j �f �'p/ /� q/j/Jr =01%d1eS Agency Name: C, -?A4&lrn-�CedeA_4A� ' _ Executive Director: In order to evaluate the suitability of a child caring agency and its staff, OAR 413-215-0021(5) requires a child caring agency to immediately disclose to the Department all of the information contained in (a) through (f). Please complete this form (attaching additional documentation where necessary) and sign and return with your completed application. Indicate whether or not any of the following applies to your agency, or any of your agency's employees or board members by checking the appropriate box (yes or no). Exclude incidents which have already been reported through other methods of notification to DHS. (a) Each instance in which the child -cuing agency or a member of its staff or board of directors has permanently lost the right to prayide services to children or families in any jurisdiction, and the basis for each action. If yes, please explain: (b) The circumstances and disposition of any licensing denial, suspension, or revocation; or any other negative sanction or proposed sanction by an oversight body against the child -caring agency or a member of its staff or board of directors, if the denial, suspension, or revocation; or any other negative sanction or proposed sanction results from conduct that is relevant to the child -caring agency's, staffs, or board member's ability or fitness to carry out the duties imposed by these rales and governing statutes If yes, please explain: (c)For the previous 10 years, any disciplinary action against or investigation or me cram -caring agency to a member of its staff or board of directors by a licensing or accrediting body, including the basis and disposition of each action, if the disciplinary action or investigation results from conduct that is relevant to the agency's or staffs or board member's ability or finess to carry out the duties imposed by these rules and governing statutes. If yes, please explain: IrILJCENS/NGCCLP Forms & TemplatesWew Applicants —FormsIDRAFTS (Rev 170828) (d) Any instance the child -caring agency becomes aware of in which the child -caring agency or a member of its staff or board of directors has been found guilty of any crime under federal, state, or foreign law. If yes, please explain: (e) Any civil or administrative violation involving financial irregularities by the agency or a member of its staff or board of directors ulider federal, state, or foreign law. If yes, please explain: (f) For the previous five years, any instance in which the child -caring agency, a member of its board of directors, or its executive or program director has filed for bankruptcy. If yes, please explain: New Applicants Only. In addition to (a) through (f), OAR 413-215-0081(3)(o) requires the following at the time of application: "For the previous 10 years, a copy of each report by a federal or state authority concerning a criminal charge, charge of child abuse, malpractice complaint, or lawsuit against the child caring agency, a member of the child -caring agency's board of directors, or ane of, mployees related to the provision ofservices, and the basis and disposition ofeach action, tfappllcable." W E -Mail j Phone )DHS Oregon Department of Human Services Background Check Form Children's Care Licensing Program Background Check Form (Please complete all areas of the form, asterisk indicates a required field) Social Security # (Note This is voluntary. The SI must approve): f �(.A pp ­& 0'3 5 *Complete Name /, �.V,, , /; _ b yv .— *Date of birth(mm/dd/yyyy) ` UJ *Residential address 11❑ *Mailing address (if different) *Residential History outside OR, past five years (SI will also disclose this); List Addresses below *Include years lived at each address that was outside of OR within the past 5 years. Year From: Year to: *Prior names and aliases ,TUQF\A fAl-tl�.IR�ijr *Gender: mark applicable box Male: Female:Unknown/Not Specified: Other: Both: 11❑ ❑ ❑ *Phone(� r71 Z7 q *Type of Phone (home, mobile, etc.) ISWI I:\LICENSING\CCLU Forms & Templates (Rev 11/10/2020( )DHS Oregon Department of Human Services Background Check Form Children's Care Licensing Program 2nd Phone f — %O Type of Phone (home, mobile, etc.) yl/L U , 15.11, , *Email address *Position Title I _/K Vz_ Dlrel *Provide Position Description to CCLP when submitting this form: i .tY_rtYyi �V l5A7Y r *Position Requires Direct Contact Adults: Children: ❑ Confidential Information: with: (mark each applicable box) ❑ *Expiration Date — 7-o2- -a03c� Finances/Financial Information Technology Systems: Seniors: ❑ Records: *Position Requires: Driving? ❑ *Driver's License *Issuing State/Authority 02 *Drivel's License# (,4 �-7& 36'1141i *Expiration Date — 7-o2- -a03c� *Provide copy of front and back of driver's license. j2rovLAuA * Will you be housing youth in the Custody of Child Welfare?�' *Will the location(s) be secure facilities? I(/m�5 I:\LICENSINGl Forms&Templates (Rev 11/10/2020) ARTICLES OF INCORPORATION Corporation Division www.filinginoregon.com REGISTRY NUMBER 157894891 TYPE DOMESTIC NONPROFIT CO ZPOPj 1. ENTITY NAME G STREET INTEGRATED HIT 2. MAILING ADDRESS PO BOX 10567 EUGENE OR 97440 USA 3. NAME & ADDRESS OF B KEVIN BURGESS 1203 WILLAMETTE STS EUGENE OR 97401 USA 4. INCORPORATORS B KEVIN BURGESS PO BOX 10567 EUGENE OR 97440 USA S. INITIAL PRESIDENT JENNIFER OCKER 1435 G ST SPRINGFIELD OR 97477 US 6. INITIAL SECRETARY JENNIFER OCKER 1435 G ST SPRINGFIELD OR 97477 USA AGENT 7. TYPE OF NONPROFIT CORPORATION Public Benefit 8. MEMBERS? No E -FILED Jul 24, 2019 OREGON SECRETARY OF STATE Corporation S. DISTRIBUTION OF ASSETS OREGON SECRETARY OF STATE Upon the dissolution or final Ik uidation of the Corporation, the assets of the Corporation remaining after satisfaction of the Corporations obligation and liabilities shall be distributed to any organization selected by the Corporations board of directors which at the time of distribution is qualified as a Section 501(c)(3) corporation under the Internal Revenue Code, and no assets of the corporation shall inure to any director, officer or member of the Corporation or any other individual. Notwghs ending anything to the contrary herein, no articles of dissolution shall be filed with the Corporation Division until the Corporation has given the notice required by law to the Oregon Attorney General, and no asset shall be transferred conveyed as a part of the dissolution, until all provisions of Oregon law have been complied with. S. OPTIONAL PROVISIONS The corporation elects to indemnify its directors, officers, employees, agents for liability and related expenses under ORS 65.387 to 65.414. I I declare as an authorized signer, ththis filing has been examined by me and is, to the best of my knowledge and belief, true, correct, and comple . Making false statements in this document is against the law and may be penalized by fines, imprisonment, or oth. By typing my name in the electronicSform ignature field, I am agreeing to conduct business electronically with the State of Oregon. understand that Vidreactions and/or signatures in records may not be denied legal effect solely because they are conducted, execu[ d, or prepared in electronic and that if a law requires a record or signature to be in writing, an electronic record or signature satisfies that requirement. q a x91:i•]: I bi-9 [d: C\ i rf:7 � NAME B KEVIN BURGESS TITLE AUTHORIZED AGENT DATE SIGNED 07-24-2019 BYLAWS OF G STREET INTEGRATED HEALTH 1. OFFICES 1.1. Principal Office. The principal office of the Corporation in the state of Oregon shall be located in Springfield, Oregon. The Corporation may have such other offices in or out of the state of Oregon as the Board of Directors may designate or as the business of the Corporation may require from time to time. 1.2. Registered Office. The registered office of the Corporation required by the Oregon Nonprofit Corporation Act to be maintained in the state of Oregon may be, but need not be, identical with the principal office in the state of Oregon, and the address of the registered office may be changed from time to time by the Board of Directors upon compliance with the requirements of the Oregon Nonprofit Corporation Act for change of the registered office. 2. MEMBERSHIP. The Corporation shall have no members, and shall not issue any shares of capital stock. 3. BOARD OF DIRECTORS. 3.1. General Power. The business and affairs of the Corporation shall be managed by its Board of Directors. 3.2. Number, Tenure, and Oualificalions 3.2.1. The number of directors of the Corporation shall be not less than three nor more than fifteen. The initial Board shall consist of three directors. The Board is authorized to increase or decrease the number of directors serving by action of a majority of directors then serving, provided that no action to decrease the number of directors shall be effective other than at the end of a director's term of office. 3.2.2. Except for the initial directors, each director shall serve for a term of three years. The initial directors shall be classified as having a term of either one, two, or three years. As each director's term of office expires, that vacancy shall be filled for a new three-year term. 3.2.3. No director may serve for more than two consecutive terms. For the purpose of this paragraph, a term is any term lasting 18 months or more. 3.3. Regular Meetings. A regular annual meeting of the Board of Directors shall be held during the last month of the Corporation's fiscal year, at such time and place as determined by the directors, and with appropriate notice. The Board of Directors may provide, by Bylaws - I S:WAGS1 NRMI G nCm \Byla s(103319).do resolution, the time and place, either within or without the state of Oregon, for the holding of additional regular meetings. The resolution shall set forth the notice for the meeting. In addition, the Board shall schedule quarter-annual meetings. 3.4. Special Meetings. Special meetings of the Board of Directors may be called by or at the request of the president or any two directors. The person or persons authorized to call special meetings of the Board of Directors may fix any place, either within or without the state of Oregon, as the place for holding any special meeting of the Board of Directors called by them. 3.5. Notice. Notice of any special meeting shall be delivered at least three days prior to the meeting and notice of any regular meeting shall be delivered at least 10 days prior to the meeting, all notices may be delivered either orally by telephone or in person, or by written notice delivered personally or mailed to each director at the director's address. If mailed, such notice shall be deemed to be delivered on the second day following deposit in the United States mail. Any director may waive notice of any meeting. The attendance of a director at a meeting shall constitute a waiver of notice of such meeting, except where a director attends a meeting for the express purpose of objecting to the transaction of any business because the meeting is not lawfully called or convened. Neither the business to be transacted nor the purpose of any special meeting of the Board of Directors must be specified in the notice or waiver of notice of such meeting. 3.6. Quorum. A majority of the number of directors in office immediately before the commencement of the meeting shall constitute a quorum for the transaction of business at any meeting of the Board of Directors. 3.7. Manner of Acting. Unless expressly provided otherwise in these Bylaws, the act of a majority of the directors present at a meeting at which a quorum is present shall be the act of the Board of Directors. Directors shall be deemed to be present at a regular or special meeting where all directors participating may simultaneously hear each other during the meeting, irrespective of whether or not they are present in the same location, as by a telephonic conference. 3.8. Vacancies. Any vacancy occurring on the Board of Directors may be filled by the affirmative vote of the majority of the remaining directors. If there is only one remaining director, the remaining director may appoint the person or persons required to fill any vacancies. A director elected to fill a vacancy shall be elected for the unexpired term of that director's predecessor in office. - 3.9. Presumption of Assent. A director of the Corporation who is present at a meeting of the Board of Directors at which action on any corporate matter is taken shall be presumed to have assented to the action taken unless his dissent shall be entered in the minutes of the meeting or unless he or she shall file his or her written dissent to such action with the person acting as the secretary of the meeting before the adjournment thereof or shall forward such dissent by registered mail to the secretary of the Corporation immediately after the adjournment of the meeting. The right to dissent shall not apply to a director who voted in favor of the action. Bylaws - 2 3.10. Removal. At any meeting of the Board of Directors, any individual director may be removed from office with or without cause by a vote of two-thirds of the directors then serving. 3.11. Resienation. Any director of the Corporation may resign at any time by giving written notice to the Corporation, to the Board of Directors, or to the chair of the Board, or to the president, or to the secretary of the Corporation. Any such resignation shall take effect at the time specified in the notice, or, if no time is specified, upon its acceptance by the Board of Directors. 3.12. Annual Election of Directors. Directors shall be elected by the Board of Directors. The Nominating Committee shall present a slate of directors. Other nominations may be made. The person receiving the most votes for each director position vacancy shall be elected to that position. 4. OFFICERS. 4.1. Number. The officers of the Corporation shall be a president and secretary, each of whom shall be elected by the Board of Directors. Other officers, such as vice-presidents, treasurer, or assistant officers, may be elected by the Board of Directors. 4.2. Election and Term of Office. The officers shall be elected annually by the Board of Directors at the first meeting of the Board of Directors. If the election of officers shall not be held at such meeting, such election shall be held as soon thereafter as conveniently may be. Each officer shall hold office until that officer's successor shall have been duly elected and shall have qualified or until that officer's death or until the officer shall resign or shall have been removed in the manner hereinafter provided. 4.3. Removal and Resignation. Any officer or agent elected or appointed by the Board of Directors may be removed by an affirmative vote of two-thirds of the directors then serving whenever in its judgment the best interests of the Corporation would he served thereby. Any officer of the Corporation may resign at any time by giving written notice to the Corporation, to the Board of Directors, or to the chair of the Board, or to the president, or to the secretary of the Corporation. Any such resignation shall take effect at the time specified therein, or, if the time be not specified therein, upon its acceptance by the Board of Directors. 4.4. Vacancies. A vacancy in any office because of death, resignation, removal, disqualification or otherwise, may be filled by the Board of Directors for the unexpired portion of the term. 4.5. Salaries. The salaries of the officers may be fixed from time to time by the directors. 4.6. Chair of the Board. The Board of Directors may elect a chair of the Board. If such chair is elected, the chair shall preside at all meetings of the Board of Directors and shall perform such other duties as may be prescribed from time to time by the Dowd of Directors. Bylaws - 3 4.7. President The president shall be the principal executive officer of the Corporation and, subject to the control of the Board of Directors, shall in general supervise all of the business and affairs of the Corporation. The president shall preside at all meetings of the Board of Directors where there is no chair of the Board. The president may sign, with the secretary -treasurer or any other proper officer of the Corporation authorized by the Board of Directors, any deeds, mortgages, bonds, contracts, or other instruments which the Board of Directors has authorized to be executed, except in cases where the signing and execution thereof shall be expressly delegated by the Board of Directors or by these Bylaws to some other officer or agent of the Corporation, or shall be required by law to be otherwise signed or executed; and in general shall perforin all duties incident to the office of president and such other duties as may be prescribed by the Board of Directors. 4.8. Vice -President. In the absence of the president or in the event of the president's death, inability or refusal to act, the vice-president, if any (or in the event there be more than one vice-president, the vice-presidents in the order designated at the time of their election, or in the absence of any designation, then in the order of their election) shall perform the duties of the president and when so acting, shall have all the powers of and be subject to all the restrictions upon the president. Any vice-president shall perform duties as from time to time may be assigned to the vice-president by the president or by the Board of Directors. 4.9. Secretary. The secretary shall 4.9.1. Keep or cause to be kept at the principal office, or such other place as the Board of Directors may order, a book of minutes of all meetings of directors showing the time and place of the meeting, whether the meeting was regular or special and, if a special meeting, how authorized, the notice given, the names of those present at directors meetings, and the proceedings thereof. 4.9.2. In general perforin all duties incident to the office of secretary and such other duties as from time to time may be assigned to the secretary by the president or the Board of Directors. 4.10. Treasurer. The treasurer shall 4.10.1. Be responsible for the funds of the Corporation, shall pay them out only on the checks of the Corporation signed in the manner authorized by the Board of Directors, shall deposit and withdraw such funds in such depositories as may be authorized by the Board of Directors, and shall keep full and accurate accounts of receipts and disbursements in books maintained at the Corporation's principal office. 4.10.2. In general perform all of the duties incident to the office of treasurer and such other duties as from time to time may be assigned to the treasurer by the president or by the Board of Directors. Bylaws - 4 5. CONTRACTS, LOANS, CHECKS, AND DEPOSITS. 5.1. Contracts. The Board of Directors may authorize any officer or officers, agent or agents to enter into any contract or execute and deliver any instrument in the name of and on behalf of the Corporation, and such authority may be in general or confined to specific instances. 5.2. Loans to Corporation. No loans shall be contracted on behalf of the Corporation and no evidences of indebtedness shall be issued in its name unless authorized by a resolution of the Board of Directors. Such authority may be general or confined to specific instances. 5.3. Checks. Drafts, Etc. All checks, drafts or other orders for the payment of money, notes or other evidences of indebtedness issued in the time of the Corporation, shall be signed by such officer or officers, agent or agents of the Corporation and in such manner as shall from time to time be determined by resolution of the Board of Directors. 5.4. Deposits. All funds of the Corporation not otherwise employed shall be deposited from time to time to the credit of the Corporation in such banks, trust companies or other depositories as the Board of Directors may select. 5.5. Execution of Documents. The Board of Directors may, except as otherwise provided in these Bylaws, authorize any officer or agent of the Corporation to enter into any contract or execute any instrument in the name of and on behalf of the Corporation. Such authority may be general or confined to specific instances. Unless so authorized by the Board of Directors, or unless inherent in the authority vested in the office under the provisions of these Bylaws, no officer, agent or employee of the Corporation shall have any power or authority to bind the Corporation by any contract or engagement, or to pledge its credit, or to render it liable for any purpose or for any amount. 5.6. Loans. The Corporation shall not lend money to, nor guarantee the obligations of, any director, officer or employee of the Corporation. 6. FISCAL YEAR. The fiscal year of the corporation shall begin and end at such time as the Board of Directors shall provide. 7. SEAL. If the Board of Directors elects to provide a corporate seal, it shall be circular in form and shall have inscribed thereon the time of the Corporation and the state of incorporation and the words, "Corporate Seal - Oregon." 8. WAIVER OF NOTICE - FORM OF NOTICE. 8.1. Waiver of Notice. Whenever any notice is required to be given to a director of the Corporation under the provisions of these Bylaws or under the provisions of the Oregon Bylaws - 5 Nonprofit Corporation Act, a waiver thereof in writing, signed by the person or persons entitled to such notice, whether before or after the time stated therein, shall be deemed equivalent to the giving of such notice. 8.2. Form of Notice. Whenever, under the provisions of the Oregon Nonprofit Corporation Act or these Bylaws, notice is required to be given to a director, it shall not be construed to mean only personal notice, but shall include notices as defined below. 8.3. Director Notice. Required notice to a director may be given in writing by mail or facsimile, addressed to such director at the address as it appears on the records of the Corporation, or at the last known business or residence address of the director, prepaid, and such notice if mailed shall be deemed to be given at the time when the same shall be deposited in the United States mail (except as expressly provided for otherwise in paragraph 3.5), and if transmitted by facsimile shall be deemed to be given upon the earlier of personal receipt by the director or 24 hours following the completed transmittal. 9. AMENDMENTS. These Bylaws may be altered, amended, or repealed and new Bylaws adopted by a majority of the directors of the Corporation. 10. INDEMNIFICATION OF DIRECTORS AND OFFICERS. 10.1. Directors and Officers. The Corporation shall indemnify to the fullest extent permitted by law, any person who is made, or threatened to be made, a party to or witness in, or is otherwise involved in, any threatened, pending or completed action, suit or proceeding, whether civil, criminal, administrative, investigative, or otherwise (including any action, suit or proceeding by or in the right of the Corporation) by reason of the fact that: 10.1.1. The person is or was a director or officer of the Corporation or any of its subsidiaries; 10.1.2. The person is or was serving as a fiduciary within the meaning of the Employee Retirement Income Security Act of 1974 with respect to any employee benefit plan of the Corporation or any of its subsidiaries; or 10.1.3. The person is or was serving, at the request of the Corporation or any of its subsidiaries, as a director or officer, or as a fiduciary of an employee benefit plan, of another corporation, partnership, joint venture, trust or other enterprise. 10.2. Employees and Other Agents. The Corporation may indemnify its employees and other agents to the fullest extent permitted by law. 10.3. Advances of Expenses. The expenses incurred by a director or officer in connection with any threatened, pending or completed action, suit or proceeding, whether civil, criminal, administrative, investigative, or otherwise, which the director or officer is made or threatened to be made a party to or witness in, or is otherwise involved in, shall be paid by the Corporation in advance upon written request of the director of officer, if the director or officer: Bylaws - 6 10.3. 1. Furnishes the Corporation a written affirmation of his or her good faith belief that he or she is entitled to be indemnified by the Corporation; and 10.3.2. Furnishes the Corporation a written undertaking to repay such advance to the extent that it is ultimately determined by a court that he or she is not entitled to be indemnified by the Corporation. Such advances shall be made without regard to the person's ability to repay such expenses and without regard to the person's ultimate entitlement to indemnification under this or otherwise. 10.4. Nonexclusivity of Rights. The rights conferred on any person by this paragraph shall be in addition to any rights to which a person may otherwise be entitled under any articles of incorporation, bylaw, agreement, statute, policy of insurance, vote of Board of Directors, or otherwise. 10.5. Survival of Rights. The rights conferred on any person by this paragraph shall continue as to a person who has ceased to be a director, officer, employee or agent of the Corporation; and shall inure to the benefit of the heirs, executors and administrators of such person. 10.6. Amendments. Any repeal of this paragraph shall be prospective only and no repeal or modification of this paragraph 10 shall adversely affect any right or protection that is based upon this paragraph 10 and pertains to an act or omission that occurred prior to the time of such repeal or modification. 11. TRANSACTIONS BETWEEN CORPORATION, INTERESTED DIRECTORS. 11.1. Conflict of Interest. A transaction with the Corporation in which a director of the Corporation has a direct or indirect interest is not voidable by the Corporation solely because of the director's interest in the transaction if either (1) the material facts of the transaction and the director's interest were disclosed or known to the Board of Directors or a committee of the Board of Directors, and the Board of Directors or committee authorized, approved or ratified the transaction; or (2) the transaction was fair to the Corporation. Authorization, approval or ratification occurs if a majority of the directors on the Board of Directors or on the committee, who have no direct or indirect interest in the transaction vote to authorize. 11.2. Disqualification. A director of the Corporation shall not be disqualified by the director's office from contracting with the Corporation as vendor, purchaser, or otherwise; nor shall any contract or arrangement entered into by or on behalf of the Corporation in which any director is in any way interested be voided on that account, provided that such contract or arrangement shall have been approved or ratified by a majority of the Board of Directors without counting in such majority the director so interested, although such director may be counted toward a quorum. Bylaws - 7 12. MISCELLANEOUS. 12.1. Informal Action by Directors. Any action required by the Oregon Nonprofit Corporation Act to be taken at a meeting of directors or any other action which may be taken at a meeting of the directors may be taken without a meeting if a consent in writing setting forth the action so taken be signed by all of the directors entitled to vote with respect to the subject matter thereof. Such consent shall have the same force and effect as the unanimous vote of such directors. 12.2. Books and Records. The Corporation shall keep correct and complete books and records of account and shall keep minutes of the proceedings of its Board of Directors. 13. COMMITTEES. The Board of Directors may establish special committees from time to time as they deem necessary for the effective management of the Corporation. In addition, there shall be the following standing committees, the members of which shall be appointed by the Board. 13.1. Executive Committee. The Executive Committee shall have primary responsibility for the Corporation's day-to-day operations and shall consist of three members. The Committee members shall be appointed by the Board. 13.2. Nominating Committee. The Nominating Committee shall present a slate of directors for election as vacancies occur. The Nominating Committee shall consist of three persons, all to be appointed by the Board. 14. CORPORATE PURPOSE. 14.1. This Corporation is intended to qualify as a tax-exempt nonprofit entity under Section 501(c)(3) of the Internal Revenue Code, as amended from time to time, and as a public benefit corporation as defined under Oregon Revised Statutes, Chapter 65, as amended from time to time. The Corporation is organized exclusively for charitable, scientific and educational purposes within the meaning of Section 501(c)(3) of the Internal Revenue Code. Notwithstanding any other provisions of these Articles, the Corporation shall not carry on any activity not permitted to be carried on (a) by a corporation exempt from Federal income tax under Section 501(c)(3) of the Internal Revenue Code of 1986 (or the corresponding provision of any future United Sates Internal Revenue Law) or (b) by a corporation contributions to which are deductible under Section 170(c)(2) of the Internal Revenue Code of 1986 (or the corresponding provision of any future United States Internal Revenue Law). ADOPTED effective July 24, 2019. 4 c, lean Munro, Secretary Bylaws - 8 FIRE CODE INSPECTION FIELD NOTES OCCUPANCY: ADDRESS: Person Contacted (Print): Business Phone: Cell Phone: REINSPECTION TO VERIFY COMRC AN UCORRECTION Email: REINSPECTION BE DONE ON OR ABOUT s Date Inspectors: 6;7St' t -1 V l ShiMflon Date C e VIOLATION V COMMENTS (See back for explanation) fJ) - U4�WzeFq Gl % d'' L EM -- This inspection is intemIFLIoryour safety and the safety of our community. The Item(s) noted may be in violation of the Springfield or Eugene dF'An lolal Notice of Violation and Opportunity to Correct will be provided to you. LJI aAaAreeing to rec email COunicat on is inspection. Receive 'By: (sign J FPS J Key Box EOCENE EUGENE SPRINGFIELD FIRE SPRINGFIELD PO BOX 4120 PMB 47649 PORTLAND, OR 972084120 FIRE Dear Building Owner or Responsible Party, We are notifying you because our records indicate one or more fire protection system(s) is past due for testing or in need of repairs at 1600 H ST, SPRINGFIELD, OR 97477-4235. Fire Protection Systems Past Due for Testing: Premises Profiles Past Due Last Test Date Renewal Date Fire Alann 1 864 days 1 05/13/2019 1 06/13/2020 Reviewed Reports with Outstanding Deficiencies: (None found.) What to Do / Next Steps I Did Have My Testing or Repairs Completed If the testing and/or repairs listed have been completed simply notify the company you had complete them and that they need to update The Compliance Engine database with the proper documentation. I Did NOT Have My Testing or Repairs Completed System testing and repairs must be completed in order for this building to be updated to a compliant status. Please contact a licensed contractor to complete the testing and/or repairs. Once completed, they need to submit the documentation to www.thecomplianceengine.com. Keith Haggas Deputy Fire Marshal EUGENE SPRINGFIELD FIRE NID 5098093 n a rT$ Gee CCB 16559 L^STSTEMS, 1NC..n INSPECTION AND TESTING FORM Data: 6/13/19 - - Time: 9:00 AM SERVICE ORGANIZATION PROPERTY NAME (USER) Name: INTEGRATED ELECTRONIC SYSTEMS INC - - - _ - - - - Name: LAZER SOLUTIONS Address: PO BOX 708 - EUGENE, OR 97440 1 ____ "" ---- ' - -'- - - - - - Address: 1600 H ST SPRINGFIELD, 97477 Representative: Owner Contact NATASNA mense No.: CCB#165599 '- ' - - Telephone: 45&201-7084 Telephone: 5_41_-085.4.456 - _ - APPROVING AGENCY NTITY MONITORING. IE Content: Contact: N ._. Telephone:_ Telephone: - _ Monitoring Amount Ref. No.: SERVICE - - ❑ Weekly ❑ Monthly ❑ Quarterly TYPE TRANSMISSION ❑ Semiannual) y ®Annually ❑McCulloh ❑Multiplex ®Digital ❑ Other (Specify) Sensitivity N OR [I Reverse Priority [I RF- Y ❑ Other (Specify) - r. Cannot Unit Manufacturer:n Mc fk&A' 't Model No.: Circuit Styles:-- NumberofCirefte: Software Rev.: AJpj. Last Data System Had Any Service Performed: Last Data That Any Software Or Configuration Was Revised: ALARM -INITIATING DEVICES AND CIRCUIT INFORMATION Quantity of Quantity of Devices Installed Circuit Style Devices Tested -- - - - - - .. Manual Fire Almm Boxes I ton Detectors Photo Detectors Duct Detectors Heat Detmons - Watertlow Switches - Supervisory Switches - Other(Specify): Alarm verificetiod4fti fte is ❑ disabled ❑ enabled COVE-AIAW Compuke Cablinr Fre Alam.. N.—Call Telepbone Sycmme PA/Sound Aaeucen,ml: SeaAy Akmv P.O.Bo008 Eugene, OR 97440.0708 - 5411485_W4. 734RW1TA#z&P(P I Of 6) ALARM NOTIFICATION APPLIANCES AND CIRCUIT INFORMATION Quantity of Quantity of Appliances Installed Circuit Style Appliances Tested Bells q Homs Chimes Strobes Speakers Othcr(Specify): No. of alarm notification appliance circuits� Are circuits monitored for integrity?L3<s ❑No SUPERVISORY SIGNAL -INITIATING DEVICES AND CIRCUIT INFORMATION Quantity of Quantity of Devices Installed Circuit Style Devices Tested WA NIA WA Building Temp. WA NIA N/A Site Water Temp. WA N/A N/A Site Water Level WA NIA WA Fire Pump Power NIA NIA N/A Fire Pump Running WA N/A WA Fire Pump Auto Position WA NIA NIA Fire Pump or Pump Controller Trouble NIA WA NIA Fire Pump Running WA N/A NIA Generator in Auto Position WA WA WA Generator or Controller Trouble WA N/A N/A Switch Transfer N/A WA WA Generator Engine Running N/A WA N/A otnm (specify): SIGNALING LINE CIRCUITS Quantity and style of signaling line circuits connected to system (see NFPA 72", Table 6.6.1): Quantity Style(s) SYSTEM POWER SUPPLIES (a)Primary(Main): Nominal Voltage Amps Overcument Protection: Type Amps Location (of Primary Supply Penelboard): Disconnecting Means Location: NFPA 72. Figure 10.6.2.3 (p. 2 of 6) CappipM®]apa NNonv Flre PmleGlon gsettglls, lute lwm mq becppleE lw IMlgyel u¢e olMrNm Mnula.11mnyml be replMlw commmeal ca4 ppclnylion. (b) Secondary (Standby): Storage Battery: Amp -Hr Rating Calculated capacity in Amp-Hrs to operate system for hours Engine -driven generator dedicated to fire alarm system: Location offuel storage: , TYPE BATTERY ❑ Dry Cell ❑ Lead -Acid ❑Nickel -Cadmium D Other (specify): ® Sealed Lead Acid (c) Emergency or standby system used as a backup to primary power supply, instead of using a secondary power supply: NIA Emergency system described in NFPA 701, Article 700 WA Legally required standby described in NFPA 701, Article 701 Optional standby system described in NFPA 70u, Article 702, which also meets the performance NIA requirements of Article 700 or 701 NFPA 72. Figure 10.6.2.3 (p. 3 of 6) Caoagni oaooeweua,u ra "euessen nlanu.u.nrms ram es" -isee OW re,nm,i use mn.rdan mneme. 11uras na semy.d kr wmmaca 1. adumkamn. PRIOR TO ANY TESTING NOTIFICATIONS ARE MADE Yes No/ Who Time Monitoring Entity 0/ `B _ Building Occupants .,/ tL7JJ/ ❑ Building Management 71ne,l�i Other(Speeify) 0 AH) Notified of Any Impairments El 0 SYSTEM TESTS AND INSPECTIONS TYPE Visual Functional Comments Control Unit El_� d Interface Equipment � /� LJJ Lamps/LEDs P� LJ Fuses Q- Primary Power Supply �/ ar Trouble Signals �L'7,/ Lh Disconnect Switches Gmund-Fault Monitoring d NFPA 72. Figure 10.6.2.3 (p. 3 of 6) Caoagni oaooeweua,u ra "euessen nlanu.u.nrms ram es" -isee OW re,nm,i use mn.rdan mneme. 11uras na semy.d kr wmmaca 1. adumkamn. SECONDARY POWER TYPE Battery Condition Load Voltage Discharge Test Charger Test Specific Gravity TRANSIENT SUPPRESSORS REMOTE ANNUNCIATORS NOTIFICATION APPLIANCES Visuni Functional // , . Comments El El ❑ ❑ Audible Visual Functional Qr 9' Visible Phone Jacks ❑ 6r Pr Speakers ❑ Amplifiers) ❑ ❑ Voice Clarity ❑ ❑ Call-in Signal ❑ ❑ INITIATING AND SUPERVISORY ❑ DEVICE TESTS AND INSPECTIONS Device Visual Functional Measured Loc. & SIN Type Check Test Factory Setting Setting ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ Comments: SEE FOLLOWING DEVICE SHEETS EMERGENCY COMMUNICATIONS EQUIPMENT Visual Functional Phone Set ❑ ❑ Phone Jacks ❑ ❑ Off -Hook Indicator ❑ ❑ Amplifiers) ❑ ❑ Tone Generators) ❑ ❑ Call-in Signal ❑ ❑ System Performance ❑ ❑ Pass Fail Comments PVT- vv c—ma,,�v f NFPA 72. Figure 10.6.2.3 (p. 4 of 6) Coartyl 011)(9 National F IMmon Anndum. nal form my he coplM be irdindaluoy oaeraar lm neeala. It may not be oop" for mmmeatj a vRa,mon. COMBINATION SYSTEMS Fire Extinguisher Monitoring Device/System Carbon Monoxide Dichu mr/System (Specify) INTERFACE EQUIPMENT (Specify) (Specify) (Specify) SPECIAL HAZARD SYSTEMS (Specify) (Specify) (Specify) Special Procedures: Comments: SUPERVISING STATION MONITORING Alarm Signal Alarm Restoration Trouble Signal Trouble Signal Restoration Supervisory Signal Supervisory Restoration NOTIFICATIONS THAT TESTING IS COMPLETE Building Management Monitoring Agency Building Occupants Other (Specify) The following did not operate correctly: System restored to normal operation: Visual III t Yes No ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ Yes No M'/ ❑ ❑ ❑ Ili ❑ ❑ ❑ Device Operation Simulated Operation ❑ ❑ ❑ ❑ ❑ ❑ Time Comments . Nor -t ti ,� Q���Whh�o Time OIS (1co Date: 61(;j111 Time: (700 NFPA 72, Figure 10.6.2.3 (p. 5 of 6) evyyiiam®3110a Na6va1 Flre pr acnAsweeron. Tssram" is wles"s iMiitlel use ossa a fisussslen nus ml W agleaMwmmntlal ale u a,aeui . THIS TESTING WAS PERFORMED IN ACCORDANCE WITH APPLICABLE NFPA STANDARDS Nameoflnspectar. Dare: 6//3//' Time: ( 'ZC-Z> Signature: / �ct.l.�Y-�yr.� (t. Name ofOwne)or R present .vc: V V Date: fll.51l6 Time: j?,eV Signature: ( __[[ NFPA 72. Figure 10.6.2.3 (p. 6 of 6) CDPOIINO aagnelvW FW `Me fts l lm l Mttm may be¢geUbrintlividmluwolM1vtlwbfre¢Ye.11=yw b�%]fwmnmmciel selew6slRW4en. 4+Fk \\ ,! 2 ®m|jKm & � %k;m=r © \\( )§(\) \kk) ) ek) - `���$ - \ / ) \ 7 EUGIN6 SPRINOFFffiID NOTICE OF VIOLATION 8 OPPORTUNITY TO CORRECT FIRE LOCATION INFORMATION Name: Kaitlyn's House- Integrated Health ID: 131590 Street Number. 1601 Organization: Direction: City: Springfield Street Name: I State: Oregon Street Type: Street Postal Code: 97477 INSPECTION INFORMATION The violations listed below must be corrected no later than the identified Re -Inspection Date. If they are not corrected by the listed Re -Inspection Date, the City may issue you a notice of Civil Penalty and start assessing daily civil penalties against you, the responsible person. If a violation is corrected by the listed Re -Inspection Date, no civil penalty will be imposed for that violation. Inspector: Johnston, Sandra Inspection Date: 11/30/2022 Inspection Type: Re -Inspection Inspection Number: 22-0631 Violations Violation Code Set Code Description Re - Repaired inspection Date Date Oregon 1010.1.9. *Door at parking lot- change to be one step egress. Hardware. Door 11/30/20 11/30/202 Fire Code i handles, pulls, latches, locks and other operating devices on doors 22 2 2019 required to be accessible by Chapter 11 of the International Building 00:00:00 Code shall not require tight grasping, tight pinching or twisting of the wrist to operate. Oregon 906.S * Add additional extinguisher so you have one readily available For ever 11/30/20 11/30/202 Fire Code 75ft of travel.- Conspicuous location. Portable Fire extinguishers shall 22 2 2019 be located in conspicuous locations where they will have ready access 00:00:00 and be immediately available For use. These locations shall be along normal paths of travel, unless the Fire code official determines that the hazard posed indicates the need for placement away from normal paths of travel. Oregon 901.6 -Provide service report for the Fire Alarm System within the last 12 11/21/20 11/21/202 Fire Code months. There is no record in the database for this Fire Alarm System. 22 2 2019 (normally we see records dating back to 2014 when we adopted the 00:00:00 records management system). Contact service provider and remind them to upload the report or schedule service. —Inspection, testing and maintenance. Fire detection and alarm systems, emergency alarm systems, gas detection systems, fire extinguishing systems, mechanical smoke exhaust systems and smoke and heat vents shall be maintained in an operative condition at ail times, and shall be replaced or repaired where defective. Nonrequired Fire protection systems and equipment shall be inspected, tested and maintained or removed. EUGENE SPRINGFIELD FIRE -OFFICE OF THE FIRE MARSHAL 1320 Willamette Street Eugene, Oregon 97401 Page 1 of 2 Oregon 901.6 *Provide service report for the Fire Sprinkler System within the last 12 11/21/20 11/21/202 Fire Code months. There is no record in the database for this fire Sprinkler 22 2 2019 system. (normally we see records dating back to 2014 when we 00:00:00 adopted the records management system). Contact service provider and remind them to upload the report or schedule service. Note: regarding the Sprinkler -onsite we saw a sticker From H & P that showed a 5 year service. Remind them to upload that report as well. -- Inspection, testing and maintenance. Fire detection and alarm systems, emergency alarm systems, gas detection systems, fire extinguishing systems, mechanical smoke exhaust systems and smoke and heat vents shall be maintained in an operative condition at all times, and shall be replaced or repaired where defective. Nonrequired fire protection systems and equipment shall be inspected, tested and maintained or removed. The Fire Marshal's Office expects that the above violation(s) will be corrected prior to the Re -Inspection Date. Assessing civil penalties For these violations is not the primary goal of this office, however, if these violations are not corrected by the listed Re -Inspection Date, our next step will be to issue a Notice of Civil Penalty that wilt assess penalties daily until the corrections are made. If you have further questions or requests For alternative methods of compliance, please contact us at 541-682-5411. We would appreciate your cooperation with our efforts to make a safer city in which to live and work. EUGENE SPRINGFIELD FIRE - OFFICE OF THE FIRE MARSHAL 1320 Willamette Street Eugene, Oregon 97401 Page 2 of 2 OD lko. fe �tlJ`tI�-2 Rx—t SG15y Environmentai Health iwpecdon For Child -Crating Agencies Licensed under Chanter 413 Division 215 Agency Name: � '1 Date oftospecdon: G .{ -r win wiefA Netµ+ �iNew 11Renewal Address (when children m s house and cared for): (601 �'I* St ole 4,ti,7 Agency Direetor'�" -t, _ 4ge range' J'S- 1-7 Tekphane mumher� 7j5 -q y22 Capacity: 10 Fa: Dumber. Eman: nS frIsr • • h' Building Safety and Envlrommmm it Health a Nam Commam Garbege/solid waste method ofdisposal and V (..IecrYy a4.('aW. "M 4. 6are 4A cfq lane approved wh, f "AW, Q/at qr. `T Garbege/selid were, disposed ofweekly a m(mf ati fy is un e . la'm 3&, he necessarywi11 - �e Aligg~14 d Sewage & liquid waste controlled & disposed of ✓ CrfY I,4 abfV i feamff. UYi .yrs er D.E.Q. mine All tubs/showms/siekskoikts elm and See 'n rn CW io �. Horn vle.r..+grn/ than odore pbt{arlal id taro /a/ 1 ea h Hotwmatemperrtuesforhand V id" thpwerw "M in Csns7r-01e7. washmgfbatbmg does not exceed 120°Fahrenhen w ar Y n Si4� A r Hot and cold mmaing water me available atmos 1/ i un GgtS1/nt my ser hnvf C� m a ro dare Ypi A raved hand washing sink Hazardous materials (such as cleaning supplies, ,r/;tft h*ZW4 s ,twYCra/s poisons, insecticides, and other hazardous ✓ Willy� erdel iaa s%m'yir O&w1 norAe materiels) am properly handled and kept in dInw*le Yr, Chi rPrn locked stuage Adequate vector and pest conhol (inaludmgthe ✓ ORK (Nt rm�i/ngC?w coil/d 1e use ofpesticides and What chemical S ITYN Ad Sons, walls, cotmgs, and equipment are Still ;n Cdn .r-?. dylzl ✓fes✓ MRIMY41s clean and in good repair V are ,Mi / q Grounds sR five oflitter and refuse V fYra Soiled human& clothing ere smedm an area separaR from kitchen, dining ares, clean linea (y 1Fr S h' wllNe Cf n /.:eras/ p* kll- clodhin and non-reti ereRd food Sdil i?'r Building is ventilated and See ofezceasiWheat, Zn par y6q /a7rC7 S Pn/. k,47,w-, condensation and obnoxious odoR Yfwf Food Services b main Comadsta Food is cooked, stated and served at proper el ho l m nay be aY H/Far be(,✓ tem a No foods from unappreved sources aR served p� p uthtst/ ?fro, 51"5 a.h (e-9 Rw milk impamemized juice. uninspected meats 175fenSe ✓ icili7S'P; CaYa :' ' .Sfalr� h A11 fend and drink utemik/dishedsilva ere Aym:111: of Hrwm SeMm. CAddrn lCarr Lkwl4 (an IM16) Uw,f= ACC)IRoT CERTIFICATE OF LIABILITY INSURANCE Dn Darty o2z n THIS CERTIFICATE IS ISSUED ASA MATTER OF INFORMATION ONLYAND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATB/ELYAMEND, MEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURERS),AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: Nthe certlfieste holtler is an ADDITIONAL INSURED, the policy(hes) must have ADDITIONAL INSURED provisions or be endorsed. M SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. Astmtement on this certificate does not confer rights to the carts icate holder in lieu of such endorsement(s). PRODUCER c0 AC NAME: John Serge PBC InsuranceIxE 450 Country Club Read 4:130 (5411489-6fi24 Ne, (541)686-2726 ADDRess: jsema@pbdn$.can INSURESSI AFFORDING COVERAGE NAIC0 Eugene OR 97961 INSURERA: Charter Oak Fire 25615 INSURED T..m Casualty INSURER e: vB. PDeM N 25674 G Street Integrated HeeNM1 INSURER c: 1435 G St INSURER D: INSURER E: Springfield OR 9747 INSURER F: COVERAGES CERTIFICATE NUMBER: CIM72542141 REVISION NUMBER: THIS IS TO CERTIFYTHAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED MOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDINGANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECTTO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CI -AIMS. me LTR TYPE OF INSURANCE som POLICY NUMBER MMT Eugene OR 97440 LIMITS COMMERCIAL GENERAL LIABILITY CV,IM$AWDE ® OCCURP E cG =URRENCE $ 2.000,000 /SES E9ygIn9M- $ 300,000 MED E\P(My one persw) $ 5,000 PERSONALAADINUURY $ 2.000.000 A Y 6809N776828 08126/2022 0812612023 GENYAGGRE U?ARPPPUESPER: POLICY JfiQ ❑ LOC GENEMLAGGREGATE $ 4,00,000 PRODUCTS - COMP/OPAGG $ 4,000,000 Hlredlbanomad $ 21000,000 OTHER: AUTOMOBILE LIABLITVWRI RMGLELWn $ BODILY INJURY (Per pemonl $ ANVpUTO OWNED SCMEOULED AUTOS ONLY AUTOS BODILY INJURY /Per ealEmO $ HIRED NON.OWNEO AUR15 ONLY AUTOS ONLY pappEi$IyppgpTiE $ $ X UMBRELLA LMB X OCCUR EACH OCCURRENCE S 1,00.000 B EXCESS UM LLAIMSJ$AOE CUPQN781390 06/26/2022 0812612023 AGGRE. $ 1,000,000 E. I I RETENTION $ $ WORXERSCOMPENSATON PER OTn AND EMPLOYERS' LWBILRY YIN STATUTE ER E.L. EACH ACCIDENT $ ANY PROPRIETO RNARTNE W EXECUTI V E OMICERRAEMBER EXCLUDED, ❑ NIA E.L. DISEASE - EA EMPLOYE£ $ Bu,m "m NNl E.L. OI$FABE- POLICY LIMIT $ DESCRIPTION OF OPERATIONS beICW I I DESCRIPTIONOFOPERATIONSILOC NSIVEHICLES (ACORD 101. AEONonal Remarks Scbed,I, may ba anacbea If more eparo Is m umd) '30 days cancellation. EXeept f 0 days notice in event cancellaAon for non payment of premium. Certificate is for Location: 1600 H Street & IBut I Street Springfield. OR 97477 CERTIFICATE HOLDER castle. 1 eTln. 01988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks WACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Wood Duck Properties LLC ACCORDANCE WITH THE POLICY PROVISIONS. PO BOX 10691 AUTIORRED REPRESENVATIVE Eugene OR 97440 mO ` "'o.— 01988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks WACORD Program Description Kaitlin's House is a medically monitored youth detox facility for youth of all genders ages 12-17 who are suffering from substance use and need medically monitored and assisted treatment in order to detox from substances. Kaitlin's House offers youth inpatient detox which includes medical treatment by a licensed medical professional, substance use counseling with a CADC II, and discharge planning. Medical services shall include comprehensive history and physical examination along with a 6 -dimension ASAM assessment, and Laboratory assessments to include CBC, CMP, Mg, GGT, CDT, Drug toxicology panel with GC/MS confirmation, RPR, TSH, Acute Hepatitis Panel with reflex, U/A with reflex to C/S, HIV screening with reflex, GC/Chlamydia screening, Tuberculosis screening via PPD or IGRA testing (with Chest X-ray confirmation as may be indicated), and other specific lab studies as may be indicated by clinical findings, with follow-up lab for abnormal results. A 12 -lead ECG will be obtained for baseline assessments upon admission. Medication management to mitigate acute withdrawal syndromes including benzodiazepine taper regimens, buprenorphine induction and taper or induction and maintenance regimens, along with medications to prevent complications of withdrawal and seizure prophylaxis, ancillary comfort medications, medications for bowel stabilization, as well as medication management of acute disorders such as infections, and continuation of chronic medications not otherwise contraindicated, and initial use of psychiatric medications as clinically indicated. Medication use will be minimized as tolerated with a goal of discontinuation or minimization for ongoing stabilization by the end of the admission. Injuries present upon admission or acquired thereafter shall be treated with standard -of -care means, with more complex conditions being referred to appropriate specialty care as may be required. 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MJN s ES 11ifj••yAyII i 3 sa'1 1 HEALTH SYSTEMS DIVISION Licensing and Certification Kate Brown, Governor 500 Summer Street NE, E-86 Salem, OR 97301-1118 "Voice" 503-945-5763 "TTY" 800-375-2863 "Fax" 503-378-8467 www.oregon.gov/dhs/mentalhealth APPLICATION FOR LICENSURE Wa ttulth hOrity RESIDENTAL SUBSTANCE USE DISORDERS/DETOXIFICATION/ PROBLEM GAMBLING TREATMENT PROGRAMS Licensure Application of Residential SUDs/Detux/Problem Gambling Treatment Programs 1 SECTION 1: INSTRUCTIONS • Please complete this application in full, incomplete applications may require resubmission. • Remember to sign and date the Attestation of Compliance, found in Section V. • Attach all required documents in the order as outlined in section VI. Mail to: Oregon Health Authority, Health Systems Division Licensing and Certification Unit 500 Summer Street, NE, E86 Salem, OR 97301 PROCESS FOR APPLICATION REVIEW 1. Review and utilize the following Oregon Administrative Rules (OAR) governing Standards for Approval/Licensure of Alcohol and Other Drug Abuse Programs prior to beginning the application process: Standards for Approval/Licensure of Alcohol and Other Drug Abuse Programs OAR 415-012-0000 through 415-012-0090 h ://ucweb.sos.state.or.us/jD��lages/rutes/oan 400/oar 415/415 0121tm1 2. Within 60 days of receiving the complete application HSD will complete a desk review of all submitted materials and respond with questions, requests for additional information, a request to conduct an onsite walkthrough of the building(s), or a request for a complete resubmission of application materials if incomplete. 3. When additional information is required to approve the application, the applicant must provide the requested information to HSD within 14 days of receipt of the request for additional information. If a new two lication, skip to number 6. 4. For renewal applications, prior to the expiration of the license, HSD will conduct an onsite review to determine the level of compliance with the applicable Oregon Administrative Rules. Licensure Application of Residential SUDs/Detux/Problem Gambling Treatment Programs 1 5. For renewal applications, HSD will send a final report within 30 days after completion of the onsite review. The agency is required to submit a written Plan of Correction (POC) to HSD within 30 days of receiving the final report. The POC must show how the agency will resolve all areas of 6. Upon approval of this application, a license will be issued for up to one year for new licenses and two years for renewal licenses. 7. Upon issuing a COA, HSD will contact the Background Check Unit (BCU) notifying them of the certification and sending them a copy of the COA. A. B. SECTION If: APPLICANT INFORMATION Name of agency: I Name and title of responsible party: C. Phone number of responsible party: 5cll -7-3 5 D. Email address of responsible party: Elk- E. Name of authorized person preparing this application: F. Agency Federal Entity Tax Identification number: D 3 G. Agency National Provider Identification (NPI) number: ), 6 5150 1O H. Agency MMIS (Medicaid) number: D D'7 D I. Agency license registration number: r J. Is the agency registered as a nonprofit? Yes No ❑ K. Complete physical address of the administrative office: L. Complete mailing address of the administrative office: M. County were administrative address is located: N. Main agency phone number: /_7 3S; _ a -Q O. Main agency fax number: 50 - 7 Y-1 — 4'0 70 P. Agency website: (A) 1 Q. Is agency contracted with a Coordinated Care Organization (CCO): Wyk No ❑ R. Name of CCO (if applicable): !111( (l CQ � r-7 T1x�CxLTt'GC.1ty-xLu- 1h^1 Licensure Application of Residential SUDs/Detox/Problem Gambling Treatment 2 S. Name and contact information for ALL board of directors, sponsors, shareholders, and/or owners T. Please list action taken on any certificate or license of Owners and Program Directors, including denial, suspension, conditions, intent to revoke or revocation by the Division, Oregon Health Authority, Oregon Department of Human Services, or any other state agency for those listed in question Q. Use a separate sheet if necessary. Name of Owner/Director Name of Certification or License Issued/Expired Dates Agency Name Action Taken �✓`l/ L U. Name of all accreditation entifies with whom the agency is affiliated (such as Joint Commission, SAMHSA, CARE, Public Health, etc.): V Complete address of each facility location: Services Delivered Address Phone Fax -IEEE p �✓`l/ L I W. Is each office location compliant with applicable ADA building requirements? YesA No ❑ I Licensure Application of Residential SUDs/Detox/Problem Gambling Tnatment 3 X. For substance use disorder applicants only: Are the bathrooms used for UA collection in a space and manner that ensures confidentiality? Yes 0 No 0 Y. All personnel responsible for managing delivery of services for the agency (please include Program Director or Administrator, Medical Director, License Medical Practitioner and Clinical Supervisor(s). For each personnel listed, include their resume/CV and all credentials applicable to their position. Name Credentials Title Phone Email SECTION ILL SERVICE DELIVERY RULES Please review and select the applicable OAR that pertains to the license for which you are requesting for your agency: Please note: The following services have specific Oregon Administrative Rules describing minimum standards for state approval. You will need to submit separatepolicies and procedures for each service listine you wish to be approved Residential Substance Use and Problem Gambling Treatment and Recovery Services 309-018-0100 0 Residential Substance Use Disorders Treatment and Recovery Services 0 Residential Problem Gambling Treatment and Recovery Services Standards for Alcohol Detoxification Centers 415-050-0000 0 Clinically Managed Residential Detoxification Medically Monitored Detoxification Please be advised that state approval does not automatically guarantee eligibility to participate as an OHP provider. To become an OHP (Medicaid) provider, please contact HSD Provider Enrollment Unit by phone 800-336-6016, or by visiting the provider enrollment webpage: htlp�//www oreeon vov/oha/healthnlan/Papes/nroviderenroll aspx Licensure Application of Residential SUDs/Detox/Pmblem Gambling Treatment 4 1. SECTION IV —NEW LICENSE QUESTIONAIRE please use a sepai ate document to ansiier these questions and altach to theapplication - 1. Description of philosophy and approach to provision of services. 2. Description of each evidence -based practices to be used for each service type. 3. Description of the agency's plan to assess trauma informed policies, procedures and planning. Please 3. include planning as related to existing practices, the environment and treatment approaches. 4. Discuss continuum of care including: levels of care, case management, outreach, and population 4. specific programming (youth, women, medication assisted treatment, etc.) Discuss plan to access and 5. collaborate with local continuum of services. 5. If applicable, any agency artnershi s/communipartners. 6. Any applicable resources, facilities adequacy to meet community demand. 1. SECTION IV: RENEWAL LICENSE QUESTIONAIRE -pleascuscasepatat document to answer these questions and affach tothe application - Description of each evidence -based practices used for each service type. 2. Discuss continuum of care including: levels of care, case management, outreach, and population specific programming (youth, women, medication assisted treatment, etc.) Discuss plans to access and collaborate with local continuum of care services. 3. Description of the agency's plan to assess trauma informed policies, procedures and planning. Please include planning as related to existing practices, the environment and treatment approaches. 4. List all of the agency's major referral sources. 5. Describe the business's working partnerships with the community: 6. If applicable, discuss any lack of resources, facilities, or inadequacies to meet community demand. 7. Since the last site review, have any of the business's credentialed staff (e.g., MD, LCSW, LPC, QMHP, QMHA, CADC) had any of the following actions taken on their license or certification: denied, limited, suspended, revoked, not renewed, voluntarily or involuntarily relinquished, subjected to stipulated or probationary conditions, had corrective action, or been fined or received a letter of reprimand or is any such action pending under review? 8. Since the last site review, has the business's professional liability insurance ever been terminated, denied renewal, restricted, or modified (e.g., reduced limits, restricted coverage, surcharged)? 9. Does the business have any variances approved by HSD? Is yes, please explain. 10. Describe how the business addresses multicultural needs of individuals served: 11. Describe what procedures (including outcome tools) the business uses to assess for short- and long-term outcomes (for example, standardized assessment, level of functioning scales, UA results, recidivism rates, consumer and family satisfaction surveys): 12. Describe service outcomes in the past three years (for example, total # served and # who have successfully completed the program; results of consumer and family satisfaction surveys, etc.): 13. Describe changes in business structure/staff changes since last review: 14. Describe business successes since the last review: 15. Describe the business's current quality improvement goals: Licensure Application of Residential SUDs/Detox/Problem Gambling Treatment 5 Licensure Application of Residential SUDs/Detox/Problem Gambling Treatment 6 SECTION V: ATTESTATION OF COMPLIANCE su t to re a ents in [he�dministrative Rules and as the legal authority of lr* �' agency), by my signature below I attest to the following: 1. I am an authorized person representing the agency intentions and best interest of all board members, shareholders and/or owners; 2. The information provided on the application is valid and complete; 3. The agency will comply with the Oregon Administrative Rules, guidelines, and standards that govern these services; 4. If applicable, the agency is in compliance with all other licensing or accreditation entities that apply, i.e., Department of Human Services, Drug Enforcement Administration (DEA), etc.; 5. The agency will maintain continuous liability insurance; 6. The agency is compliant with federal, state, and local regulations that govern individual privacy and confidentiality, including, but not limited to, HIPAA, and Code of Federal Confidentiality Regulations 7. (42 CFR Part 2); 8. The agency will prioritize the assurance of individuals' health, safety, and welfare. 9. The agency will fulfill all mandatory reporting duties; 10. The agency is not employing personnel who have been convicted of any felony, or a misdemeanor associated with the provision of behavioral health services; 11. Agency staff will adhere to the agency code of conduct. In addition, agency staff will report suspected ethical violations (including impairment) to the responsible party and appropriate credentialing parties (such as certification boards, licensing entities, etc.); 12. The agency will notify HSD within 15 days of change to the Medical or Executive Director by submission of qualifications of the new Director; 13. The agency will notify HSD, in writing, of office or facility location changes. I understand that the agency may not deliver any state approved service until the office or facility is approved by HSD. 14. Within two weeks after receiving state approval for residential substance use disorder, detoxification, or problem gambling treatment services, the agency will register with the mandated state data system ("MOTS") and immediately begin reporting the entry of all individuals in MOTS. 15. If an organization is receiving any SAMHSA Grant funds, grant funds may not be used, directly or indirectly, to purchase, prescribe, or provide marijuana or treatment using marijuana. Treatment in this content includes the treatment of opioid use disorder. Grant funds also cannot be provided to any individual who or organization that provides or permits marijuana use for the purposes of treating substance use or mental disorders. See, e.g., 45 C.F.R. § 75300(a) (requiring HHS to "ensure that Federal funding is expended ... in full accordance with U.S. statutory ...requirements."); 21 U.S.C. §§ 812(c) (10) and 841 (prohibiting the possession, manufacture, sale, purchase or distribution of marijuana). This prohibition does not apply to those providing such treatment in the context of clinical research permitted by the DEA and under an FDA -approved investigational new drag application where the article being evaluated is marijuana or a constituent thereof that is otherwise a banned controlled substance under federal law. 16. I understand that Licenses are not transferable to any other person, entity, provider, or non -Division approved service delivery location. Licensure Application of Residential SUDs/Detox/Problem Gambling Treatment 6 v L G lxreqp-y Licensure Application of Residential SUDs/Detox/Problem Gambling Treatment i „ Date �ds�.tls.7.�da�■ �. v L G lxreqp-y Licensure Application of Residential SUDs/Detox/Problem Gambling Treatment i SECTION VI: SUBMISSION REQUIREMENTS PART I: GENERAL REQUIREMENTS in.state Application Form ( .2-6) m loyee code of conduct Verification of liability insurance anizational chart(including the names and credentials of all agency staff) t�lverificatioaa of licensing with other agencies when applicable (i.e. licensed child care facility) Fire inspection report for each location Floor plan of proposed office, including emergency evacuation routes PART II: RESIDENTIAL PROVIDER POLICIES (OAR 309-018-0110) Personnel Oualifications, Credentialing and Training ❑ ' inal Records Checks, compliant with ORS 181.533 through 181.575and O 943-007-0010-0501 throu 07-007-0370 ❑ Fraud, ste and abuse in Federal Medicaid and Medicare programs co iant with OAR 410-120- 1380 and 410420-15 10 ❑ Drug free wor ce ❑ Fee agreements ❑ Confidentiality and co Hance with HIPAA, Federal Cons tiality Regulations (42 CFR, Part 2), and State confidentiality regulatiam as specified in ORS 179.503and 192.518 through 192.530• ❑ Compliance with Title 2 of th ericans with Disab' 'es Act of 1990 (ADA); ❑ Grievances and Appeals ❑ Individual Rights ❑ Quality Assessment and Performance Imp vement ❑ Crisis Prevention and Response ❑ Incident Reporting ❑ Family Involvement ❑ Trauma -informed serviced ' ery, consistent with the Di ' 'on's Trauma Informed Services Policy ❑ Provision of culturally W linguistically appropriate services ❑ Medical protocols ❑ Medication admi tration, storage, and disposal ❑ Facility star ds ❑ General pfity and emergency procedures to include an evacuation plan and ergency plan in case of fire, ex Sion, accident, death, or other emergencies. The evacuation and emerge procedures and plans shall current and posted in a common area. Additiqually, providers must establish written policies that PROHIBIT: sychologicaland physical discipline of an individual eclusion, personal restraint, mechanical restraint, and chemical restraint ithbolding shelter, regular meals, medication, clothing or supports for physical functioning iscipline of one individual receiving services by another 121 Titration of medications prescribed for the treatment of opioid dependence as a condition of receiving or continuing to receive treatment Licensure Application of Residential SUDs/Detox/Problem Gambling Treatment 8 PART III: DETOXIFICATION CENTERS POLICIES AND PROCEDURES ,The Pro 's philosophical approach to stabilization ules of em to ee conduct, includingethical standards tandards for em to ee use and abuse of alcohol and other drugs Compliance with the Civil Rights Act of 1964, as amended in 1972, the Equal Pay Act of 1963, Age Discrimination in Employment Act of 1967, and any subsequent amendments Prohibiting client abuse consistent with OAR 407-045 Resolving employee performance problems, which must specify the sequence of steps to be taken when performance problems arise, and identify the resources to be used in assisting employees to deal with r blems which interfere with job performance. Client rights in accordance with 415-050-0020 Written criteria for admission and for rejecting admission requests in accordance with 415-050-0025 ndividual assessment and evaluation in accordance with 415-050-0030 Ef Stabilization services and standards in accordance with 415-050-0035 anagement of medication in accordance with 415-050-0045 Staffing patterns and qualifications in accordance with 415-050-0050; 415-050-0055; 415-050-0060; 415-050-0065 ndividual furnishing and linens in accordance with 415-050-0075 Safety in accordance with 415-050-0080 anitation in accordance with 415-050-0085 ood Service in accordance with 415-050-0090 Yl Provision for immediate transportation for individuals to a general hospital in case of a medical erdergencv. De cription of medical policies and procedures. The description must: P4pecify the level of medical careprovided; and Include a written policy and procedure, developed by the Medical Director, for determining the individual's need for medical evaluation. The Medical Director's involvement in the development and review of medical operating procedures, quarterly reviews of physicians' standing orders, and consultation in any medical emergencies must be d cumented. In clinically managed environments, individuals must have access to intensive inpatient treatment servi s outlines in oli and procedure as follows: Transfer to medically monitored services as necessary; 21 Medical evaluation and consultation is available 24 hours a day by appropriately credentialed p ons who are trained and competent to implement physician -approved protocols; Medical evaluation and consolation must be available 24 hours a day, in accordance with ty6atment/transfer practiceguidelines; The initial assessment must be conducted by appropriately credentialed personnel. Appropriately licensed and credentialed staff must be available to administer medications in accordance with physician orders. (5) In medically monitored environments, individuals must have ess to services which provide intensive inpatient treatment services, as follows: LMPs must be available 24 hours a day by telephone; Licensure Application of Residential SUDs/Detcx/Problem Gambling Treatment 9 An individual must be seen by an LMP within 24 hours of admission, or sooner if medically ness A LMP must be available to provide onsite monitoring of cue and further evaluation on a daily bis' The initial assessment must be conducted by a skilled nursing staff. El On-site skilled nursing care must be provided twenty-four (24) hours per day, seven (7) days per elc and w Appropriately licensed and credentialed staff must be available to administer medications in accordance with physician orders. 1 V FOR XM APPLICATIONS ONLY P T IW. SAMPLE PERSONNEL RECORD Where required, verification of a criminal record check consistent with OAR 407-007-0000 through 4 -007-0370 A current 'ob description(s) that includes applicable competencies; ❑ Copies of relevant licensure or certification, diploma, or certified transcripts from an accredited college. indicating that the program staff meets applicablequalifications; Performance appraisal document; Stag orientation documentation which specifically includes evidence of training on each: A review of crisis prevention and response procedures review of emergency evacuation procedures ff/A review of program policies and procedures A review of rights for individuals receiving services and supports >fandatory abuse reporting rocedures; )IIPAA, and Fraud, Waste and Abuse For ECS services,positive behavior support training Y41,isciplinary documentation En,kesults of a Tuberculosis screening as per OAR 333-071-0057 A A confidentiality agreement for contracted, intern, and volunteer staff PART V: SAMPLE INDIVIDUAL SERVICE RECORD —NO Pffi • Please do not submit Protected Health Information (PHI) • Only submit copies of blank templates to be used in practice • All documents required to fully reflect current service delivery OARS Th sam le individual service record should include: Entry and orientation packet, to include all templates given to individuals upon entry, pursuant to AR 309-018-0135 Ed Assessment (ASAM compliant) ervice PEl lan ervice Note Transfer Summary For Residential Services:—-' ❑ M'dicjtWW3MTffi4s#ation and disposal logs in accordance with 309-018-0190 e drill log in accordance wi Fo Detoxification Services: Pro m's philosophical approach to stabilization A written description of the Program's services Licensure Application of Residential SUDs/Detox/Problem Gambling Treatment 10 Information on the rules governing Individual's behavior and those infractions, if any, that may result in schara or other actions dividualized stabilization plan in accordance with 415-050-0035 ransition lan in accordance with 415-050-0035 MyAedication administration and disposal logs in accordance with 415-050-0045 15 Fire drill log in accordance with 415-050-0080 SECTION Vill: RESOURCES The following links may be useful resources as you prepare your application materials: Tools for Providers htto://www.oregon.eov/oha/amh/Pages/Tools-For-Providers asnx 42 CFR, Part 2 htFps://www.re ations.gov/document?D=HHS-OS-2016-0005-0377 ADA http://www.ada.gov/ OR Trauma Policy http://wwworeeonpov/oha/HSD/AMH/Trauma°/a20Policy/Tratima°/20Policvpdf Drag Free Workplace Kit htto://wwwsamhsa.gov/sites/default/files/workplace-kitodf Evidence -based Practices hU( Z/wwworegon.gov/OHAIHSD/AMH/Paeec/EBPasnx HIPAA http://www.hhs. ovg /ocr/privacy/hipaa/understandine/coveredentities/index htm] Initial Application Procedures: hU,//arcweb.sL)s.state.or.us/pages/mles/oan 400/oar 415/415 tofc html 309-018 rules htip7//arcweb sos state or us/gages/mles/oars 300/oar 309/309 018 html 415-050 rules httu://arcweb.sos.state.orus/2ages/rules/oars 400/oar 415/415 050 html Licensure Application of Residential SUDs/Detox/Problem Gambling Treatment 11 Section N 1 -Philosophy and Approach to Provision of Services Kaitlin's House philosophy is to utilize evidence based practices in a client centered and humanistic manner within a fully integrated care system to promote positive changes and personal growth. We believe that addiction is a chronic and progressive disease and challenges related to physical, mental and emotional health can be interconnected with a person's substance use disorder. Through individualized, integrated, and holistic treatment recovery is not only possible, but is a springboard for the overall improvement of a person's complete health. Kaitlin's House utilizes a comprehensive and holistic psychosocial model that is trauma informed and acknowledges and addresses substance use and Co -Occurring disorders. Approach to the Provision of Services: Services provided by Kaitlin's House - Inpatient Alcohol and Drug Medically Monitored Detox - Substance Abuse Counseling: Individual, Grief and Loss, and Family Counseling sessions. - Screenings: Standardized Intake Screening Assessments utilizing ASAM and DSM -V criteria and also utilized standardized screenings such as; DAST and SBIRT. - Full Medical examination - Medically managed and medically monitored stabilization services for acute and severe withdrawal symptoms that utilize ASAM criteria for best practices. - Case Management: Providing services to assist individuals who are transitioning into a community setting in gaining access to needed medical, social, educational, entitlement, and other applicable services. - Outreach: Providing behavioral health services, referral services, and case management services in non-traditional settings including but not limited to the individual's residence, shelters, streets, jails, transitional housing sites, drop-in centers, single room occupancy hotels, child welfare settings, educational settings, or medical settings. Kaitlin's House also attempts to engage or re-engage an individual in services by such means as letters or telephone calls. Services provided by formal written referral agreements - Obstetrics services are contracted for referrals with Women's Care - Toxicology and laboratory services are contracted with Quest Diagnostics - Food Services Kaitlin's House 12/9/2022 Page 1 of 2 -Description of Evidence Based Practices Kaitlin's House utilizes a mixed model for behavioral health services. Our model is primarily based in the Cognitive Behavioral Model to address the relationship between thoughts, feelings, and behaviors and explore belief systems as they relate to a person's substance use disorder. Our service model also incorporates the Social Model to address challenges related to family and social circles, the Matrix Model to address challenges related to stimulant use, and the Harm Reduction model to address challenges related to a person's motivation, risk behaviors, and their stage of change. All services are provided with Trauma Informed Care and Best Practices standards. Service Types with Evidence Based Practice Description - ASAM approved medication adjunctive therapy: addressing Post Acute Withdrawal Syndrome, Maintenance, and Anti -Craving. - Standardized Screening Assessments: We utilize standardized comprehensive screening assessments to gather client information that is then summarized to create a Clinical Assessment formatted with ASAM and DSM -V criteria to assess the medical necessity for care and to provide recommendations for levels of care placement, treatment planning, and service recommendations. - Individual Counseling Sessions: Motivational Interviewing, Cognitive Behavioral Therapy, Family Systems Therapy, the Matrix Model, and Internal Family Systems Therapy, Harm Reduction, and Trauma Informed Care. - Physical Modalities: Primary Medical Care, Acupuncture, Massage, Acupressure, Non -Narcotic Pain Management. - Medication Assisted Treatment/Office Based Opiate Treatment- Harm Reduction and Motivational Interviewing. - Non -Pharmacological Pain Management - Medically monitored stabilization and detox services provided under the guidance of a board certified addiction medicine specialist. Other Services - Coping with Trauma - Grief and Loss - Anger Management - Parenting Education - Nutrition Kaitlin's House 12/9/2022 Page 2 of 6 Kaidin's House is affiliated with G Street Integrated Health which provides services for medical conditions and co-occurring conditions due to a substance use disorder as part of a comprehensive, holistic, and integrated program. 3- Plan to assess trauma informed policies, procedures, and planning. Kaitlin's House will continually assess the agency's policies and procedures regarding trauma informed care. A Trauma informed care committee that consists of at least four staff members will review policies and procedures quarterly to ensure that current practices are up to date with the most recent scientific evidence for trauma informed care. The committee will also ensure that all staff participate in regular yearly training on trauma informed care and participate in team building exercises. Regular training on Trauma Informed Care will be provided in house and will occur at a minimum of once yearly with the goal of twice per year. Team building exercises will occur at scheduled staff retreats and will also be scheduled periodically for in house staff meetings. Training in Cultural Sensitivity and Gender for specific groups and special populations will be on-going as a part of the collaborative process of the Trauma Informed Care Committee. Kaidin's House clinical environment has been carefully chosen with trauma informed care in mind. Patient rooms me designed with comfortable lighting, neutral artwork, and classical music is played for patients in the waiting room. The medical exam room will be designed with white or neutral wall colors, decorative plants, and motivational artwork that supports a therapeutic environment. Treatment approaches will consider known histories of trauma in patients and also consider potentially re -traumatizing situations and ensure that patients safety and well being are prioritized. All treatment approaches will consider: -Safety: Everyone (staff and patients) feels physically and psychologically safe. -Trustworthiness and Transparency: Kaitlin's House maintains trust with staff and patients. -Collaboration and Mutuality: everyone in the organization plays a role in creating a trauma informed care environment. This is achieved through regular staff training and education, regular team building exercises, and regular Trauma Informed Care committee meetings. Kaitlin's House 12/9/2022 Page 3 of 6 -Empowerment: ensuring that the approach reflects individual experiences/strengths. -Cultural, historical, and gender issues: Kaitlin's House is culturally responsive, respects traditional cultural connection, and recognizes historical trauma. - Peer support specialist(s): these valuable staff will be made available to help build a sense of safety, trust, and empowerment. Existing medical practices operate under the understanding that patients are never to be shamed or made fearful regarding potential factors impacting their physical health. All factors impacting an individual's physical health me discussed in an open and compassionate manner and staff should always respect the patients rights regarding decisions for their medical care. Treatment decisions will be made with full involvement with the patient and information for alternative treatments will be provided to ensure that patients are empowered regarding their medical care. Behavioral health practices will also follow these guidelines regarding treatment approaches. The Executive Director, Medical Director, and Clinical Supervisor will oversee the implementation of trauma informed care policies for services provided and ensure that practices are consistent with trauma informed care best practices. 4- Continuum of care Kaitlin's House will provide inpatient medically monitored detox for substance abuse disorders. Patients that are assessed with a need for a higher level of care will be routed to an appropriate local hospital or acute care setting. Once the patient completes detox services they will be referred to the appropriate intensive inpatient program such a Rimrock or Madrona or they will be referred to the appropriate intensive outpatient services. A patient will be asked to sign a release of information for care coordination with the agency providing subsequent aftercare. Kaitlin's House may provide supportive services until the patient has been enrolled and admitted to a higher level of care. Upon discharge from a higher level of care a patient may re-emoll with G Street Integrated Health. Treatment records will be requested from the previous provider for coordination of care. Case Management will be provided for coordination of care with: outside agencies that provide higher levels of care, outside agencies who specialize in services not provided by this agency that are needed to assist our patients with specific and individualized needs, court and government Kaitlin's House 12/9/2022 Page 4 of 6 agencies. Status reports may also be requested by the client to be provided to their employer if necessary. Upon enrollment patients will be asked if there is any other agency or individual that they wish to have treatment information disclosed to. They will also be asked about involvement with courts and criminal justice agencies for coordination of care and status reports for progress and participation in services. Any outside agency that requires status reports for legal issues will be provided regular monthly status reports and will be notified in accordance with state administrative rules regarding positive urine drug screenings, reported relapses, disemolhnent and completion of services. Any communication with outside agencies will require a written release of information signed by the patient. Two way releases provided by court agencies and government agencies will be accepted for transmission of records. Population specific programming is provided by Kaitlin's House for: Parents in recovery, youth and families, DUII, medication assisted treatment, and HIV/HCV/STD counseling and testing. Collaboration with local providers for continuum of care will be made to address levels of cue not provided by this agency and services outside of the scope of practice of this agency. Collaboration with local hospitals and local youth residential programs that provide medical detoxification services and inpatient services will be essential for serving our clients who meet clinical criteria for higher levels of cue. Case management will be utilized for coordination of care for patients who require residential and inpatient services. Information regarding the patient's status at intake and current status in the program will be provided to outside agencies. Kaitlin's House staff will attend local provider meetings to build relationships with outside agencies and inform outside agencies of our services. For mental health disorders that are outside of the scope of practice of this agency we will provide and coordinate referrals to appropriate community agencies such as; Lane County Behavioral Health, Center for Family Development, and other agencies that specialize in a patient's specific mental health disorder. For mental health emergencies we will coordinate referrals with the Behavioral Health Unit at Peacehealth Sacred Heart Hospital. 5- Agency Partnerships/Community Partners - Department of Human Services - Oregon Youth Authority - Department of Youth Services Kaitlin's House 12/9/2022 Page 5 of 6 Quest Diagnostics 6-Auolicable Resources, Facilities Adequacy to meet community demand. Kaitlin's House currently has a 3,550 square foot building with 4 bedrooms with attached bathrooms which will be able to house up to 10 youth at any given time, 2 office spaces which will be utilized for individual counseling and case management, a large space which will be dedicated for living space, and an exam room which will be utilized for physical examinations and medical treatment. Kaitlin's House is located within several blocks of G Street Integrated Health which currently has a fully functional urgent care clinic and currently employs three Medical Doctors and three Physicians Assistants who are able to provide acute medical services for detox clients if necessary. Kaitlin's House 12/9/2022 Page 6 of 6 Amanda Aldrich, FNP 37198 Wheeler Rd, Pleasant Hill, OR 97455 1541-799-6279 1 aaldrich@gstih.org Education FAMILY NURSE PRACTITIONER I JANUARY 2017 -APRIL 2019 1 BRADLEY UNIVERSITY MASTERS OF NURSING SCIENCES 2014 1 WESTERN GOVERNORS UNIVERSTIY Emphasis in Leadership and Management Certifications NCCPA Experience FAMILY NURSE PRACTITIONER I G STREET INTEGRATED HEALTH, SPRINGFIELD, OR I MAY 2021 -PRESENT Family Medicine Nurse Practitioner working with underserved populations. Special interests include urgent care, behavioral health, and women's health. AESTHETICS NURSE PRACTITIONER I DR. LEE B DANIEL AESTHETIC PLASTIC SURGERY, EUGENE, OR I DECEMBER 2019 -MAY 2021 CLINICAL NURSE SUPERVISOR I PEACEHEALTH RIVERBEND, SPRINGFIELD, OR I NOVEMBER 2016-2019 STAFF NURSE I RIVERBEND DAY SURGERY, SPRINGFIELD, OR I JANUARY 2015 -AUGUST 2016 Anna Hancock, PA -C 2929 Portland St, Eugene, OR 97405 1541-325-6527 1 ahancock@gstih.org Education MASTER OF PHYSICIAN ASSISTANT STUDIES I AUGUST 2020 -MAY 20111 IDAHO STATE UNIVERSITY BACHELOR OF ARTSI MAY 20111 LEWIS AND CLARK COLLGE Major in Biology Certifications NCCPA Experience PHYSICIAN ASSISTANT I G STREET INTEGRATED HEALTH, SPRINGFIELD, OR I MAY 2021 - PRESENT Family Medicine Physician Assistant working with underserved populations. Special interests include urgent care and behavioral health. Sebastian Brunning, PA -C 210 North Ave, Brownsville, OR 97327 1503-490-1837 1 sbrunning@gstih.org Education MASTER OF PHYSICIAN ASSISTANT STUDIES I MAY 2018 -AUGUST 2020 1 ROCKY MOUNTAIN UNIVERSITY OF HEALTH PROFESSIONS Applied Scholarly Project: Management of Adolescents and Children with Gender Dysphoria BACHELOR OF SCIENCES SEPTEMBER 2014 -JUNE 2017 1 UNIVERSITY OF OREGON Major in Human Physiology Minor in Biology Certifications NCCPA Experience PHYSICIAN ASSISTANT I G STREET INTEGRATED HEALTH, SPRINGFIELD, OR I OCTOBER 2020 -PRESENT Family Medicine Physician Assistant working with underserved populations. Special interests include emergency medicine and behavioral health. FIREFIGHTER/EMT I GOSHEN FIRE AND RESCUE, PLEASANT HILL, OR I OCTOBER 2020 - PRESENT Community Engagement ADJUNCT PROFESSOR - PRECEPTOR I OREGON HEALTH & SCIENCE UNIVERSITY PHYSICIAN ASSISTANT PROGRAM I OCTOBER 2020 -PRESENT ADJUNCT PROFESSOR - PRECEPTOR I ROCKY MOUNTAIN UNIVERSITY OF HEALTH PROFESSIONS I OCTOBER 2020 -PRESENT Michelle Kaplan, MD 3344 Videra Dr, Eugene, OR 97405 1541-912-2880 1 dr.michellek@yahoo.com Education RESIDENCY I JULY 2001 -JUNE 2004 1 RIVERSIDE COUNTY REGIONAL MEDICAL CENTER Family Practice MEDICAL SCHOOLS AUGUST 1997 -MAY 20011 KECK SCHOOL OF MEDICINE AT THE UNIVERSITY OF SOUTHERN CALIFORNIA MD degree earned UNDERGRADUATES SEPTEMBER 1993 -MAY 1997 1 UNIVERSITY OF JUDAISM, LOS ANGELES, CA Bachelor of Arts, Bioethics Certifications BOARD CERTIFIED FAMILY MEDICINE JULY 2004 -PRESENT BOARD CERTIFIED ADDICTION MEDICINE DECEMBER 2021 -PRESENT Experience MEDICAL DIRECTOR I KAITLIN'S HOUSE I OCTOBER 2021 -PRESENT Medical supervision of Detox for Youth program, Springfield OR MEDICAL DIRECTORS SPRINGFIELD TREATMENT CENTER I JANUARY 2018 -PRESENT Medical supervision of outpatient methadone treatment center FAMILY PHYSICIANS G STREET INTEGRATED HEALTH I FEBRUARY 2022 -PRESENT Primary care physician in a non-profit integrated community health center; Substance Use Disorder Clinic also supported by on-site psychiatry, case management, and CADC lI FAMILY PHYSICIANS THURSTON MEDICAL CLINIC I MARCH 2006 -JANUARY 2022 Primary care physician FAMILY PHYSICIANS LOCUM MEDICAL GROUP I OCTOBER 2005 -FEBRUARY 2006 Primary care physician FAMILY PHYSICIANS COUNTY OF RIVERSIDE, COMMUNITY HEALTH CENTER, INDIO, CAIJULY 2004 -SEPTEMBER 2005 Primary care physician for a county operated FQHC Kaitlin Richards olden Court OR 478 n skills Manage daily operations, process intakes, ensure policies and procedures (Springfield, 541)84459389 are followed, manage and orient staff, process referrals, community excel krichardsOgstih@gmaii.com EXPERIENCE SKILLS Kaitlin's House, Springfield, OR —Youth Services Director Interpersonal/communicatio Nov. 2022 - PRESENT n skills Manage daily operations, process intakes, ensure policies and procedures Microsoft office, outlook, are followed, manage and orient staff, process referrals, community excel outreach, and track program progress. Leadership and supervisory skills. State Of Oregon, Oregon Judicial Department Eugene, OR — juvenile Treatment Court Coordinator Experience working with Dec. 2019 - Oct 2022 diverse and underserved Ran the Lane County Juvenile Treatment Court program and populations Differentiated Case Management Program. Applied for federal funding as Experience working with needed, oversaw the program operations, ensured adherence to best juveniles and the juvenile practices and standards, attended and ran court sessions, tracked justice system progress and statistics, and coordinated between court staff, judges, Knowledge of basic state laws attorneys, probation officers and treatment providers. and practices State Of Oregon Department of Human Services, Eugene, OR — Court Worker/Intake Worker Sept 2015 - Dec. 2019 Assessed families for concerns of child abuse and neglect. Trained incoming workers and attended court proceedings as needed. Triaged cases of abuse and neglect for the need to file a petition in the Juvenile court. EDUCATION University of Oregon, Eugene, OR — Bachelors of Science Sept 2011 -lune 2013 Focused on studies in human services, sociology, juvenile justice, substance use. Lane Community College, Eugene, OR — Associates of Arts Transfer Degree, Dental assisting certification Sept. 2008 -June 2014 Core college classes completed for transferring to a university. Obtained certification as a dental assistant. Bioaraphy Education and Certifications CADC II (Certified Alcohol and Drug Counselor, Bachelor's proficiency) QMHA (Qualified Mental Health Associate) 2019 - Lane Community College, AA, Major Psychology Currently pursuing a Bachelors degrees in Psychology 2016 - Parenting Educator, trained in "Make Parenting a Pleasure" curriculum Employment July 2020 - Present - G Street Integrated Health, Counselor & Behavioral Health Director April 2017 - July 2020 - Interactional Dynamics, Trainer and Administrator March 2020- July 2020 - Serenity Lane, Counselor, MAT program development November 2019 - February 2020 - Integrated Health Clinics, Counselor and MAT program development August 2015 - September 2019 - White Bird Clinic, Counselor, Opiate Program, and Parenting Program Manager Skills and Experience I have worked serving underserved populations as an alcohol and drug counselor for the past 6 years and have built effective skills in direct client services as well as program development and administration. During my employment I have had the honor and opportunity to develop and refine medication assisted treatment programs and also a parenting program to DAVID assist our community members in reaching their goals. Through this work I have assisted in building effective teams of medical RYAN and counseling providers within fully integrated health care systems. NO W A K I also have knowledge and experience with compliance in regards to state and federal regulations. I have served as an C A ®C administrator and provided oversight in regards to policy and I I procedure development and implementation. I have also served on quality assurance and improvement committees as well as Director, Behavioral other work groups such as: financial planning and budgeting, community outreach, grant procurement, federal and state Health Services clinical audits, financial audits, and program development. Interests Guitar and music, fire dancing, juggling, and spending time with - --- - --- my daughters. A A A A C A L G G A A W O O N VOi O UJi °, W S J W y0i tip O O b O O �+ to P a0O a O N£ (1 O A 4 H N w A O A A A A C A L G G A A W O O N VOi O UJi °, W S J W y0i tip O O b O O �+ to P � 0 3 3 = - - 3 0 3 THE SATRE GROUP Land Use Planners, Landscape Architects, Environmental Specialists 375 West 4^ Avenue, Suite 201, Eugene, Oregon 97401 (541) 686-4540 www.satregroup.com TO: City of Springfield 225 5^ Street Springfield, OR 97477 ATTN: TRANSMITTED: Herewith X� Separate Cover Other TRANSMITTED: #Copies Item TRANSMITTAL DATE: January 23, 2023 PROJECT: Kaitlin's House Site Plan Review CLIENT PROJ #: SG PROJ #: 2243 DISPOSITION: For Your Approval For Your Information/Use X For Reply Dated No. Pages 4 paper copies and a CD of a: Site Plan Review Application Packet Varies Several REMARKS: This Site Plan Review application packet is hereby submitted for processing. The submittal package includes: 1. This Transmittal 10. Plan Sets 2. Application Fee a. Landscape Set 3. Application Form b. Architect Set 4. Written Statement 5. Deed 6. Title Report 7. State License — OHA & DHS 8. Applicant's Letter of Intent 9. Reduced Site Plan We look forward to your assistance with the project. Do not hesitate to contact us should you have any questions or need any additional information. Thank you. COPIES TO: Agency x File X Consultant Team X Owner X Other BY: John Schmidt, ASLA