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

Compliance and Safety Site Visit Report
2023
* Required
* This form will record your name, please fill your name.

1. ORR Region *
Arizona
Central Texas
Houston/El Paso
Mid-Atlantic
Midwest
Northeast
Rio Grande Valley East
Rio Grande Valley West
Southeast
Special Populations
West Coast

Other

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2. Program Name *
Abbott House Shelter
Abbott House TFC
ADORE Children & Family Services
BCFS Chavaneaux
BCFS Dallas LTFC
BCFS Driscoll
BCFS Extended Care
BCFS San Antonio LTFC
BCFS San Antonio Shelter
BCFS San Antonio TFC
Berkshire Farms Center and Services for Youth- Sheltered Hearts
Bethany Christian Services - Wedgwood Christian Services (MI LTFC Group Home)
Bethany Christian Services of Indiana
Bethany Christian Services of Indianapolis
Bethany Christian Services of Michigan (SILP)
Bethany Christian Services of Middle Tennessee
Bethany Christian Services of North Carolina
Bethany Home Inc.
Board of Child Care - Caminos Nacional Program Cunningham Children’s Home (CCH)
Board of Child Care - Caminos Nacional Program Florida United Methodist Children's Home (FUMCH)
Board of Child Care - Caminos Program LTFC
Board of Child Care - Caminos Program Shelter
Board of Child Care - Caminos West Program Falling Waters

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Board of Child Care - Caminos West Program UMHC

Board of Child Care- Campolina Way
Board of Child Care- Kentucky United Methodist Home
Bokenkamp Shelter
Bokenkamp TFC
Catholic Charities Boystown
Catholic Guardian Services - University Residence
Catholic Guardian Services Crotona
Catholic Guardian Services Seton
Catholic Guardian Services TFC
Cayuga Centers LTFC
Cayuga Centers TFC
Center for Family Services - Bridgewater
Center for Family Services Camden
Center for Family Services EHT TFC
Center for Family Services Northfield
Center for Family Services Shelter
Center for Family Services TFC
Center for Famly Services - Mother & Baby Shelter
Center for Juvenile Management INC
Children's Home of Kingston
Children's Home of Poughkeepsie Shelter
Children's Home of Poughkeepsie LTFC
Children's Village Shelter
Devereux Advanced Behavioral Health Massachusetts (New Beginnings)
Devereux Foundation-Connecticut

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Devereux Foundation-Texas
Gulf Coast Jewish Family and Community Services
Heartland Beverly
Heartland CHAP
Heartland ICC
Heartland ICRC
His House
His House, Inc.
Holy Family Institute - Emsworth Campus
Holy Family Institute - LTFC
Holy Family Institute - Moon Campus
Incarnation
Jewish Child Care Association
Kids in Crisis
Kids Peace Shelter
LaSalle School
Latin American Youth Center (LAYC) - Esperanza
Lincoln Hall Boys Haven
LIRS - Ascentria Care Alliance MA Worcester LTFC
LIRS - Bethany Christian Services GA Atlanta TFC
LIRS - Bethany Christian Services MD Crofton TFC
LIRS - Bethany Christian Services MI Alma Shelter
LIRS - Bethany Christian Services MI Grand Rapids LTFC - Casa Agape
LIRS - Bethany Christian Services MI Grand Rapids Shelter (TAC)
LIRS - Bethany Christian Services MI Grand Rapids TFC
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LIRS - Bethany Christian Services MI Kalamazoo LTFC TGH - Hacienda De Luz
LIRS - Bethany Christian Services MI Kalamazoo Therapuetic Group Home - Glenn House
LIRS - Bethany Christian Services PA Havertown TFC
LIRS - Bethany Christian Services PA Pittsburgh TFC
LIRS - Bethany Christian Services PA Reading TFC
LIRS - Bethany Christian Services TN Smyrna TFC
LIRS - CHRIS 180 GA Atlanta Group Home
LIRS - CHRIS 180 GA Atlanta Therapeutic Group Home
LIRS - Kennedy Krieger Institute and LIRS Therapeutic Foster Care
LIRS - Lutheran Services Carolinas SC Columbia TFC
LIRS - Lutheran Social Services National Capital Area VA Fairfax TFC
LIRS - Samaritas MI Lansing LTFC
LIRS - Samaritas MI LTFC Group Home Jackson House
LSS of New York Safe Haven 2
LSS of New York Shelter
LSS of New York TFC
Lutheran Services of Florida
Maryville Academy - St. Gabriel and St. Anne
Maryville Casa Esperanza
Maryville San Francisco
Maryville San Juan Diego
Maryville St. Rose of Lima
Mercy First Shelter
NAFI of CT, Inc.
National Youth Advocate Program Naperville LTFC
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National Youth Advocate Program Gurnee LTFC
National Youth Advocate Program OH TFC
National Youth Advocate Program Sycamore TFC
National Youth Advocate Program Matteson TFC
National Youth Advocate Program Columbia TFC
National Youth Advocate Program Decatur TFC
National Youth Advocate Program Tampa TFC
National Youth Advocate Program - GA Atlanta
National Youth Advocate Program - Homestead
National Youth Advocate Program - IL Chicago
National Youth Advocate Program - IN
National Youth Advocate Program - SC Greenville
Noank
Noank Community Support Services, Inc. TFC
Rising Ground Shelter (formerly Leake & Watts)
Rising Ground TFC (formerly Leake & Watts)
Seton Home
St. Christopher's - Welcoming Arms for Unaccompanied Minors - Dobbs Ferry
St. Christopher's - Welcoming Arms for Unaccompanied Minors - New Windsor
St. PJ's Children's Home Shelter
SWK Casa Blanca
The Children's Community Programs of Connecticut, Inc.
The Villages, Inc.
Timber Ridge School
Twin Oaks Juvenile Academy
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Urban Strategies - Refugio Iglesia De Dios Shelter
Urban Strategies - Refugio Iglesia De Dios TFC
Urban Strategies - Refugio Ignite TFC
Urban Strategies - Refugio Ignite Shelter
Urban Strategies - Refugio Maranata
USCCB - Bethany Christian Services Grand Rapids
USCCB - Catholic Charities Fort Worth Shelter
USCCB - Catholic Charities Fort Worth TFC
USCCB - Catholic Family Center
USCCB - Commonwealth Catholic Charities LTFC
USCCB - Commonwealth Catholic Charities Shelter
USCCB - Commonwealth Catholic Charities TFC
USCCB- Archdiocese of Philadelphia Northeast Family Service Center (CSS of Philadelphia)
USCRI - Rinconcito Del Sol Shelter
Youth For Tomorrow LTFC
Youth For Tomorrow Shelter
Youth for Tomorrow TFC

Other

If Other, please list Program Region and Name

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3. Level of Care *
Shelter
TFC
LTFC
Long Term Group Home
Therapeutic Placement
Staff Secure
Secure
RTC

Other

4. ORR Representative Name *

5. Report Date *

Format: M/d/yyyy

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Site Visit Walk Through
Prior to your visit, please remind the program you will request the checklist noted below
from them.  This is a walk through to identify and ensure compliance for major
requirements and safety concerns. 
"Yes" indicates compliance.   "No" indicates out of compliance and requires a
comment indicating specifically what was non-compliant.  

6. Did the program have a Facility Inspection Checklist for a Child Friendly Environment
completed?
*
Yes
No

7. Please note date it was completed

Format: M/d/yyyy

8. Did the Checklist for a Child Friendly Environment meet all satisfactory markings? (was it
all marked "yes")
(FFS may use this form, past site visit concerns, recent UC behavioral or run away SIRs to
determine if they will also check specifically on the next seven questions) *
Yes
No

9. Please note any deficiencies

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10. Does the program have working video cameras and are they reviewed by the program?
Yes
No

11. If No, a comment is required

12. Are all entry and exit alarms tested to ensure they work (includes windows and doors)?
Yes
No

13. If No, a comment is required

14. Do all entries and exits have safety measures? (perimeter barriers, perimeter lighting,
alarms to note for entry/exit without permission)?
Yes
No

15. If No, a comment is required

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16. All required bulletin board postings to educate youth about sexual abuse, sexual
harassment, and reporting are posted in ALL required areas in language UC
understands *
Yes
No

17. If No, a comment is required

18. Required Preprogrammed phone is accessible to UC, private, and correctly preprogrammed for UC to report sexual abuse, sexual harassment, and sexually
inappropriate behavior (all three must be compliant to indicate “yes") *
Yes
No

19. If No, a comment is required

20. Overall appearance of the program is neat, organized, and clean that does not present
any health or safety concerns *
Yes
No

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21. If No, a comment is required

22. Is the program in compliance with all staffing ratio requirements?

Yes

No

23. Are there staffing concerns? *
Yes
No

24. If. Yes, please confirm you elevated this to the Project Officer for resolution or to address
UC capacity

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

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26. Concerns: (focus on safety issues for UC or staff - blind spot supervision, etc.) *

Child Interviews
Child interviews are a small group of children at one time.  Child interviews are for the
purposes of general information and general well-being and safety. Children have a right
to refuse an interview. If this occurs, please document the reason the child refused an
interview.  This is not an investigation. This should not evolve into counseling.  FFS and
CFS are mandated reporters to CPS and law enforcement.  Do not promise children
anything. Do not discuss the child’s legal case.  Redirect issues that move away from the
intent of this site visit report and encourage them to speak with their clinician/case
manager or attorney/legal services provider.  If you have any immediate safety concerns,
please contact the FFS Supervisor.
UC may be interviewed as a small group at one time in an informal setting.  If any
child responds in the negative or "NO" then mark it as "NO" but you can add any
comments.

27. Please note the number of children in the group interviewed *

28. Please note the estimated age range of the group of children you interviewed *

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29. Interpreter used by FFS or CFS *
Yes
No

30. If yes, note language

31. Does the UC have the opportunity for daily Recreation (large and small muscle)? *
Yes
No

32. Comments

33. Does the UC have access or a choice to participate in preferred Religious Services? *
Yes
No

34. Comments

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35. Does
.
the UC have Leisure Time? *
Yes
No

36. Comments

37. Does the UC meet with his/her CM once per week? *
Yes
No

38. Comments
.

39. Does the UC meet with his/her Clinician for one hour sessions per week? *
Yes
No

40. Comments

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41. Does the UC have a Clinical Group? *
Yes
No

42. Comments

43. Are there Community Meetings the UC can participate in? *
Yes
No

44. Comments

45. Does the UC get at least two calls per week with his/her parent and/or sponsor? *
Yes
No

46. Comments

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47. Are Sexual Abuse Hotline pre-programmed phones accessible to the UC at any time? *
Yes
No

48. Comments

49. Is the UC aware of the legal services provider and his/her access to the LSP? *
Yes
No

50. Comments

51. Does the UC understand his/her family reunification case? *
Yes
No

52. Comments
.

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53. Does
.
the UC attend school/education classes for at least 6 hours per day MondayFriday? *
Yes
No

54. Comments

55. Is the UC aware of how to file a grievance?  *
Yes
No

56. Comments

57. Are Garza Notices and Infographics posted?
58. Do you feel safe? *
Yes
No

59. Comments

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Yes

No

60. .Do you like living at this program? *
Yes
No

61. If yes, what is it that you like about the program?

62. If no, what is it that you don't like and what would you like to see changed?

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63. Would you ask for help if you have a problem while living here at the program? *

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

65. Please mark Yes or No if you need/want to follow up on any items that came up during
the interview? *
Yes
No

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66. If yes, what items require follow up?

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Trends and Follow Up
Utilize the trends and follow up sections of the report for a record of your overall findings,
reporting to your supervisor, and to check on the program’s improvements from month to
month, as well as have a record in the event a corrective action is required for identified
trends.
This is the final section where you record your findings for the visit, and what you left in
place for the program to follow up on. Share this with your supervisor, PO, and CFS. Also,
it is fine to give it to your program so that when you go back to the program, you have a
record of what has already been addressed and whether progress has been made.
Please feel free to engage your supervisor along the way should you have questions or
need support with anything. Remember that this visit and form is a tool for you to use to
help the programs improve. Lastly, remember you are a mandated reporter to CPS and
law enforcement.  For any immediate safety concerns or findings, contact your supervisor.

65. Trends/Comments: Please provide a narrative discussion of your main findings and
areas of potential concern. *

66. Did you identify any potential issues to monitor or for additional follow up?  *
Yes
No

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67. If yes, list any specific issues that need to be reviewed again during the next site visit?

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

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

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of
this information collection is to allow ORR Federal Field Specialists to document site visit observations and
interview responses. Public reporting burden for this collection of information is estimated to average 1.0 hour
per response, including the time for reviewing instructions, gathering and maintaining the data needed, and
reviewing the collection of information. This is a mandatory collection of information (Homeland Security Act,
6 U.S.C. 279). An agency may not conduct or sponsor, and a person is not required to respond to, a collection
of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a
currently valid OMB control number. The OMB control number is 0970-0564 and the expiration date is MM/
DD/2026. If you have any comments on this collection of information please contact [email protected].

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