Inspection Date: 6/3/2021

Division of Licensing
315 Deaderick Street Consultants: Becky Ervin
UBS Tower 7th Floor
Mark Anderson
Nashville, TN 37243
Inspection Type: Unannounced Visit
License Type(s): Residential Child Care
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LICENSURE NOTICE OF COMPLIANCE REVIEW

CORRECTIVE ACTION AND APPROVAL STATUS FORM

Agency Name: La Casa de Sidney/The Baptiste Group, LLC

Agency Address: 1914 Vance Avenue

Chattanooga, TN 37404
Agency Contact: Gretchen Baptiste
Contact Phone: 800-619-7450
DCS Contractor: No
Current Licensure Period: February 28, 2021 – February 27, 2022
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Agency Information:

The Baptiste Group, LLC currently maintains a contract with the United States Department of Health and Human
Services (HHS) Administration for Children and Families, Office of Refugee Resettlement (ORR) to provide short-
term housing, personal care, supervision and monitoring for up to 100 children classified by HHS as
unaccompanied minor children.
La Casa de Sidney, owned and operated by the Baptiste Group, LLC, provides care to minor youth aged 12-17
pending reunification/placement with a sponsor home or a youth’s appearance at an immigration hearing
where other, ongoing arrangements for care may be ordered. The facility serves both male and female youth.
The targeted length of stay within the program is 30 days, though some youth may remain beyond the initial
assessment period pending hearing or the identification of a sponsor home.

Terrance Ware, Director of Operations, is the acting interim director of the facility. Landon Zilbert is the Facility
Manager.

On February 23, 2021 the agency was granted a Residential Child Care Agency license effective February 28,
2021 through February 27, 2022.
Licensed Capacity: 100
Census at Time of Inspection: 62 male youth were present in program on the date of this visit.
_______________________________________________________________________________________________________________________________

Summary of Site Inspection:

A routine unannounced site visit was conducted by licensing staff on June 3, 2021. Present were Becky Ervin and
Mark Anderson from the DCS Division of Licensing and Melina Smith, Program Manager, DCS Office of Quality
Improvement. Ms. Smith is bilingual and was asked to accompany licensing staff on this review for the purpose
of conducting interviews with resident youth. This report was compiled by Licensing Director Mark
 LICENSURE NOTICE OF COMPLIANCE REVIEW CORRECTIVE ACTION AND APPROVAL STATUS FORM

Entrance Conference

DCS staff met with acting director, Terrance Ware, upon arrival at the facility. Licensing staffed explained the
purpose of the visit and asked Mr. Ware for a current list of resident youth and agency staff for the purpose of
random sampling for file reviews and resident interviews. Licensing staff identified 6 youth for file review and
resident interviews and 7 personnel files for administrative review.

Mr. Ware explained that the primary purpose of La Casa de Sidney is to provide care and support services for
unaccompanied youth while the agency works to locate stable, long-term placement in a sponsor home,
alternately referred to by the agency as “reunification”. The disposition of each youth is categorized by ORR
according to their prospects for sponsor home placement.

These categories are identified as follows:

Category 1- Youth has contact and/or access to a parent or guardian for placement
Category 2- Youth has contact and/or access to a family member for placement
Category 3- Youth has contact and/or access to a close family friend for placement
Category 4- No potential sponsor home has been identified

In the event a sponsor home is not readily identifiable for a resident youth (Category 4) staff at La Casa de
Sidney work with ORR to locate a long-term placement option. Youth in Category 4 may remain in program at La
Casa de Sidney until such placement is identified. Mr. Ware advised that the program has completed 148
reunifications to date.

Mr. Ware advised that to date, no youth have absconded from the facility and that there have has been only
three fights break out among resident youth. Youth who are identified by administrative staff at the facility as
aggressive or disruptive are immediately removed from program by HHS and placed in a more structured level
of care within the ORR system.

Support services available to resident youth include:

• Education Services provided 6 hours a day, Monday through Friday

• Clinical Services which include individual and group therapy
• Sex Abuse Prevention Education
• Medical Services (including dental services and vision examinations) through Erlanger Medical Center

Mr. Ware reported that youth who arrive at the facility without personal belongings are provided 5 changes of
clothing and a pair of shoes. Youth are allowed recreation periods (indoors and outside) daily. Apart from
medical/dental appointments, youth do not leave the La Casa de Sidney campus during their stay in program.
Mr. Ware advised that most staff at the facility, and all education staff, are bilingual. Mr. Ware estimated that
around 5% of the resident youth could be considered bilingual and that most spoke no English at all.

Mr. Ware was asked how youth were transported to the facility and how many youth were admitted into the
program at a time. Mr. Ware advised that youth are frequently flown into Nashville or Atlanta from the border
and then transported to the facility by bus or van and that several youth may be admitted at a time. (A review of
all admission dates for current residents reflects that the average number of admissions on a single day is
currently 3.6 and the most admitted on a single day was 9 youth.)

Currently there are 14 youth who have been in program longer than 30 days; the admission date for the longest
length of stay (LOS) was 12/28/20; though this appears to be an exception compared to most other LOS data.
 LICENSURE NOTICE OF COMPLIANCE REVIEW CORRECTIVE ACTION AND APPROVAL STATUS FORM

Physical Plant

Mark Anderson and Melina Smith were accompanied by Facility Manager Landon Zilbert and Assistant Program
Director Vernita Latten for a physical inspection of the facility. Areas reviewed included:

• Residential areas/dorms including bedrooms, bathrooms and common spaces

• Cafeteria and food service areas
• Classrooms
• Case management offices
• Security/Central Control

The following observations were noted-

The program currently maintains one wing (dorm) for youth who are quarantined for assessment, Covid-
19 exposure, or other medical issues. This area was observed from a distance but not visited by the
inspection team.

All fire extinguishers reflected current inspections, evacuation posters were present throughout facility
and all emergency lighting that was tested was functional. (One emergency light was observed to be
partially broken and a work order was called in during the inspection to ensure it was repaired.) Wall
mounted AED devices were also located throughout the facility.

Resident bedrooms were clean and neatly maintained. The facility is maintained within the former
dormitories of the now closed Temple University. As the original building did not offer central heat and
air each bedroom is now cooled by an individual AC unit set into the wall. Each bedroom houses two
youth.

Bathroom/shower areas are communal, and Mr. Zilbert advised that only a limited number of youth are
scheduled/allowed into bathroom/shower areas at a time. These areas were observed to be clean and
neat at the time of review.

One group of youth had just finished lunch and were playing a game in the cafeteria at the time of the
physical review. Mr. Zilbert advised that the food services director frequently engages youth in such
activities following mealtimes. Food for the facility is not prepared onsite but rather is catered through a
local service. Mr. Zilbert advised that the caterer specializes in organic and healthy food options. Menus
are posted in both English and Spanish.

Each common area featured a display case that contained posters detailing the rights of residents and
supplying contact numbers for reporting abuse. Grievance boxes were likewise observed in common
areas.

While class was not in session at the time of inspection the classrooms were well-supplied and amply
decorated. Mr. Zilbert advised that, upon admission, youth are administered an initial education
assessment to ensure they are placed within a learning curriculum at their current functioning grade
level. Classroom instruction includes computer based learning and individual instruction. The onsite
school, while using an approved curriculum, does not offer “educational benefit” to youth subsequently
placed within a local school system. Educational needs are detailed in each youth’s Individual Service
Plan and a “Weekly Academic Progress Report” is generated for each youth and included in their file.

The facility maintains a “phone room” where individual kiosks are arranged to allow youth to make
and/or receive calls; including international calls. The facility also maintains phones that are pre-
programmed specifically for the purpose of reporting abuse or harassment to the proper receiving
 LICENSURE NOTICE OF COMPLIANCE REVIEW CORRECTIVE ACTION AND APPROVAL STATUS FORM

agencies. These include DCS, the ORR Sex Abuse Hotline, the National Sexual Assault Center and various
consulates for originating countries.

All hallways and common areas were clean and free from dirt and debris. Mr. Zilbert advised that the
manager of their custodial services worked in hospital settings for several years and therefor has high
standards for cleanliness and sanitation. Mr. Zilbert remarked that this has been particularly helpful in
maintaining sanitary conditions within the quarantine dorm.

Case management offices are located within one wing of the facility. These areas were observed from
the hallway and were not individually inspected during this review.

The program maintains a central control area that features a comprehensive bank of monitors
displaying information from 74 individual onsite cameras. Monitors are arranged to directionally
correspond with camera locations throughout the property. Senior administrative staff have access to
all monitoring data through a secure online portal. Central key control is also maintained at this
location; keys are issued to staff when they arrive onsite and collected prior to their exiting the building.

Personnel Files

Seven personnel files were reviewed by Licensing Consultant Becky Ervin during this review. All files
were found to be complete and well organized. There were 2 of the personnel files that contained copies
of the college transcript, as opposed to official versions of the transcript. It was explained to Mr. Ware
during exit conference that official transcripts must be obtained to meet compliance.

Resident Files

Six resident files were reviewed by Mark Anderson and Becky Ervin. Resident files were found to be
complete and well organized.

One resident file (H.R.) lacked documentation of Sex Abuse Prevention Education. This information was
requested during exit conference and Mr. Ware advised he would send it via email which was received
by licensing within an hour of completion of the visit.

It was noted that, by state law, treatment plans are required for any resident remaining in program past
30 days. However, the Individual Service Plans currently developed and maintained by the agency are
fairly robust and will be assessed to determine if they meet compliance for this requirement for those
youth remaining in program for protracted periods of time.

Resident Interviews

Six youth were selected for interview based on the corresponding resident files that were selected for
review. Melina Smith served as interpreter between the youth and Mark Anderson. Each youth was
asked the following questions:

• How do you feel you are treated at this program?

• Do you feel safe around staff?
• Do you feel safe around other youth?
• Are you aware of the procedure for accessing medical services when needed?
• Are you aware of the process for filing a grievance? Have you used this process?
• How many hours a day are you in school?
• What do you do during your free time?
• How is the quality of the food? Are you provided adequate portions? Are you provided a
 LICENSURE NOTICE OF COMPLIANCE REVIEW CORRECTIVE ACTION AND APPROVAL STATUS FORM

substantial snack before bedtime?

• Do you find individual and group therapy services beneficial?
• What is something you would change about this program if you were able to?

Observations

• Each of the six resident youth interviewed advised they were well treated by staff. Comments
included “I am treated very well”, “Staff are polite”, “Staff are teaching me”, “Staff are caring”.
• Each of the six resident youth interviewed advised they felt safe around both staff and peers.
• Five of six youth were aware of the process for accessing medical services when needed. One
youth reported medicine had purposefully be withheld when he reported a sore throat.
• Five of six youth were aware of the grievance process. None of the youth reported they had
utilized the process.
• Five of the six youth stated they attended school from 8 am-3 pm with one youth stating he
didn’t know.
• Regarding free time youth responded that they “play games”, “play soccer” or “spend time with
their friends”.
• Most of the comments regarding the quality of the food were mixed, with some youth stating it
was good and some stating they didn’t care for it. All youth reported receiving adequate
portions and a substantial snack before bedtime.
• All youth reported they felt they benefitted from individual and group therapy.
• When asked what changes they would make to the program one youth reported he was unable
to get an appointment for a haircut and, while he had only been at the facility for one month, he
had been in HHS custody for three months and had not received a haircut during that time.
Another youth reported he felt he was “wasting time” at the facility. The other four youth
reported they would make no changes to the program.
• During the interviews one youth alleged having witnessed a staff member kissing another youth
who has since left the program. This was discussed with Mr. Ware upon exit conference and a
referral was made to the CPS hotline by Mr. Anderson immediately upon leaving the facility. On
June 5 Mr. Ware contacted the licensing office to report that the employee had been terminated.

Documents Requested/Reviewed:
☐ Board/Board Minutes Board Chair: N/A
☐ Agency Bylaws Most Recent Review: N/A
☐ Liability Insurance Company Name: N/A
☐ Local Policy and Procedure
☐ Annual Operating Budget
☐ Financial Audit Most Recent Audit: N/A
☐ Fire Drill Logs Frequency: N/R
☐ Posted Evacuation Plan: Most Recent Review: Evacuation plans are present and current
☐ Child/Youth Interviews: Number Interviewed: Six Youth (see inspection summary)
☐ Medication Log (s):
☐ Fire Inspection: Most Recent Review: December 18, 2020
☐ Health Inspection: Most Recent Review: May 20, 2020 (new inspection requested)
☐ SOS Verification Current
☐ Staff/Child Ratios Most Recent Review: N/A
Days Reviewed: N/A
 LICENSURE NOTICE OF COMPLIANCE REVIEW CORRECTIVE ACTION AND APPROVAL STATUS FORM

Files Requested/Reviewed
☐ Personnel Records Number of Files Reviewed: Seven
☐ Foster Home Records Number of Files Reviewed: N/A
☐ Children/Youth Records Number of Files Reviewed: Six
☐ Adoption/Home Studies Number of Files Reviewed: N/A
_______________________________________________________________________________________________________________________.

Exit Interview Details:

An exit interview was conducted with acting director Terrance Ware. Observations from the physical review, file
reviews and resident interviews were shared with Mr. Ware. Licensing requirements for official college
transcripts to meet academic requirements was discussed and Mr. Ware advised that the agency would obtain
these documents upon hiring new staff whose positions required specific academic qualifications. Mr. Ware was
also advised regarding the allegation made by one of the youth during the resident interviews and that licensing
staff would call in a referral to the CPS Hotline for processing. The need for an Individual Treatment Plan for all
youth in residence beyond 30 days was discussed and Mr. Ware was advised that the current service plans
generated by the agency would be reviewed to determine if they meet compliance with this requirement.

Mr. Ware was advised that all of the youth had made positive comments about their treatment and general
conditions within the program, that the files were well organized and complete and that the physical inspection
had yielded no findings or need for corrective action.

New licensure approval period: Current

Date notice of corrective action to agency:

Date corrective action received back from agency:

Licensing Office Use Only

☐ Corrective Action Approved

☐ Corrective Action Not Approved
☒ Corrective Action Not Required

Mark Anderson, Director DCS Licensing

mark.anderson@tn.gov
June 17, 2021
Signature/Date ____________________________________________________________________________________________________

Jennifer Williams, Assistant Commissioner OCQI

Jennifer.willams@tn.gov
June 17, 2021
Signature/Date: _____________________________________________________________________________________________________