| 340:110-3-153.1(g)(1) | References. The program obtains three references for personnel prior to employment. Copies are maintained in the employee's personnel record. | References for two personnel not obtained prior to employment. | Program will obtain three references for all employees including those under contract prior to employment. | 03/13/2025 | No |
| 340:110-3-153.1(h)(1)(C) | personnel applicants, prior to hire; however, the program may hire individuals, when: | One personnel hired prior to receiving approved results from OBI. | Program will obtain complete approved, exempt or preliminary results from OBI prior to hire for all employees including those under contract. | 03/13/2025 | Yes |
| 340:110-3-153.1(l) | Orientation. Personnel receive orientation after employment date and within 30-calendar days of employment. | Orientation for one personnel not completed within 30 days of employment. | All employees including those under contract will complete orientation within 30 days of employment. | 03/13/2025 | No |
| 340:110-3-153.1(o)(2)(A) | an OKDHS-provided personnel information sheet, completed for each personnel upon employment and submitted to Licensing within two weeks of his or her employment; | Form not submitted to licensing within two weeks of employment for three personnel. | Program will submit personnel information form for all employees including those under contract to licensing within two weeks of employment. | 03/13/2025 | No |
| 340:110-3-153.1(m)(3)(E) | When residents are in care on the facility premises or on a program-sponsored field trip, at least one personnel is present with current age-appropriate first aid and cardio-pulmonary resuscitation (CPR) documentation. All other child care personnel obtain and maintain age-appropriate first aid and CPR within 90-calendar days of employment. CPR and first aid training are conducted by a certified instructor from an OKDHS-approved source. | One personnel without current CPR/First Aid certification on file. | Documentation will be submitted to licensing for personnel identified during this audit. | 03/13/2025 | No |
| 340:110-3-154(a)(6) | Residents receive a medical examination by a licensed health care professional within 60-calendar days prior to admission or within 30-calendar days following admission. However, a documented medical exam performed within the 12 months prior to admission is acceptable when a resident is transferred from another licensed program. | One resident admitted for over six months without a medical examination on file. | Medical examination will be scheduled for resident and verification submitted to licensing. | 03/13/2025 | No |
| 340:110-3-157(h)(3) | Hand sinks, bathtubs, and showers have cold and hot water with temperatures between 100 and 120 degrees Fahrenheit. | Bathroom sink temperature on Blue Moon reading 133 degrees, Pointe reading 131 degrees and Plus A reading 55 degrees. | Work order to correct water temperatures in bathroom sinks identified during this audit will be submitted to maintain between 100 and 120 degrees. Program will notify licensing personnel once this is completed. | 03/13/2025 | No |
| 340:110-3-157(j)(5) | Indoor resident areas are maintained between 65 and 85 degrees Fahrenheit. | Bedroom in Thunder A unit temperature reading 64 degrees and bedroom on Pointe unit temperature reading of 62 degrees. | Program will perform indoor temperature readings morning, afternoon and overnight and adjust thermostat as necessary to maintain temperature between 65 and 85 degrees. | 03/13/2025 | No |
| 340:110-3-157(j)(7) | Floors, walls, ceilings, doors, and windows are in good condition. | Dust particles and lint clinging to ceiling in numerous resident bedrooms directly in line with air vents. Ceiling in dayroom of Blue Moon continues to show disrepair in location where water leakage was observed during the 11-5-24 visit. Clothing closet with hole in drywall. Baseboards missing and peeling in resident bedrooms and day rooms. | Program will clean ceilings, and repaint. Repair drywall hole in clothing closet. Replace or repair baseboard throughout facility. Notify licensing personnel of progress. | 03/13/2025 | No |
| 340:110-3-157(k)(5) | During mealtimes, each resident is provided table space with a chair or a rotation schedule is followed. | Two units did not have adequate table space for residents use during meal time. | At least two tables should be on all units to provide adequate table space for resident use during meals. | 03/13/2025 | No |
| 340:110-3-163(1)(A) | Exterior and interior surfaces are maintained in sound condition and free of holes, peeling paper, and paint. | Peeling paint on ceilings and walls throughout the facility. | Program will begin repairing and painting interior walls and ceilings as necessary keeping licensing updated with progress. | 03/13/2025 | No |
| 340:110-3-163(12) | Electrical. The electrical distribution system is sized, installed, and maintained in a safe manner, per the Oklahoma Electrical Licensing Act. Portions of the electrical system constructed, repaired, or replaced after June 1, 1987, are installed, per the current National Electrical Code. | Electrical outlet in resident room secured by tape on Plus B unit. | Electrical outlet in resident bedroom will be repaired and program will notify licensing of completion. | 03/13/2025 | No |
| 340:110-3-164(4)(C) | A thermometer is located in a conspicuous place in each refrigerator and freezer. | Several freezers did not have thermometers locating in them and others were not working properly. | Operable thermometers will be placed in freezers and program will notify licensing of completion. | 03/13/2025 | No |
| 340:110-3-165(5)(A) | Smoke detectors. The residential child care facility has operable smoke detectors located according to NFPA 72 as adapted by the state fire marshal. The detector is powered by battery, alternating current, or other power source. Upon inspection, a battery operated detector found inoperable is replaced immediately with an operable system. For facilities licensed after October 1, 2001 a hard-wired system is installed. | Smoke detector located in resident bedroom presented with disconnected wiring. | Repair of smoke detector will be completed and licensing notified of completion. | 03/13/2025 | No |
| 340:110-3-163(13) | Garbage and rubbish disposal. Prior to disposal, garbage and rubbish containing food wastes or diapers are stored in leak-proof, non-absorbent containers and covered with tight-fitting lids when filled, stored, or not in continuous use. | Garbage containers on all units without tight fitting lids. There was also a trash bag attached to the wall used for containing waste items. | Garbage container with a tight fitting lid will be on all units. Program will notify licensing once completed. | 03/13/2025 | No |
| 340:110-3-153.1(o)(2)(C) | criminal history review requests and results documentation; | Program did not have documentation on file for two personnel with valid results issued by OBI. | Program provided result for one personnel at the end of this visit. Other documentation will be requested from OBI and program notify licensing once obtained. | 03/13/2025 | No |