Summary of Facility Monitoring
Facility Name: CommunityWorks ITS Date: 11/6/2026 Time: 6:08:34 AM
Case Number: K850054574



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Program Name CommunityWorks ITS Director Rashida Richardson
Location 805 East Robinson

Norman, Oklahoma 73069
E-Mail Address tspurgeon@cworksok.com
Program Phone (405) 447-4499 County of Facility Cleveland
Program Type Residential Program Subtype Residential
Residential Specialist Name Elizabeth Patterson Residential Specialist
Phone Number
(918) 776-7411
Capacity 9 Services Provided


Monitoring Summary since 11/6/2023
Listed below are the non-compliances OBSERVED during a visit. The regulation, its description, the non-compliance observed according to the regulation, and a plan of corrective action are all provided. The column "NRS" indicates Numerous, Repeated and/or Serious non-compliances with Licensing Requirements.
Visit Date 10/12/2026 Visit Type Full Purpose of Visit Periodic
RequirementRegulation DescriptionNonCompliance ObservedPlan To CorrectCorrection DateNRS
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.1 personnel with 3 references not prior to hire date; 1 personnel with 3 references; 2 not prior to hire date, and 1 personnel with 1 reference and was not prior to the hire date. Will obtain 2 references for one new personnel and will ensure all references are completed prior to the hire date. Program will send copy of 2 references when received. 10/22/2026No
340:110-3-153.1(l)Orientation. Personnel receive orientation after employment date and within 30-calendar days of employment.1 personnel with orientation prior to the hire date. Will have personnel obtain orientation after the hire date. 10/12/2026No
340:110-3-157(n)Fire safety. The program complies with the state fire marshal's office regulations for construction and fire safety and is inspected annually by the state fire marshal's office or its designee.Fire inspection expired 09/16/2025. Fire inspection is scheduled for 10/12/2026 at 4 pm. Program will send copy when completed. 10/22/2026No

Visit Date 5/12/2026 Visit Type Full Purpose of Visit Periodic
No non-compliances observed

Visit Date 1/21/2026 Visit Type Full Purpose of Visit Periodic
RequirementRegulation DescriptionNonCompliance ObservedPlan To CorrectCorrection DateNRS
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.One personnel re-hired prior to obtaining required references. Program will obtain updated references when personnel are re-hired. 01/22/2026No

Visit Date 9/9/2025 Visit Type Full Purpose of Visit Periodic
RequirementRegulation DescriptionNonCompliance ObservedPlan To CorrectCorrection DateNRS
340:110-3-157(n)Fire safety. The program complies with the state fire marshal's office regulations for construction and fire safety and is inspected annually by the state fire marshal's office or its designee.Last inspection performed 9-4-24. Program will contact proper authority to request a fire inspection. Documentation will be submitted to licensing once completed. 09/10/2025No
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 observed throughout the facility. Work order will be submitted to remove peeling paint and apply new coat. Program will notify licensing once this is completed. 09/10/2025No

Visit Date 5/6/2025 Visit Type Full Purpose of Visit Periodic
No non-compliances observed

Visit Date 1/23/2025 Visit Type Full Purpose of Visit Periodic
RequirementRegulation DescriptionNonCompliance ObservedPlan To CorrectCorrection DateNRS
340:110-3-165(7)(C)Use of open-face space heaters, unvented space heaters, and portable heating devices is prohibited.Program had portable heaters located in offices being used. Program will only use an approved portable heater that is oil filled within the building. All other portable heaters will be removed. 01/23/2025No
340:110-3-165.1(1)Fire drills. Residents participate in fire drills at least six times annually on a bi-monthly basis with at least two drills conducted at night during sleeping hours.No documented fire drills performed during sleep hours. Program will perform and document at least two fire drills that are conducted during normal sleep hours. 01/23/2025No
340:110-3-154(a)(1)On admission, a resident assessment is completed indicating the placement is appropriate. The admission assessment is documented and available for Licensing review. An assessment includes the resident's:Child was discharged from program on 1-7-25 and re-admitted on 1-8-25. New admission paperwork was not completed. Program will complete new admission paperwork when residents are discharged and return for services after the date of discharge. 01/23/2025No

Visit Date 10/8/2024 Visit Type Full Purpose of Visit Periodic
RequirementRegulation DescriptionNonCompliance ObservedPlan To CorrectCorrection DateNRS
340:110-3-154(a)(5)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 without verification of medical examination on file that shows compliance with licensing standard. Program will obtain verification for resident identified during audit and place in file for future review. 10/11/2024No
340:110-3-154.3(e)(2)When any medication is administered to a resident, a precise record is kept that includes:Precise record regarding administration of medication to residents is not maintained with dates left blank with no explanation of why medications not given. Program will keep a precise record of medication administration that includes explanation of why they were not administered. 10/08/2024No
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.Outlet cover missing on north wall of dayroom. Cover will be placed over outlet. 10/09/2024No
340:110-3-157(h)Bathrooms. Bathrooms are maintained in a clean and sanitary condition with adequate ventilation.North bathroom presented with paper products and other objects laying on floor with trash container used to prop the door open. Program will maintain bathroom in sanitary condition. 10/08/2024No
340:110-3-164(4)(C)A thermometer is located in a conspicuous place in each refrigerator and freezer.No thermometer located in refrigerator/freezer unit used to store food items. Thermometer will be placed in refrigerator/freezer unit. 10/09/2024No

Visit Date 6/19/2024 Visit Type Full Purpose of Visit Periodic
No non-compliances observed

Visit Date 2/5/2024 Visit Type Full Purpose of Visit Periodic
RequirementRegulation DescriptionNonCompliance ObservedPlan To CorrectCorrection DateNRS
340:110-3-154(e)(1)(I)signed documentation the resident and parents were provided copies of program policies.Guardian signature not obtained acknowledging receipt of program policies. Guardian signature will be obtained to verity receipt of program policies. 02/05/2024No




Complaint Summary since 11/6/2023
Any complaint investigation that rises to the level of abuse/neglect is referred to OKDHS Child Welfare Services for screening and investigation. All other complaint allegations are investigated by Oklahoma Child Care Services. Only substantiated complaints are available for viewing online.
Complaint Received 7/24/2026
RequirementDescriptionAllegation DescriptionPlan To CorrectAllegation Findings
340:110-3-154.3(e)(3)Prescription medications are administered, per container instructions, including only administering when the medication is part of a prescribed therapeutic treatment and only to the resident whose full name is on the container label.Health and Medical Services: Program mismanaged administration of schedule II medication causing twelve pills to be unaccounted for at the time of discharge. Requested of program. Substantiated
340:110-3-154.3(e)(2)(C)(iii)the dosage, date and time administered, and signature of the individual administering the medication;Additional Non-Compliance Found During Investigation: Health and Medical Services: Three personnel did not sign and initial MAR for resident who was administered medications by them. Requested of program. Determined During Course of Investigation
340:110-3-153.1(b)(2)Program director. The program director is responsible for implementing and supervising programs and services. The program director is also responsible for the day-to-day program operation.Additional Non-Compliance Found During Investigation: Personnel: Program director aware of pill count discrepancy failed to take appropriate action to safeguard resident or file police report regarding missing schedule II medication. Requested of program. Determined During Course of Investigation

Complaint Received 2/11/2026
RequirementDescriptionAllegation DescriptionPlan To CorrectAllegation Findings
340:110-3-154.3(e)(3)Prescription medications are administered, per container instructions, including only administering when the medication is part of a prescribed therapeutic treatment and only to the resident whose full name is on the container label.Health and Medical Services: Program incorrectly administering medication to resident. Medication Administration procedures reviewed and clarified with staff. Verification required prior to each medication pass. Training completed during staff meeting held on 3-18-26. Substantiated
340:110-3-154.3(c)Medical care. Residents receive proper medical and dental care. When a serious injury or illness occurs, the program takes the necessary emergency action and notifies the parents or legal custodian immediately.Health and medical services: Program failed to provide necessary medical care to resident as reflected on MARs reviewed. End of shift MAR check and shift-change double verification put into place. Weekly MAR audits will be performed. Training completed 3-18-26. Substantiated

Complaint Received 4/18/2025
RequirementDescriptionAllegation DescriptionPlan To CorrectAllegation Findings
340:110-3-154.2(b)(1)behaviors that could cause physical pain, such as shaking, striking, spanking, grabbing, yanking, pulling, pushing, choking, threatening, or other cruel treatment;Behavior Management: Staff members used prohibited behavior management actions toward residents.Plan of correction received from program. Staff members involved completed mandatory refresher MAB training with completion date of 9/6/25 and 10/15/25.Substantiated
340:110-3-154.2(d)Physical restraint. Restraint may only be used when less restrictive interventions, according to facility policy, have been attempted or when an immediate intervention is required to protect the resident, a staff member, or others. The restraint technique used must be the least restrictive intervention that will be effective to protect the resident or others from harm. Restraint must be discontinued at the earliest possible time. A written incident report is completed within 24-hours following each use of physical restraint.Behavior Management: Staff member used improper restraint techniques, causing pain to resident. Plan of correction received from program. Staff members involved completed mandatory refresher MAB training with completion date of 9/6/25 and 10/15/25. Additional training was provided in areas of Prudent Parenting, Mandatory Reporting, Crisis Intervention and Duty to Warn.Substantiated

Complaint Received 12/14/2024
RequirementDescriptionAllegation DescriptionPlan To CorrectAllegation Findings
340:110-3-152(f)(1)(F)any time a resident receives emergency medical treatment by a licensed health care professional;Additional Non-Compliance Found During Investigation: Organization: Program failed to notify licensing within one OKDHS working day of resident receiving emergency medical attention on 12-10-24. As of 1-2-25 program will notify licensing within one OKDHS working day when resident is taken to emergency room for emergency medical treatment. Determined During Course of Investigation
340:110-3-152(f)(1)(G)incidents involving law enforcement, excluding residents absent without permission; orAdditional Non-Compliance Found During Investigation: Organization: Program failed to notify licensing within one OKDHS working day of police involvement at facility on 12-11-24 that was not related to AWOL. Program is implementing plan to notify licensing within one OKDHS working day of any police involvement at facility. Determined During Course of Investigation

Complaint Received 10/4/2024
RequirementDescriptionAllegation DescriptionPlan To CorrectAllegation Findings
340:110-3-154.3(e)(2)When any medication is administered to a resident, a precise record is kept that includes:Additional Non-Compliance Found During Investigation: Health and Medical Services: Program not maintaining a precise record of medication administration. Policy reinforcement and staff training to ensure medications are documented only after official resident admission. Measures will be taken to confirm that only on-shift personnel document medication administration, with weekly supervisory audits. Training to emphasize the importance of date accuracy on MAR, with monthly audits to identify any omissions. Shift change pill counts, supported by regular supervisory audits. Tracking system to monitor medication quantities and prevent premature depletion, with weekly compliance checks. Program will notify licensing promptly when a resident is taken to the hospital. Determined During Course of Investigation
340:110-3-152(f)(1)(F)a serious resident injury requiring emergency medical treatment by a licensed health care professional; orAdditional Non-Compliance Found During Investigation: Resident taken to hospital on 8-21-24 and program failed to notify licensing within required time frame. Requested of program.Determined During Course of Investigation