Summary of Facility Monitoring
Facility Name: Evolve Date: 11/6/2026 Time: 6:07:57 AM
Case Number: K850055271



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Program Name Evolve Director Aaron Sampson
Location 6980 E 19th
Tulsa, Oklahoma 74112
E-Mail Address asampson@okcyc.org
Program Phone (405) 253-4314 County of Facility Tulsa
Program Type Residential Program Subtype Residential
Residential Specialist Name Wayne Flanagan Residential Specialist
Phone Number
(405) 397-9672
Capacity 6 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 11/5/2026 Visit Type Full Purpose of Visit Periodic
RequirementRegulation DescriptionNonCompliance ObservedPlan To CorrectCorrection DateNRS
340:110-3-157(j)(7)Floors, walls, ceilings, doors, and windows are in good condition.Southwest bedroom ceiling with crack in drywall. Northeast bedroom with paint peeling on wall. Program will submit a work order and contact licensing once repairs are completed. 11/13/2026No
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;Personnel information forms submitted late for two staff. Program will submit personnel information forms to licensing within two weeks of employment. 11/06/2026No

Visit Date 7/9/2026 Visit Type Full Purpose of Visit Periodic
RequirementRegulation DescriptionNonCompliance ObservedPlan To CorrectCorrection DateNRS
340:110-3-154(b)(1)(B)(vi)names and dated signatures of those participating in service plan development.Initial service plan for one resident did not include dated signatures. Program will obtain dated signatures and notify licensing personnel once completed. 07/10/2026No

Visit Date 3/31/2026 Visit Type Full Purpose of Visit Periodic
No non-compliances observed

Visit Date 11/6/2025 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 without verification of references being completed prior to hire. References for personnel identified during audit will be obtained and submitted to licensing. 11/10/2025No
340:110-3-165(5)(B)(i)All fire extinguishers are inspected, serviced, and tagged annually by a trained individual.Extinguisher located in kitchen expired 9-25. Program will have a currently tagged extinguisher located in kitchen and notify licensing once completed. 11/11/2025No
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;One document not provided within two weeks of hire date. Personnel information forms will be submitted to licensing within two weeks of hire. 11/07/2025No

Visit Date 7/15/2025 Visit Type Full Purpose of Visit Periodic
RequirementRegulation DescriptionNonCompliance ObservedPlan To CorrectCorrection DateNRS
340:110-3-157(h)(3)Hand sinks, bathtubs, and showers have cold and hot water with temperatures between 100 and 120 degrees Fahrenheit.Sink water in bathroom reading 140 degrees. Water heater will be adjusted and periodically checked to ensure it is registering at the highest temperature of between 100 to 120 degrees. 07/15/2025No

Visit Date 3/11/2025 Visit Type Full Purpose of Visit Periodic
No non-compliances observed

Visit Date 12/11/2024 Visit Type Full Purpose of Visit Periodic
RequirementRegulation DescriptionNonCompliance ObservedPlan To CorrectCorrection DateNRS
340:110-3-163(1)(C)Floors are cleanable and in good repair.Tile floor in east bathroom near shower entrance has numerous cracks. Work order will be placed for repair of floor tiles in east bathroom. Program will notify licensing once repair has been completed. 12/11/2024No

Visit Date 7/11/2024 Visit Type Full Purpose of Visit Periodic
RequirementRegulation DescriptionNonCompliance ObservedPlan To CorrectCorrection DateNRS
340:110-3-154(a)Admission. The program involves the resident and parents in the admission process.Admission paperwork on file for one resident dated 5-17-23 that was from prior program placement under the same ownership. Current placement date at this program is 4-18-24. Program will complete admission paperwork to reflect current admission at this program. 07/12/2024No

Visit Date 3/28/2024 Visit Type Full Purpose of Visit Periodic
RequirementRegulation DescriptionNonCompliance ObservedPlan To CorrectCorrection DateNRS
340:110-3-153(c)(2)When completed, a copy of the auditor's letter including a statement verifying the programs financial records accurately reflect its financial operations per generally accepted accounting principles, is submitted to Licensing.Auditor letter that meets licensing requirements was not provided. Program will submit a current auditor letter that meets licensing requirements. 03/28/2024No

Visit Date 11/21/2023 Visit Type Full Purpose of Visit Periodic
RequirementRegulation DescriptionNonCompliance ObservedPlan To CorrectCorrection DateNRS
340:110-3-165(4)(B)Means of exit are adequately lighted by natural or electric light at all times to permit safe evacuation of occupants.Exit light located in northeast part of dayroom has broken light. Work order to replace exit light will be submitted today. Program will email licensing when it has been installed. 11/21/2023No
340:110-3-153.1(o)(2)(A)an OKDHS-provided personnel information sheet, completed for each personnel and submitted to Licensing within two weeks of his or her employment;Two personnel information forms not submitted to licensing within required time frame. Program will submit personnel information form to licensing within required time frame for all personnel regardless of length of employment. 11/21/2023No
340:110-3-154(b)(1)Comprehensive service plan. A written service plan is developed and documented for residents within 30-calendar days of admission.Initial service plan on file did not identify date of development or include any signatures. Program will document on service plan form the effective/development date and obtain all required dated signatures. 11/21/2023No
340:110-3-154.3(e)(2)When any medication is administered to a resident, a precise record is kept that includes:Documentation indicating why medication was not administered to resident was not included on form. Program will document why medication was not administered to resident as instructed on MAR. 11/21/2023No




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 9/22/2026
RequirementDescriptionAllegation DescriptionPlan To CorrectAllegation Findings
340:110-3-154.2(b)(2)threatening, harsh, humiliating, cruel, abusive, or degrading language;Behavior Management: Program personnel used verbal and non-verbal communication to escalate a residents' behavior.Staff will continue to receive ongoing training regarding the appropriate use of de-escalation techniques and physical restraints. Training content and techniques will be routinely reviewed and evaluated to ensure that current best practices, safety standards, and organizational expectations are consistently being followed. Staff will receive training focused on Managing Youth Behaviors: De-escalation and Professional Response. This additional training reinforced appropriate de-escalation strategies, professional responses to challenging behaviors, and the importance of utilizing approved interventions in accordance with agency policies and procedures. As a testament to our commitment to maintaining a safe environment for the youth, the staff member allegedly involved in the incident is no longer employed by our agency.Substantiated

Complaint Received 3/2/2026
RequirementDescriptionAllegation DescriptionPlan To CorrectAllegation Findings
340:110-3-152(d)(2)personnel;Additional Non-Compliance Found During Investigation: Policy: Staff member violated facility policy by having extensive contact with a former resident following discharge.Plan of correction received from program that the staff member involved was terminated for violating facility policy. Policy and expectations regarding professional boundaries was reviewed with all staff during staff meeting. Plan of correction date: 9/4/26Determined During Course of Investigation

Complaint Received 1/26/2024
RequirementDescriptionAllegation DescriptionPlan To CorrectAllegation Findings
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: Notification: Resident received emergency medical attention and program failed to notify licensing as required. Program will notify licensing at the time of a medical emergency. Determined During Course of Investigation

Complaint Received 12/15/2023
RequirementDescriptionAllegation DescriptionPlan To CorrectAllegation Findings
340:110-3-163(3)(C)in resident's presence.Tobacco Use: Staff members vaped nicotine in front of residents.Plan of correction received from program as follows: "All staff are trained and sign the company's tobacco police at the time of hire. Staff reviewed the policy in staff training to ensure that it is understood that the use of tobacco is prohibited." Plan of correction was due 2/8/24 and was received 3/25/24.Substantiated
340:110-3-154.2(b)(3)food or sleep denial;Behavior Management: Staff members withheld food and water as punishment.Plan of correction received from program as follows: "All staff are trained at the time of hire and provided refresher training on behavior management. A refresher training was given covering withholding food and water as punishment is not an acceptable form of behavior management." Plan of correction was due 2/8/24 and was received 3/25/24.Substantiated

Complaint Received 11/27/2023
RequirementDescriptionAllegation DescriptionPlan To CorrectAllegation Findings
340:110-3-153.1(b)(4)Child care personnel. Child care personnel are responsible for meeting residents' needs, taking in account the residents' ages, physical and mental conditions, and other factors affecting the amount of attention indicated.Personnel: Personnel denied residents access to facility after returning from AWOL. While the alleged incident has been denied by the staff member in question. As a testament to our commitment to maintaining a safe environment for the youth, the staff member allegedly involved in the incident is no longer employed by our agency. We have completed additional training to all staff members on missing from care protocols, ensuring they are equipped with the necessary skills and knowledge to respond effectively to various situations. We want to reiterate our dedication to addressing the concerns raised by the licensing violation and ensuring the safety and welfare of the youth under our care. Substantiated

Complaint Received 11/17/2023
RequirementDescriptionAllegation DescriptionPlan To CorrectAllegation Findings
340:110-3-154.2(b)(2)threatening, harsh, humiliating, cruel, abusive, or degrading language;Behavior Management: Personnel told resident "I'm going to drop you" prior to picking resident up and then releasing hold causing resident to fall to the ground. Staff are trained in de-escalation techniques and professionalism upon being hired. Staff will continue to receive refresher training. Substantiated
340:110-3-154(e)(1)(G)reports of separation, physical restraint use, and other restrictions;Additional Non-Compliance Found During Investigation: Social Services: Resident was physically restrained, and no report was completed by personnel. Incident reports will be written and submitted within 24 hors of all physical restraints performed by staff. The program director will monitor this for compliance. Determined During Course of Investigation
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.Additional Non-Compliance Found During Investigation: Behavior Management: Resident was physical restrained by personnel when that was not the least restrictive intervention. Staff will continue to receive training on the use of de-escalation techniques, physical restraints, and report writing. Training techniques and content are continuously reviewed to ensure best practices are utilized. Staff member involved in the incident is no longer employed by agency. Determined During Course of Investigation