LICENSING: 10050 - CCLR s.11(1) - A licensee must display in a prominent place in the community care facility both the licence, including any terms or conditions of the licence, and the name of the manager.
Observation: Licensing observed that the Manger name was not posted - this was further discussed as to the intent of legislative requirement.
Corrective Action(s): Please ensure the Manager name is prominently displayed.
Date to be Corrected: Feb 9, 2023
STAFFING: 12050 - CCLR s.19(1)(b) - A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has first met with the person and obtained all of the following: (b) character references in respect of the person.
Observation: On review of 3 staff files, Licensing observed that the Manager only had 2 references where the requirement is 3, and 1 other staff did not have references on file. Both staff were on site today.
Corrective Action(s): Please ensure staff files are complete prior to employment at the facility
Date to be Corrected: Feb 6, 2023
STAFFING: 12070 - CCLR s.19(1)(d) - A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has first met with the person and obtained all of the following: (d) copies of any diplomas, certificates or other evidence of the person's training and skills.
Observation: Copies of any diplomas, certificates or other evidence of the person's training and skills were not obtained for two staff, out of the 3 staff files reviewed.
Corrective Action(s): Please ensure all staff documentation is in place prior to the staff working on site
Date to be Corrected: Feb 9, 2023
POLICIES AND PROCEDURES: 13020 - CCLR s.22(1)(b) - A licensee must: (b) have an emergency plan that sets out procedures to prepare for, mitigate, respond to and recover from any emergency.
Observation: Licensing observed that the fire extinguisher did not indicate last date of service. Extinguishers must be serviced annually or a receipt displayed as to purchase date of the extinguisher if within the last year. Facility policy also did not provide an alternate location for evacuation. This was further discussed. The Manager is also aware that the annual evacuation drill is required to be completed in the first year of operation.
Corrective Action(s): Please ensure there is an appropriate plan in place with available resources in case of an emergency and provide a compliance plan to Licensing.
Date to be Corrected: Feb 9, 2023
CARE AND/OR SUPERVISION: 14010 - CCLR s.34(1) - A licensee must ensure that children are adequately supervised by qualified employees in sufficient numbers to meet the needs of each child.
Observation: In discussion with staff, Licensing observed that on occasion, a second staff supervises children off site and does not hold the qualification of ECE certification as required by Schedule E.
Corrective Action(s): Please ensure that any staff solely caring for children meet the requirements of the service type in Schedule E. Please provide a compliance plan to Licensing.
Date to be Corrected: Feb 9, 2023
CARE AND/OR SUPERVISION: 14360 - CCALA s.7(1)(b)(i) - A licensee must do all of the following: (b) operate the community care facility in a manner that will promote (i) the health, safety and dignity of persons in care,
Observation: Through review of attendance records, Licensing observed that on at least 4 occasions in January, capacity was exceeded. In discussion with the Manager, it was identified that a second staff was caring for some children off-site until capacity was reduced to accommodate them at the facility. This was further discussed.
Corrective Action(s): Please ensure that enrolment and attendance meets the approved capacity of the community care facilities licence at all times. Please provide a compliance plan to Licensing.
Date to be Corrected: Feb 8, 2023.
RECORDS AND REPORTING: 19080 - CCLR s.57(2)(b) - A licensee must keep, for each child, a record showing the following information: (b) date of enrolment in the community care facility.
Observation: On review of 3 children's files, Licensing observed that all 3 did not contain an enrolment date.
Corrective Action(s): Please ensure children's files are complete at the time of registration
Date to be Corrected: Feb 9, 2023
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