LICENSING: 30240 - RCR s.61 - A licensee must regularly monitor the physical environment of the community care facility, and the care and services provided by it, to ensure that the requirements of the Act and this regulation are being met.
Observation: Nutrition Menu Audits information indicates that most recent audits were done 2021.
Corrective Action(s): Discussion occurred regarding regular monitoring is in place.
Date to be Corrected: March 31, 2023
STAFFING: 32010 - RCR s.37(1)(a) - 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 obtained all of the following: (a) a criminal record check for the person.
Observation: 7 staff files reviewed, one renewal CRC and one new CRC was missing
Corrective Action(s): Please ensure compliance pertaining CRC is complete
Date to be Corrected: March 31, 2023
STAFFING: 32083 - RCR s.37(3)(c) - Despite this section, a licensee may employ a person as a volunteer who does not provide care to persons or supervise persons if the licensee or manager has first met with the person and obtained all of the following: (c) evidence that the person has complied with the Province's immunization and tuberculosis control programs.
Observation: One staff was missing their evidence of TB compliance
Corrective Action(s): Please ensure staff records are complete
Date to be Corrected: March 31, 2023
RECORDS AND REPORTING: 39130 - RCR s.78(1)(a) - A licensee must keep, for each person in care, a record showing the following information: (a) name, sex, date of birth, medical insurance plan number and immunization status.
Observation: Review of PICS records indicate one PIC immunization status is missing
Corrective Action(s): Please ensure all records are complete
Date to be Corrected: February 28, 2023
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