PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 11220 - CCLR s.23(2) - A licensee must have first aid kits that are readily accessible to all employees, including while care is provided off the community care facility premises.
Observation: An inspection of 2 first aid kits revealed that both kits have insufficient supplies
Corrective Action(s): Ensure all first aid kids have sufficient supplies to address and respond to first aid situations
Date to be Corrected: May 28, 2021
STAFFING: 12040 - CCLR s.19(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 first met with the person and obtained all of the following: (a) a criminal record check for the person.
Observation: A review of staff files found that 1 file contained a criminal record check issued by the RCMP dated 2019. Although this RCMP CRC indicated that the person did not have a criminal record it was not obtained through the Criminal Records Review Program and was not specific to this facility and location.
Corrective Action(s): Ensure each person has obtained a Criminal Record Check through the Criminal Records Review Program and is specific to this facility and location.
Date to be Corrected: May 28, 2021
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: A review of 3 staff files found that 2 were missing verified references
Corrective Action(s): Ensure all staff files have verified references available for review on site.
Date to be Corrected: May 28, 2021
STAFFING: 12090 - CCLR s.19(1)(f) - 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: (f) evidence that the person has complied with the Province's immunization and tuberculosis control programs.
Observation: A review of 3 staff files found that one file did not have evidence of immunization status.
Corrective Action(s): Ensure staff files are complete
Date to be Corrected: May 28, 2021
STAFFING: 12140 - CCLR s.19(4)(a) - A licensee must not employ a person in a community care facility as (a) an educator or an assistant unless the person holds a certificate issued under Division 2 [Employee Qualifications], which must be verified by the licensee using a system established and maintained by the director of the early childhood educator registry,
Observation: During review of staff files, it was found that 2 out of 3 files did not have certificate validation present.
Corrective Action(s): Ensure each person's certificate has been verified through the system established by the director of the ECE registry
Date to be Corrected: May 28, 2021
POLICIES AND PROCEDURES: 13020 - CCLR s.22(1)(b) - A licensee must have all of the following: (b) an emergency plan that sets out procedures to prepare for, mitigate, respond to and recover from any emergency.
Observation: A review of facility emergency supplies found that there were insufficient supplies to respond and recover from an emergency
Corrective Action(s): Ensure there are sufficient supplies to respond and recover from any emergency.
Date to be Corrected: June 4, 2021
POLICIES AND PROCEDURES: 13060 - CCLR s.56(1)(d) - A licensee must keep current records of each of the following: (d) written policies and procedures that are intended to guide employees in the care and supervision of children.
Observation: A review of facility policies found that there is no procedure identified for when a child goes missing or wandering.
Corrective Action(s): Ensure all policies intended to guide employees in the care and supervision of children are complete
Date to be Corrected: June 4, 2021
RECORDS AND REPORTING: 19030 - CCLR s.55(2)(a) - A licensee must notify the medical health officer within 24 hours after (a) a child is involved in, or may have been involved in, a reportable incident described in Schedule H while under the care or supervision of the licensee.
Observation: A review of the facility log book found that an incident involving a child was recorded but was not reported to the MHO within 24 hours after occurring
Corrective Action(s): Ensure all reportable incidents as described in Schedule H are reported within 24 hours
Date to be Corrected: May 20, 2021
RECORDS AND REPORTING: 19170 - CCLR s.57(2)(j) - A licensee must keep, for each child, a record showing the following information: (j) a record of any person who is not permitted access to the child.
Observation: A review of 7 files found that 2 files are missing information regarding persons not permitted access to children.
Corrective Action(s): Ensure all children's files are complete
Date to be Corrected: June 4, 2021
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