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: Upon review of four staff files one staff person does not have a CRC completed through the criminal record review agency in Victoria. This staff person currently has a clear criminal record check from the RCMP.
Corrective Action(s): Please ensure all staff persons have a criminal record check through the criminal records review branch in Victoria
Date to be Corrected: December 15,2021
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: 3 out of 4 staff files reviewed were missing character references. One staff had a reference that was not verified.
Corrective Action(s): Ensure that character references are obtained and verified for each employee before they start employment.
Date to be Corrected: November 29, 2021
STAFFING: 12060 - CCLR s.19(1)(c) - 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: (c) a record of the person's work history.
Observation: 2 out of 4 staff files reviewed were missing evidence of work history.
Corrective Action(s): Ensure that staff records are complete before they start employment.
Date to be Corrected: November 25, 2021
STAFFING: 12200 - CCLR s.22(2)(c) - A licensee must ensure that each employee (c) practices implementing the emergency plan at least once each year.
Observation: The last emergency plan was implemented in August 2020.
Corrective Action(s): Please ensure all staff participate in implementing the emergency plan at least once a year.
Date to be Corrected: December 8, 2021
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: Facility's first aid kit had insufficient first aid supplies. Manager stated it will be replenished.
Corrective Action(s): Please ensure the facility is able to prepare, mitigate, respond and recover from an emergency.
Date to be Corrected: November 26, 2021
RECORDS AND REPORTING: 19070 - CCLR s.57(2)(a) - A licensee must keep, for each child, a record showing the following information: (a) name, sex, date of birth, medical insurance plan number and immunization status.
Observation: Licensing reviewed four children files. One file was missing medical insurance plan number.
Corrective Action(s): Ensure all children's files are complete before they start attending the facility.
Date to be Corrected: November 25, 2021
RECORDS AND REPORTING: 19100 - CCLR s.57(2)(d) - A licensee must keep, for each child, a record showing the following information: (d) name and telephone number of a parent, medical practitioner and emergency contact.
Observation: Licensing reviewed four children files. One file was missing:
·Medical practitioner name
·Medical practitioner telephone number
·Emergency contact information
Corrective Action(s): Ensure all children's files are complete before they start attending the facility.
Date to be Corrected: November 26, 2021
RECORDS AND REPORTING: 19210 - CCLR s.58(1)(a) - A licensee must keep, for each child requiring extra support, a current care plan showing the following information: (a) the diagnoses relevant to the child's requirement for extra support, as made by health care professionals.
Observation: No care plan available for a child requiring extra support. Manager was able to verbally explain the needs of the child but there is no care plan written down to follow.
Corrective Action(s): Please ensure there is a care plan written and in place for each child who requires extra support.
Date to be Corrected: December 6, 2021
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