PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31290 - RCR s.22(1)(b) - A licensee must ensure that all rooms and common areas are (b) maintained in a good state of repair.
Observation: Observations:
1). 2 of 4 resident's bedroom blinds are broken at different places making it difficult to fully close these blinds. The staff person assisting with this inspection informed the LO that the plans are being made to replace the blinds.
2). The garage has a leak from the ceiling where water is seeping from the exposed deck overtop. This garage is used as a gym and activity space for the PICs. Emergency supply and extra food items are also stored for the PICs consumption in this space.
Corrective Action(s): Please ensure that all rooms and common areas are maintained in good state of repair.
Date to be Corrected: February 15, 2022
POLICIES AND PROCEDURES: 33280 - RCR s.85(1)(d) - A licensee must do all of the following: (d) ensure that policies are implemented by employees.
Observation: 1). 1 of 5 staff persons on the checklist provided did not have the current performance evaluation completed. The staff person assisting with the inspection was made aware of the staff missing the evaluation.
2). The food served by staff the previous Saturday did not match the winter menu for the day. The LO discovered this oversight while auditing the completed menu substitution form which recorded the item that was substituted for the food that not found on the day's menu.
Corrective Action(s): Please ensure that all policies are implemented appropriately by all employees.
Date to be Corrected: February 15, 2022
CARE AND/OR SUPERVISION: 34750 - RCR s.81(4)(b)(i) - A licensee must ensure that (b) each care plan is reviewed and, if necessary, modified (i) if there is a substantial change in the circumstances of the person in care.
Observation: 1 of 4 PICs care plan has not been revised post a significant reportable incident requiring a closer guidance, supervision and monitoring of the PIC by staff persons. The staff person assisting with the inspection was made aware of the same and will be revising the care plan.
Corrective Action(s): Please ensure that each care plan is reviewed and modified if there is a change in the circumstances of the PIC.
Date to be Corrected: February 15, 2022
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