PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31300 - RCR s.22(1)(c) - A licensee must ensure that all rooms and common areas are (c) maintained in a safe and clean condition.
Observation: 2 pieces of approx. 1mx1m plyboards and 4 approx. 4ft poles were stores in the outside PIC's activity area to the front of the building. Of concern is the safety of the PICs when accessing this area for their leisure and activity.
Corrective Action(s): Please ensure that all excess building materials are disposed off appropriately and the common areas maintained in safe condition.
Date to be Corrected: February 10, 2023
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: The following were observed:
1. The falls documentation did not have 24-48hr follow up completed by staff according to Falls Monitoring Policy.
2. 2/4 PICs' charts were missing the height and weight on the admission sheet and information records checklists.
3. The volunteer staff does not have the record of criminal record check (CRC) on file however, staff assisting with inspection informed the LO that the staff also works for the organization and has completed CRC.
Corrective Action(s): Please ensure that policies are implemented by employees
Date to be Corrected: February 10, 2023
CARE AND/OR SUPERVISION: 34290 - RCR s.59(a) - A licensee must provide an opportunity, at least annually, for persons in care and their parents or representatives, family members and contact persons to (a) establish one or more councils or similar organizations to represent the interests of the persons in care, or their parents or representatives, family members and contact persons, or both.
Observation: A resident or family council has not been established however, the staff assisting with the inspection informed the LO that the staff are looking into assisting setup of a resident/family council.
Corrective Action(s): Please ensure that resident/family council or a group is setup to represent the interests of the PICs.
Date to be Corrected: February 28, 2023
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