LICENSING: 10050 - CCLR s.11(1) - A licensee must display in a prominent place in the community care facility both the licence, including any terms or conditions of the licence, and the name of the manager.
Observation: During inspection Licensing noted that the facility manager's name is not posted in the facility.
Corrective Action(s): Ensure facility manager's name is posted in the facility in a prominent location.
Date to be Corrected: October 13, 2016
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: During inspection Licensing reviewed staff files and noted one staff person is missing immunization status.
Corrective Action(s): Manager will give staff person the Employee Immunization Status form to complete.
Date to be Corrected: November 12, 2016
STAFFING: 12430 - CCLR s.56(1)(b) - A licensee must keep current records of each of the following: (b) for each employee, the records required under section 19 (1) [character and skill requirements].
Observation: During inspection Licensing reviewed staff records and noted two staff persons Criminal Record Approval letters are addressed to a different employer/ training institution. The Criminal Record Review Program requires that the Criminal Record approval letters be addressed to the current employer.
Corrective Action(s): Licensing will give information to manager regarding how to have the Criminal Record Approval letters shared with them. Ensure all required staff documentation is current.
Date to be Corrected: December 12, 2016
POLICIES AND PROCEDURES: 13050 - CCLR s.56(1)(c) - A licensee must keep current records of each of the following: (c) a record respecting compliance with section 22 (2) (b) and (c) [emergency training and equipment].
Observation: During inspection Licensing reviewed emergency drill records and noted that the month of the emergency drill is recorded but not the actual date, and the annual emergency evacuation drill is not recorded.
Corrective Action(s): As these records are legal proof that the emergency drill was practiced, ensure that each drill is recorded with the actual date that the drill was practiced.
Date to be Corrected: November 01, 2016
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