PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31830 - RCR s.36(2) - If necessary to protect the health or safety of persons in care, a licensee must ensure that the outside activity area is secured by a fence or other means.
Observation: The lock to the gate was not replaced after being removed, leaving it unsecured.
Corrective Action(s): Please ensure the gate preventing PICs from leaving the premise is secured.
Date to be Corrected: January 13, 2023
POLICIES AND PROCEDURES: 33130 - RCR s.68(3)(a) - The medication safety and advisory committee must establish and review as required (a) training and orientation programs for employees who store, handle or administer medications to persons in care.
Observation: Implementation of the licensee's corrective action plan continues to be in progress and will be reviewed at the time of the next follow up inspection.
Corrective Action(s): In progress
Date to be Corrected:
CARE AND/OR SUPERVISION: 34310 - RCR s.59(b)(ii) - A licensee must provide an opportunity, at least annually, for persons in care and their parents or representatives, family members and contact persons to (b) meet with the licensee, either as a council, or, if no council is established, as a group, for the purpose of (ii) involving the persons in care in decision making on matters that affect their day to day living.
Observation: Implementation of the licensee's corrective action plan continues to be in progress and will be reviewed at the time of the next follow up inspection.
Corrective Action(s): In progress
Date to be Corrected:
HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: Implementation of the licensee's corrective action plan continues to be in progress and will be reviewed at the time of the next follow up inspection
Corrective Action(s): In progress
Date to be Corrected:
MEDICATION: 36050 - RCR s.68(2)(b) - A licensee must appoint a supervising pharmacist to (b) inspect the areas of the facility where medications will be stored.
Observation: The medication storage area was last inspection in June 2022, more than three months prior.
Corrective Action(s): Please ensure inspection is completed at least every three months as required for a facility.
Date to be Corrected: January 13, 2023
PROGRAM: 38010 - RCR s.55(1)(a)(i) - A licensee, other than a licensee who provides a type of care described as Hospice, must (a) provide persons in care, without charge, with an ongoing planned program of physical, social and recreational activities (i) suitable to the needs of the persons in care.
Observation: Implementation of the licensee's corrective action plan continues to be in progress and will be reviewed at the time of the next follow up inspection.
Corrective Action(s): In progress
Date to be Corrected:
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