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: The kitchen cabinet doors in front of the kitchen sink is broken and does not close properly.
Corrective Action(s): Please ensure that all areas are maintained in good state of repair.
Date to be Corrected:
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31320 - RCR s.22(3) - A licensee must ensure that all rooms and common areas, emergency exits, equipment, and monitoring and signalling devices are inspected and maintained on a regular basis.
Observation: One wall mounted fire extinguisher at the entrance door of the facility did not have the current annual inspection indicated on it. The staff person assisting with the inspection stated that the fire technicians probably missed that fire extinguisher.
Corrective Action(s): Please ensure that all emergency equipment and monitoring devices are inspected and maintained in working order on a regular basis.
Date to be Corrected:
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31760 - RCR s.35(1)(c) - A licensee must provide the following appropriately furnished and equipped areas: (c) secure, safe and adequate storage areas for cleaning agents, chemical products and other hazardous materials.
Observation: Bleach and other cleaning supplies are kept in the laundry room that had both doors open on first day of inspection and one door open on the second day. There is a PIC who is mobile at the facility.
Corrective Action(s): Ensure safe and adequate storage of cleaning agents and chemical products.
Date to be Corrected:
STAFFING: 32320 - RCR s.68(4) - A licensee must ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Observation: 1). 2 PICs medication boxes had combs, nail polish bottles and other personal items stored together with the medications. (CORRECTED DURING INSPECTION)
2). A small bottle of liquid with plunger dropper cap was found in one PIC's medication box. Upon conversation with staff it was determined that the label has fallen off the bottle.
Corrective Action(s): Please ensure that staff comply with the policies and procedures of the MSAC.
Date to be Corrected:
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 was observed:
1). 2/5 staff did not have evidence of a current criminal record check,
2).1/5 staff had expired food safe certification, and
3). 2/5 had expired CPR/First Aid as per the checklist provided.
4). The fridge temperature was not documented as per the facility policy. The fridge temperature records for the fridge was not recorded for month of June, 2021.
Corrective Action(s): Please ensure that policies are implemented by employees.
Date to be Corrected:
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