STAFFING: 12040 - CCLR s.19(1)(a) - 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: (a) a criminal record check for the person.
Observation: Audit of staff files revealed one staff on site with an expired CRC letter
Corrective Action(s): Please ensure all required documenation is obtained and maintained at all times
Date to be Corrected: March 28, 2022
STAFFING: 12050 - CCLR s.19(1)(b) - 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: (b) character references in respect of the person.
Observation: Audit of 4 staff files revealed 2 files evidence of references checked
Corrective Action(s): Please ensure all references have been checked prior to employment
Date to be Corrected: March 28, 2022
STAFFING: 12070 - CCLR s.19(1)(d) - 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: (d) copies of any diplomas, certificates or other evidence of the person's training and skills.
Observation: Copies of any diplomas, certificates or other evidence of the person's training and skills were not obtained.
Corrective Action(s): Please ensure all staffing credentials are posted and valid
Date to be Corrected: March 21, 2022
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: Immunization status was not obtained for one or more employees.
Corrective Action(s): Please ensure all required documentation has been obtained prior to employment
Date to be Corrected: March 18, 2022
POLICIES AND PROCEDURES: 13020 - CCLR s.22(1)(b) - A licensee must: (b) have an emergency plan that sets out procedures to prepare for, mitigate, respond to and recover from any emergency.
Observation: Fire extingushers have not been serviced since 2019
Corrective Action(s): Please ensure all fire extinguishers are serviced annually
Date to be Corrected: March 28, 2022
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: Audit of fire drill records revealed that fire drills are not practised in the months of July and August when the Manager is not on site
Corrective Action(s): Fire drills must be practised and recorded monthly
Date to be Corrected: March 31, 2022
POLICIES AND PROCEDURES: 13070 - CCLR s.56(1)(e) - A licensee must keep current records of each of the following: (e) written policies and procedures respecting food and drink to be given to children.
Observation: During review of nutrition policy, it is noted that children will not be involved with the prepartion of food, however it was stated that the children do assist with food prepartation
Corrective Action(s): Please follow nutrition policy as written or adjust accordingly
Date to be Corrected: March 28, 2022
RECORDS AND REPORTING: 19080 - CCLR s.57(2)(b) - A licensee must keep, for each child, a record showing the following information: (b) date of enrolment in the community care facility.
Observation: Audit of 5 children's files revealed 3 missing enrolment date
Corrective Action(s): Please ensure all required documentation is obtained and maintained at all times
Date to be Corrected: March 28, 2022
RECORDS AND REPORTING: 19090 - CCLR s.57(2)(c) - A licensee must keep, for each child, a record showing the following information: (c) daily attendance record, indicating for each day whether the child is absent or, if the child is present, the time of arrival and departure.
Observation: Audit of attendance records show missing information
Corrective Action(s): Please ensure attendance reflect arrival and departure times, and any absences daily
Date to be Corrected: March 15, 2022
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