Complaint Investigation
Inspection Information
Facility Type
Residential Care - 400
Received Date
07-Jun-2024
Subject
["Access by Others (Includes access to parents, family, others)"]
Contraventions: A summary of the new contraventions found during the inspections are listed below.
Code
Category/Description
A licensee must ensure that no one other than a person in care engages in a restricted activity while on the premises of the community care facility
Observation: Through the investigation process, Licensing determined that a visitor was smoking on the premises.
Corrective action: Ensure that no one other than a person in care engages in a restricted activity while on the premises of the community care facility. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On June 27 and July 24, 2024, Licensee submitted a corrective action plan to Licensing. The corrective action plan included: visitors were not to smoke on the property, there was an attendant staff 24/7 that monitored everyone on the patio, including visitors and advised them not to smoke on the patio, if the attendant observed a visitor smoking on the patio, the Manager would speak to the visitor and if the visitor resisted, an onsite security officer would escort the visitor off the premises. This corrective action plan has been reviewed and accepted by Licensing. On February 18, 2025, the Licensee indicated that monitoring of the outdoor patio area was implemented through the Behavioral Support Attendant who monitored persons in care on the patio and ensured immediate communication regarding the no-smoking policy for visitors, If instances of non-compliance occurred, there was an escalation process and Protection Services Officers were available, and the security response protocol has been strengthened through the presence of 24/7 Protection Services Officers on site. On February 20, 2025, Licensing conducted a Follow Up to Routine Inspection and requested documentation related to visitors engagement of restricted activity and the record of the Behavioral Support Attendant monitoring. On February 24, 2025, Licensee submitted a copy of the Incident Logs which indicated there was an incident of a visitor being asked to stop smoking on two occasions which were addressed as per the corrective action plan submitted.
A licensee must do all of the following: operate the community care facility in a manner that will promote in the case of adult persons in care, the rights of those persons in care;
Observation: Through the investigation process, Licensing determined that the persons in care's environment did not promote the health, safety and dignity of persons in care due to a visitor.
Corrective action: Ensure the community care facility is operated in a manner that promotes the rights of persons in care. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On June 27 and July 24, 2024, Licensee submitted a corrective action plan to Licensing. The corrective action plan included that the Bill of Rights was already posted in all units, staff ensured that the Bill of Rights was upheld and a visitor was restricted to outdoor visits only for the time being. This corrective action plan has been reviewed and accepted by Licensing. On February 18, 2025, the Licensee indicated that The Bill of Rights remained prominently posted throughout the facility, staff continued to ensured the Bill of Rights was upheld in their interactions with persons in care, and staff had been trained to escalate concerns to their leaders if there was a conflict between a person in care's personal rights and the ability to maintain the health, safety and dignity of all persons in care. On February 20, 2025, Licensing conducted a Follow Up to Routine Inspection and requested documentation for staff training and observed the Bill of Rights posted in the main lobby. On February 24, 2025, Licensee submitted a copy of the staff education related to the Bill of Rights.