Facility Evaluation Report

At 10:00am, Licensing Program Analyst (LPA) Angela Panushkina conducted unannounced visit to this facility in conjunction with a complaint, control # 31-AS-20260511130957. LPA met with the Administrator and explained the reason for the visit.

During the visit, LPA was informed of the following:

· S1 started working here as of 05/07/2026. LPA conducted review of Licensing Information System and did not observe S1's association to this facility. LPA informed the Administrator that all staff members must be fingerprint cleared and associated prior to employment.

· Administrator informed the LPA that R1 moved to this facility on 04/28/2026. LPA was also informed that R1 would go outside and interact with neighbours, however on 05/08/26 and 05/09/26 R1 wondered around the neighborhood, and the staff was unable to redirect R1 due to R1's combative behavior. LPA was informed that on both days 911 was initiated. However, no incident report was submitted to the Community Care Licensing Department (CCLD) in a timely manner. LPA reviewed all incident reports on a system and did not observe an Incident Report regarding R1. In addition, the Administrator admitted that no incident was submitted to the Regional Office (RO). Based on Title 22 Regulation: a written Unusual Incident / Injury Report shall be submitted to CCLD within seven (7) days of occurrence. LPAs informed the Administrator that all staff members are mandated reporters and they are all responsible for reporting.

· LPA was unable to obtain any staff/resident records. The Administrator informed LPA that three (3) residents were admitted within the same week, along with S1. Administrator informed LPA that she was unable to complete any of the files. No documents were provided to LPA during todays visit. Only R1's facility file was available, however, all documents were not valid due to being incomplete and or missing signatures/dates. Continue on LIC809-C