Pals Autism Society

No violations recorded at this inspection.

• STAFFING

  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. 3/5 staff lacked at least 2 references checks in their files. This is a repeat contravention from inspection reports #CGEE-CW62KP and CGEE-C9KTAN. As per the Manager, all staff references are kept at head office and the facility is in the process of obtaining these missing references.

  Corrective action. Please ensure all staff have at least 2 reference checks on file..

  12050 - CCLR s.19(1)(b)

• STAFFING

  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. Repeat violation from FIR #CGEE: - BGUVXT (11/Oct/2019) - BRCMVF (08/Jul/2020) - C9KTAN (10/Dec/2021) An employee lacked a character reference in her file.

  Corrective action. ≥ 2 references/employee must be obtained by their 1st day of employment.

  12050 - CCLR s.19(1)(b)

• ADDITIONAL CCALA SECTIONS

  Despite subsection (1), a medical health officer may grant an exemption to section 1 of the Act in respect of the definition of "child" such that a youth who, but for the youth's age, would be a child requiring extra support may be considered a child for the purpose of recieving care in a care program.

  Observation. There is no exemption in place for a youth w/ extra support needs to receive care.

  Corrective action. An approved exemption request is required for this youth to continue receiving care; otherwise, care must be terminated.

  50002 - CCALA s.1
• RECORDS AND REPORTING

  A licensee must have in writing from a parent, and maintain at the community care facility, consent (a) to call a medical practitioner or ambulance in case of accident or illness if the parent cannot immediately be reached.

  Observation. 0/5 children had written parental consent to call a doctor or ambulance in the event of an accident or illness.

  Corrective action. All requirements of s. 57 must be obtained by children's 1st day of care.

  19190 - CCLR s.57(3)(a)
• RECORDS AND REPORTING

  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. REPEAT VIOLATION from FIR #CGEE-BGUVXT (11/Oct/2019) & FIR #CGEE-C9KTAN (10/Dec/2021): Only children's AM arrival & PM departure times are documented, which makes them appear to be in care all day.

  Corrective action. If a child attends in the AM & PM, they must be signed: - IN upon arrival - OUT upon transfer of care to school (09:00) - IN upon arrival (15:00) - UPON upon departure

  19090 - CCLR s.57(2)(c)
• RECORDS AND REPORTING

  A licensee must keep, for each child, a record showing the following information: (a) name, sex, date of birth, medical insurance plan number and immunization status.

  Observation. REPEAT VIOLATION from FIR #CGEE-BGUVXT (11/Oct/2019): 4/5 children lacked their immunization status.

  Corrective action. All requirements of s. 57(2) must be obtained before children's 1st day of care. CCFL provided the Head of School w/ FHA CCFL's "Child Immunization Status Declaration" form.

  19070 - CCLR s.57(2)(a)
• STAFFING

  A licensee must ensure that children have at all times immediate access to an employee who (a) holds a valid first aid and CPR certificate, provided on completion of a course that meets the requirements of Schedule C.

  Observation. REPEAT VIOLATION from FIR #CGEE-C9KTAN (10/Dec/2021): The lone 1st aid certified employee is absent today.

  Corrective action. Children must have @ all times immediate access to ≥ 1 1st aid/CPR certified employee. The course must meet all requirements of CCLR Schedule C (s. 23 [1st aid]).

  12210 - CCLR s.23(1)(a)
• STAFFING

  A licensee must ensure that each employee (b) practices implementing the fire drill system at least once each month.

  Observation. REPEAT VIOLATION from FIR #CGEE-BRCMVF (08/Jul/2020) & FIR CGEE-C9KTAN (10/Dec/2021): A few fire drills were missed this year.

  Corrective action. Fire drills must be practiced monthly, even on the same month as the annual emergency drill & shortened months.

  12190 - CCLR s.22(2)(b)

• OR SUPERVISION

  A licensee must do all of the following: (b) operate the community care facility in a manner that will promote (i) the health, safety and dignity of persons in care,

  Observation. There are currently 5 youth/adults in care between age 13-21.

  Corrective action. Children can no longer attend the facility on their 13th birthday. FHA & the manager discussed ways to come into compliance.

  14360 - CCALA s.7(1)(b)(i)
• RECORDS AND REPORTING

  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 (CORRECTED DURING INSPECTION): *Repeat violation from FIR #CGEE-BGUVXT (11-Oct-2019)* Today's & yesterday's attendance weren't documented.

  19090 - CCLR s.57(2)(c)
• STAFFING

  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. 6/15 employees lacked their immunization status in their files.

  Corrective action. All requirements of s. 19(1) must be obtained by employees' 1st day of employment.

  12090 - CCLR s.19(1)(f)
• STAFFING

  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. *Repeat violation from FIR #CGEE-BGUVXT (11-Oct-2019) & FIR #CGEE-BRCMVF (08-Jul-2020)* 10/15 employees lacked ≥ 2 character references in their files.

  Corrective action. All requirements of s. 19(1) must be obtained by employees' 1st day of employment.

  12050 - CCLR s.19(1)(b)
• STAFFING

  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. *Repeat violation from FIR #CGEE-BGUVXT (11-Oct-2019) & FIR #CGEE-BRCMVF (08-Jul-2020)* 10/15 employees lacked evidence of their training & skills in their files.

  Corrective action. All requirements of s. 19(1) must be obtained by employees' 1st day of employment.

  12070 - CCLR s.19(1)(d)
• STAFFING

  A licensee must ensure that each employee (b) practices implementing the fire drill system at least once each month.

  Observation. *Repeat violation from FIR #CGEE-BRCMVF (08-Jul-2020)* A few fire drill practices were missed this year.

  Corrective action. Fire drills must be practiced monthly.

  12190 - CCLR s.22(2)(b)
• STAFFING

  A licensee must ensure that children have at all times immediate access to an employee who (a) holds a valid first aid and CPR certificate, provided on completion of a course that meets the requirements of Schedule C.

  Observation. There are times when there are no first aid/CPR certified employees onsite.

  Corrective action. There must be ≥ 1 first aid/CPR certified employee available to children @ all times.

  12210 - CCLR s.23(1)(a)

• STAFFING

  A licensee must ensure that each employee (c) practices implementing the emergency plan at least once each year.

  Observation. The annual emergency drill hasn't been conducted yet.

  Corrective action. The emergency drill must be conducted annually.

  12200 - CCLR s.22(2)(c)
• STAFFING

  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. * REPEAT VIOLATION FROM FIR #CGEE-BGUVXT (11/OCT/2019) * FHA reviewed 6 employees' files & found that 1 employee lacked a character reference.

  Corrective action. 3 character references/employee must be obtained & checked by employees' 1st day of employment.

  12050 - CCLR s.19(1)(b)
• STAFFING

  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. * REPEAT VIOLATION FROM FIR #CGEE-BGUVXT (11/OCT/2019) * FHA reviewed 6 employees' files & found that all employees lacked a copy of diplomas, certificates, or other evidence of training/skills that are required to be employed in the facility.

  Corrective action. Evidence of training/skills must be obtained by employees' 1st day of employment.

  12070 - CCLR s.19(1)(d)
• STAFFING

  A licensee must ensure that each employee (b) practices implementing the fire drill system at least once each month.

  Observation. A few fire drills have been missed over the past ¾ year.

  Corrective action. Fire drills during licensed care hours are separate from those conducted during school hours.

  12190 - CCLR s.22(2)(b)